Naso orbital ethmoid fractures- part 2 /certified fixed orthodontic courses by Indian dental academy


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  • Main dictum in Rx of noe # is to over treat than undertreat. The main reason behind this is to avoid any secondary deformities which are extremely difficult to manage at a latter stage for the following reasons.
  • This is what I mean by.its always preferable to try and achieve a near normal result during primary correction of the fracture.
  • Surgical Treatment particulary involves reconstruction of the medial orbital rims, the medial orbital walls, reattachement of the medial canthal ligament…A particular sequence is desired in performing these tasks to achive the best possible result.
  • Exisiting lacerations if present over the NOE region can be readily used to access the region as in these pictures. But in cases like these though we can anticipate an excellent exposure, the impending risk of delayed healing due to the contiminated wound is always present. Besides we can anticipate some amount of loss of tissue while refining the margins of these lacerations in an attempt to achieve better access.
  • Naso orbital ethmoid fractures- part 2 /certified fixed orthodontic courses by Indian dental academy

    1. 1. NOE II INDIAN DENTAL ACADEMY Leader in continuing dental education Abhijit joshi
    2. 2. Management of NOE #: • Better over treated then undertreated. • Why over treat? – Inadequate treatment  secondary deformities. - Soft tissue scarring difficult to treat - Malposition - Missing or displaced bone fragments. Abhijit joshi
    3. 3. Secondary deformities Abhijit joshi
    4. 4. Ideal proportions Goals of management: • Management of CSF leaks. • Management of damage to Nasolacrimal drainage system  dacrocystorhinostomy • Restore the ideal nasofrontal angle 115° to 130° TheRestore the ideal 115° to 130° • ideal nasofrontal angle nasal project The ideal nasal project  1:1.  1:1. • Restore ideal intercanthal distance ideal intercanthal distance should be approximately 1/3. Abhijit joshi
    5. 5. Pre op Post op Abhijit joshi
    6. 6. Management of injured lacrimal drainage system DCR – Dacrocystorhinostomy Abhijit joshi
    7. 7. DACROCYSTORHINOSTOMY (8-18%) • Dacryocystorhinostomy (DCR) is the repair of the lacrimal drainage system through the creation of a new “ostomy” or track from the lacrimal canaliculi to the nasal cavity. • Principle: large nasal osteotomy can allow greater lacrimal drainage in upright position than will a lacrimal sac with an interrupted lacrimal pump. • Techniques that have been described include open (external),endonasal, and soft tissue conjuctivorhinostomy. Abhijit joshi
    8. 8. Open DCR • 10 mm vertical/curvilinear incision placed 10 to 12 mm medial to the medial canthus of the affected eye. • Blunt dissection  approach the lacrimal crest. • A periosteal incision is followed by careful dissection of the lacrimal sac away from the bony fossa, Abhijit joshi
    9. 9. DCR - Osteotomy • Periosteum reflected temporally  along with lacrimal sac . • Anterior lacrimal crest revealed. • Osteotomy created involving : – ant. Lacrimal crest – Wall of lacrimal groove – Bone of posterior crest. • Nasolacrimal canal unroofed. • Osteotomy is as large as surgeons thumb. Abhijit joshi
    10. 10. DCR - Incisions . • After the sac has been freed, it is incised on its medial surface, and superior and inferior releasing incisions are made on the superficial side of the sac (posterior flap). • This procedure is followed by a vertical incision of the nasal mucosa and anterior releasing incisions (anterior flap). • H shaped incisions Abhijit joshi
    11. 11. DCR -Silicone tubing. • Crawford silicone micro tubes used to intubate both the superior and the inferior canaliculi. • Ends of the Crawford tubes are visible in the lacrimal sac and can be inserted through the lacrimal osteotomy and retrieved intranasally inferior to the middle turbinate. Abhijit joshi
    12. 12. DCR- closure • Closure is then begun with anastomosis of the lacrimal sac and the nasal mucosa. • The anterior flap of the nasal mucosa is closed to the posterior flap of the lacrimal sac • The tubing is left in place for 4 to 6 months, and patients should use saline nasal sprays to prevent crusting of the tubes Abhijit joshi
    13. 13. DCR Incision of lacrimal sac. View of the polymeric silicone tubes exiting through the nasal mucosa into the nose. Osteotomy, made with a round bur, through which the polymeric silicone tubes are placed. The lacrimal sac flap is shown being held in the forceps over the polymeric silicone tubing that exits into the nasal cavity. Abhijit joshi
    14. 14. Management of NOE # • Reduction of the NOE fractures requires special attention. • Reasons: - Complex is wedge-shaped: reduction of base decides restoration of projection (width:- 20-22mm). - Fracture reduction should be sequenced to restore alignment of bone that makes the central fragment. Abhijit joshi
    15. 15. A. Wedge shaped geometry of the complex. B. Application of compressive forces at the base increases the projection Abhijit joshi
    16. 16. Strategy for treating NOE # - 8 steps. Sequencing treatment for NOE fractures ; Edward Ellis JOMS’93 1. Exposure. 2. Identify the MCL or the MCL bearing bone. 3. Reduce / reconstruct medial orbital rims. 4. Reconstruct medial orbital walls. 5. Transnasal conthopexy. 6. Reduce septal displacement. 7. Nasal dorsal reconstruction. 8. Soft tissue readaptation. Abhijit joshi
    17. 17. I. Exposure Abhijit joshi
    18. 18. Exposure • Unobstructed visualization of the articulations of all the bones in the region. • One of the main reasons for treating NOE # is esthetics  hence incisions made keeping in mind the esthetics. • Remote incisions preferred. Abhijit joshi
    19. 19. Surgical Approaches to NOE skeleton: • Existing lacerations. • Coronal incision + eyelid incisions. Skin incisions : • Vertical/horizontal radix incision. • Open sky approach-H shape incision. • W shape incision. -Visible Scar -Scar contracture and webbing • Lynch incision. • Transcaruncular incision. - No external scars • Pre caruncular incision. - ? access • Transoral  degloving incision. • Midfacial degloving incision great access / no scar Abhijit joshi
    20. 20. Existing lacerations Abhijit joshi
    21. 21. Coronal flap. Advantage : • correction of associated frontal sinus fracture. • Harvesting of calvarial bone graft for primary reconstruction. • Harvesting of pericranial flap of sufficient length for sealing of defects in the ant. Cranial fossa. Disadvantage : cannot be used when the skull has been opened up previously for craniotomies by the neurosurgeons • Abhijit joshi
    22. 22. Coronal flap 1 .Initial incision extends from one superior temporal line to the other to the depth of pericranium. Dissection  subgaleal  loose CT-cleaves easily 2. Incision made through periosteum 3 cms above supraorbital rims Abhijit joshi
    23. 23. Coronal flap Subperiosteal plane Periosteal incision Subgaleal/supraperiosteal plane Abhijit joshi
    24. 24. Coronal flap • Supraorbital rims exposed • Orbital contents elevated in subperiosteal plane along the medial wall and orbital roof to a point 2-3 cms post to orbital rims for sufficient relaxation of flap. • flap now reflected to level of nasal bridge  stay in the midline!! • anterior ethmoidal of medial wall. identified while dissection Abhijit joshi
    25. 25. Coronal flap • Avoid stripping of MCL •Anterior lacrimal crest identified. •Usually the strong anterior limb of MCL sits just below the lacrimal crest. •Lacrimal fossa also identified. Abhijit joshi
    26. 26. Coronal incision can be coupled with the following eyelid incisions for better access Abhijit joshi
    27. 27. Lynch/medial canthal incision. • Curved incision over lateral nasal bones ant. To MCL attachement. • Skin here is thin allows easy exposure. • Sufficient for limited reconstruction. Cannot be used in : - bilateral canthopexies - bone grafting. • Z plasty modification. Esclamado Laryngoscope 99: 986,1989. Abhijit joshi
    28. 28. W-shaped incision BURM Plast. Recon surg 2001 • Skin incision approx 3 cm in length made along the superior medial orbital rim from 1 cm medial to the medial canthus to the lower border of the medial eyebrow. • Angles of limbs of the W 110 to 120o • Four limbs of the W placed parallel or oblique to the RSTL • The lateral limb of the W can be extended laterally along the lower border of the medial eyebrow, depending on the desired exposure. Abhijit joshi
    29. 29. W-shaped incision • Muscle dissection, supratrochlear nerve located and preserved. • Periosteum is incised from upper half of medial canthal tendon to medial portion of sup. Orbital rim  periorbita is laterally reflected. Abhijit joshi
    30. 30. W shaped incision Advantages: • W has small-segmented limbs parallel or oblique to the relaxed skin tension lines. • W-limbs break up the scar into smaller components minimal external scar. • Pulling both ends of the W along its longitudinal axis provides the increase of its longitudinal length  allows implant up to 3 cm to be inserted. • Superior access to medial orbital wall Abhijit joshi
    31. 31. Midfacial degloving incision A. Baumann, Int. J. Oral Maxillofac. Surg. 2001 Incisions utilized: - Transoral degloving from 2nd molar - Intercartilaginous incision - Transfixion incision - Sill incision to connect nasal and oral incisions Abhijit joshi
    32. 32. Midfacial degloving incision between the upper and lower lateral cartilage (anterior of the nasal septum) Intra-oral degloving incision Abhijit joshi
    33. 33. Procedure : Orbital rim • Mucoperiosteal flap till piriform aperture raised. • Both intercartilaginous and transfixion incisions connected across the septal angle. • The osseocartilaginous nose is degloved over the upper lateral cartilage as for a septorhinoplasty. • The intranasal incisions connected with the oral incision by Rib graft at glabella a nasal sill incision. • Midface can now be degloved. Abhijit joshi
    34. 34. Midfacial degloving incision Advantages: • No external visible scars. • Excellent visibility – as good as a coronal incision. • Minimal risk to vital structures. • No aesthetic sagging of tissues. • Provides concurrent access to zygoma on both sides. Disadvantages : • Suturing is vital  ? Stenosis of nasal aperture. • ? damage to infraorbital nerves. Abhijit joshi
    35. 35. Converse and Smith Horizontal radix Seagul approach Dingman ‘60 Strene ‘70 Bowermann ‘75 Abhijit joshi
    36. 36. Precaruncular approach to medial orbit Kris Moe,Arch of Plast Surg 2003 Abhijit joshi
    37. 37. Possible scenarios after exposure. 1. Both MCL remain attached and the laterization of the complex is counteracted by the orbicularis oculi.  Type I : b/l single segment NOE # 2. Tendon is still attached to the bone but the bone fragment is separate from complex : U/l single segment type I injury. 3. Avulsion of tendon from bony connection  type III. 4. Bone into which the tendon inserts is missing. Abhijit joshi
    38. 38. II. Identify MCL – capturing/tagging MCL Abhijit joshi
    39. 39. II. Identify MCL – capturing/tagging MCL • Canthal ligament grasped with forceps and pierced with braided 2.0 / 3.0 Mersilene/ethibond. • MCL pierced again but at 90o to previous first pass  compleley Abhijit joshi encircles and secures the tendon  MCL thus tagged.
    40. 40. III. Reconstruction of medial orbital rim. Abhijit joshi
    41. 41. Biomechanics in fixation of mid face # Ruderman and Muller Clin Plast Surg ‘92 • Biomechanics of midface made complicated by: – Nonuniform geometry of bones – Number and orientation of various attached ligaments and soft tissues. • treatment aimed to restrict three types of movements of a fractures segment in 6 directions 3 translatory movements Along X,Y,Z axes 3 rotational movements • Translatory movement  essentially 2D  restricted by wires as well as plates. Abhijit joshi
    42. 42. • Rotatory movements : 3-D  need restrictions at 3 separate points  plates more effective. • Farther apart the fixation points  better the stability  wider plates thus preffered. • 3 wires or several small plates oriented at different angles  increase stability. Abhijit joshi
    43. 43. Abhijit joshi
    44. 44. Advantages of rigid fixation • Adjunct to primary bone grafting • Avoids supplemental maxillomandibular or extraskeletal fixation • Better rigid support and immobilization • Prevents overriding of the fractured fragments Abhijit joshi
    45. 45. III. Reconstruction of medial orbital rim. • Transnasal reduction of canthal bearing fragment  most important step in preserving intercanthal distance. • Loose nasal bones may be removed temporarily for better access. • Fragment bearing the MCL identified. • If fragment is large enough  reduce and fix it to adjacent bone with miniplates. Abhijit joshi
    46. 46. Transnasal wiring for type II and III • Imperative to drill one hole posterior to lacrimal fossa to prevent lateral splaying coronal section : horizontal mattress posteriorly and telecanthus. •Other wire passed superior and posterior to lacrimal fossa on Proper placement of transnasal wires posteriorly other side. •Wires tightened as much as possible to “overreduce” and narrow the base  to gain the Improper placement with lateral splaying : wire placed too anteriorly. projection. Abhijit joshi
    47. 47. IV.Reconstruction of medial orbital wall: Abhijit joshi
    48. 48. IV.Reconstruction of medial orbital wall: • Importance : – to regain anatomic morphology. – To regain lost orbital volume  in blow out # – To achieve normal eye position after injury. Abhijit joshi
    49. 49. IV.Reconstruction of medial orbital wall: • Bone  material of choice for reconstruction  calvarial graft/rib graft. • Long pieces of bone used should extend just behind the medial orbital rim. • fixed with lag screws or miniplates. • If Bone pieces extend too posteriorly  poor access.  loss of stability Abhijit joshi
    50. 50. Medial canthal reconstruction Abhijit joshi
    51. 51. Is this the right time for canthopexy? • Canthal ligament was identified and tagged earlier. • Followed by orbital wall and rim reconstruction. • Steps demanded greatest traction. • If canthopexy performed earlier : – Vigorous traction could pull through the MCL and further damage the ligament. Abhijit joshi
    52. 52. Options for medial canthopexy. A. Transnasal wiring B. Ipsilateral/homolateral techniques: • Nylon anchor suture, • Stainless steel screw, • Cantilevered miniplate (Y-shaped, five holes), • Bone anchor systems. Abhijit joshi
    53. 53. Transnasal canthopexy – fundamental principles.. • Holes: – medial orbital rim posterior and superior to posterior lacrimal crest. – 2-4mm diameter. • Direction of transnasal wire  high to low  The essential biomechanical principle is that although the tightening produces a vertical force, the MCT moves medially in its prepared area of attachment. • Abhijit joshi
    54. 54. Transnasal canthopexy – fundamental principles.. Location of holes High to low vector Abhijit joshi
    55. 55. Basic Procedure for transnasal canthopexy • A contouring burr is used to create a depression in the frontal process of the maxilla just superior and posterior to the anterior lacrimal crest to inset the MCT. • On the contralateral fronto-glabellar area, a 1.5-mm hole is drilled and taken through to the depression created to receive the MCT. A second drill hole is made 5 mm below the first. Medial Canthopexy: A Proven Technique Kelly , Opthalmic Plastic and Reconstructive Surgery, Vol20(5), Sept 2004,Abhijit joshi
    56. 56. • 18-gauge syringe needle is passed through the first hole to the medial canthal area and the superior wire is fed through . • This is repeated through the second hole, and the wire is tightened until the canthus is firmly secured. Abhijit joshi
    57. 57. left, A depression is created to receive the medial canthal tendon (MCT), and drill holes are made from the glabella through the depression. right, A 28-gauge wire with sharpened tips is double-passed through the MCT and an 18-gauge syringe needle is used to guide the wire tips through the created holes. Medial Canthopexy: A Proven Technique Kelly , Opthalmic Plastic and Reconstructive Surgery, Vol20(5), Sept 2004,Abhijit joshi
    58. 58. left, Traction is applied to the wire to ensure it is pulling on the MCT, which is then brought into the depression. right, The wires are twisted, securing the MCT in its correct position. Twist around a broken burr end?? PWB Medial Canthopexy: A Proven Technique Kelly , Opthalmic Plastic and Reconstructive Surgery, Vol20(5), Sept 2004,Abhijit joshi
    59. 59. ?Skin necrosis Abhijit joshi
    60. 60. Why frontoglabella region?? • Nasal bone forming medial orbital wall and the bridge of the nose  fragile  ? Withstand wire tightening. • Glabellar portion of the frontal bone is solid and can withstand wire tightening. • The fixation is secure. • Due to the relatively large amount of soft tissue covering the twisted wire, extrusion of the wire through the skin does not occur. • No injury to delicate structures of the contralateral medial orbit such as the lacrimal sac or lacrimal duct. Abhijit joshi
    61. 61. Transnasal: – technically difficult. – Necessitates wide exposure sufficient to allow transverse passage of a wire through a bony fenestration deep within the orbit. – Weakening of the bones ( when central fragment is drilled twice), – dissection of the contralateral orbit. Abhijit joshi
    62. 62. A NEW METHOD FOR TRANSNASAL CANTHOPEXY AND FRACTURE FIXATION Özyazgan Volume 114(5), Plast and Recon surgery October 2004, pp 1338-1339 • A Kirschner wire with one of the tips hammered and shaped into a simple drill is passed from the left orbit toward the right thru central fragment. • plastic catheter is pushed forward over the Kirschner wire guide and through the transnasal hole. Abhijit joshi
    63. 63. • A bent, looped wire is introduced from left to right through the plastic tube left in the transnasal hole after the Kirschner wire is removed. Abhijit joshi
    64. 64. • A titanium microplate is placed in the loop at the second penetration site. • second microplate is placed between the exiting wires at the first penetration site, • Ends of the wires are twisted together. • The free tips of the wire at the site of first penetration can be used for canthopexy without microplate placement, if desired. Abhijit joshi
    65. 65. Ipsilateral fixation of MCL. Simple innovation for medial canthal fixation, sharma Plas and Recon surg; Volume 116(7), Dec ’05. • 30-gauge stainless steel wire and a two-hole miniplate used. • two-hole plate transversely adapted on frontal process of the maxilla in the region of the lacrimal crest . • The posterior hole is used to anchor the canthal tendon and the anterior hole is used to fix the screw Abhijit joshi
    66. 66. • After passing thru ligament;The 30G wire is passed through the posterior hole of the miniplate and loosely twisted. • The plate is positioned, with the medial canthal tendon pushed deep, near the posterior lacrimal crest. The drill hole is made in the area of the anterior hole of the plate and fixed with a stainless steel screw (2 × 6 mm). • The stainless steel wire is then tightened. • The frontal process of the maxilla in the region of the lacrimal crest is utilized for fixing the two-hole plate transversely Abhijit joshi
    67. 67. MCL reconstruction with miniplates and wire Wittkampf IJOMS 2001 • A simple method for medical canthal wiring reconstruction. • A homolaterally fixed osteosynthesis plate and a metal wire is used. • Avoids transnasal wiring and gives superior control when correcting the position of the lacerated medial canthus. Abhijit joshi
    68. 68. • 20 metal wire is fixated to the ligament by a double stitch. • One end of the metal wire is brought through the last hole of the plate and the plate is then fixed at the nasal bone in such a way that the end of the plate is at least some millimetres posterior and superior to the lacrymal fossa. • Reach the desired position  the wire can be twisted and the wound closed. Abhijit joshi
    69. 69. Securing the MCL to a cantilever microplate fixed in the glabella with a nonresorbable anchor suture.. Abhijit joshi
    70. 70. Bone anchor systems Medial Canthal Ligament Reattachment in skull Base Surgery and Trauma Yadranko Ducic, Laryngoscope 111: April 2001 • Have provided for effective longterm biomechanical stability in extremity tendon reattachment to bone in  orthopedics • prethreaded bone anchor system  Mitek mini bone anchor system used. Abhijit joshi
    71. 71. “The key to replicating the delicate threedimensional contour of the medial canthus lies in addressing all three vectors of attachment”. Abhijit joshi
    72. 72. • Optimal position for bone anchor placement is determined. • The hole for screw placement is positioned within the central portion of the lacrimal fossa. • If bone loss present no lacrimal fossa, the screw hole is placed within a rigidly fixated medial orbital wall bone graft at a point corresponding to the contralateral central lacrimal fossa position. Abhijit joshi
    73. 73. Then the bone anchor is placed within the drilled hole using the provided introducer system and a mallet Abhijit joshi
    74. 74. One of the double-armed needles is passed through the anterior portion of the canthal ligament; the second needle is passed through the posterior portion of the canthal ligament and the suture tied securely with a minimum of five knots. At this point, both needles are passed through the soft tissue overlying the ascending process of the maxilla as it attaches to the frontal bone. All 3 attachments of ligament are replicated (anterior lacrimal crest, posterior lacrimal crest, and ascending process of maxilla). Abhijit joshi
    75. 75. Reduce septal fractures/displacement Abhijit joshi
    76. 76. Reduce Septal fractures/displacement • NOE # are associated with fractures of perpendicular plate of ethmoid, septal deviation, septal hematomas. • Goal should be to – assure midline positioning of septum to prevent airway compromise. – Reduce septal fractures.. Abhijit joshi
    77. 77. • Intranasal manipulation of septum. • Asch forceps. • Forceps inserted carefully with one blade on either side of septum. • Forward and anterior forces with digital manipulation of the nose, septum can be guided into position. Abhijit joshi
    78. 78. Drainage of septal hematoma Abhijit joshi
    79. 79. Nasal dorsal augmentation Collapse of the bony architecture  broadening of base Weakening of nasal septal structures. Damage to upper lateral cartilages. Complete loss of dorsal nasal projection and loss of support. Abhijit joshi
    80. 80. Aim for overprojection of the dorsum and not underprojection. Abhijit joshi
    81. 81. Bone grafts • Reinforcement of thin bones • Prevention of overriding and displacement of fragments • Maintenance of vertical dimension • Provides substrate for osseous union • Prevention of soft tissue scarring Abhijit joshi
    82. 82. - Bone graft sites : calvarial  excellent choice. - Shape it like a surf board  gently tapering it at the end. - Length should extend from frontonasal junction to nasal tip. - Colummelar strut if needed. Fixation: - Single lag screw into the nasal pyramid. - Microplate to cantilever off the frontal bone. Abhijit joshi
    83. 83. Bone grafts Abhijit joshi
    84. 84. Soft tissue readaptation: • Post surgical soft tissue thickening can hamper esthetics. • Soft tissue thickening  appearance of telecanthus. • Solution: Soft tissue thermoplastic stents. - Splint is contoured and overextended into nasorbital valley.  into junction of nose and medial orbit.  reinforced with elastic tapes. Abhijit joshi
    85. 85. Conclusion… • NOE region is an anatomic confluence of important structures, trauma can influence contents of cranium,orbit,sinus and nasal cavities. • Clinical and radiological evaluation (CT scans)  play an important role in treatment planning. • Identify CSF leak  rule out. • Early management with emphasis on primary repair and reconstruction. Abhijit joshi
    86. 86. Thank you Abhijit joshi
    87. 87. References • Fonseca – trauma vol 2 • OMFS Fonseca – vol 3 • Trauma and Esthetic reconstuction – PWB • Surgery of facial bone fractures – Sherman • Neurosurgical principles in otolaryngology – Diaz. • Sequencing NOE fractures- Ellis JOMS 51:1993 • Surgical approaches to facial skeleton – ellis . Abhijit joshi
    88. 88. Thank you For more details please visit Abhijit joshi