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

NOE II

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Abhijit joshi

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

Secondary deformities
Abhijit joshi

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.

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Pre op

Post op

Abhijit joshi

Management of injured lacrimal drainage system

DCR – Dacrocystorhinostomy

Abhijit joshi

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

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

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

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

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

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

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

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

A. Wedge shaped geometry of the complex.
B. Application of compressive forces at the base increases the projection

Abhijit joshi

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

I. Exposure

Abhijit joshi

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

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

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Existing lacerations

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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
•

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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
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Coronal flap

Subperiosteal plane

Periosteal incision
Subgaleal/supraperiosteal plane

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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 arterywww.indiandentalacademy.com of medial wall.
identified while dissection

Abhijit joshi

Coronal flap

• Avoid stripping of MCL
•Anterior lacrimal crest identified.
•Usually the strong anterior limb of MCL sits just
below the lacrimal crest.
•Lacrimal www.indiandentalacademy.com
fossa also identified.
Abhijit joshi

Coronal incision can be coupled with the
following eyelid incisions for better access

Abhijit joshi

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

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

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

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

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

between the upper and lower lateral cartilage
(anterior of the nasal septum)

Intra-oral degloving incision

Abhijit joshi

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

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

Converse and Smith

Horizontal radix

Seagul approach

Dingman ‘60

Strene ‘70

Bowermann ‘75

Abhijit joshi

Precaruncular approach to medial orbit

Kris

Moe,Arch of Plast Surg 2003

Abhijit joshi

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

II. Identify MCL – capturing/tagging MCL

Abhijit joshi

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.

III. Reconstruction of medial orbital rim.

Abhijit joshi

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

• 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

Abhijit joshi

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

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

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. www.indiandentalacademy.com
projection.

Abhijit joshi

IV.Reconstruction of medial orbital wall:

Abhijit joshi

• Importance :
– to regain anatomic morphology.
– To regain lost orbital volume  in blow out #
– To achieve normal eye position after injury.

Abhijit joshi

• 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

Medial canthal reconstruction

Abhijit joshi

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

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

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

Transnasal canthopexy – fundamental
principles..

Location of holes

High to low vector

Abhijit joshi

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

• 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

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.

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


?Skin necrosis

Abhijit joshi

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

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

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

• 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

• 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

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

• 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

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

• 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

Securing the MCL to a cantilever microplate fixed
in the glabella with a nonresorbable anchor
suture..
Abhijit joshi

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

“The key to replicating the delicate threedimensional contour of the medial canthus lies in
addressing all three vectors of attachment”.

Abhijit joshi

• 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

Then the bone anchor is placed within the
drilled hole using the provided introducer system and a
mallet

Abhijit joshi

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

Reduce septal fractures/displacement

Abhijit joshi

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

•

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

Drainage of septal hematoma
Abhijit joshi

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

Aim for overprojection of the dorsum and not
underprojection.

Abhijit joshi

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

- 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

Bone grafts

Abhijit joshi

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

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

Thank you
Abhijit joshi

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

Thank you
For more details please visit

Abhijit joshi

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

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