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Approaches to maxillofacial skeleton
1. M O D E R ATO R –
D R . R A JA S E K H A R G .
P R E S E N T E D BY -
D R . S H E E TA L K A P S E
2. Introduction
General principles of
approaches and placing
incisions
Extraoral approaches
Intraoral approaches
Conclusion
References
Transfacial Approaches to the Mandible
Approaches to the condyle
Periorbital Incisions
Surgical Approaches to the Nasal Skeleton
Coronal Approach
Approaches to the Maxilla
Approaches to the Mandible
Approaches to the Orbit
3.
4. 1. Age
2. Aesthetics
3. Location
4. Proximity of vital structures
5. Accessibility to underlying bone
6. Tension on closure
7. Direction of wound
8. Shape of the wound
9. Local condition of tissues
10. Systemic condition of the patient
11. Technique
5. 1. Use of natural lines
2. Hiding the scar in hair bearing area, inside
the hairline
3. Course of major vessels and important
nerves with their branches should be
considered in order to prevent any injury
4. Adequate accessibility : length of incision
should be adequate.
5. Use of Z-plasty
27. Once the incision is
made, there are 3
pathways available to
the underlying
orbit—
• the “skin flap”
dissection, the
• “skin-muscle flap”
dissection,
• the “stepped skin
muscle flap
(Converse)”
dissection
28.
29.
30.
31.
32.
33. The incision for the
extended
transconjunctival
approach is exactly as
described for the
standard
transconjunctival
approach, but the
incision must be
extended further
laterally,
1 to 1.5 cm in a natural
crease.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46. Postauricular placement of the coronal incision.
The incision can be extended into the
postauricular sulcus or within the hairline
Illustration showing zigzag incision across the
entire incision. Alternatively, the zigzag can be
used in the temporal areas only, with straight
incision across the vertex. The resultant scar
becomes less noticeable.
48. Scroll area where upper and lower
lateral cartilages are joined by
fibrocartilaginous
tissue
Base of the nose. IDL,
interdomal ligaments; LC, lateral
crus of the lower lateral cartilage;
MC, medial crus of the lower
lateral cartilage; S, septum
49. Submucosal injection of the nasal septum, membranous septum
and along the medial crus of the lower lateral cartilage injection along the location of
the marginal incision
injection just
superficial to
the upper lateral
cartilages and
the nasal bones
injection along
the location of
the marginal
incision
57. Axial section through the maxilla
at the level of the tooth root apices
showing the relation of the buccal
fat pad (BFP) to the lateral
maxilla. Note that the fat pad
extends anteriorly to
approximately the first molar.
Also, posterior to the origin of the
buccinator muscle on the maxilla,
the buccal fat pad is just lateral to
the periosteum.
58.
59.
60.
61.
62. Closure of the posterior incision is performed
in one layer. In the anterior region, delayed
sutures are placed in the mentalis muscle prior
to mucosal closure.
63.
64. ENDOSCOPIC TECHNIQUES IN ORALAND
MAXILLOFACIAL SURGERY. Atlas Oral Maxillofacial Surg
Clin N Am 11 (2003).
Markiewicz M R, Bell R B. Traditional and Contemporary
Surgical Approaches to the Orbit. Oral Maxillofacial Surg Clin
N Am. 2012; 24 (4):573–607.
65. 3 factors distinguish facial access from that in the remainder of the body.
1. The prominent location and social importance of the face mandates that
incisions be placed in locations that are as inconspicuous as possible.
2. The presence of peripheral nerves makes the location of the incisions
and the dissection around them critically important. Loss of sensory
input and, more importantly, weakness or loss of facial movement can be
devastating for many patients and difficult to correct secondarily.
3. The compact nature of facial structures exposes structures in the path
of dissection to injury, especially as the incision is located more remotely
from the defect site.
The intraoral approach should be used whenever possible to avoid skin
incisions.
66. 1. Surgical approaches to the facial skeleton / Edward Ellis III, Michael F. Zide ;
illustrations by Jennifer Carmichael and Lewis Calver.—2nd ed.
2. Maxillofacial trauma and esthetic facial reconstruction / [edited by] Peter Ward
Booth, Barry L. Eppley, Rainer Schmelzeisen.—2nd ed.
3. ENDOSCOPIC TECHNIQUES IN ORALAND MAXILLOFACIAL SURGERY.
Atlas Oral Maxillofacial Surg Clin N Am 11 (2003).
4. Markiewicz M R, Bell R B. Traditional and Contemporary Surgical Approaches to the
Orbit. Oral Maxillofacial Surg Clin N Am. 2012; 24 (4):573–607.
5. Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a malar fracture. Ann
Plast Surg 37:178, 1996
6. Hui Li, Gang Zhang, Junhui Cui,Weilong Liu, Dilnu Dilxat and Lei Liu. A Modified
Preauricular Approach for Treating Intracapsular Condylar Fractures to Prevent Facial
Nerve Injury: The Supratemporalis Approach. J Oral Maxillofac Surg -:1-10, 2016.
Editor's Notes
Injuries to hard and soft tissues are very common during trauma. Soft tissues are repaired by primary, secondary or tertiary (grafts) closure, while repair of hard tissues requires adequate reduction and most of the times fixation. That means maximum of maxillofacial fractures require open reduction and internal fixation for their adequate management.
In absence of existing lacerations or old scars, surgeons need to approach the skeleton through various incisions either intraoral or extraoral. These incisions are placed electively in such a manner that they should not produce any conspicuous scar on face as well as should not injure any adjacent vital structures, like facial vessels and cranial nerves V & VII with their branches.