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ORBIT IN ENT
INTRODUCTION
 ORBIT - interface between ENT & Eye
specialist
 Surrounded by PNS on 3 sides
 Infection, inflammation & n...
SURGICAL ANATOMY
 Orbit:
 Quadrilateral
pyramid
 Relationships:
 Sup:
 Med:
 Inf:
 Lat:
 Apex:
SURGICAL ANATOMY
 Orbit:
 Avg vol of 30 ml
 Fixed bony cavity
 Contains:
 Globe
 Intraconal space
 Muscle cone
 Ex...
Medial wall:
 5 inch long
 From ant lacrimal crest to body of sphenoid & optic
canal
 Lacrimal fossa: antero medial
 F...
Inferior wall/ Floor of orbit:
 Consists of 3 bones
 Orbital plate of maxilla, zygoma, palatine bone
 Floor is thin: 0....
Superior wall:
 Triangular
 2 bones:
 Orbital plate of frontal
 Lesser wing of sphenoid
 Thin: <3mm
 Onodi cells:
 ...
Lateral wall:
 5 cm long
 3 bones:
 Orbital surface of Zygoma
 Marginal tubercle of Whitnall
 Greater wing of Sphenoi...
Lacrimal Apparatus
 Lacrimal gland ( Serous gland )
 Parts: Orbital & Palpebral
 12-15 ducts
 Lacrimal sac:
 Apparatu...
Periorbita:
 Orbital perisoteum:
 Adherent to to orbital margin, sutures, foramen & fissures
and lacrimal fossa
 Contin...
Periorbita:
 Orbital septum:
 Attached to ant lacr crest & margin of orbit
 Palpebral fissure
 Thickened at sup & inf ...
Periorbita:
 Orbital septum:
 Lateral palpebral ligament:
 Thinner
 Fuses with lateral palpebral raphe of orbicularis ...
Extra Ocular Muscle
 All ms arise from the
common tendinous ring
(Annulus of Zinn at orbital
apex) except Inferior
obliqu...
SURGICAL ANATOMY
 Arterial supply
 Ophthalmic artery
 Ocular branch: CRA, ciliary artery, br to optic n
 Orbital branc...
SURGICAL ANATOMY
 Nerve Supply:
 Enter via Superior orbital fissure & optic canal
 CN II, III, IV, V, VI
Changes with age:
 Growth with facial skeleton
 Initially:
 Large orbital fissure
 High orbital index
 Infraorbital f...
RADIOLOGY
 Plain X-Ray:
 Adjacent sinus ds
 Orbital floor #
 Metallic Foreign body
 Ultrasound:
 Good for lesion wit...
RADIOLOGY
 CT scan:
 Axial & coronal
 Investigation of
choice
 Adv:
 Readily available
 Fast & versatile
 Bone deta...
RADIOLOGY
 MRI scan:
 Usually when CT
doubtful
 Graves
ophthalmopathy
 IC complications
 Adv:
 Better for optic n le...
A. SINONASAL PATHOLOGY OF
ORBIT
 I. INFECTION AND INFLAMMATION:
 Variety of infective & inflammatory condition
 Orbital...
I. Infection & Inflammation
 Orbital complications:
 Uncommon now-a-days
 Source
 Route of spread
 1970, Chandler, La...
II. Mucocoele
 Definition:
 Most commonly:Frontoethmoid
sinus’
 Only 4% bilateral
 40-70 yrs
 M>F
 Theories:
 Press...
II. Mucocoele
 Initial ophthalmic referral
 Clinical features:
 Proptosis: 90%
 Diplopia: 95%
 Displacement of globe:...
II. Mucocoele
 Investigation:
 Plain Xray
 CECT- PNS
 MRI
CECT PNS
FRONTAL MUCOCOELE BILOCULATEDETHMOIDMUCOCOELE
26
Homogenous smooth walled mass expanding the sinus
MRI
ENHANCING ETHMOID
MUCOPYOCOELE
NON ENHANCING MAXILLARY
MUCOCOELE
27
II. Mucocoele
 Treatment:
 Goals
 Eradication of disease
 Minimal morbidity
 Prevention of recurrence
 Endoscopic
 ...
III. Chronic dacrocystitis
 Presents with epiphora &
swelling
 Etiology:
 Idiopathic
 Trauma
 Malignancy
 Granulomat...
III. Chronic dacrocystitis
 Indication for surgery
 Symptomatic distal obstruction of NLD not
relieved by syringing & pr...
B. ORBITAL
DECOMPRESSION
 Finite capacity of orbit increased volume
anterior displacement of orbital contents
 Indicat...
B. ORBITAL
DECOMPRESSION
 Approach:
 Single Wall
 Endoscopic
 Combined
 Transantral + Endoscopic:
 3 walled decompre...
ENDOSCOPIC
DECOMPRESSION
THREE WALLEDDECOMPRESSION OF RIGHT
EYE
C. OPTIC NERVE
DECOMPRESSION
 Indication:
 Trauma: direct or indirect
 Thyroid eye disease
 Neoplastic compression of ...
C. OPTIC NERVE
DECOMPRESSION
 Approaches:
 External:
 Superior: external frontoethmoidectomy
 Lateral
 Medial: Extrac...
D. TRAUMA TO ORBIT
 ETIOLOGY:
 Part of Mid Facial Injury
 Complication of ESS
 I. Facial trauma involving
orbit
 Blow...
Clinical Features:
 Blow out #:
 Restriction of upward gaze
 Infraorbital anesthesia
 Tripod #
 Flattening of orbital...
Imaging
 CT Facial bones (most
useful)
 ‘Tear Drop’ sign in blow out #
 Plain Films of limited use
 Demonstrate # in 7...
Indications for Repair in Blow
out #
 Entrapment that causes an oculocardiac reflex
with resultant bradycardia and cardio...
Access:
 Fronto-Zygomatic area:
 Lateral brow incision
 Lateral upper lid incision
 Lateral rim:
 Lower lid conjuctiv...
 Access to Floor #
 Transantral
 Transnasal endoscopic
 Access to Medial wall #:
 Lynch Howarth
 Transcaruncular
 M...
Collapse of Anterior wall of maxilla or Orbital floor
fracture
 Endoscopic ballon catheter
repair:
 Wide MMA
 Insert Fo...
TRAUMA TO ORBIT
 II. Iatrogenic Orbital Trauma:
 Most commonly due to ESS
 Risk factors:
 Distorted anatomy
 Anatomic...
 II. Iatrogenic Orbital Trauma:
 ESS:
 MMA damage to NLDepiphora
 Ethmoidectomy damage to AEA retro-orbital hemorr...
E. Neoplasia
 Wide variety of benign & malignant neoplasia
may spread to orbit from adjacent structures
 +/- remove eyes...
I. Benign Tumors:
 Angiofibroma:
 Young males
 Arise from sphenopalatine foramen
 Presents in nose & nasopharynx as a ...
I. Benign Tumors:
 Inverted Papilloma:
 Intermediate tumor arising in lateral wall of nose
 Spreads extraperiosteally t...
II. Malignant Tumors:
 Tumors of sinonasal regions can invade orbit
 Invasion from ethmoids occurs early: Visual
symptom...
II. Malignant Tumors:
 Orbital perisoteum is resistant to tumor spread
 Once breached orbital contents cannot be salvag...
II. Malignant Tumors:
 Clinical features suggestive of orbital
involvement:
 Visual complaints
 Diplopia
 Proptosis
 ...
Investigations
 Nasal endoscopy
 Imaging:
 CECT: coronal and axial images
 Erosion and involvement of skull base
 Cri...
II. Malignant Tumors
 Treatment options:
 Palliative:
 Painful blind eye with proptosis  orbital clearance
 Orbital e...
Treatment options:
 Maxillectomy
 Total maxillectomy
 Extended
maxillectomy
 Access to orbital apex
 Medial Maxillect...
Medial Maxillectomy
 Osteotomy
 1: vertically thro’ Ant margin of
medial wall
 2: horizontally along inferior
aspect of...
Total Maxillectomy:Incisions
Total Maxillectomy: Bony Cuts
Inf Orbital
Fissure
Premaxilla and
Anterior Alveolar
Arch Preserved
Total Maxillectomy: Bony cuts
Naso maxillary
suture
Pterygoid plates separated
from post sinus wall
Horizontal cut if back...
II. Malignant Tumors
 Rehabilitation:
 Orbital prosthesis
 Attached to spectacles
 Adhesive glue
 Osseointegrated tit...
THANKYOU
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19 orbit in ent final

  1. 1. ORBIT IN ENT
  2. 2. INTRODUCTION  ORBIT - interface between ENT & Eye specialist  Surrounded by PNS on 3 sides  Infection, inflammation & neoplasia can spread in either direction  Relationship heightened by advent of ESS
  3. 3. SURGICAL ANATOMY  Orbit:  Quadrilateral pyramid  Relationships:  Sup:  Med:  Inf:  Lat:  Apex:
  4. 4. SURGICAL ANATOMY  Orbit:  Avg vol of 30 ml  Fixed bony cavity  Contains:  Globe  Intraconal space  Muscle cone  Extraconal space
  5. 5. Medial wall:  5 inch long  From ant lacrimal crest to body of sphenoid & optic canal  Lacrimal fossa: antero medial  Foramen for AEA, PEA & Optic N  Frontoethmoid suture  ‘Rule of 24-12-6’  Rough indication: crib. plate  16% lack AEA foramen  30% multiple  4.6% none  Poor anatomical barrier
  6. 6. Inferior wall/ Floor of orbit:  Consists of 3 bones  Orbital plate of maxilla, zygoma, palatine bone  Floor is thin: 0.5 to 1.0mm  Infraorbital foramen:  Halfway along inf rimContinuous with Infraorbital canal  25 mm from post wall of maxilla  Damage due to trauma or surgery, Medial maxillectomy
  7. 7. Superior wall:  Triangular  2 bones:  Orbital plate of frontal  Lesser wing of sphenoid  Thin: <3mm  Onodi cells:  Supra-orbital notch & Frontal notch  Trochlea: connective tissue sling  Anchors tendinous part of Superior Oblique muscle to orbit  Fovea for trochlea: small
  8. 8. Lateral wall:  5 cm long  3 bones:  Orbital surface of Zygoma  Marginal tubercle of Whitnall  Greater wing of Sphenoid  Zygomatic process of frontal  Superior Orbital fissure  Optic N lies 8 mm behind it  Syndromes:
  9. 9. Lacrimal Apparatus  Lacrimal gland ( Serous gland )  Parts: Orbital & Palpebral  12-15 ducts  Lacrimal sac:  Apparatus to remove excess tears  Lacrimal cannaliculi:  Flap valves of mucous membrane  Naso Lacrimal Duct:  2cm long & 3.5mm  Mucous membrane folds  Valve of Hasner
  10. 10. Periorbita:  Orbital perisoteum:  Adherent to to orbital margin, sutures, foramen & fissures and lacrimal fossa  Continuous with dura thro’ sup orb fissure, optic canal, ethmoidal canal  Encloses lacrimal gland & surrounds NLD upto Inf Meatus  Importance:  Protects the orbital contents  Resists spread of infection & malignancy
  11. 11. Periorbita:  Orbital septum:  Attached to ant lacr crest & margin of orbit  Palpebral fissure  Thickened at sup & inf margin: Tarsal Plate  Medial Palpebral ligament  Preseptal & Pretarsal head of orbicularis oculi ms  Superficial heads attach to ant lacr crest  Deep heads attach to post lacr crest  Together compress sac on blinking  Detachment of MCL  rounding of Medial canthus, Telecanthus
  12. 12. Periorbita:  Orbital septum:  Lateral palpebral ligament:  Thinner  Fuses with lateral palpebral raphe of orbicularis oculi  Attach at Marginal tubercle of Whitnall  Fascia Bulbi (Tenon’s Capsule):  Thin membrane from corneoscleral junction to optic N  Medial(MR ms) & Lateral(LR ms) check ligament  Suspensory ligament of Lockwood inferiorly  Stability of eye : Total Maxillectomy
  13. 13. Extra Ocular Muscle  All ms arise from the common tendinous ring (Annulus of Zinn at orbital apex) except Inferior oblique  Inferior oblique arises from the periosteum of maxilla  LR6 SO4 Rest3
  14. 14. SURGICAL ANATOMY  Arterial supply  Ophthalmic artery  Ocular branch: CRA, ciliary artery, br to optic n  Orbital branch: lacrimal, muscular & periosteal branch  Extraorbital br: AEA, PEA, Supraorbital A, Medial palpebral A, Dorsal nasal A & Frontal A  Infraorbital artery  Venous drainage:  Superior Ophthalmic vn Cavernous sinus  Inferior Ophthalmic vn  Cavernous sinus & Pterygoid plexus  Lymphatics: NIL
  15. 15. SURGICAL ANATOMY  Nerve Supply:  Enter via Superior orbital fissure & optic canal  CN II, III, IV, V, VI
  16. 16. Changes with age:  Growth with facial skeleton  Initially:  Large orbital fissure  High orbital index  Infraorbital foramen not fully formed  Little change after 7 yrs  Advancing age:  Resorption of bone widening of fissures  Female orbit: more elongated & larger
  17. 17. RADIOLOGY  Plain X-Ray:  Adjacent sinus ds  Orbital floor #  Metallic Foreign body  Ultrasound:  Good for lesion within globe  FB in orbit  Poor penetration
  18. 18. RADIOLOGY  CT scan:  Axial & coronal  Investigation of choice  Adv:  Readily available  Fast & versatile  Bone detail & calcification  Spatial resolution  Disadvantage:  Radiation induced cataract 
  19. 19. RADIOLOGY  MRI scan:  Usually when CT doubtful  Graves ophthalmopathy  IC complications  Adv:  Better for optic n lesions  No radiation  Disadvantage:  Time consuming  Metallic FB  Poor resolution  Carotid angiography  Vasular tumors & malformations  Invasive  Time consuming  Orbital venography  Dacrocystogram  CT / MRI dacrocystogrpahy
  20. 20. A. SINONASAL PATHOLOGY OF ORBIT  I. INFECTION AND INFLAMMATION:  Variety of infective & inflammatory condition  Orbital complication of sinusitis  Mucocoele  Polyposis
  21. 21. I. Infection & Inflammation  Orbital complications:  Uncommon now-a-days  Source  Route of spread  1970, Chandler, Langenbrunner & Stevens  Preseptal cellulitis  Orbital cellulitis without abscess  Orbital cellulitis with extra periosteal abscess  Orbital cellulitis with intra periosteal abscess  Cavernous Sinus Thrombosis
  22. 22. II. Mucocoele  Definition:  Most commonly:Frontoethmoid sinus’  Only 4% bilateral  40-70 yrs  M>F  Theories:  Pressure erosion  Cystic degeneration  Active bone resorption & formation  Slow expansion rapid if infected
  23. 23. II. Mucocoele  Initial ophthalmic referral  Clinical features:  Proptosis: 90%  Diplopia: 95%  Displacement of globe: 55%  Limited ocular movt. : 55%  Visual impairment: 10%  Mass, epiphora,  Others:  Nasal Endoscopy:
  24. 24. II. Mucocoele  Investigation:  Plain Xray  CECT- PNS  MRI
  25. 25. CECT PNS FRONTAL MUCOCOELE BILOCULATEDETHMOIDMUCOCOELE 26 Homogenous smooth walled mass expanding the sinus
  26. 26. MRI ENHANCING ETHMOID MUCOPYOCOELE NON ENHANCING MAXILLARY MUCOCOELE 27
  27. 27. II. Mucocoele  Treatment:  Goals  Eradication of disease  Minimal morbidity  Prevention of recurrence  Endoscopic  Osteoplastic flap  Ext. Frontoethmoidectomy  Combined
  28. 28. III. Chronic dacrocystitis  Presents with epiphora & swelling  Etiology:  Idiopathic  Trauma  Malignancy  Granulomatous disease  Incidence:  10% @ 40 yrs 40% @ 90 yrs  Assessment:  Syringing & probing  Nasal endoscopy
  29. 29. III. Chronic dacrocystitis  Indication for surgery  Symptomatic distal obstruction of NLD not relieved by syringing & probing  Functional obstruction  Combined proximal & distal obstruction  Methods:  External DCR  Conventinal endonasal DCR  Endonasal Laser assisted DCR  Antimitotic agents: decrease fibrosis  Mitomycin-C: 0.2mg/ml x 30 min  5-FU: 0.5mg/ml x 5 min
  30. 30. B. ORBITAL DECOMPRESSION  Finite capacity of orbit increased volume anterior displacement of orbital contents  Indication:  Graves ophthalmopathy  Retro-orbital hematoma  Orbital abscess  Pseudotumor  Orbital infiltration by Wegeners Granulomatosis  Foreign body  Neoplasia : Benign or malignant or metastatic deposits  Vascular causes
  31. 31. B. ORBITAL DECOMPRESSION  Approach:  Single Wall  Endoscopic  Combined  Transantral + Endoscopic:  3 walled decompression:  Lower lid swinging flap: Horizontal canthotomy & Inferior cantholysis  Removal of lateral wall  Removal of medial wall & floor of orbit
  32. 32. ENDOSCOPIC DECOMPRESSION THREE WALLEDDECOMPRESSION OF RIGHT EYE
  33. 33. C. OPTIC NERVE DECOMPRESSION  Indication:  Trauma: direct or indirect  Thyroid eye disease  Neoplastic compression of nerve eg Meningioma  Chronic inflammation + fibrosis  Wegener’s Granulomatosis  Radiation neuritis  Irreversible damage after 90 mins  Alternative treatment: steroids in high doses
  34. 34. C. OPTIC NERVE DECOMPRESSION  Approaches:  External:  Superior: external frontoethmoidectomy  Lateral  Medial: Extracranial Transnasal Endoscopic  Combined  Extracranial transnasal endoscopic  Ophthalmic artery may lie in inferomedial quadrant : 15%  Craniofacial approach  Decompression upto optic chiasma  Indication: More extensive or bilateral decompression
  35. 35. D. TRAUMA TO ORBIT  ETIOLOGY:  Part of Mid Facial Injury  Complication of ESS  I. Facial trauma involving orbit  Blow out # of orbital floor/ medial wall  Tripod #  Naso-Orbito-Ethmoid complex #  Mechanism of injury:
  36. 36. Clinical Features:  Blow out #:  Restriction of upward gaze  Infraorbital anesthesia  Tripod #  Flattening of orbital rim  Inferior displacement of lat canthus  Ecchymosis of buccal mucosa, trismus  NOE complex #:  Flattening of nasal root  Disruption of med canthus Telecanthus  Others:  Visual complaints, Epistaxis, CSF leak, Enophthalmos/ Exophthalmos  Malocclusion, Ecchymosis, Epiphora
  37. 37. Imaging  CT Facial bones (most useful)  ‘Tear Drop’ sign in blow out #  Plain Films of limited use  Demonstrate # in 70%  MRI if retinal, optic nerve, or intracranial concerns
  38. 38. Indications for Repair in Blow out #  Entrapment that causes an oculocardiac reflex with resultant bradycardia and cardiovascular instability  Relative enophthalmos greater than 2mm  Fracture that involves greater than 50% of the orbital floor (most of these will lead to significant enophthalmos when the edema resolves)  Diplopia that persists beyond 7 to 10 days  Obvious signs of entrapment  Progressive V2 numbness
  39. 39. Access:  Fronto-Zygomatic area:  Lateral brow incision  Lateral upper lid incision  Lateral rim:  Lower lid conjuctival incision + canthotomy  Orbital floor:  Transconjuctival incision +/- lateral canthotomy  Transcutaneous incision  Subciliary, Lower lid crease, Infraorbital
  40. 40.  Access to Floor #  Transantral  Transnasal endoscopic  Access to Medial wall #:  Lynch Howarth  Transcaruncular  Materials for repair  Autogenous bone/cartilage: Calvarial bone, iliac crest, rib, septal or auricular cartilage  Alloplastic: Gelfilm, polygalactin film, marlex mesh, teflon, prolene, polyethylene, hydroxyapatite, silastic sheet, titanium  Miniplates
  41. 41. Collapse of Anterior wall of maxilla or Orbital floor fracture  Endoscopic ballon catheter repair:  Wide MMA  Insert Foley and inflate  Leave in place for 7-10 days  Best for large trapdoor fractures without entrapment  Broad spectrum antibiotics
  42. 42. TRAUMA TO ORBIT  II. Iatrogenic Orbital Trauma:  Most commonly due to ESS  Risk factors:  Distorted anatomy  Anatomical variants: preop CT scan useful  Higher incidence with GA: No pain  Prevention:  Eyes uncovered  During uncinectomy sickle knife angled away from globe  ? Periosteum incised gentle pressure on globe  Prolapsed fat reposition + gelatin foam, avoid nose blowing x 14days  Tissues placed in NS
  43. 43.  II. Iatrogenic Orbital Trauma:  ESS:  MMA damage to NLDepiphora  Ethmoidectomy damage to AEA retro-orbital hemorrhage  Onidi cells damage to optic nerve(6% bone dehiscent) diminished vision  Caldwell Luc:  Damage to infra-orbital nerve  Lynch Howarth external ethmoidectomomy approach:  Damage to trochlea Superior oblique underaction  Patterson’s approach:  Damage to NLD  Detachment of Inferior oblique & Medial canthal ligament  NLD can also be damage in Lat Rhinotomy & Cranio-Facial resection
  44. 44. E. Neoplasia  Wide variety of benign & malignant neoplasia may spread to orbit from adjacent structures  +/- remove eyes psychological issues  Preservation of eye  Emotional decision  Should not jeopardize prognosis  Consider the functional capacity of eye  Complicated by combined radiotherapy cataract, retinal atrophy
  45. 45. I. Benign Tumors:  Angiofibroma:  Young males  Arise from sphenopalatine foramen  Presents in nose & nasopharynx as a vascular tumor  Spread PPF & ITF Infraorbital fissure & orbital apex compress optic n visual loss  MRI: Salt & pepper appearance  Treatment:  Preop embolization  Complete excision of tumor
  46. 46. I. Benign Tumors:  Inverted Papilloma:  Intermediate tumor arising in lateral wall of nose  Spreads extraperiosteally to orbit  Invasive consider associated SCC  Treatment :  Medial maxillectomy  Endoscopic resection  High recurrence rate Imaging follow up  Osteoma:  Arise in frontoethmoid region encroach orbit  Proptosis  Treatment if symptomatic  Craniotomy via coronal incision
  47. 47. II. Malignant Tumors:  Tumors of sinonasal regions can invade orbit  Invasion from ethmoids occurs early: Visual symptoms & epiphora  Routes:  Thin lamina payracea  Can spread extraperiosteally to orbital apex & MCF  Foramen  Perineural spread: Adenoid cystic CA  Meningioma involving sphenoid:  B/l optic canal compression
  48. 48. II. Malignant Tumors:  Orbital perisoteum is resistant to tumor spread  Once breached orbital contents cannot be salvaged  If orbital clearance required lids are preserved
  49. 49. II. Malignant Tumors:  Clinical features suggestive of orbital involvement:  Visual complaints  Diplopia  Proptosis  Unilateral epiphora  Features of cranial nerves involvement: ophthalmoplegia  Rounding of orbital margin
  50. 50. Investigations  Nasal endoscopy  Imaging:  CECT: coronal and axial images  Erosion and involvement of skull base  Critical areas: fovea, cribriform plate, posterior wall of maxillary sinus, optic foramen, medial orbit and sphenoid sinus  MRI with contrast:  Flow voids: Vascularity  Orbital invasion  Soft tissue extension in deep face, intracranial compartment
  51. 51. II. Malignant Tumors  Treatment options:  Palliative:  Painful blind eye with proptosis  orbital clearance  Orbital exentration  Tumors involving skin of medial canthus  Lateral orbitotomy  Extensive lesion of lateral portion of orbit  And or extending to Anterior Cranial Fossa  Removal of lateral rim: frontal + zygoma + supraorbital margin
  52. 52. Treatment options:  Maxillectomy  Total maxillectomy  Extended maxillectomy  Access to orbital apex  Medial Maxillectomy  Lateral rhinotomy incision +  Medial canthal ligament transected & tagged  Lacrimal Sac mobilized & Lacrimal duct transected  AEA & PEA identified &
  53. 53. Medial Maxillectomy  Osteotomy  1: vertically thro’ Ant margin of medial wall  2: horizontally along inferior aspect of medial maxillary sinus wall  3: thro’ medial wall of orbit just inferior to fronto-ethmoid suture  4: thro’ orbital floor medial to infra-orb canal  5: posteriorly thro’ posterior aspect of medial maxillary wall at Pterygomaxillary fissure Optic foramen Infra orbital canal & foramen 1 3 2 4
  54. 54. Total Maxillectomy:Incisions
  55. 55. Total Maxillectomy: Bony Cuts Inf Orbital Fissure Premaxilla and Anterior Alveolar Arch Preserved
  56. 56. Total Maxillectomy: Bony cuts Naso maxillary suture Pterygoid plates separated from post sinus wall Horizontal cut if back wall of sinus involved
  57. 57. II. Malignant Tumors  Rehabilitation:  Orbital prosthesis  Attached to spectacles  Adhesive glue  Osseointegrated titanium implants  If RT given : Prosthesis after 6 months
  58. 58. THANKYOU

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