\

Dr. Nikil Jain

Residual Deformity

Introduction For a variety of reasons, trauma patients can experience unsuccessful initial management and the associated morbidities of a post-traumatic craniofacial deformity (PTCD) that would benefit from secondary correction.

Experienced surgeons recognize the challenge of restoring premorbid form and function to patients with established deformities after craniofacial trauma

Soft tissue deformity Resulting from facial injuries

For repair that problem can classified :

1)Without tissue loss2)With tissue loss

In some cases there will some overlap and both kinds of problem will exist side by side

Without tissue lossScar

Scar excisions

Abrrasions

Scar Definition of scar: The trace of a healed wound , sore or burn. A fault or blemish remaining as a trace of some former condition or resulting from some particular cause. (oxford english dictionary)Scarsare areas of fibrous tissue (fibrosis) that replace normalskinafter injury. A scar results from the biological process ofwoundrepair in the skin and othertissuesof the body. Thus, scarring is a natural part of thehealingprocess. With the exception of very minorlesions, every wound (e.g. afteraccident,disease, orsurgery) results in some degree of scarring. An exception to this is animals withregeneration, which do not form scars and the tissue will grow back exactly as before

Characteristics Scar usually red immediately following wound healing considered an immature scar

It may become hard and nonpliable

May develop bands of fibres on or below the surface that feel like a cord or rubber band on pressure with finger

May be pain full ,itchy or sensitive

A contracture or tightness /shortening of the skin may developes as scar heals .this is especially characteristics of scars across joints and may limit joint RANGE OF MOTION(ROM),compromise function

The scar may become raised over the skin surface as body produces an abundance of collagen the substance found an abundance of collagen, the substance found in scar tissue.

This type of raise scar termed Hypertrophic scar which is thick ,rough and irregular

These scar produced in large and deeper wounds that require skin grafting and wounds that are delayed in healing

Hypertrophic scar that are considerably larger than the original wound known as Keloid

It is most common in individuals with dark skin

Scar typesImmature scar : A red, sometimes itchy or painful and slightly elevated scar in the process of remodeling. Many of these will mature normally over time and become flat and assume a pigmentation that is similar to surrounding skin, although they can be paler or slightly darker

Mature scar : a light colored , flat scar

3. Linear hypetrophic : (surgical or traumatic scar)- a red raised, sometimes itchy scar. Confined to the border of original surgical incision. This usually occurs within weeks after surgery. These scars may increase in size rapidly for 3 to 6 months and then after a static phase begin to regressThey mature to have an elevated, slightly rope like appearance with increased width which is variableThe full maturation process may take upto 2 years

Widespread hypertrophic : eg burn scarA wide spread, red, raised, sometimes itchy scarConfined to the border of burn injury

Minor keloid : a focally raised itchy scar extending over normal tissueThis may develop upto 1 yr after injury and does not regress on its own

Simple surgical excision is often followed by recurrence

There may be a genetic abnormality involved in keloid scarring

Typical site includes earlobes

Major keloid : a large raised (>0.5 cm) scar

Possibly painful or pruritic and extending over normal tissueThis often results after minor trauma and can continue to spread for years

Scar excisionIt must be made clear to the patient that it is quite impossible to remove a scar.

All that can be done is to replace the existing scar with a new one which is hoped to be of better quality

A broad scar can be reduced in width but should be supported with narrow adhesive tape (Steristrips) for several weeks to minimise stretching

Even then the scar is likely to broaden again in an unfavourable situation such as lower cheek where the constant movements of speech and mastication exert undesirable tension

Rearrangement of scar line A linear scar may fall naturally into an inconspicious situation such as the hairline or along a contour line such as junction of cheek with nose or ear

In more exposed situations a lengthy linear scar should be avoided as it may catch the eye as it crosses natural lines of expression or its contraction may cause deformity of features such as the eyelid or mouth

Scar revision : Face The most common technique for scar revision is fusiform excisionThe length of the elliptical shape is 3 to 4 times as long as it is wide to prevent dog earsShort, linear and minimally wide scars of the face generally do well with such revision

The classic Z plasty involves triangular transposition flaps to lengthen a contracted scar or to reorient a scar parallel to the resting skin tension lines

The limbs of Z must be of equal length

Increasing the angles between the limbs theoretically increases gain in length

The usual Z plasty angle is 60 degrees

Z plasty scar revision of the face following traumatic defects is indicated in treatment of :

Anti tension line scars of the eyelids, lips and nasolabial folds

Scars on the forehead, temples, nose, cheeks and chin, running at less than 35 degrees of inclination to the resting skin tension lines

Severe trapdoor and depressed scars, linear scars not amenable to simple excision and areas of multiple scarring

W plasties are often indicated for antitension line scars of the forehead, eyebrows, temples, nose, cheeks and chin

The running Y-V plasty has also been described to to help break up the direction of linear scars

With tissue lossMinor tissue loss

Substantial loss of tissue

Minor tissue lossFacial skin is the most suitable, both in colour and texture, for repairing defects which are not too extensiveLocal flaps are given first consideration where possibleSkin bordering the defect is raised and rotated into the defect, care should be taken to place the scar of the secondary defect in a favourable positionSplit skin grafts are not usually acceptable in the repair of small areas of facial skin loss, although necessary in replacing large areas of burn scarsFull thickness grafts can give a good cosmetic result

Substantial tissue lossGunshot wounds account for majority of injuries of this nature

There soft tissue loss and often associated skeletal damage

Flaps used for repairing outer wall of a cavity (antrum, orbit, mouth and nose) must have a provision of lining raw under surface which could lead to stenosis

A great degree of flexibility in case of cheek flap may be obtained by using a double flap. i.e.one where both the outer and inner aspects are composed of full thickness skin and subcutaneous tissue

By using flaps whose component parts have never been detached from the bloodstream, fibrosis can be reduced

With lip defects it is possible to lose up to one third of tissue with only a moderate secondary deformity following resuture

Palate :Substantial loss of tissue can be from hard palate, soft palate or both

The hard palate defects are preferably closed with an obturator

In case of soft palate additional tissue must be obtained from elsewhere

In larger defects a myofascial temporalis flap may be rotated downwards following resection of zygomatic arch and passed through a mucosal tunnel to enter the oral cavity (Bowerman 1983)

Bone graftsBone graft in maxillofacial surgery are used to correct or replace missing bone.Bone defect can be Consequence of congenital and developmental deformities Originate from tumour surgery, trauma or infection Bone graft in cosmetic surgery.

Types of graft Auto graft transplanted from one region to another in same individuals.Allograft (Homograft) is transplated from one individual to a genetically non identical individual of same species.Xenograft (Heteorgraft) transplant from one species to another species.]Isograft graft exchanged between genetically identical individual such as identical things.

Anatomical Classification of Bone graft 1.Cortical bone (as block, chip)2.Cancellous bone 3.Cortico cancellous bone4.Periosteal and osteoperiosteal graft5.Marrow graft 6.Segment of shaft of long bone such as clavicle, ribs, scapula or tibia.7. Whole bone graft8.Osteoarticular graft9.Pedicle bone graft 10.Free vascularized bone graft involving microvascular ananstomosis.

Clinical uses and function of bone graft Delayed and nonunion of fracture Filling of cavities in bone Replacement of bone and joint loss Augmentation of skeletal deficiency in the forehead, nose, maxilla and mandible. Fusion of growth graft cartilage Function of bone graft in mandible Restore normal continuity and function Restore an overall satisfactory appearance of face Furnishes a source of viable osteogenesis cells

Principles of Bone graft State of health and nutrition of patient Aseptic technique surgical techniques should be extra oral to prevent contamination of oral flora. Graft Bed - tissue scar from previous wound should be excises to ensure quality and quantity of recipient site.Handling of the graft graft must be handled carefully to prevent contamination and mechanical injury.

Storage media isotonic normal saline, tissue culture medium. Osteoprogenitor cells are hardly capable of withstanding the trauma of removal upto 4 hours. Fixation and immobilization of the graft

Wound Closure -Wound should be closed in layers without tension. Antibiotic Coverage

BIOLOGIC BASIS OF BONY GRAFT Most effective form of bone grafting is cancellous cellular bone. Mechanism of bone formation in a cancellous cellular bone emanate from survival of the osteoprogenitor cells (osteoblst & marrow cells).

Transplanted osteoprogenitor cells survive within the recipient tissue for first 3-4 days by a nutritional diffusion from the surrounding vascular tissue envelop.

From 3rd day capillary buds start proliferation from surrounding tissue. This establish oxygen gradient and acidosis, lactate in the graft signals macrophages to form macrophage derived angiogenesis factor.

Between 3rd and 14th day complete revascularization occur. Endosteal osteoblast survive transplant and proliferate neoosteoid upon the surface of the cancellous bone trabeculae.

Mineral component undergoes a gradual physiologic resorption mediated by osteoclast. Osteoclasts resorbs the bony trabeculae pattern, they release bone morphogenetic protein (BMP) from non-collagenase mineral matrix of bone.

BMP direct stem cells transferred within the graft, stem cell within the local tissue and circulatory stem cells to differentiate into functional bone forming cell.

Phase I Bone formation It arise from the survival endosteal osteoblast and marrow stem cells transferred within the graft material which form bone in a random haphazard fashion.Phase II Bone formation The revascularization dependent resorption of transplated bone trabeculae in the early phase I bone followed by remodeling and replacement with new bone. Phase II Bone begins about the third week after placement of graft. Via endosteum and periosteum of bone.

Importance of phase I bone arise from the knowledge that the maximum quantity of bone available to the graft is formed in this phase. The importance of phase II bone is remodeling of phase I bone to a long lasting bone capable of self renewal. Usually phase II bone replaces phase I bone in a one to one ratio.

Deformities Nasal Naso orbitalNaso frontalNaso - frontal ethmoidalZygomatic Maxilla Mandible

Anatomy of nose

Nasal Deformities (dorsum)In this group injury involves only nasal bridge and lateral walls of the nasal cavity

Pathogenesis : the fracture here involves 1) nasal bones (2)frontal process of maxilla (3) septal cartilage

A force directed from lateral aspect will result in a deviation of the nasal pyramid (bridge and lateral wall) to the opposite side

An impact directed in antero posterior plane will cause a depression of nasal bridge associated with crushing of supporting walls producing a posterior collapse of bony structures

It is essential to treat not only the aesthetically unacceptable external deformity but also the internal displacement which interferes with function

The repositioning of external nasal bony pyramid or porch must be accompanied by repositioning of cartilaginous and bony septum ( otherwise deviation of latter is liable to cause a relapse of the deformity , owing to its inherent elasticity or resilience)

Nasal deviationRequires the fragment to be freed and repositioned Intra nasal approach to avoid all external cutaneous scarSepration of bony and cartilaginious components of nasal skeleton from their investing soft tissueChondrotomy for the mobilization of septal cartilageOsteotomy to reduce the displacement of the nasal bridge and dorsumCareful immobilisation to maintain the fragments in position during the period of union

Surgical approachIt is intranasal Corresponds to classic incisions employed for aesthetic rhinoplastyIn each nasal vestibule the mucosa is incised at a point corresponding to the groove between the upper margin of the alar cartilage and lower margin of upper nasal or triangular cartilageIncision is carried from behind forwards and upwards across the roof of vestibule where it is reflected downwards, passing from before backwards along the lower border of the nasal septum

Dissection It consists of freeing or seperating the external investing tissues and elevating the mucous membrane which lines the nasal fossa

the liberation of underlying soft tissues is effected through the intra nasal incisions

Initially perichondrium is raised from triangular upper nasal cartilage

Then at the level of piriform aperture periosteum is incised to carry out subperiosteal dissection upto frontonasal angle

The mucosa is freed at the dihedral angle ( formed at junction of medial and lateral components )

Chondrotomies Performed at inferior and anterior margins of the cartilage and also in the region of folds resulting from buckling of the septumAlong the lower border the nasal septum is freed from the nasal crest of maxillae

It is more a matter of disimpaction rather than a true chondrotomy

2. At the anterior border chondrotomies are performed bilaterally seperating on each side the septal cartilage from the upper nasal cartilage .

Osteotomies These are performed laterally at the base of each side the nasal pyramid and medially on each side of nasal crest or bridge

Lateral osteotomies: a small incision made at the edge of piriform fossa, close to the floor of the nasal cavity, allows the soft tissues covering the frontal process of maxilla to be elevated from the bone

the osteotomy commences at the rim of the base of piriform aperture and terminates above just in front of anterior lacrimal crest

Median osteotomies: these separate the nasal bones from the osseous part of the nasal septum

Immobilisation Before suturing it is essential to the perfect alignment of nasal crest both in median sagittal plane and also with regard to the profile Immobilisation is ensured both externally and internally by means of a double procedureExternal device, of plaster of paris, holds the nasal crest as well as the lateral walls of the nose in a straight line in the median vertical plane to achieve perfect symmetryInternal device is an intranasal pack or stent which maintains the septum in a strictly midline position and ensures that the dimesnsions of nasal passages are identical

Depression of the nose Total depression

Depression of lower half of nasal crest

Total depressionWhen the deformity is due to depression of the dorsum of the nose along its entire length, it is simple, more rapid and more certain to insert a bone graft Best type of material is autogenous bone graft Procedure is divided into :Surgical approachPreparation of bony bedRemoval of graft from donor siteFixation

Surgical approaches:Intranasal route, the classic technique employed for rhinoplasty A vertical columella incision A combined incision shaped like yoke of an ox

Preparation of bony bed:The bone is freshened the upper half of depressed nasal crest in the region of bridge is levelledIt is done by use of a raspatory

Removing the bone graft:Opttimum donor site is iliac crestTriangular in cross sectionForming the future roof of the crestCortical on the anterior surface and cancellous on the undersurface or base

Fixation :It must be firm to maintain perfectly in the median plane, vertical and sagittal planes the position achieved following reconstructionIt is achieved by 3 factorsMortise and tenon joint aboveThe osteosynthesisThe support below

Mortise and tenon joint is assured by mortise slot or atleast by a transverse retentive groove in anteroposterior planeThe osteosynthesis is carried out by means of a nasal transfixion The support at the lower end is derived from the septum upon which the graft rests

Depression of lower half of nasal crest2 different concepts for correction of this particular deformity:

Resection of the upper half of nasal crest

in this way the width of the upper half of the crest increases and to correct this lateral osteotomy of lateral walls to bring the sectioned edges of nasal crest together

2. In selected cases a cartilage graft, taken at the expense of the septum, provides a simple solution to the problem to fix it: the easiest method is to pass a temporary cutaneous transfixation suture

Naso Orbital deformityExtreme severity of impact received by the nasal complex

To involve the frontal process of maxillae and the two orbital plates of ethmoid bone

Comparatively small area,complexity of its osseous structure,variety of displacements make impossible to classify

3 essential anatomical factor specific to and characterstic of frontal process:

1)They determine the morphology of base of nasal pyramid and orbito nasal angle

2)They form the anterior part of the lacrimal fossa

3)They provide a point of insertion for medial palpebral ligament in the region of anterior crest

Ethmoid bone participates in the formation of lacrimal canal on its lateral aspect

It is continued posteriorly as the orbital plate which forms the medial wall of the orbit

It contributes to the formation of posterior part of the nasal septum through the medium of its perpendicular plate

If untreated or inadequately treated NOE injury not only leads to residual deformity to nasal crest but equally to:

Orbito nasal angle

Dystophy to medial canthus

Alteration to continuity of lacrimal passage

Reduction in the patency of nasal airway

Clinical featuresNasal crest may be deviated or depressedThere will be either lateral displacement or an anteroposterior crusshing of nasal boneOrbital nasal angle reduced or obliteratedWidening of bridge of the nose either due to displacement of frontal process of maxilla outward and backwards or due to exuberant callus produced by malunionMedial canthus deviation Lacrimal passage may be torn Patency of nasal airway altered

Basic Principles for treatment:

The nasal porch or pyramid can not be effectively reconstituted if not supported on a solid bone

Reconstruction can not be aestheticaly acceptable if the revision of the base or foundation is not itself smooth,regular and well proportioned

Shape of nose can not be satisfactory if two medial canthi not lie in their exact position

Medial canthal ligament prevents surgical access to the lacrimal passage ,if an approach to these structures is necessary the insertion of ligament must be divided and subsequently reattached

An infection in region of lacrimal passage will have an adverse effect on healing and compromise the quality of repair,so appropriate prophylactic measures essential

Relatively small amount of tissue in the region of naso-orbital angle makes it very difficult to carry out a repeated number of operations without incurring the risk of beneficial effect of preceding interventions

How ever deviated a septum may be ,it may still provide a sound support for a nasal reconstruction

Reconstruction of nasal base and orbito nasal angleResection Comminuted fracture produces excess amount of callus which thickens and widens the nasal bridge and nasal base

Reduced by rotating bone file mounted in the handpiece of dental drill

Thin down the area to an acceptable contour

Maintain sufficient degree of solidity to support the nose and retain the ligatures used for canthoprexy

Osteotomy

Frontal process of maxillae displaced,but fracture is a single isolated fragment of adequate width,logical to consider repositional osteotomy

Taking care to avoid injury to nasal mucosa on internal aspect

After osteotomy necessary to to carry out osteosynthesis for fixation of fragments and to insert a bone graft into gap created by the reduction of displacement

Holes drilled for passage of wire should not weakens the strength of bone at opening for transnasal canthprexy

Take care that bone graft does not became a factor producing thikness of lateral nasal wall or medial part of inferior orbital margin

Bone graft callus associated with malunion at naso orbital angle is too thin to permit abrasion And existence of many multiple fragments makes it impossible to divide these by osteotomySo a complete resection of affected area should be carried out and then to reconstitute this immediately by means of bone graft

CanthopexyWhether it has been cut across, avulsed or displaced with the frontal process, the medial palpebral ligament must be reinserted or repositionedTechnique by Tessier et al 1962

Identification of ligamentIntroduce a small curved hemostat into the medial angle of conjunctival fornix

After having been located the ligament is transfixed with 2 stainless steel wires

Localisation of medial ligament has correctly achieved if traction exerted on wires draws the canthus in desired direction

This mobilisation requires liberation of periorbital tissues

Liberation of periorbital tissuesRequires subperiosteal dissection of lower and internal surface of orbit

Inferior oblique muscle will also be released from its bony margin during operation

This stage is complete when medial canthus can be mobilised easily

Further impediment to this mobilisation may occur as result of dense scar tissue in region of lacrimal passages

Liberation of lacrimal pathwaysLigament first should be seperated from lacrimal sac

Assistance may be derived from introduction of a fine lacrimal sound passed through the lacrimal canals

Free any adhesions of lacrimal pathways which are causing retraction of the tissues

Dissection must be pursued as far as nasolacrimal canal

Nasal transfixionThis may be achieved by a special awl using hand pressure or with a bur driven by an electric motor

The position and direction of holes are of cardinal importance for precise alignment of canthopexy

On the opposite lateral nasal wall the drill hole is made at level of anterior lacrimal crest and in front of ligamentous insertion when not involved in injury

When the medial canthopexy is bilateral, after their transnasal passage, twist each of the canthopexy wires wih those of the other side over the nasal crest

Reconstitution of lacrimal passagesThis procedure should be carried out at the same time as canthopexy because reinsertion of ligaments block further access posteriorly

If the sac although obstructed remains intact, the method of ensuring the drainage of lacrimal fluid is by means of a dacryocystorhinostomy

If this is not the case, it will be necessary to perform a conjunctivorhinostomy

Surgical approachesTo carry out these surgical procedures it is necessary to achieve a wide exposure of the lesion

Different routes: Original facial scars

Lateral nasal incisions

A frontal scalp flap

Original facial scar

Their extent and location may provide adequate exposure

Used when scars are hypertrophic and unsightly

Also used when scar excision is to be performed where fibrous tissue contracture restricts mobilisation of either the medial or lateral canthus

Lateral nasal incisionPlaced vertically in the naso orbito angle and may be extended as required by an incision beneath the lower rim of the orbit

An incision which is limited to the naso orbital angle is adequate for an approach to contralateral aspect when this is required for unilateral canthopexy

Should be supplemented by a columella incision for introduction and fixtion of a nasal bone graft

Bicoronal incisionThe frontal scalp is raised by making a transverse or coronal incision behind the hairline and extending this laterally just in fron of tragus on both sides

The dissection is carried downwards and forwards in the plane immediately superficial to pericranium

Operative sequenceReconstruction of the bony base of the nose is the initial procedure upon which all steps will be basedCanthopexy may then be undertaken, but it will not be complete till the time wires are twisted togetherRepair of lacrimal passages is undertaken before the canthopexy is complete by twisting of wiresRestoration of nasal crest may then be effectedFinal tightening of the wires used in bilateral canthopexySuturing followed by application of cotton wool rolls or pledgets in the region of each orbito nasal angle held in position by a transnasal loop or suture and followed by application of an external plaster of paris

Naso-frontal deformityDeformity not confined to the pyramid region but also involves its base,or area of implantation into frontal bone, thus altering the shape, both from a frontal and lateral aspect, of naso frontal angle

Pathogenesis :When the frontal reegion, in the median and paranasal portion inferiorly is involved in injury, the secondary malunited callus formed in this locationdeforms the profile at naso frontal angle

Lesions of anterior wallIt gives rise to a hollow in the midline Taken in isolation without any involvement of other walls of sinus, this injury is of cosmetic importance only

Lesions of inferior wall or floorOccuring in midline such injuries involve nasal spineA depression in this area will alter frontonasal angle and may affect patency of fronto nasal ductIt can also involve the medial portion of roof of orbit and may give rise to alteration of naso orbital angle

Lesions of posterior wallAn injury into this area endangers brain and meninges

Persistent unhealed fissure following such fracture may allow infection to reach meninges from the sinus

It may also cause herniation of brain and meninges

Sharp bone fragment may penetrate the meninges and give rise to a CSF rhinorhoea

Treatment A simple onlay graft may be sufficient to fill up the defect arising from depression of nasal crest or anterior wall of frontal sinus

Grossly dis organised sinus must be treated in its entirety and concurrently with nasal reconstruction

The following procedures are considered:1. Fronto nasal graft2. Repair of frontal sinus

Fronto Nasal graftOnly indicated in the lesion confined to the nasal crest or bridge and the anterior wall of frontal sinus, without any obstruction to patency of naso frontal canal

The material of choice is iliac crest

The best contour will be obtained by placing the cortical aspect of graft towards the anterior or subcutaneous surface

Secure the graft in position by means of pressure exerted by the overlying tissues and support obtained by applying a plaster of paris splint over the area

Repair of frontal sinusDepression of anterior wall and floorObliteration is effected by filling up the cavityThe procedure consists of:A bitemporal coronal incision and turning downward of scalp flapResection of malunited callus on anterior wall

Careful removal of all mucous membrane

Examination of posterior wall for its integrity

5. The inversion, like a pouch, of the nasal mucosa into the naso frontal canal

6. Total blockage of naso frontal canal by forcibly impacting a wedge or plug of cancellous bone above the invaginated nasal mucosa

7. Filling in every portion of the extensive frontal sinus

8. Covering the area with a corticocancellous bone graft secured firmly to the margins of defect by transosseous wires

Depression of posterior wallThe obliteration of sinus in this case is effected by cranialisation.Technique 1. A transfrontal approach by means of an osteoplastic flap 2. Resection of entire posterior wall

3. Removal of all traces of mucous membranes

4. Careful invagination of nasal mucosa into the drainage canals

5. Obstructing and blocking of these canals by wedges of cancellous bone

6. Reinforcing the strength of anterior wall by joining together a double layer of bone graft

7. Finally complete isolation of cranium from facial skeleton is increased by placing layers or lamellae of cancellous bone along the floor of the sinus and filling up all crevices with bone powder derived from the discs of bone left over from the original trephining of the skull

Naso-fronto-ethmoidal injuryWhen an even greater degree of force strikes the central bony mass,the shock wave will be transmitted as far as the cribriform plate of ethmoid bone which forms its upper wall or roof in posterior part

Pathogenesis

Fracure lines pass in front to behind across the nasal spine,floor of the sinus and extend into the cribriform plate

Associated displacement of fragments involves the section through which the filaments of olfactory nerve pass and gives rise to a laceration of dura mater which produces an escape of cerebrospinal fluid or CSF rhinorrhoea

Clinical featuresThe extension of injury into the region of the cribriform plate does not further increase the degree of deformity

There is an associated anosmia and CSF rhinorrhoea if the tear in the meninges does not become spontaneously sealed off

Even though the leak dries up, the patient remains under the threat of a long term risk because of poor quality of scar tissue and the permeability of the malunited callus

Treatment There is tear in dura and nasal deformity

Combining neurosurgery and omfs team in same operation for repair of dura mater and complete isolation of nasal and cranial cavities from one another.

Transfrontal approach

Also knowns as open sky technique

Safer and providing great access

Neurosurgical operationTransfrontal approach and osteoplastic flap to provide access to adhesions of dura mater to the floor of anterior fossaCarefully and meticulously dissection Pattern and distribution of fracture examinedSuture of the tears in duraReinforcement of sutured dura with an extensive lining,The graft being taken from epicranial aponeurosis or if area too great ,from dermis

Resection of crista galli with associated displaced fragmentsTake care not to dammage nasal mucosaAny torn fragments of nasal mucosa turned downwards or inverted or coagulatedLamellae or layers of cortical bone from illiac to fill up gaps in anterior fossa and act as a re-inforcement Hemetic seal is further enhanced by fillin up spaces between graft used

Thank you

Fracture of the zygomatic complexBoth facial deformity and malfunction of eye can result from malunited zygomatic complex fracture

After 10 weeks of injury a fractured zygomatic complex is called as a old fracture

Slightly different technique to repair

Symptoms and clinical findingsIn case of trauma to zygomatic complex bone may be:Broken or dislocatedSoft tissue torn ,squeezed,strangulated ,incarceratedClinical sign and symptoms Facial assymetryDislocation of eyeballDiplopiaParesthesia of infraorbital nerveLimitation of mandibular movements

Radiographs Occipito mental waters view for fronto-zygomatic-suture inferior orbital rim maxillary sinus

PA view to study orbital rim and floor

Submentovertex or jug handle view

Tomograms to examine orbital floor space btween the coronoid process and zygomatic arch

Indications for surgical treatmentAestheticaly unacceptable bony steps or obvious asymmetries of orbital rims and pathological diffrences between the two malar prominences of more than 5 mm

Diplopia not caused by pure or muscular damage with or without downward displacement of eyeball by more than 3 mm due to displacement of orbital floor .

Treat enopthalamos when it is found in combination either with a downward displacement of orbital floor or with ptosis

Paresthesia of infraorbital nerve which has persisted for more than 12 months after surgical reposition of bony fragments

A depressed zygomatic arch which has radiologically been proven to be bony obstacle to free mandibular excursions

Therapeutic MeasuresThe surgeon has to choose from among the following procedures:Minor operative corrections like removing obvious bony steps or freeing the infraorbital nerve from small stangulating bone fragments

2) osteotomy and reposition of malunited fragnments

3) Camouflage surgery by means of onlays and inlays.

From among the following approaches one is selected depending on the prevailing situation and advantage offered1)Bicoronal2)Peri-orbital3)Oral4)Through old facial scars

Removal Or Reposition of malunited fragmentsIf intercuspation and occlusion appear to be unaltered by the trauma , if no abnormal ophthalmological findings can be detected and the overall symmetry and harmony of face is undisturbed , no major osteotomy is indicated

If a visible bony step at the orbital rim is present it should be removed surgically through an lower eyelid incision

Orbital floor is explored subsequently so as not to overlook any undiagnosed adhesions

If persistent paraesthesia is present , infra orbital foramen is widened to free the nerve

It can be done through intra oral approach

If a depressed zygomatic arch hindering the coronoids free excursion is the finding it can be approached by a bicoronal or a curvilinear pre-auricular and/or lateral eyebrow incision

Refracture , reposition and fixation are therapy of choice

It is advised to glue a cellulose gauze roll , 3 cm in diameter and 10 cm long , on to the skin of cheek above as well as below the arch.

This dressing discourages the patient from lying on the operated side of face

A completely dislocated zygoma with a depressed malar prominence , a caudally displaced eyeball and diplopia should be treated by osteotomy

The zygomatic complex is detached at F-Z suture , at inferior orbital margin , inferior and lateral orbital walls and at zygomatic arch

The orbital floor is covered with a sheet of lypophilised dura or PDS foil

Special miniplates have been developed to stabilize the zygomatic bone If antral pack is used , a gauze bandage soaked in furacin solution is preferred(this supports both the malar bone and orbital floor)

Inlays and onlaysIf the only pathological finding in a patient is either a downward displacement of the globe or asymmetry of the malar prominences, contour restoration with implants is preferred

Today a great variety of materials is being used as implant material by surgeons all over the world: autologous, homologous and heterologous bone, cartilage and duramater; ceramic, plastic and metallic substances

Depending on the size of the graft, this is placed on zygoma using infraorbital or an intra oral approach

No specific fixation is necessary if the soft tissue pocket into which the transplant is placed not too large

If the downward displacement of the orbital floor is to be corrected the following schedule is recommended:

1. Minor differences in the level of globes can be compensated by two or three layers of lyophilised dura

2. Downward displacement by up to 5 mm can be corrected, in the first instance, by either a lyophilised or an autologous cartilage chip of equivalent thickness

3. However major displacement by more than 5mm is best corrected in two stages

In the first operation an alloplastic implant is brought in and its size, shape and location are tested postoperatively

If the result is acceptable, it is replaced by an autologous or a lyophilised cartilage graft 3 months later

During this second operation minor improvements can also be carried out

Residual Maxillary deformitiesUntreated dislocated fractures of maxilla and mid face complex can be regarded as old 2-3 weeks after trauma

After this period rapid inter fragmentary cicatrisation and the formation of callus normally make it impossible to repostion

Planning of corrective therapyDetailed assessment of complete dentition ,vitality,apical and periodontal conditions

Lateral cephalogram and analysis. It is important soft tissue clearly visible in ceph .It permits assessment of vertical relationship

Photographs

Models and model operations

Therapeutic possibilities of treatment1.Gradual repositioning of maxilla and mid-face complex-

Fixation had already doneMobilisation method to produce slow non surgical reposiotioning viaIntermaxillary elastics tractionElastic traction using the wassmund method (1938)Roll extension with tractionOrthopaedic apparatusElastic traction or buccally placed wires attached by a system of rod to a plaster of paris headcap or head frame

Immidiate repostioning of maxilla and mid-face complex:

Closed active mobilisation

Open operative mobilisation

Closed active mobilisation

Indicated only for malpostioned maxilla with cicatrical fixation

Using first 2-5 weeks after the accident

Ruttelung procedure consist of totally mobilising the maxilla with special instrument under GA3-4 weeks of IMF

In Principle the same treatment as for fresh maxillary fractures with impacting and telescoping of mid face fractures

Open immediate mobilisation :

Applied in case where total mobilisation impossible

Mostly used in cases in which the mid facial fractures were only treated 6 weeks or more after trauma or perhaps year later and in which consolidation has taken place

In order to prevent damage to the roots of teeth,osteotomy carried out not exactly along the path of previous fracture

Adequate blood supply to palatal area verified with doppler

3. Old fractures of alveolar process segments:Cases with residual deformities after fractures of segments of the upper alveolar process occur rarely

In the region of anterior maxilla the operating procedure used are those described by Wassmund (1935) and Wunderer (1962) in cases of protrusion of anterior maxilla

The Wunderer method is dependent on labial blood supply to the alveolus, so there should be no scar present in the maxillary vestibule

Dislocation of lateral maxillary alveolar process are corrected as recommended by Schuchardt 1955

Old le fort I and II fracturesIn residual deformity resulting from untreated le Fort I fractures osteotomy should be carried out so that wire sutures or mini plates are located on both sides of osteotomy in stable regions of bone

Osteotomy line does not follow the fracture line

The approach in most cases being horizontally through the lateral and the anterior maxillary sinus walls

For old le fort II fractures same type of osteotomy is carried out provided dislocation in the nasal bones is minor

If bridge of nose is sunk and midface shortened , le fort II osteotomy is carried out

The vertical dimension of midface is restored by forward and downward displacement of osteotomised midface

Bone grafts are introduced in region of bridge of nose , below the buttress and between the pterygoids and the tuberosity of maxilla.

Old Le fort III FracturesWhere the entire midface region including the inferior orbital margins and the zygoma are dislocated a Le Fort III osteotomy is indicated

If only half of the face is affected unilateral le Fort III osteotomy and refracture in the region of alveolar process carried out

In cases of midface comminuted fractures it is neccesary to carry out a Le Fort I osteotomy in addition to Le Fort III osteotomy for treatment of craniofacial malformation

Post Traumatic HypertelorismFractures involving dislocation of one or both orbits can be treated in the same way as congenital hypertelorism

Transcranial access is necessary

Residual deformity of MandibleDeformity in the ascending ramus

Deformity of angle and body

Deformity of larger defects of ascending ramus and body of mandible

Deformity in the ascending ramusProviding that occlusion is satisfactory, defects in this region produce minimal deformities and may not need any treatment

An exception to this is destruction of developing mandibular condyle

Destruction of articular cartilaginous disc allows the bony fragments of ascending ramus and glenoid fossa to come into direct contact

This may lead to ankylosis

Ankylosis

Apart from this pseudoankylosis should be identified as a separate pathological state. It affects joint mobility indirectly by mechanical interference

Early surgical intervention should be done along with aggressive physiotheraupyProduces marked cosmetic deformityCan cause obstruction to airway

Deformity of Angle and BodyFracture in angle region are frequently associated with a fracture on contralateral side (usually in canine region)

In such injuries if more anteriorly placed fracture is incorrectly positioned and a malunion develops, this will be reflected in an angulation in the region of angle of mandible

Non union at this site develops if medial pterygoid becomes interposed b/w fractured fragments

Defects present in this region can be restored by blocks of bone from ilium, angle of rib or by cancellous bone chips

According to Mowlem 1945, cancellous bone chips are rapidly vascularised and stabilised in this site

Malunion and Non unionDeviation from normal course of healing may lead to delayed union, malunion or non union which requires surgical correction

Failure to reduce displaced fracture leads to disturbed occlusion with corresponding impairment of masticatory efficiency and at times pain on occluding the teeth (either in tooth bearing area or TMJ region)

Excessive seperation between bone ends will also lead to non union or fibrous union

As a guiding rule seperation of more than 1.5 cm will not readily unite without introduction of a bone graft

In gunshot wounds of mandible, the remaining fragments must be placed in their correct relationship with upper jaw and a bone graft used to bridge the gap

When the gap is present in tooth bearing segment then slight forward movement of edentulous posterior fragment is permissible

If malunion in edentulous is such that fitting of dentures becomes impossible then surgical intervention is imperative

In the elderly edentulous mandible, particularly when bilateral fractures have occurred at parasymphysis region, suprahyoid musculature causes the anterior segment to rotate (as if it were the handle of bucket)

The proximal fragment under the inflence of pterygomassetric sling rotates in opposite direction

In such cases even gunning splint is not effective

Malunion resulting from this may make the fitting of denture insatisfactory because of lack of space b/w maxillary tuberosity and malpositioned fragment

Bloomquist 1982 advocates the use of a body sagittal osteotomy in management of such casesAdvantages are:Osteotomy is performed at original site of fractureA relatively good area of bone contact exists allowing freedom in movement of fragmentsThe plane of sagittal cut allows rotation of both fragments in a manner that will restore a normal functional positionDirect bone wiring or lag screw fixation of fragments coupled with intermaxillary splint fixation is advocated

In dentate cases, the same degree of rotation of anterior segment is unlikely

Exposure of mandible at lower border and approximation of bone ends accurately may produce occlusal discrepancy and vice versa

Equal attention should be given to occlusal surface of teeth and inferior border of mandible

A preoperative evaluation is necessary and based on this evaluation decision is made as to whether use of cap splints will facilitate correct alignment of occlusion

Rconstruction of larger defects of the ascending Ramus and Body of the mandibleGunshot wounds account for the majority of injuries where both soft tissue and bone has to be restored

If the periosteum in children, it retains remarkable osteogenic properties and in absence of any graft, large areas of mandible may regenerate spontaneously

Where bone is transplanted it acts as a scaffold for subsequent in growth of new bone

In large grafts the objective is to find an adequate source of bone which is going to induce osteogenesis without itself being resorbed or lost before this process is complete

For osteogenic purposes, cancellous bone, with its large endosteal surface area and rapid ability with which it can be invaded by blood vessels, is vastly superior to cortical bone

The ilium is ideal source of such large quantities of cancellous boneIn cases where a particularly strong piece of bone is required or where the ilium is unduly thin, the entire thickness of iliac crest can be used

In the event of larger defects in the mandible requiring reconstruction, various other alternatives have been advocated:Metallic implantsTemporary metallic implantsAn immediate extensive bone graftBone grafts associated with a vascular pedicleFree transfer of osteomyocutaneous grafts and microvascular anastomosis

Metallic ImplantsA permanent metallic implant may provide a satisfactory replacement because of simplicity with which they may be inserted

Disadvantages They are purpose made for specific patients, involving a two stage operative procedure

Incompatible with body tissues

In 1969, Bowerman and Conroy introduced a jaw replacement kit in titanium- which is both malleable and readily acceptable to body tissues

The selected unit is bolted to the lingual aspect of the mandible on either side of the defect, producing a rigid mandible

It also provides positive immobilisation of fragments without the need of Intermaxillary fixation

Temporary Metallic implantsThese may be used in one of 2 ways :If inserted initially they may be replaced subsequently by a bone graft

In this way many of previously mentioned benefits of prosthesis may be exploited and their disadvantages avoided

Spiessl 1980 advocates a second approach in which mandibular bone ends are secured by means of a 3 dimensionally bendable defect bridging plate

A minimum of 4 screws are inserted in each segment to ensure rigid fixation

Utilising a cancellous bone press, the body of mandible can be moulded, with the aid of suitable tools, in 3 separate segments

Resultant pressed body will fit accurately into the defect

Immediate extensive Bone GraftingWhen extensive bone grafting is required in excess of the size previously described the operative procedure is prolonged as is the period of immobilisation of the jaw

Restoration in the mental region is essential but difficult

Various techniques have been described using rib which may be notched on its inner aspect to enable it to be bent round to a more acute curve

Periosteum is retained on the outer aspect to increase the strength of this rather weak graft(Gillies & Millard)

If rib happens to fracture, advantages of a one piece graft are lostSplit rib grafts may be used since they can be more readily curved to conform to a desired shape and subsequently wired together to restore their strength

In either case, a careful apposition of the graft to the lingual aspect of mandible and fixation by transosseous wiring is important for establishment of bony union

Ilium is an optimum site for a graft and a suitable U shaped piece can be cut from tubercle region.

The only disadvantage of this graft is that its limbs are relatively short and it may be necessary to join 3 pieces of bone together in order to obtain a graft of adequate size

Fixation can be achieved by external pins secured where necessary to supraorbital pins, a Levant frame or a halo.

Now a days direct bone plating is used for fixation

Bone grafts associated with a vascular pedicleDepending on how extensive the defect of the overlying tissues are, grafts may include bone, muscle and overlying skin

These are achieved by vascularised regional flaps

Where bone is predominantly involved, possible donor sites are rib or the clavicle

Where more soft tissue is required, greater use may be made of pectoralis major myocutaneous flap, including a segment of underlying attached rib

Conley 1972 discussed the use of compound myoosseous flaps for mandibular reconstruction

Siemssen et al 1978 first described the use of sternocleidomastoid clavicular myoosseous flap in the reconstruction of mandibular defects resulting from trauma

The vascular supply is derived from thyrocervical trunk which serves the inferior third of the muscle, the middle third by branches superior thyroid artery and superior third by branches from posterior auricular artery

The medial portion of the clavicle can be taken as a whole or part in continuity with SCM to form a pedicled graft

In extensive injuries requiring grafts involving skin, it is possible to gain bone from underlying 5th or 6th ribs in association with a pectoralis major musculocutaneous flap, utilising only the pectoral portion of the muscle, based on its supply from thoracoacromial artery

Such flap provides soft tissue which can be used to line a defect of oral cavity as well as provides suitable skin colout

Free osteomyocutaneous grafts and microvascular anastomosisWith the development of microvascular surgical techniques it has become feasible to transfer larger portions of bone and soft tissue in a single procedure in order to reconstruct extensive defects

The advantage of free bone grafts supported by microvascular anastomoses are that the immediate re establishment of an intact blood supply to the graft results in no loss of the osteogenic potential of the donor bone

ILIAC GRAFT Ilium is major source of graft for maxilllofacial reconstruction.Anatomy of Iliac Medially -iliac muscle, ceacum, ascending colon Laterally -Abductor muscle of hip (gluteas muscle)Nerves -Lateral Femoral nerve innervate lateral thigh.Subcostal nerve over anterior iliac spineIliohypogastric nerve over iliac tubercle

Approach to Iliac crust Lateral approach stripping tensor fascia lata and gluteas medius Medial approach stripping iliac muscle Crystal approach splitting or removing proportion of iliac crestDisadvantages of Lateral Approach Dissection of tensor fascia lata muscle laterally create gait disturbance. Difficult to the strip muscle from the lateral aspect of ilium Failure to appose the muscle to the ilium can results in gait disturbance. In extreme situation dragging limp or gluteal gait occur

Disadvantages of Crestal Approach In long term will usually result in irregularity of crest - below the age of 20.Disadvantages of Medial Approach It is associated with greater risk of damage to lateral fermoral cutaneous nerve of thigh. Meralgia paraesthesia in the upper lateral thigh. Increased incidence of post operative ileus. Increase post operative pain from disruption of abdominal wall musculature

Surgical Approach Guideline to length of incision is depend on the maximum width of bone to be harvested.Types of Incision Lateral incision Medial incision Lateral Incision Approach Incision is less likely visible than medial incision Incision are made lateral to crest to avoid lateral fermoral nerve, 1cm posterior to anterior ilia spine to avoid subcostal nerve, extend upto 2cm posterior iliac tubercle.

Incision carried down through skin, subcutaneous fact, scarpas fascia to the muscular aponeurosis. Iliac bone is approach 1cm below the crest in young. (Where the crest is cartilaginous and growth is expected) and 5mm below in adult.VARIOUS APPROACH TO PARTICULATE CANCELLOUS BONE MARROW Clamshell approach expand medial and lateral cortex to gain access to cancellous bone. Trap door approach pedicle the medial or lateral cortex on muscle to gain access.

Tschopp approach pedicle the iliac crest on the external oblique muscle to gain access. Tessier approach pedicle the medial and lateral portion of the crest by mean of oblique osteotomy.TREPHINE TECHNIQUE Incision is 2cm in length No medial lateral stripping and incision carried down to iliac crest. Trephine is used to perforate iliac crest and cancellous bone is harvested upto depth of 3cm using a rotatary action. Trephine is angulated 30 to vertical proceed between medial and lateral cortex.

Approach to posterior Iliac Bone Posterior approach is used when a greater quantity of particulate bone is required.Advantage More cancellous bone is available approx. 2 to 2.5times the quantity taken from anterior iliac. Less bleeding, less gait pain and disturbance Disadvantage Overall operative time increased Nerve damage (cluneal nerve)

Approach Incision is made at well defined bone prominence laterally, where gluteaus maximumus inserts. Curvilinear incision course medially about 3cm lateral to midline ending at length of about 10cm. Direct approach avoid damage to superior cluneal and middle cluneal ner

ILIAC GRAFT FOR MANDIBULAR RECONSTRUCTION

Iliac crest to form the lower border of the mandible Anterior superior iliac spine angle of the mandible Anterior inferior iliac spine - condyle Ipsilateral iliac crest is harvested pedicle emerges from the newly constructed angle to recipient vessels in the same side of the neck. Contralateral crest pedicle is positioned anteriorly and is positioned for vessel in apposide of the neck.

Complication Hernia formation is 12% in osteocutaneous flap and 4% pure osseous flap.Advantages Iliac provides 6-16cm graft in length which allows three dimensional carving the shape of hemimandible.Disadvantage Iliac crest is not ideal for angle to angle defect Intra oral defect is not handle well by the bulk is skin paddle Color match of iliac skin to fascia skin is poor

FIBULA GRAFT First reported by Ueba and Fujikawa in Japan and OBrien & Morrison in Melbourne in 1977. Hidalgo was the first to describe fibula transplantation for reconstruction of the mandible.Surgical Anatomy Fibula head articulated with tibia 2cm below the knee joint. A fibula is 40cm long bone this provide upto 26cm for transplantation. Peroneal nerve run around the fibula head. Damage to the peroneal nerve are avoided by leaving 8cm of cranial fibula and angle joint by leaving 8cm of distal end.

Anterior to fibula extensor hallucis longus muscle and extensor digitorium longus muscle. Laterally -Peroneus longus and peroneus brevis muscle. Dorsally -Soleus muscle and centrally flexor hallucis Distally -Peroneus brevis muscle Vascular supply Fibula is supply by peroneal artery It is a branch of posterior tibial artery and it run dorsal to intraosseous membrane and medial to fibula between tibialis posterior muscle and flexor hallucis longus muscles.

Anterior crural septum between peroneus and extensor lodge Posterior crural septum peroneus and flexor lodgeIncision Fibula is situated at the point of attachment of triceps fermoralis tendon. Straight line connecting the fibula head and lateral malleolar mark the posterior crural septum.

Fibula is accessed by dissection on the front or rear surface of the posterior crural septum.

Detachment of anterior crural septum is followed by detachment of extensor digitorium longus and extensor hallucis longus as far as intraosseous band. Peroneal artery is ligated and is dissected with the bone in lateral dorsal direction.Advantage Constant topography Long bone High stability

Disadvantage Short vascular pedicle Low height of bone Low height of recipient site for endosteal implant Complication Damaged peroneal nerve will result in foot drop, loss of arches of the foot. Flaccid foot

Radial forearm flap - Chinese flap Flap originate in China, it was used to cover burn surface. It was introduces to Western country by Muhlbauer Indication Mandible Anterior wall of maxillary (orbital rim and floor are maintain) Palatal defect Anatomy Flap depends on ascending vascular radicals from radial artery to the over line fascia and skin and descending branch to the underlying periosteum of the radius. Venous superficial cutaneous vein and comitants accompanying the radial artery. Radial osteocutaneous flap provide upto 16cm.

Advantages It is ideal for elderly patient with an edentulous mandible with vertical height of 13 cm. Disadvantages Inadequate bone for mandibular reconstruction Two weak to withstand normal masticatory force. Limbs is immobilized for 8 weeks Incision on forearm hypertrophy and unsighty.

References Rowe and Williams Maxillofacial Injuries 2nd edition

Textbook of Oral and Maxillofacial surgery by Peterwardbooth

Facial Plastic, Reconstructive and Trauma surgery by Dolan

Thank you