noe part 2 abhijit joshi (nxpowerlite) / orthodontic courses by indian dental academy

Abhijit joshi

NOE II INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

Abhijit joshi

Management of NOE #:

• Better over treated then undertreated.

• Why over treat? – Inadequate treatment secondary deformities.

difficult to treat- Soft tissue scarring- Malposition- Missing or displaced bone fragments.


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Secondary deformities


Abhijit joshi

Goals of management:

• Management of CSF leaks.• Management of damage to Nasolacrimal drainage

system dacrocystorhinostomy• Restore the ideal nasofrontal angle 115° to 130° • Restore the ideal nasal project 1:1. • Restore ideal intercanthal distance

Ideal proportions

The ideal nasofrontal angle 115° to 130° The ideal nasal project 1:1.

ideal intercanthal distance should be approximately 1/3. www.indiandentalacademy.com

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Pre op

Post op


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DCR – Dacrocystorhinostomy

Management of injured lacrimal drainage system


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.


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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

Incision of lacrimal sac. Osteotomy, made with a round bur, through which the polymeric silicone tubes are placed.

View of the polymeric silicone tubes exiting through the nasal mucosa into the nose.

The lacrimal sac flap is shown being held in the forceps over the polymeric silicone tubing that exits

into the nasal cavity.

DCR


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.


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I. Exposure


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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.• Vertical/horizontal radix incision.• Open sky approach-H shape incision.• W shape incision.• Lynch incision.• Transcaruncular incision.• Pre caruncular incision.• Transoral degloving incision.• Midfacial degloving incision great access / no scar

Skin incisions :

-Visible Scar

-Scar contracture and webbing

- No external scars

- ? access


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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


Abhijit joshi

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

Coronal flap


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Periosteal incision

Subperiosteal plane

Subgaleal/supraperiosteal plane

Coronal flap


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• 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 artery identified while dissection of medial wall.

Coronal flap


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• Avoid stripping of MCL

•Anterior lacrimal crest identified.

•Usually the strong anterior limb of MCL sits just below the lacrimal crest.

•Lacrimal fossa also identified.

Coronal flap


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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.www.indiandentalacademy.com

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

• 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.

W-shaped incision


Abhijit joshi

W shaped incisionAdvantages:• 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

Incisions utilized:

- Transoral degloving from 2nd molar

- Intercartilaginous incision

- Transfixion incision

- Sill incision to connect nasal and oral incisions

A. Baumann, Int. J. Oral Maxillofac. Surg. 2001


Abhijit joshi

(anterior of the nasal septum)

between the upper and lower lateral cartilage

Intra-oral degloving incision

Midfacial degloving incision


Abhijit joshi

Procedure : • 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 a nasal sill incision.

• Midface can now be degloved.

Orbital rim

Rib graft at glabella


Abhijit joshi

Midfacial degloving incisionAdvantages:

• 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.


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Converse and Smith

Dingman ‘60

Strene ‘70

Bowermann ‘75

Horizontal radix Seagul approach


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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.www.indiandentalacademy.com

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II. Identify MCL – capturing/tagging MCL


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• 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 encircles and secures the tendon MCL thus tagged.

II. Identify MCL – capturing/tagging MCL


Abhijit joshi

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

• Translatory movement essentially 2D restricted by wires as well as plates.

3 translatory movements 3 rotational movements

Along X,Y,Z axes


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 joshiwww.indiandentalacademy.com

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


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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.


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• Imperative to drill one hole posterior to lacrimal fossa to prevent lateral splaying posteriorly and telecanthus.

•Other wire passed superior and posterior to lacrimal fossa on other side.

•Wires tightened as much as possible to “overreduce” and narrow the base to gain the projection.

coronal section : horizontal mattress

Proper placement of transnasal wires posteriorly

Improper placement with lateral splaying : wire placed too anteriorly.

Transnasal wiring for type II and III


Abhijit joshi

IV.Reconstruction of medial orbital wall:


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• Importance :

– to regain anatomic morphology.

– To regain lost orbital volume in blow out #

– To achieve normal eye position after injury.



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• 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



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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.

• www.indiandentalacademy.com

Abhijit joshi

Transnasal canthopexy – fundamental principles..

High to low vectorLocation of holes


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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,


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• 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.



Abhijit joshi

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


Abhijit joshi

?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.www.indiandentalacademy.com

Abhijit joshi

• 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.

A NEW METHOD FOR TRANSNASAL CANTHOPEXY AND FRACTURE FIXATION

Özyazgan Volume 114(5), Plast and Recon surgery October 2004, pp 1338-1339


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• 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.


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• 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 screwwww.indiandentalacademy.com

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• 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.


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• 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..www.indiandentalacademy.com

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 three-dimensional 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 thedrilled hole using the provided introducer system and a

malletwww.indiandentalacademy.com

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).www.indiandentalacademy.com

Abhijit joshi

Reduce septal fractures/displacement


Abhijit joshi

• 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..

Reduce Septal fractures/displacement


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 www.indiandentalacademy.com


noe part 2 abhijit joshi (nxpowerlite) / orthodontic courses by indian dental academy

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