09-09-2011-14H_PETER WARD-BOOTH

XXI Oral and Maxillofacial Surgery Brazilian XXI Oral and Maxillofacial Surgery Brazilian Congress Congress

Vitória, ES, BrazilVitória, ES, Brazil

“Naso“Naso--ethmoid & ethmoid & ZygomaticZygomatic“Naso“Naso--ethmoid & ethmoid & ZygomaticZygomaticTrauma Trauma –– a personal a personal

perspective” perspective” peter ward booth fds frcs ukpeter ward booth fds frcs uk

Most interesting facial Most interesting facial fractures?fractures?

•• NasoNaso--ethmoidethmoid––UncommonUncommon

•• ZygomaticZygomatic––Very commonVery common

Why so interesting ?Why so interesting ?

Because the Because the outcomes are not outcomes are not always good enough always good enough always good enough always good enough

Aetiology of mid face trauma in Aetiology of mid face trauma in the UKthe UK

•• Road traffic Road traffic accidentsaccidents

••WorkWork••WorkWork•• AssaultsAssaults•• “falls”“falls”•• sports sports

Cars are much safer todayCars are much safer today

•• Pedestrians Pedestrians still at risk in still at risk in urban areasurban areasurban areasurban areas

•• Children at Children at risk in inner risk in inner citiescities

Less heavy industry & much saferLess heavy industry & much safer

••Work related Work related facial injuries facial injuries very rarevery rarevery rarevery rare

“falls”“falls”

•• Usually a Usually a medical medical problem in the problem in the problem in the problem in the elderlyelderly

•• Not common to Not common to get a facial get a facial injuryinjury

sportssports

•• Increasing Increasing problemproblem

•• Nasal and Nasal and zygoma zygoma fracturesfractures

assaultsassaults

•• Several studies Several studies in the UK by Jon in the UK by Jon ShepherdShepherdShepherdShepherd

•• Hutchison I, Magennis P, Shepherd JP, Brown AEHutchison I, Magennis P, Shepherd JP, Brown AE•• The BAOMS United Kingdom survey of facial The BAOMS United Kingdom survey of facial

injuries. Part I: aetiology and the association with injuries. Part I: aetiology and the association with alcohol consumption. Br J Oral Maxillofac Surg alcohol consumption. Br J Oral Maxillofac Surg 19981998

Assaults main cause of facial Assaults main cause of facial injuries in the UKinjuries in the UK

•• Victims & culpritsVictims & culprits

––Young malesYoung males––Young malesYoung males––Unemployed or menial jobsUnemployed or menial jobs––Alcohol usually involved Alcohol usually involved

NasoNaso-- ethmoid injuriesethmoid injuries

My “key points”My “key points”

•• The injury is a “spectrum” & The injury is a “spectrum” & needs a good classificationneeds a good classification

•• Open access & fixation neededOpen access & fixation needed

•• immediate grafting should be immediate grafting should be consideredconsidered

Nasoethmoid fracturesNasoethmoid fractures

•• Must be seen as Must be seen as a spectruma spectrum

•• Severity increases withSeverity increases with•• Severity increases withSeverity increases with–– ComminutionComminution–– Soft tissue damageSoft tissue damage–– displacementdisplacement

Simple nasal fracture to severe nasoSimple nasal fracture to severe naso--ethmoid fractureethmoid fracture

So we need a “helpful” So we need a “helpful” classificationclassification

•• Rowe & Williams (1994)Rowe & Williams (1994)––bibi--laterallateral––uniuni--laterallateral––uniuni--laterallateral–– isolatedisolated––with frontal #with frontal #

classificationclassification

•• Gruss (1984) Gruss (1984) ––nasoethmoidnasoethmoid––nasoethmoid & central maxillanasoethmoid & central maxilla––nasoethmoid & central maxillanasoethmoid & central maxilla––+Le Fort II or III+Le Fort II or III––+Orbital dystopia+Orbital dystopia––+loss of bone+loss of bone

classificationclassification

••Markowitz (1991) Markowitz (1991) ––goodgood••––single unit with canthussingle unit with canthus––single unit with canthussingle unit with canthus––comminution but not to canthuscomminution but not to canthus––comminution involving canthuscomminution involving canthus––uni or bi uni or bi --laterallateral

classificationsclassifications

•• MarkowitzMarkowitz––recognises the importance recognises the importance of:of:of:of:••comminutioncomminution••canthal attachmentcanthal attachment

a new classificationa new classification

•• Peter Ayliffe Peter Ayliffe (Consultant at Gt.Ormond St. (Consultant at Gt.Ormond St.

London)London)

•• aims to identify all the aims to identify all the •• aims to identify all the aims to identify all the aspects which are likely to aspects which are likely to produce a produce a POORPOOR outcome outcome ––i.e. “difficult case”i.e. “difficult case”

Ayliffe’s classification of Ayliffe’s classification of Nasoethmoid fracturesNasoethmoid fractures•• Type 0Type 0•• Type IType I•• Type IType I•• Type IIType II•• Type IIIType III•• Type IVType IV

•• Type 0Type 0UnUn--displaceddisplacedUnUn--displaceddisplaced

•• Type IType IComminuted,Comminuted,Comminuted,Comminuted,but “platable”but “platable”

•• Type IIType IIRequiringRequiringRequiringRequiringbone graftbone graft

•• Type IIIType IIICanthal Canthal Canthal Canthal disruption,disruption,requiringrequiringcanthoplexycanthoplexy

•• Type IVType IVLacrimal Lacrimal Lacrimal Lacrimal reconstructionreconstruction

Should there be a V type?Should there be a V type?

Other fractures for example Other fractures for example orbitalorbital

Why the need for Why the need for classification?classification?

•• Surgical planningSurgical planning•• Measuring outcomesMeasuring outcomes

Examination & diagnosisExamination & diagnosis

General appearanceGeneral appearance•• nasal nasal deformitydeformity–– “pig’s snout” !!“pig’s snout” !!–– “pig’s snout” !!“pig’s snout” !!

––DeviationDeviation

––broadeningbroadening

Soft tissueSoft tissue•• inspect lacerations inspect lacerations for:for:–– foreign bodiesforeign bodies

–– damage to VII nerve or damage to VII nerve or lacrimal apparatuslacrimal apparatus

–– tissue losstissue loss

Soft tissueSoft tissue

••mobility of canthusmobility of canthus

peter.wardbooth@btope

nworld.com

Evaluate the orbitEvaluate the orbit

standard eye examinationsstandard eye examinations••visual acuityvisual acuity

••movements /diplopia (Hess movements /diplopia (Hess ••movements /diplopia (Hess movements /diplopia (Hess chart)chart)

••EnophthalmosEnophthalmos

•• intra ocular intra ocular

Bone damageBone damage

•• Clinical Clinical examination examination still still examination examination still still importantimportant

•• radiologicalradiological

radiological radiological

•• look for:look for:––fractures linesfractures lines––fractures linesfractures lines––comminutioncomminution––bone + canthal attachmentbone + canthal attachment––other relevant #, intracranial other relevant #, intracranial bleedsbleeds

Radiological AFTER clinical Radiological AFTER clinical examinationexamination

•• basic screenbasic screen––occipital occipital mentalmental––occipital occipital mentalmental–– lateral skulllateral skull

radiologicalradiological

•• if NOE # suspectedif NOE # suspected––C.T. essentialC.T. essential

––dycrocystogram rare in dycrocystogram rare in acute situationacute situation

C.T. essential for NC.T. essential for N--E fractures?E fractures?

DCR DCR

It is said most audiences loose It is said most audiences loose concentration after 15 minutesconcentration after 15 minutes

•• But how do I get But how do I get •• But how do I get But how do I get the attention of the attention of females?females?

SurgerySurgery

•• TimingTiming

•• AccessAccess

•• fixationfixation

timingtiming

•• ? as soon as possible? as soon as possible––other injuries frequently other injuries frequently delaydelaydelaydelay–– let swelling reducelet swelling reduce

•• long delays = poor resultslong delays = poor results

A delayed caseA delayed case

accessaccess

•• Use lacerationsUse lacerations•• Coronal flap usually enoughCoronal flap usually enough

––Transconjunctival may be Transconjunctival may be needed for medial wall/floor needed for medial wall/floor of orbitof orbit

operative sequenceoperative sequence

•• Commonsense! Build up from Commonsense! Build up from the foundations the foundations ––fix the mandiblefix the mandible––fix the mandiblefix the mandible––start laterally in the maxillastart laterally in the maxilla––central mid face lastcentral mid face last

Have a logical plan!Have a logical plan!

•• The “pillars” for The “pillars” for reconstructionreconstruction–– These are obvious as the These are obvious as the bone is thickest and bone is thickest and bone is thickest and bone is thickest and easiest to plateeasiest to plate

•• Restoring the Restoring the zygomatic arch is zygomatic arch is more easily more easily “missed”“missed”

fixationfixation

•• Use the smallest platesUse the smallest plates

Supplementary fixationSupplementary fixation

•• The special problem of the The special problem of the completely detached canthuscompletely detached canthus

•• However most canthal However most canthal attachments remain if only to attachments remain if only to small fragments of bonesmall fragments of bone

Complete canthal Complete canthal detachmentdetachment

•• Requires canthoplexyRequires canthoplexy––Is simple trans nasal wiring Is simple trans nasal wiring enough???enough???enough???enough???

•• As shown in this diagram the As shown in this diagram the wire will:wire will:–– “cut through” the ligament“cut through” the ligament––And is too far forwardAnd is too far forward

Trans nasal canthoplexyTrans nasal canthoplexy

––Wire Wire ––pullingpulling

––Acrylic Acrylic button button pushingpushing

When to graftWhen to graft

•• Grossly comminuted boneGrossly comminuted bone

•• Missing boneMissing bone•• Missing boneMissing bone––Don’t delay and plan a Don’t delay and plan a secondary proceduresecondary procedure

Missing or grossly Missing or grossly comminuted bonecomminuted bone

Some casesSome cases

•• Direct access to ensure good Direct access to ensure good reduction (via laceration)reduction (via laceration)

•• Direct plating Direct plating onto lachrymal onto lachrymal bone bone bone bone

•• medial canthus medial canthus still attachedstill attached

•• Check Check xx--rayray

•• C.T. C.T. --yes yes ideallyideallyideallyideally

complicationscomplications

•• Poor reductionPoor reduction

•• Soft tissueSoft tissue•• Soft tissueSoft tissue••LidsLids••DrainageDrainage

•• (Orbital)(Orbital)

telecanthustelecanthus

•• Poor canthal reductionPoor canthal reduction

•• Lacerations will always be less Lacerations will always be less satisfactory satisfactory –– but they maturebut they mature

Lachrymal damageLachrymal damage

•• Despite Despite immediate immediate canalisation canalisation canalisation canalisation of duct with of duct with tubestubes

Zygoma traumaZygoma trauma

•• Zygoma & orbital Zygoma & orbital wallswalls

•• GlobeGlobe•• GlobeGlobe•• Soft tissueSoft tissue––Skin & periSkin & peri--orbital orbital tissuestissues

My “key points”My “key points”••Ocular injury likely Ocular injury likely

•• Access, fixation & Access, fixation & •• Access, fixation & Access, fixation & reconstructionreconstruction

•• Don’t delay surgeryDon’t delay surgery

Ocular injuryOcular injury

––A separate topic but covered A separate topic but covered well by Leo Stassen’s paperwell by Leo Stassen’s paper

alal--Qurainy IA, Stassen LF, Dutton GN, Moos KF, elQurainy IA, Stassen LF, Dutton GN, Moos KF, el--Attar A.Attar A.•• Br J Oral Maxillofac Surg. 1991 Oct;29(5):302Br J Oral Maxillofac Surg. 1991 Oct;29(5):302--77

Leo Stassen BJOMS 1991Leo Stassen BJOMS 1991

••The definitive workThe definitive work••The definitive workThe definitive work––363 pts 363 pts (prospective study(prospective study

––2 year study2 year study

Leo Stassen Leo Stassen --ocular injuriesocular injuries

••63% minor63% minor

•• 16% moderate16% moderate

•• 12% severe12% severe

Most ocular problems resolveMost ocular problems resolve

––SwellingSwelling––DiplopiaDiplopia––Loss of Loss of ––Loss of Loss of motilitymotility

Ocular injuriesOcular injuries

••Severity of injury Severity of injury increases riskincreases risk

••Reduction in visual acuity Reduction in visual acuity --main problemmain problem

••2.5% optic neuropathy2.5% optic neuropathy

Conclusion:Conclusion:

•• Use a scoring systemUse a scoring system

•• Involve ophthalmologistInvolve ophthalmologist•• Involve ophthalmologistInvolve ophthalmologist

My question!My question!

•• But how many injuries were But how many injuries were important and could be important and could be treated?treated?

•• DiplopiaDiplopiatreated?treated?

•• DiplopiaDiplopia•• Visual lossVisual loss––Retro bulbar hemorrhage Retro bulbar hemorrhage (0.5%)(0.5%)––Optic nerve compressionOptic nerve compression

what should we do?what should we do?

••Examine and document the Examine and document the problemproblem

••Treat those who will Treat those who will ••Treat those who will Treat those who will benefit i.e.benefit i.e.••potentially reversible potentially reversible damagedamage

reversible damagereversible damage

••Retro bulbar hemorrhage Retro bulbar hemorrhage ••BUT very rare <1%BUT very rare <1%

At least you can At least you can say you have seen say you have seen one!one!

Cook et al 1996Cook et al 1996

••Meta analysis of treatment Meta analysis of treatment of traumatic neuropathyof traumatic neuropathy––Treatment improves Treatment improves outcomeoutcome––Treatment improves Treatment improves outcomeoutcome––Unable to show benefit of Unable to show benefit of different treatmentsdifferent treatments

The treatmentsThe treatments

••SteroidsSteroids

••SurgerySurgery

••Surgery & steroidsSurgery & steroids

Zhonghua 2004Zhonghua 2004

•• 118 pts, 5 levels of 118 pts, 5 levels of neuropathy neuropathy ••BlindBlind••BlindBlind••Hand movementHand movement••Finger countFinger count••Light perceptionLight perception••Acuity lowest scoreAcuity lowest score

Endoscopic Endoscopic decompressiondecompression

••50% of the blind 50% of the blind “effective”“effective”

•• 100% of those with 100% of those with minimal acuity minimal acuity “effective”“effective”

“effective” means?“effective” means?

••Move up one or more Move up one or more grades ie not a “cure”grades ie not a “cure”

••Treat within 3 daysTreat within 3 days

••Steroids not usedSteroids not used

The common “reversible” with The common “reversible” with treatment ocular problemstreatment ocular problems

•• DiplopiaDiplopia

––Loss of motilityLoss of motility––Loss of motilityLoss of motility

––Displaced globeDisplaced globe

A “full house” A “full house” ––the perils of delaythe perils of delay

•• Loss of Loss of motilitymotility

•• DiplopiaDiplopia•• DiplopiaDiplopia•• DystopiaDystopia•• Ectropion Ectropion

Management zygoma traumaManagement zygoma trauma

•• DiagnosisDiagnosis––ClinicalClinical––radiologicalradiological––radiologicalradiological

clinicalclinical

•• OcularOcular

•• BoneBone•• BoneBone

•• neurologicalneurological

Ocular examinationOcular examination

••visual acuityvisual acuity(Chart or paper!)(Chart or paper!)••Examine the eyeExamine the eye

Eye examinationEye examination

•• Intra ocularIntra ocular––Specialist Specialist opinion?opinion?opinion?opinion?

Diplopia & motility examinationDiplopia & motility examination

•• Record Record findingsfindings

•• Hess chartHess chart•• Hess chartHess chart

Position of the globePosition of the globe

••Enophthalmos/ dystopiaEnophthalmos/ dystopia

bonebone•• Most of the Most of the information you need information you need is at your finger tips!is at your finger tips!is at your finger tips!is at your finger tips!

neurologicalneurological

•• SensorySensory––IO nerveIO nerve

•• MotorMotor––VII & ocular movementsVII & ocular movements

radiologicalradiological

•• Plain filmPlain film––Occipital Occipital mental 30mental 30mental 30mental 30

•• CT (gold CT (gold standard)standard)

•• uu/sound MRI ??/sound MRI ??

SurgerySurgery

Timing Timing –– as soon as possible as soon as possible –– if if not before!not before!

Surgical accessSurgical access

••All have potential All have potential complicationscomplications••Except intra oral Except intra oral ••Except intra oral Except intra oral approach, but inadequate approach, but inadequate accessaccess•• ?endoscopic approaches?endoscopic approaches

Very traditional approachesVery traditional approaches

Surgical access of choiceSurgical access of choice

•• LacerationsLacerations•• TransTrans--conjunctival +conjunctival +-- lateral lateral extension extension extension extension

Surgical Access To The Surgical Access To The OrbitOrbitOrbitOrbit

Mr Kenneth SneddonMr Kenneth SneddonFDSRCS, FRCSFDSRCS, FRCS

Surgical Approaches to the Surgical Approaches to the Orbital SkeletonOrbital Skeleton

Transconjunctival + Transconjunctival + Orbital SkeletonOrbital Skeleton

Transconjunctival + Transconjunctival + canthotomycanthotomy

FollowFollow--upupComplete followComplete follow--up to 6 months up to 6 months 4949 80.3%80.3%

Ongoing followOngoing follow--upupOngoing followOngoing follow--upup10 16.4%10 16.4%

Lost to followLost to follow--upup2 3.3%2 3.3%

ChemosisChemosis

ImmediateImmediate 1 month 3 months1 month 3 months

27.8%27.8% 0%0% 0%0%

Scleral ShowScleral Show

1 1 monthmonth 3 3 monthsmonths 6 6 monthsmonths

18%18% 6.4%6.4% 3.2%3.2%

(11pts)(11pts) (4 pts)(4 pts) (2 pts)(2 pts)

Other ComplicationsOther ComplicationsWebbing at outer canthusWebbing at outer canthus 1pt1pt

Canthal malpositionCanthal malposition 1pt1pt

Temporary weakness upperTemporary weakness upper 1pt1ptbranch of VII nervebranch of VII nerve

•• Avoids two separate incisionsAvoids two separate incisions

•• Superior surgical accessSuperior surgical access

•• Simultaneous visualisation of Simultaneous visualisation of •• Simultaneous visualisation of Simultaneous visualisation of FZ & orbital rimFZ & orbital rim

•• Excellent cosmesis & low Excellent cosmesis & low morbiditymorbidity

surgical accesssurgical access•• lacerationslacerations•• subsub--conjunctivalconjunctival•• coronal flap for displaced coronal flap for displaced malar/multi wall injuriesmalar/multi wall injuriesmalar/multi wall injuriesmalar/multi wall injuries

•• quick ‘n easyquick ‘n easy

•• still needs to be still needs to be

coronal flapcoronal flap

•• still needs to be still needs to be in the right in the right place!place!

•• Only needed in Only needed in complex casescomplex cases

coronal flapcoronal flap

fixationfixation

Internal fixationInternal fixation

••OrbitoOrbito--zygoma trauma zygoma trauma needs the smallest plate in needs the smallest plate in the box???the box???the box???the box???

•• Don’t remove themDon’t remove them

Degradable platesDegradable plates

•• “degradable” plates “degradable” plates ????••Large screwsLarge screws••Large screwsLarge screws••Swell before Swell before degradingdegrading

Orbital wall repairOrbital wall repair

••Close the holesClose the holes

••Maintain the volumeMaintain the volume••Maintain the volumeMaintain the volume

••Which material?Which material?

Orbital wall repairsOrbital wall repairs

•• Are we over obsessed by Are we over obsessed by precise reconstructions?precise reconstructions?

•• Does not need to be exactly Does not need to be exactly the correct volume +the correct volume +--5%?5%?

What really matters?What really matters?

•• Good motilityGood motility

•• No diplopiaNo diplopia•• No diplopiaNo diplopia

•• Position of globe Position of globe –– least least importantimportant

Poor motility reasonable positionPoor motility reasonable position

Poor position good motility & no Poor position good motility & no diplopiadiplopia

Know your anatomyKnow your anatomy

key pointskey points•• optic nerve optic nerve to rimto rim

•• the “ridge” in the “ridge” in orbital floororbital floor

Lecturer’s nightmareLecturer’s nightmare

bonebone

•• BiocompatibleBiocompatible•• CheapCheap•• CheapCheap

other materialsother materials

••Titanium meshTitanium mesh••Effect of further Effect of further trauma?trauma?trauma?trauma?••Usually in young Usually in young people and difficult to people and difficult to removeremove••effectiveeffective

other materialsother materials

••SiliconeSilicone••Well provenWell proven••Minimal tissue Minimal tissue ••Minimal tissue Minimal tissue reactionreaction••Only small defectsOnly small defects••May get infected, but May get infected, but easy to removeeasy to remove

other materialsother materials

•• “degradable” materials“degradable” materials••F.B. reaction F.B. reaction --?scarring?scarring?scarring?scarring••Shrink on degradationShrink on degradation••Swell before shrinkingSwell before shrinking••Not rigid for large Not rigid for large defectsdefects

other materialsother materials

•• MedporeMedpore••ExpensiveExpensive••Lot of fibrosisLot of fibrosis••Lot of fibrosisLot of fibrosis••RigidRigid

•• Polyether ether ketone (PEEK) Polyether ether ketone (PEEK) –– can be custom madecan be custom made

Increasing the accuracy of Increasing the accuracy of the reconstructionthe reconstruction

If you want a perfect If you want a perfect reconstruction (+ orreconstruction (+ or-- 1mm) 1mm) then get a navigation systemthen get a navigation system

Surgical navigation in Surgical navigation in craniomaxillofacial Surgery: craniomaxillofacial Surgery: expensive toy or useful toolexpensive toy or useful tool

Lubbers JOMS 2011Lubbers JOMS 2011

•• A very good question !A very good question !•• A very good question !A very good question !

•• But does not give the answer !!But does not give the answer !!•• Invaluable in oncologyInvaluable in oncology

Computer Assisted PlanningComputer Assisted PlanningBell B et al JOMS 2009Bell B et al JOMS 2009

•• Describes his experienceDescribes his experience

•• AND acknowledges the problems AND acknowledges the problems •• AND acknowledges the problems AND acknowledges the problems of scarring in fully correcting of scarring in fully correcting dystopia & diplopiadystopia & diplopia

Or use a 3Or use a 3--D modelsD models

••Much cheaperMuch cheaper•• Also allows titanium Also allows titanium plate to be made plate to be made prepre--opopplate to be made plate to be made prepre--opop

––Reduces Reduces operating timeoperating time

Still limitationsStill limitations

•• Rely on “mirroring”Rely on “mirroring”

•• Artefacts with thin bonesArtefacts with thin bones•• Artefacts with thin bonesArtefacts with thin bones

•• In secondary reconstruction In secondary reconstruction scar tissue may prevent rescar tissue may prevent re--positioningpositioning

But is it that simple ?But is it that simple ?

Why are children a Why are children a special problemspecial problem

••Can we learn Can we learn from them?from them?

Remember what’s happeningRemember what’s happening

•• Plast. Reconstr Surg 57:233Plast. Reconstr Surg 57:233--235, 1976. 3. Korneef L: 235, 1976. 3. Korneef L: Orbital septa: Anatomy and function. Ophthalmology 86: Orbital septa: Anatomy and function. Ophthalmology 86: 876876--. 880, 1979. 880, 1979

Early diagnosis & Early diagnosis & treatment essentialtreatment essential

mid face trauma is mid face trauma is fascinatingfascinating

andandwe do not have all the we do not have all the we do not have all the we do not have all the

answersanswers

I am very grateful to your I am very grateful to your President & Committee for their President & Committee for their kind invitation & hospitalitykind invitation & hospitality

muito obrigadomuito obrigado

Thank you Thank you