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XXI Oral and Maxillofacial Surgery Brazilian Congress Vitória, ES, Brazil

“Naso-ethmoid & Zygomatic “NasoTrauma – a personal perspective” peter ward booth fds frcs uk

Most interesting facial fractures? • Naso Naso--ethmoid – Uncommon • Zygomatic – Very common

Why so interesting ? Because the outcomes are not always good enough

Aetiology of mid face trauma in the UK • Road traffic

accidents • Work • Assaults • “falls” • sports

Cars are much safer today • Pedestrians

still at risk in urban areas • Children at risk in inner cities

Less heavy industry & much safer • Work related

facial injuries very rare

“falls” • Usually a

medical problem in the elderly • Not common to get a facial injury

sports • Increasing

problem • Nasal and

zygoma fractures

assaults • Several studies

in the UK by Jon Shepherd • •

Hutchison I, Magennis P, Shepherd JP, Brown AE The BAOMS United Kingdom survey of facial injuries. Part I: aetiology and the association with alcohol consumption. Br J Oral Maxillofac Surg 1998

Assaults main cause of facial injuries in the UK • Victims & culprits – Young males – Unemployed or menial jobs – Alcohol usually involved

Naso-- ethmoid injuries Naso

My “key points” • The injury is a “spectrum” &

needs a good classification • Open access & fixation needed • immediate grafting should be


Nasoethmoid fractures • Must be seen as a


• Severity increases with – Comminution – Soft tissue damage – displacement

Simple nasal fracture to severe nasonaso-ethmoid fracture

So we need a “helpful” classification • Rowe & Williams (1994) – bibi-lateral – uni uni--lateral – isolated – with frontal #

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

classification • Markowitz (1991) –good • – single unit with canthus – comminution but not to canthus – comminution involving canthus – uni or bi -lateral

classifications • Markowitz

–recognises the importance of: • comminution • canthal attachment

a new classification • Peter Ayliffe (Consultant at Gt.Ormond St. London)

• aims to identify all the

aspects which are likely to produce a POOR outcome – i.e. “difficult case”

Ayliffe’s classification of Nasoethmoid fractures • Type 0 • Type I • Type II • Type III • Type IV

• Type 0 UnUn-displaced

• Type I

Comminuted, but “platable”

• Type II

Requiring bone graft

• Type III Canthal disruption, requiring canthoplexy

• Type IV Lacrimal reconstruction

Should there be a V type? Other fractures for example orbital

Why the need for classification? • Surgical planning • Measuring outcomes

Examination & diagnosis

General appearance • nasal

deformity – “pig’s snout” !! – Deviation – broadening

Soft tissue • inspect lacerations


– foreign bodies – damage to VII nerve or

lacrimal apparatus

– tissue loss

Soft tissue • mobility of canthus


Evaluate the orbit standard eye examinations • visual acuity • movements /diplopia (Hess


• Enophthalmos • intra ocular

Bone damage • Clinical

examination still important • radiological

radiological • look for: – fractures lines – comminution – bone + canthal attachment – other relevant #, intracranial bleeds

Radiological AFTER clinical examination • basic screen – occipital mental – lateral skull

radiological • if NOE # suspected – C.T. essential –dycrocystogram rare in

acute situation

C.T. essential for NN-E fractures?


It is said most audiences loose concentration after 15 minutes • But how do I get

the attention of females?

Surgery • Timing • Access • fixation

timing • ? as soon as possible – other injuries frequently delay – let swelling reduce • long delays = poor results

A delayed case

access • Use lacerations • Coronal flap usually enough – Transconjunctival may be

needed for medial wall/floor of orbit

operative sequence • Commonsense! Build up from

the foundations – fix the mandible – start laterally in the maxilla – central mid face last

Have a logical plan! • The “pillars” for


– These are obvious as the

bone is thickest and easiest to plate

• Restoring the

zygomatic arch is more easily “missed”

fixation • Use the smallest plates

Supplementary fixation • The special problem of the

completely detached canthus • However most canthal

attachments remain if only to small fragments of bone

Complete canthal detachment • Requires canthoplexy – Is simple trans nasal wiring


• As shown in this diagram the

wire will: – “cut through” the ligament – And is too far forward

Trans nasal canthoplexy – Wire –

pulling – Acrylic

button pushing

When to graft • Grossly comminuted bone • Missing bone – Don’t delay and plan a

secondary procedure

Missing or grossly comminuted bone

Some cases

• Direct access to ensure good

reduction (via laceration)

• Direct plating

onto lachrymal bone • medial canthus still attached

• Check

x-ray • C.T. -yes ideally

complications • Poor reduction • Soft tissue •Lids •Drainage • (Orbital)

telecanthus • Poor canthal reduction

• Lacerations will always be less

satisfactory – but they mature

Lachrymal damage • Despite

immediate canalisation of duct with tubes

Zygoma trauma • Zygoma & orbital

walls • Globe • Soft tissue – Skin & periperi-orbital tissues

My “key points” • Ocular injury likely • Access, fixation &

reconstruction • Don’t delay surgery

Ocular injury – A separate topic but covered

well by Leo Stassen’s paper

al al--Qurainy IA, Stassen LF, Dutton GN, Moos KF, elel-Attar A. • Br J Oral Maxillofac Surg. 1991 Oct;29(5):302Oct;29(5):302-7

Leo Stassen BJOMS 1991

• The definitive work –363 pts (prospective study –2 year study

Leo Stassen -ocular injuries

• 63% minor • 16% moderate • 12% severe

Most ocular problems resolve – Swelling – Diplopia – Loss of


Ocular injuries

• Severity of injury

increases risk

• Reduction in visual acuity -

main problem

• 2.5% optic neuropathy

Conclusion: • Use a scoring system • Involve ophthalmologist

My question! • But how many injuries were

important and could be treated? • Diplopia • Visual loss – Retro bulbar hemorrhage (0.5%) – Optic nerve compression

what should we do?

• Examine and document the


• Treat those who will

benefit i.e. •potentially reversible damage

reversible damage

â&#x20AC;˘ Retro bulbar hemorrhage â&#x20AC;˘BUT very rare <1%

At least you can say you have seen one!

Cook et al 1996

• Meta analysis of treatment

of traumatic neuropathy –Treatment improves outcome –Unable to show benefit of different treatments

The treatments

• Steroids • Surgery • Surgery & steroids

Zhonghua 2004

• 118 pts, 5 levels of


• Blind • Hand movement • Finger count • Light perception • Acuity lowest score

Endoscopic decompression • 50% of the blind

“effective” • 100% of those with

minimal acuity “effective”

“effective” means?

• Move up one or more

grades ie not a “cure”

• Treat within 3 days • Steroids not used

The common “reversible” with treatment ocular problems • Diplopia – Loss of motility – Displaced globe

A “full house” –the perils of delay • Loss of

motility • Diplopia • Dystopia • Ectropion

Management zygoma trauma • Diagnosis – Clinical – radiological

clinical • Ocular • Bone • neurological

Ocular examination

• visual acuity

(Chart or paper!) • Examine the eye

Eye examination • Intra ocular – Specialist


Diplopia & motility examination â&#x20AC;˘ Record

findings â&#x20AC;˘ Hess chart

Position of the globe

â&#x20AC;˘ Enophthalmos/ dystopia

bone â&#x20AC;˘ Most of the

information you need is at your finger tips!

neurological • Sensory – IO nerve • Motor – VII & ocular movements

radiological • Plain film – Occipital

mental 30 • CT (gold standard) • u/sound MRI ??


Timing â&#x20AC;&#x201C; as soon as possible â&#x20AC;&#x201C; if not before!

Surgical access

• All have potential

complications • Except intra oral approach, but inadequate access • ?endoscopic approaches

Very traditional approaches

Surgical access of choice • Lacerations • Trans Trans--conjunctival ++- lateral


Surgical Access To The Orbit Mr Kenneth Sneddon FDSRCS, FRCS

Surgical Approaches to the Orbital Skeleton Transconjunctival + canthotomy

Follow--up Follow Complete followfollow-up to 6 months 49 80.3% Ongoing followfollow-up 10 16.4% Lost to followfollow-up 2 3.3%

Chemosis Immediate 1 month



3 months


Scleral Show 1 month

3 months

6 months





(4 pts)

(2 pts)

Other Complications Webbing at outer canthus


Canthal malposition


Temporary weakness upper branch of VII nerve


• Avoids two separate incisions • Superior surgical access • Simultaneous visualisation of

FZ & orbital rim • Excellent cosmesis & low


surgical access • lacerations • sub sub--conjunctival • coronal flap for displaced

malar/multi wall injuries

coronal flap • quick ‘n easy • still needs to be

in the right place! • Only needed in

complex cases

coronal flap


Internal fixation • Orbito Orbito--zygoma trauma

needs the smallest plate in the box???

• Don’t remove them

Degradable plates • “degradable” plates


•Large screws •Swell before


Orbital wall repair

• Close the holes • Maintain the volume • Which material?

Orbital wall repairs â&#x20AC;˘ Are we over obsessed by

precise reconstructions?

â&#x20AC;˘ Does not need to be exactly

the correct volume ++-5%?

What really matters? • Good motility • No diplopia • Position of globe – least


Poor motility reasonable position

Poor position good motility & no diplopia

Know your anatomy

key points • optic nerve

to rim • the “ridge” in

orbital floor

Lecturerâ&#x20AC;&#x2122;s nightmare

bone • Biocompatible • Cheap

other materials

• Titanium mesh •Effect of further

trauma? •Usually in young people and difficult to remove •effective

other materials

• Silicone •Well proven •Minimal tissue

reaction •Only small defects •May get infected, but easy to remove

other materials

• “degradable” materials •F.B. reaction -

?scarring •Shrink on degradation •Swell before shrinking •Not rigid for large defects

other materials • Medpore • Expensive • Lot of fibrosis • Rigid • Polyether ether ketone (PEEK) – can be custom made

Increasing the accuracy of the reconstruction

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

Surgical navigation in craniomaxillofacial Surgery: expensive toy or useful tool Lubbers JOMS 2011 • A very good question ! • But does not give the answer !! • Invaluable in oncology

Computer Assisted Planning Bell B et al JOMS 2009 â&#x20AC;˘ Describes his experience â&#x20AC;˘ AND acknowledges the problems

of scarring in fully correcting dystopia & diplopia

Or use a 33-D models • Much cheaper • Also allows titanium

plate to be made pre--op pre

– Reduces

operating time

Still limitations • Rely on “mirroring” • Artefacts with thin bones • In secondary reconstruction

scar tissue may prevent rerepositioning

But is it that simple ?

Why are children a special problem

â&#x20AC;˘ Can we learn

from them?

Remember whatâ&#x20AC;&#x2122;s happening

â&#x20AC;˘ Plast. Reconstr Surg 57:23357:233-235, 1976. 3. Korneef L:

Orbital septa: Anatomy and function. Ophthalmology 86: 876--. 880, 1979 876

Early diagnosis & treatment essential

mid face trauma is fascinating and we do not have all the answers

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

muito obrigado

Thank you

09-09-2011-14H_PETER WARD-BOOTH