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

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.
Abhijit joshi

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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.
Abhijit joshi
Pre op
Post op
Abhijit joshi
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.

Abhijit joshi
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 JOMS93
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.

Abhijit joshi
I. Exposure
Abhijit joshi
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
Abhijit joshi
Existing lacerations
Abhijit joshi
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
Abhijit joshi
Periosteal incision
Subperiosteal plane
Subgaleal/supraperiosteal plane
Coronal flap
Abhijit joshi
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
Abhijit joshi
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
Abhijit joshi
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
.

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
120
o

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 incision
Advantages:
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 2
nd
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

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
Advantages:
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.

Abhijit joshi
Converse and Smith
Dingman 60
Strene 70
Bowermann 75
Horizontal radix Seagul approach
Abhijit joshi
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.
Abhijit joshi
II. Identify MCL capturing/tagging MCL

Abhijit joshi
Canthal ligament grasped with forceps and pierced with braided
2.0 / 3.0 Mersilene/ethibond.
MCL pierced again but at 90
o
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 joshi
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

Abhijit joshi
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.
Abhijit joshi
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:
Abhijit joshi
Importance :
to regain anatomic morphology.
To regain lost orbital volume in blow out #
To achieve normal eye position after injury.

Abhijit joshi
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

Abhijit joshi
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.

Abhijit joshi
Transnasal canthopexy fundamental
principles..
High to low vector Location of holes
Abhijit joshi
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,
Abhijit joshi
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.
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
zyazgan Volume 114(5), Plast and Recon surgery October 2004, pp 1338-
1339

Abhijit joshi
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.
Abhijit joshi
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 screw
Abhijit joshi
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.

Abhijit joshi
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..
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 the
drilled hole using the provided introducer system and a
mallet
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).

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

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