Endoscopic repair of a complex midfacial fracture

Endoscopic-Assisted Intraoral Three-Dimensional Reduction Mandibuloplasty

BACKGROUND

Oriental people have a square face with a prominent mandibular angle, which means masculine and coarse and is considered to be an unappealing feature. Reduction mandibuloplasty has become popular in the orient in the past 2 decades, and the operation was frequently performed through the intraoral approach. But an invisible mandibular angle forces the surgeon to perform blind ostectomy which leads to difficulty in performing an accurate ostectomy as planned, leaving unnatural mandibular contours and severe complications.

METHODS

From January 2010 to January 2013, a total of 112 patients with prominent mandibular angles underwent one-stage long-curved ostectomy combined with splitting corticectomy through an intraoral approach with endoscopic assistance for reduction of the lower face. A retractor with an adjustable endoscope provides a clear operative field; the ostectomy line was marked. The one-stage long-curved ostectomy and corticectomy were performed following the marked ostectomy line using an oscillating saw with angles of various degrees and length under direct vision.

RESULTS

Mandibular contouring was 3-dimensionally refined; the width of the lower face was reduced in the frontal view and the mandibular angle appeared natural and inconspicuous in the lateral view. The majority of patients were satisfied with both their frontal and lateral appearances. The gonial angle and the mandibular plane angle were increased effectively. No major complications such as fracture or facial nerve injury occurred.

CONCLUSIONS

Intraoral approach of long-curved ostectomy combined with splitting corticectomy with endoscopic assistance allows surgeons to perform accurate, safe, and reproducible ostectomies and to recontour mandible 3-dimensionally, which can make the face look thinner from the frontal view and, in the lateral view, keeps it more natural looking with smooth ostectomized borders.

Endoscopic assistance in the diagnosis and treatment of odontogenic maxillary sinus disease

PURPOSE

Endoscopic sinus surgery has become an increasingly popular treatment for most surgical cases of chronic sinusitis. However, in some cases, a modification of the classic Caldwell-Luc operation is unavoidable. The purpose of this paper is to present the outcome of 20 cases with pathology of the maxillary sinus which was approached endoscopically on diagnostic or interventional purpose. The primary indication for endoscopy for 11 cases was acute or chronic odontogenic sinusitis. For six cases, endoscopy was performed for removing a foreign body from the sinus cavity and for the remaining three cases, for diagnostic purpose only.

METHODS

A 4-mm rigid endoscope was used through the middle nasal meatus (eight cases) or via a puncture at the canine fossa (seven cases). A combined endoscopic approach was used in five cases. In three cases, endoscopy was combined with Caldwell-Luc technique. For the majority of the patients, the operation was performed under local anesthesia (16 cases).

RESULTS

The mean follow-up period was 9.1 months. No major complications were observed. One patient died 18 months after an endoscopically assisted detection of malignancy. Results were depended on the surgical procedure pursued and the underlying sinus pathology. Laborious surgery and chronic sinusitis gave the less satisfactory results.

CONCLUSIONS

Endoscopy of the maxillary sinus can be applied in a variety of indications. Alone or in combination with conventional surgery, it is a minimally invasive and highly diagnostic tool.

Endoscopic approach to maxillofacial trauma

Endoscopic approaches to maxillofacial trauma have included their use in temporomandibular joint arthroscopy, zygomatic arch repair, repair after orbital trauma, repair of frontal sinus fractures, and finally in the repair of subcondylar mandibular fractures. These techniques provide exciting new options for the management of facial fractures. Many of the techniques provide a steep learning curve and require specialized equipment. The approach to an orbital blowout fracture allows the use of a Caldwell-Luc approach and the use of a naturally occurring body space (the maxillary sinus) for the visualization and maneuvering of the endoscope, tools, and implants. The use of the endoscope in the management of fractures for facial structures such as mandibular subcondylar fractures, which do not have a naturally occurring body cavity, may present greater challenges when trying to obtain visualization, reduction, and fixation. When used for the treatment of subcondylar fractures, wide exposure and the use of right-angled drills and screw drivers may significantly help with this procedure. This may be considered by some surgeons as an endoscopically "assisted" procedure that can possibly be accomplished with direct visualization and the use of dental mirrors. It remains to be seen as to whether some of these diverse endoscopic applications will represent the standard of care in the future or remain a specialized technique practiced by a minority of surgeons in a few specialized centers. This article reviews various endoscopic applications to maxillofacial trauma and discusses some of the controversies of these techniques.

Endoscopically-guided core biopsy of the condylar head

The effective management of mandibular cysts and tumours relies on obtaining an accurate tissue diagnosis with the acquisition of specimens representative of the lining and/or contents of the lesion. Access to such abnormalities is not commonly an issue since bony windows can be made in readily accessible areas. However, less accessible regions such as the ascending ramus, coronoid process and condyle can be surgically challenging without an extensive lateral approach. This paper reports a minimally-invasive technique in which an endoscope was used to facilitate the core biopsy of a condylar lesion.

Endoscopic Management of Frontal Sinus Fractures

Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques.

Endoscopic Management of Frontal Sinus Fractures

Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques.

The Rationale and Technique of Endoscopic Approach to the Zygomatic Arch in Facial Trauma

The reliable form and strategic position of the zygomatic arch make it a valuable landmark in midfacial trauma management. The benefits of arch repair have been used infrequently, mainly because traditional coronal access to this structure is fraught with undesirable sequelae. Endoscope-assisted zygomatic arch realignment and fixation allow anatomic repair without sustaining the drawbacks of extensive access incisions. The relative importance of this approach increases with trauma complexity, being most useful in Le Fort III and complex zygoma injuries.

Endoscopic repair of isolated anterior table frontal sinus fractures

BACKGROUND

Recently developed endoscopic brow-lifting techniques and instrumentation are being used for treatment of anterior table frontal sinus fractures. Potential endoscopic treatment options include fracture reduction with or without plating and fracture repair with hydroxyapatite bone cement (HA).

OBJECTIVE

To evaluate the efficacy of miniplates and HA for repair of anterior table fractures.

METHODS

Frontal sinus fractures were generated in 11 cadavers. Standard endoscopic brow-lifting techniques were used to visualize the fracture from above. A 1-cm Lynch incision was used to apply instrumentation from below. Fractures were repaired with either miniplate reduction or HA recontouring.

RESULTS

All fractures were exposed without difficulty. Miniplates were applied in 5 specimens: 1 specimen had a complete reduction, 2 specimens had partial reductions, and 2 specimens had incomplete reductions. Bone cement was applied in 9 specimens: 4 specimens were rated as excellent and 5 specimens as good.

CONCLUSIONS

Frontal sinus fractures can be successfully exposed and repaired with an endoscopic technique. Endoscopic miniplate reduction of frontal sinus fractures can be accomplished. However, it is challenging, and success rates vary depending on fracture comminution. Endoscopic HA recontouring offered the best results, with good or excellent outcomes in all specimens.

Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited

In comminuted fractures of the zygoma open reduction of the malar arch is essential for correct anatomic repair. Avoiding exposure of this landmark may result in severe functional and aesthetic impairment. Exposure of the malar arch necessitated traditionally a coronal incision. However, recently several authors reported good results in malar fracture repair with minimal incisions and endoscopic assistance. To establish this technique a cadaver study was performed. Different approaches to the malar arch, fracture reduction and internal fixation were evaluated. After establishment of a satisfactory technique 12 patients with comminution of the zygoma were treated with endoscopic assistance. Repositioning of the fragments was excellent in nine cases, minimal remaining dislocation was seen in two cases and in one case revision was necessary. Postoperatively the frontal branch of the facial nerve was intact in all patients. Scarring was minimal. In three patients plating of the malar arch on a side table resulted in arch necrosis and resorption in the long-term follow-up. Operating time was remarkably longer than in conventional procedures due to the difficult technique.

Endoscopically assisted Le Fort I osteotomy

OBJECTIVES

A new technique of the Le Fort I osteotomy using endoscopic techniques through limited approaches has been evaluated.

PATIENTS

This technique was first carried out successfully in a study on six cadavers. Thereafter we performed endoscopically assisted Le Fort l osteotomy in two patients.

METHODS

Four vertical incisions were used in the vestibule (paranasally and posteriorly) as approaches. The endoscope allowed direct visualization of the osteotomy of the maxilla including the pterygomaxillary junction. The osteotomies could be accomplished with a straight 4 mm osteotome for medial and lateral antral walls and nasal septum and a curved osteotome for the pterygomaxillary junction.

RESULTS

The procedures were successful. The descending palatal arteries could be preserved in all cases as a result of endoscopic control. Rigid fixation of the downfractured maxillae was carried out using self-drilling titanium screws and plates.

CONCLUSION

Endoscopic visualization allowed safe osteotomy of the medial antral wall preserving the descending palatal artery in all cases and hence less bleeding. Postoperative oedema and swelling in the two clinical cases was definitely reduced when compared with the conventional technique. The time needed for these first two clinical cases was approximately 1 h 30 min, i.e., about 30 min more than with the open technique. Further experience and experimental work, and refinements in technique will help to improve this procedure in its clinical application.

Cranial nerve VII region of the traumatized facial skeleton: optimizing fracture repair with the endoscope

OBJECTIVE

Cranial nerve VII (CN VII) is anatomically positioned adjacent to the condylar neck of the mandible and arch of the midface. Fracture treatment of this region of the facial skeleton remains controversial because of difficult surgical access. Conservative management rarely achieves anatomic fracture repair and can result in irreversible structural deformity and dysfunction. Traditional operative methods require access through very visible facial incisions and risk injury to the facial nerve. We report endoscopic methods of facial fracture repair in the region of CN VII that achieve excellent fracture reduction and stabilization, with minimal risk of facial nerve injury by using hidden incisions.

METHODS

A consecutive series of 65 endoscopically assisted facial fracture repairs were analyzed. Endoscopic repairs of the condylar neck (n = 40) of the mandible were performed through an intraoral incision. Endoscopic arch repairs (n = 25) of the midface were performed through a preauricular incision. Outcomes were evaluated by postoperative fracture reduction on radiographs, occlusion, interincisal jaw opening, and facial nerve function.

RESULTS

Thirty-seven of 40 condylar neck mandible fractures went on to anatomic bone union, whereas 3 of 40 had either incomplete fracture reduction or re-fracture through the plate. There was one temporary palsy of CN VII that completely resolved spontaneously. Jaw opening exceeded 40 mm by the 8th postoperative week. Computed tomographic images demonstrated anatomic arch repair in all 25 endoscopically repaired cases. Six of seven endoscopically repaired Le Fort III facial fractures went on to restoration of their premorbid occlusion. One of seven had an excellent restoration of the occlusal interface but a cant to the occlusal plane. Two of seven had improved but incomplete restoration of the malar prominence and enopthalmos ipsilateral to the side of endoscopic arch repair. Eight of 25 endoscopic arch repairs developed temporary paralysis of the frontal branch of CN VII that recovered completely by the 10th postoperative week.

CONCLUSION

We have developed novel endoscopically assisted techniques to facilitate repair of facial fractures in the region of CN VII. These techniques have been successfully applied to accurately restore the facial skeleton to its preinjury anatomic position in the region of CN VII with minimal risk of facial paralysis by using limited and well-hidden incisions.

Application of minimal-access techniques in lag screw fixation of fractures of the anterior mandible

A modification of the traditional open methods for the surgical management of anterior mandibular fractures using the principles of minimal-access surgery is presented; it was successfully performed in five patients. This technique incorporates the use of lag screws introduced through small incisions transmucosally or percutaneously after anatomic reduction of the fracture, and it relies on accurate preoperative radiologic assessment of the fracture pattern and location. This technique is indicated for any favorable fracture in the anterior mandibular arch that could achieve osteosynthesis with lag screw fixation, and it depends on the use of a dental arch bar as a tension band. Contraindications include unfavorable fracture patterns (long oblique, comminuted, or flat mandibular plane), inadequate dental support to maintain an arch bar due to missing or loose teeth, the inability to determine the fracture pattern preoperatively, and operator inexperience. Potential advantages include a shorter operative time, economic savings, decreased patient morbidity (swelling, scarring, and mental nerve and lower-lip muscle dysfunction), and improvement in functional rehabilitation.

Endoscopic subcondylar fracture repair: functional, aesthetic, and radiographic outcomes

An endoscopic method of mandibular subcondylar fracture repair has been described recently. To determine the effectiveness of this new technique, we longitudinally studied functional, aesthetic, and radiographic parameters following endoscopic repair of 22 subcondylar fractures in 20 patients. Restoration of mandibular function was achieved without postoperative maxillomandibular fixation. Premorbid occlusion was restored. Clinical jaw motion was found to progressively increase with a mean interincisal jaw opening of 43 mm achieved after the eighth postoperative week. Patients were pleased with the aesthetic restoration of their chin projection,jaw line, and the symmetric midline movement of the chin point onjaw opening. Anatomic fracture reduction with rigid plate fixation was confirmed on early postsurgical radiographs. Late radiographs showed fracture union without remodeling of the condylar head. Endoscopic subcondylar fracture repair was efficacious at functional, aesthetic, and radiographic restoration of the mandible.