Post traumatic residual deformities
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This document discusses residual deformities that can occur after craniofacial trauma. It describes different types of deformities including scars, nasal deformities, injuries to the zygomatic complex, and malocclusions. The document outlines various surgical techniques for correcting these deformities, such as scar revision procedures like Z-plasty and dermabrasion. It also discusses reconstruction of soft tissue volume deficits using local flaps, free tissue transfer, skin grafting, and fat grafting.
Post traumatic residual deformities
- 1. © Ramaiah University of Applied Sciences 1 Faculty of Dental Sciences University Logo Post traumatic residual deformities -ZEESHAN ARIF
- 2. © Ramaiah University of Applied Sciences 2 Faculty of Dental Sciences University Logo Contents • Introduction • Post traumatic scars • Nasal deformities • Naso – orbital deformities • zygomatic complex • Malocclusion(maxilla and mandible) • Conclusion • References
- 3. © Ramaiah University of Applied Sciences 3 Faculty of Dental Sciences University Logo Introduction • For a variety of reasons, trauma patients can experience unsuccessful initial management and the associated morbidities of a post-traumatic craniofacial deformity that would benefit from secondary correction. • Experienced surgeons recognize the challenge of restoring premorbid form and function to patients with established deformities after craniofacial trauma
- 4. © Ramaiah University of Applied Sciences 4 Faculty of Dental Sciences University Logo The factors that lead to persistent deformities after craniofacial trauma include • severe comminution (especially that which requires bone grafting) • lack of definitive treatment • excessively delayed initial treatment • inadequate initial surgical repair
- 5. © Ramaiah University of Applied Sciences 5 Faculty of Dental Sciences University Logo Types of residual deformities • Post traumatic scars • Nasal deformities • Naso – orbital deformities • zygomatic complex • Malocclusion(maxilla and mandible)
- 6. © Ramaiah University of Applied Sciences 6 Faculty of Dental Sciences University Logo Scar • Scars are areas of fibrous tissue (fibrosis) that replace normal skin after injury. • A scar results from the biological process of wound repair in the skin and other tissues of the body.
- 7. © Ramaiah University of Applied Sciences 7 Faculty of Dental Sciences University Logo Facial esthetic units Relaxed skin tension lines
- 8. © Ramaiah University of Applied Sciences 8 Faculty of Dental Sciences University Logo Assesment of existing scar Types of scars • Good scar- a desirable scar should be inscospicuous with the face at rest as well as in the dynamic situation. • It should be flat, the same color, as the surrounding skin, soft, narrow, and oriented in the same direction as the resting skin tension line • Bad scar- is raised or depressed, hyper- or hypo pigmented, wide and crossing the resting skin tension line
- 9. © Ramaiah University of Applied Sciences 9 Faculty of Dental Sciences University Logo • Depressed scar- runs perpendicular to the resting skin tension line as a result of wound closure under tension • Hematoma formation, wound infection and inverted wound closure are the common causes of a depressed scar
- 10. © Ramaiah University of Applied Sciences 10 Faculty of Dental Sciences University Logo • Curved scar- healing of a curved scar will produce contraction along the scar, causing a purse string effect resulting in a trapdoor appearance • Stitch marks- tensionless suturing;subcutaneous suturing; use of skin hooks rather than forceps; fine sutures(7/0) and early removal (3 days)
- 11. © Ramaiah University of Applied Sciences 11 Faculty of Dental Sciences University Logo • Step off deformities- result of inaccurate epidermal closure. Dermal abrasion and resurfacing with the help of lasers. • If the step is more than 1mm, resuturing is preferred • Painful scar- entrapment of a nerve ending in the scar results in a painful scar. If analgesics are not effective the scar should be re-explored and the nerve should be cut and allowed to retract to the muscle layer and sutured again
- 12. © Ramaiah University of Applied Sciences 12 Faculty of Dental Sciences University Logo Treatment options Simple excision • elliptical fashion • peripherally undermined to facilitate closure • reapproximated with sufficient dermal suturing to ensure wound-edge eversion. • adequate eversion will help prevent formation of a depressed scar following wound contracture during healing.
- 13. © Ramaiah University of Applied Sciences 13 Faculty of Dental Sciences University Logo Subcision • management of depressed scars that may have resulted from insufficient wound-edge eversion or excessive scar contraction during healing. • circumferential insertion of a hypodermic needle into a depressed scar, followed by a gentle lifting maneuver to elevate the overlying epidermal tissue from the underlying dermis. • pain, swelling, bruising, hyperpigmentation, and hematoma formation can occur if the procedure is carried out too vigorously or if needle penetration traverses too deeply
- 14. © Ramaiah University of Applied Sciences 14 Faculty of Dental Sciences University Logo Preoperative anterior and bird’s-eye views. (C, D) The same views showing improvement in the early postoperative stage
- 15. © Ramaiah University of Applied Sciences 15 Faculty of Dental Sciences University Logo • Z-plasty -transposition of 2 triangular flaps to reorientate a scar. • It is ideal for scars that cause functional impairment or are perpendicular to the resting skin lines because it changes the direction of the scar band completely. • The central component of the Z must encompass the scar, and the other 2 limbs are designed so that the final flaps are as parallel to the resting skin lines as possible
- 16. © Ramaiah University of Applied Sciences 16 Faculty of Dental Sciences University Logo W-plasty • The major indication for W- plasty is a long scar that is not orientated perpendicular to the skin tension lines. • The main advantage of W- plasty is that it does not increase the overall length of the scar, unlike Z-plasty.
- 17. © Ramaiah University of Applied Sciences 17 Faculty of Dental Sciences University Logo Dermabrasion involves sanding of the scar using a high-speed rotary device. • It is performed down to the level of the papillary dermis, which is recognized by looking for pinpoint bleeders. • When dermabrading a raised scar, pinpoint bleeding occurs almost instantaneously; therefore, care must be taken when performing this procedure. • treating raised scars as well as atrophic or pitted scars acne pits • Dermabrasion in dark-skinned individuals can cause significant dyspigmentation that may be permanent.
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- 19. © Ramaiah University of Applied Sciences 19 Faculty of Dental Sciences University Logo Laser resurfacing • Carbon dioxide ultrapulse laser remains the gold standard. • Laser resurfacing effectively removes the entire epidermis and upper dermis and can stimulate significant neocollagen formation. • Laser resurfacing is indicated in flat scars
- 20. © Ramaiah University of Applied Sciences 20 Faculty of Dental Sciences University Logo Posttraumatic facial soft-tissue volume deficiency volume-restorative techniques include • adjacent transfer of tissue • free transfer of tissue • prosthetic or alloplastic volume replacement
- 21. © Ramaiah University of Applied Sciences 21 Faculty of Dental Sciences University Logo Timing of Large or Composite Defects Requiring Microvascular Free Tissue Transfer • After initial management and stabilization, the first step is establishment of the soft-tissue envelope with the best possible soft-tissue closure. • Debulking and vestibuloplasty may take place 6 weeks or later following the initial flap placement. • If a second debulking is required, the surgeon should wait at least 6 months, and up to a year, after the first procedure to allow for full contracture and atrophy, of both subcutaneous fat and any accompanying muscle.
- 22. © Ramaiah University of Applied Sciences 22 Faculty of Dental Sciences University Logo Local rotational and advancement flaps • Local flaps may be vascularized by specific vessels (ie, the supratrochlear artery for the paramedian forehead flap) • In general, the thickness and quality of the tissue adjacent to an avulsed defect is similar to that of the missing tissue • The lips and oral aperture are another location amenable to this type of treatment when tissue is avulsed or necessarily surgically debrided early on. • In some cases, for example with cheek defects, a facial artery musculomucosal flap may be indicated.
- 23. © Ramaiah University of Applied Sciences 23 Faculty of Dental Sciences University Logo Free Tissue Transfer • When viable tissue is needed and local tissue is insufficient, not indicated, or undesirable, free tissue may often restore volume and structure in a lasting way. • such as in radial forearm flaps for lip reconstruction • these techniques restores form and function
- 24. © Ramaiah University of Applied Sciences 24 Faculty of Dental Sciences University Logo Full-Thickness Skin Grafting • Grafting of free tissue may also take the form of full-thickness skin grafts and fat grafting. • Fullthickness skin grafting provides a good match for soft-tissue tone, quality, and thickness. • For skin replacement, if rotational flaps are not available or provide incomplete coverage, a skin graft may be obtained. • Excellent graft may be obtained from the preauricular and postauricular areas in many individuals.
- 25. © Ramaiah University of Applied Sciences 25 Faculty of Dental Sciences University Logo Structural fat transfer • Intermediate level soft tissue volume may be regained via fat transfer • Effective means of adding bulk to atrophied areas as well as smoothing out irregularities. • It may be used in conjunction with subcision of depressed scars or in recontouring larger defects, such as temporal hollowing
- 26. © Ramaiah University of Applied Sciences 26 Faculty of Dental Sciences University Logo
- 27. © Ramaiah University of Applied Sciences 27 Faculty of Dental Sciences University Logo Complications of structural fat grafting • Overcorrection • Undercorrection • surface irregularity • graft migration • infection.
- 28. © Ramaiah University of Applied Sciences 28 Faculty of Dental Sciences University Logo Soft-Tissue Fillers • Examles -nonanimal stabilized hyaluronic acids, such as Restylane and Juvederm. • improve the appearance of scars • sterile, and can be injected at various levels in the dermis and subdermal level for the desired effect. • Surgeons should consider these materials as adjuncts available for use when contemplating minor revisional procedures
- 29. © Ramaiah University of Applied Sciences 29 Faculty of Dental Sciences University Logo A) Frontal scar that became depressed after healing. Treatment was injection of hyaluronic acid (B).
- 30. © Ramaiah University of Applied Sciences 30 Faculty of Dental Sciences University Logo Vascularized Free Tissue Transfer • Composite volume deficit more commonly occurs secondary to high-velocity ballistic injuries or high-energy trauma. • In this case, skin as well as muscle and/ or bone may be lost. • Free tissue transfer may be used only for soft tissue. • Free flaps may be used to reconstruct the lips, especially the lower lip.
- 31. © Ramaiah University of Applied Sciences 31 Faculty of Dental Sciences University Logo • The radial forearm flap with palmaris longus tendon transfer may be used to create a new lower lip and restore oral competence. • Radial forearm flaps may also provide definitive orbital coverage following enucleation. • Similarly, anterolateral thigh flaps may be used when a larger amount of soft tissue is required for coverage.
- 32. © Ramaiah University of Applied Sciences 32 Faculty of Dental Sciences University Logo Alloplastic and prosthetic reconstruction of soft-tissue defects Auricular prosthesis used for reconstruction following traumatically avulsed ear. The prosthesis is retained by 2 craniofacial implants
- 33. © Ramaiah University of Applied Sciences 33 Faculty of Dental Sciences University Logo • titanium mesh • porous polyethylene (ie, Medpor) • PEEK (poly ether ether ketone) • implants such as Medpor, silicone, and PEEK may be custom- modeled from computed tomography scans to match the patient’s individual bony contours and provide a facial profile mirroring the contralateral side.
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- 35. © Ramaiah University of Applied Sciences 35 Faculty of Dental Sciences University Logo NASAL DEFORMITIES • Saddle nose • Short nose • Nasal deviation • Columellar retaction • Management
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- 37. © Ramaiah University of Applied Sciences 37 Faculty of Dental Sciences University Logo Common traumatic nasal deformities Saddle nose • Lack of structure in nasal dorsum (bone/cartilage) • Scooped out appearance – lateral view • Flat nasal bridge – frontal view
- 38. © Ramaiah University of Applied Sciences 38 Faculty of Dental Sciences University Logo Short nose • Reduced distance from nasion to tip • Obtuse nasolabial angle • Over-rotated nose • Weakning of the lower cartilages, detachment of the upper lateral cartilages from the nasal bone
- 39. © Ramaiah University of Applied Sciences 39 Faculty of Dental Sciences University Logo Nasal deviation • Nasal dorsum or deviated tip • Deviation from the glabella to the tip of the cupids bow • Because of deviation of one or both nasal bone • Collapse of an ipsilateral lateral cartilage
- 40. © Ramaiah University of Applied Sciences 40 Faculty of Dental Sciences University Logo Columellar retraction • Normal distance from ala to base of the columella is 2mm • With trauma the columellar show can decrease due to the retrodisplacement of the caudal septum • Direct blow at the base of the nose • Increased columellar show- upper and middle vault collpase
- 41. © Ramaiah University of Applied Sciences 41 Faculty of Dental Sciences University Logo Grafting of nasal dorsum • Repair of saddle nose deofmity • Bone/cartilage grafts • Cartilage grafts- smaller deformities- septum, ear or rib • Septal cartilage has the advantage of being right in the surgical field and offers a larger amount of graft material as only a cm of dorsal and caudal cartilage must be retained for adequate dorsal support in traditional septal harvest
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- 43. © Ramaiah University of Applied Sciences 43 Faculty of Dental Sciences University Logo • Auricular cartilage- harvesting of the concha through a post- auricular incision is rapid and produces less morbidity • The curved shape of this cartilage may or may not be beneficial depending on the defect • For nasal tip this is most useful • For long straight grafts of the dorsum this is not the first choice
- 44. © Ramaiah University of Applied Sciences 44 Faculty of Dental Sciences University Logo • Costal cartilage offers large amount of donor tissue • 8th and the 9th rib harvest sites are curved and cannot provide a long straight graft • Bending the graft by scoring the perichondrium or completely removing it makes it straight intraoperatively but postopertively memory and recoil • A K wire can be placed in the grafts to make it straight post operatively • Unpredictable Resorption
- 45. © Ramaiah University of Applied Sciences 45 Faculty of Dental Sciences University Logo • Autogenous bone grafts offer greater support and augmentation that is used in larger defects • Rib • iliac crest • calvarium
- 46. © Ramaiah University of Applied Sciences 46 Faculty of Dental Sciences University Logo • Alloplastic materials- silicone rubber, mersiline mesh, Gore-Tex, medpore • Silicone rubber- high excrusion rate and not used these days • Mersiline – resorb over the years • Gore – Tex- most commonly used
- 47. © Ramaiah University of Applied Sciences 47 Faculty of Dental Sciences University Logo Spreader grafts • Deformity of the middle nasal vault will lead to nasal obstruction as well as airway obstruction due to the collapse of the internal nasal valve • With significant dorsal septal deflections where scoring of the septum is inadequate, spreader grafts are used unilaterally
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- 49. © Ramaiah University of Applied Sciences 49 Faculty of Dental Sciences University Logo Osteotomies • Correction of deformities of the nasal bone • Closure of an open roof deformity, straightening of a deviated nasal dorsum and narrowing of the nasal side walls • Infracture one or both nasal bones (more stable)
- 50. © Ramaiah University of Applied Sciences 50 Faculty of Dental Sciences University Logo NASO – ORBITAL DEFORMITY Residual deformities due to NOE Reconstruction of nasal base and orbito nasal angle Bone grafting Canthopexy Reconstruction of nasal passage Dacryocystorhinostomy
- 51. © Ramaiah University of Applied Sciences 51 Faculty of Dental Sciences University Logo • If untreated or inadequately treated NOE injury not only leads to residual deformity of nasal crest but also: • Orbito nasal angle • Dystophy to medial canthus • Alteration to continuity of lacrimal passage • Reduction in the patency of nasal airway
- 52. © Ramaiah University of Applied Sciences 52 Faculty of Dental Sciences University Logo Reconstruction of the deformity
- 53. © Ramaiah University of Applied Sciences 53 Faculty of Dental Sciences University Logo Bone graft • existence of many multiple fragments makes it impossible to divide these by osteotomy • complete resection • bone graft
- 54. © Ramaiah University of Applied Sciences 54 Faculty of Dental Sciences University Logo Canthopexy • Whether the MCL been cut across, avulsed or displaced with the frontal process, it must be reinserted or repositioned • Technique by Tessier et al 1962
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- 60. © Ramaiah University of Applied Sciences 60 Faculty of Dental Sciences University Logo Dacryocystorhinostomy • Repositioning of the medial canthal-bearing fragment is the first step in any reconstruction of the lacrimal system. • Once this has been accomplished, reconstruction of the lacrimal system can be performed.
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- 65. © Ramaiah University of Applied Sciences 65 Faculty of Dental Sciences University Logo ZYGOMATIC COMPLEX RESIDUAL DEFORMITIES Signs and symptoms Enopthalmous Epiphora Removal Or Reposition of malunited fragments Inlays and onlays
- 66. © Ramaiah University of Applied Sciences 66 Faculty of Dental Sciences University Logo Symptoms and clinical findings • In case of trauma the zygomatic complex bone may be: Broken or dislocated Soft tissue torn ,squeezed, strangulated Clinical sign and symptoms Facial asymmetry Dislocation of eyeball Diplopia Enopthalmous Paresthesia of infraorbital nerve
- 67. © Ramaiah University of Applied Sciences 67 Faculty of Dental Sciences University Logo • Enophthalmos is common due to increased orbital volume or herniation of orbital contents through defects in the orbital walls, usually inferior or medial
- 68. © Ramaiah University of Applied Sciences 68 Faculty of Dental Sciences University Logo Enopthalmous management • Expose the fracture sites • Reduce/refracture • Rigidly fix ZMC (3 point fixation) • Free any herniated tissue • Graft/plate any defects • Perform FDT before closure • Close in layers
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- 70. © Ramaiah University of Applied Sciences 70 Faculty of Dental Sciences University Logo Removal Or Reposition of malunited fragments • If intercuspation and occlusion appear to be unaltered by the trauma , if no abnormal ophthalmological findings can be detected and the overall symmetry and harmony of face is undisturbed , no major osteotomy is indicated • If a visible bony step at the orbital rim is present it should be removed surgically through an lower eyelid incision • Orbital floor is explored subsequently so as not to overlook any undiagnosed adhesions
- 71. © Ramaiah University of Applied Sciences 71 Faculty of Dental Sciences University Logo Inlays and onlays • If the only pathological finding in a patient is either a downward displacement of the globe or asymmetry of the malar prominences, contour restoration with implants is preferred • Depending on the size of the graft, this is placed on zygoma using infraorbital or an intra oral approach
- 72. © Ramaiah University of Applied Sciences 72 Faculty of Dental Sciences University Logo • Onlay grafting-mild cases of malar asymmetry and can usually be carried out easily through a lower eyelid incision. • Calvarial bone, bone substitutes or alloplastic implants may be used
- 73. © Ramaiah University of Applied Sciences 73 Faculty of Dental Sciences University Logo POST TRAUMATIC MALOCCLUSION • It is present following malunion of any fracture that directly or indirectly involves the alveolar segments of the maxilla or mandible. • The introduction of ORIF makes direct anatomical segment reduction the primary aim. • If this is achieved, a normal occlusion should automatically follow. • Infection of mandibular fractures, particularly those involving the tooth-bearing segment of the mandible or angle, may result in non-union, malunion and segment displacement with malocclusion.
- 74. © Ramaiah University of Applied Sciences 74 Faculty of Dental Sciences University Logo Maxilla Indications • In order to correct occlusal abnormalities due to maxillary malunion, Le Fort I osteotomy is indicated. • Osteotomy at Le Fort II or III level, or variations of these procedures tailored to the individual needs of the patient, may be required in some instances where simultaneous correction of midface deformity is necessary. • Le Fort I osteotomy is therefore indicated for most cases of maxillary occlusal abnormality, when segmental or one- piece maxillary repositioning is necessary.
- 75. © Ramaiah University of Applied Sciences 75 Faculty of Dental Sciences University Logo • Once the correct maxillary position is established, any significant bony gaps or deficiencies are bone grafted. • These insure union, stability and support for the overlying soft tissues of the cheek. • the use of bone grafts in Le Fort I osteotomies to correct posttraumatic occlusion is uncommon due to the relatively small movements involved
- 76. © Ramaiah University of Applied Sciences 76 Faculty of Dental Sciences University Logo Mandible • Malunion of fractures behind the tooth-bearing segment of the mandible result in displacement of the whole dentoalveolar arch. • Severe condylar malposition with dislocation allows vertical shortening of the ascending ramus and this may be associated with restricted mouth opening or deviation on opening due to mechanical disruption of the temporomandibular joint.
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- 78. © Ramaiah University of Applied Sciences 78 Faculty of Dental Sciences University Logo Unilateral condylar malunion • The aim of treatment in unilateral cases is to restore the pretraumatic ramus height and correct posterior mandibular displacement if present. • This corrects the occlusal plane cant and restores a normal occlusion • an osteotomy at the site of the original fracture, repositioning and if necessary interpositional bone grafting to maintain lengthening of the ramus • a ramus osteotomy distant from the fracture site
- 79. © Ramaiah University of Applied Sciences 79 Faculty of Dental Sciences University Logo Bilateral condylar malunion • results in anterior open bite and class II jaw relationship. • The correction is achieved by adjusting the maxilla to accommodate this reduced posterior face height by carrying out a posterior maxillary impaction. • This results in an increase of the occlusal plane angle, but this is of little significance and will result in a stable correction of the anterior open bite component of the deformity, as a consequence of mandibular autorotation.
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- 83. © Ramaiah University of Applied Sciences 83 Faculty of Dental Sciences University Logo Conclusion • The basic principles of treatment of post-traumatic residual deformities include an initial major osseous reconstructive surgery to restore an anatomically correct craniofacial architecture followed by selective procedures to address soft tissue deficits and functional deformities. • Preservation of essential and basic functions will be the primary goal followed by the creation of form/function and esthetics. • Careful preoperative assessment, establishment of reasonable reconstructive goals and detailed surgical planning are critical to ensure the best possible outcome
- 84. © Ramaiah University of Applied Sciences 84 Faculty of Dental Sciences University Logo References • Rowe and Williams’ Maxillofacial Injuries 2nd edition • Maxillofacial trauma and esthetic facial reconstruction -Peterwardbooth • Managementof Naso-Orbito-EthmoidFractures: A10-YearReview MiladEtemadi • Medial canthopexy of old unrepaired naso-orbital ethmoid traumatic telecanthus – amir et al • External Dacryocystorhinostomy and Transnasal Canthopexy: New Details of Combined Surgery-Marco Sales-Sanz et al • Late revision or correction of facial truma – related soft tissue injuries- rieck et al • The Correction of Post-Traumatic Pan Facial Residual Deformity- K. Ranganath et al
- 85. © Ramaiah University of Applied Sciences 85 Faculty of Dental Sciences University Logo Thank you
Editor's Notes
- #8: The relaxed skin tension lines (RSTL) should be used in closure design and incision planning. When designing flaps, borrow tissue from the same or adjacent cosmetic units to minimize anatomic distortion and maximize tissue match. Place the suture lines along STLs and on the boundaries of the cosmetic units whenever possible
- #17: The scar is outlined circumferentially with multiple opposing W’s, each with a limb no longer than approximately 5 mm. Once the scar is excised, the 2 flaps are brought together to create a series of small W’s. Rearrangement of the scar from a wide and linear appearance into smaller geometric shapes improves the appearance of the scar
- #18: a test area (behind the ears) can be dermabraded to judge the skin reaction neocollagen formation as well neo-orientation of the collagen fibers , which can further enhance the appearance of the scar.
- #19: The adjacent skin is also dermaabraded for healthy neocollagen formation
- #20: hypertrophic scars are better treated using dermabrasion. The 2 modalities can be easily used simultaneously; after dermabrading a raised scar, the entire facial unit can be treated with laser
- #33: Prosthetics are ideal in some cases where tissues are completely avulsed or missing, such as ears or noses.
- #43: only a cm of dorsal and caudal cartilage must be retained for adequate dorsal support
- #49: Placed between the upper lateral cartilage and the nasal septum
- #50: Lateral, midlevel and superior osteotomies
- #51: Extreme severity of impact received by the nasal complex involves the frontal process of maxillae and the two orbital plates of ethmoid bone
- #53: Exposure- bicoronal incision, lynch incion, w incision, lacerations Identify the MCL or the MCL bearing bone. Reconstruct medial orbital walls. Transnasal conthopexy
- #57: 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. 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.
- #62: LACRIMAL STENTS AND TUBES Silicone, pyrex glass
- #63: 1 inferior, and superior canaliculi are identified by placing lacrimal probes within the lumen 2-6-0 monofilament sutues 3-the stent is passed through the punctum 4-Ritleng introducer is passed until a hard stop is encountered(LACRIMAL SAC). 90 DEGRESS to the naso lacrimal duct
- #64: 1- Using a Ritleng hook, the stent is retrieved from the nose 2-adjusting the tension on the silicone stents 6.0 silk suture 3- knot is then pulled through the upper canaliculus 4- second knot (B) is tied approximately 1.5 cm above A
- #65: The second knot (B) is then positioned in the lacrimal sac A-at the level of the nostril steroid and antibiotic oint 10-14 days Shut eyes 24hrs 3 months. At this point, the stent is removed by cutting the loop
- #69: 3-d CT shows over-reduction of the fracture of the left zygoma
- #71: The malunion fragments are osteotomised and fixed in its initial position Inlay or onlay bone grafts are used
- #81: unilateral condylar malunion-Vertical ramus osteotomy Pre op malocclusion Retromandibular incision Temporary imf
- #82: BSSO to correct postoperative malocclusion Unilatral condylar #
- #83: Bimaxillary osteotomy to treat anterior open bite and mandibular asymmetry Bilateral condylar fracture