Maxillofacial surgery

Question 1

Orthognathic Surgery-
1. What are the indications for orthognathic surgery?

Answer 1

• For the treatment or correction of facial deformities - e.g congenital deformities or trauma patients
• Correction of severe skeletal malocclusions which are not amenable/treatable by orthodontics aline in patients for who growth is complete
• Aim to restore function and aesthetics
• Examples of patinets who may benefit are those with severe class lll malocclusions which is preventing them from incising food, those with severe mandibular retrognathism (class ll) results in tongue being held posterior causing obstructive sleep apnoea or those with aesthetic concerns which are having a psychological affect on the patient
• Orthognathic surgery also often forms part of the tx pathway for clef lip and palate patients (stage 5 age 18-20)

Question 2

What are the risks of orthognathic surgery?

Answer 2

• Relapse
• bleeding
• Failed or poor results
• nerve damage, temporary or permenant numbness of the lip
• infection
• TMD
• General risks for GA surgery

Question 3

What investigations should be carried out prior to getting orthognathic surgery?

Answer 3

• Radiographs. OPT, lateral ceph, CBCT (for all patients)
• Mounted study models (using facebow)
• Photographs 2D and 3D (stereophotogrammetry to allow 3D soft tissue analysis)
• Predicition planning
• Psychological assessment
• Full clinical examination

Question 4

Give 2 types of mandibular surgery?

Answer 4

• Bilateral sagittal split osteotomy (BSSO)
• Vertical sub sigmoid osteotomy (VSSO)

Question 5

Give 2 types of maxillary surgery?

Answer 5

Le fort 1 osteotomy
Anterior maxillary osteotomy

Question 6

What are the signs and symptoms of a maxillary fracture?

Answer 6

• Pain, swelling, brusing, bleeding
• Facial asymmetry (swelling then flattening)
• Anterior OB
• Altered sensation
• Diplopia (Seeing double)
• Bilateral peri-orbital ecchymosis (black eyes)
• CSF rhinnorrhoea or nose bleed
• Palatal haematoma/bruising
• Traumatic dystopia (eye sockets displaced laterally)
• Epiphora (outflow of tears down cheeks)
• Derangement of occlusion - posterior impaction of teeth
• mobility of teeth
• Trismus
• Soft tissue injuries oral tears
• Teeth dull on TTP

Question 7

What is le fort classification?

Answer 7

Le fort l - Horizontal fracture, straight across the maxilla above the dentition and seperating teeth from upper face (floating palate)
Le fort ll - pyramidal facture involves nasofrontal suture (at apex) and infra-orbital rims and seperating nose, maxilla and teeth from the rest of the face (floating maxilla)
le fort lll - Transverse facture involves nasofrontal suture, maxilla-frontal suture, orbital wall and zygomatic arch and separating maxilla completely from the skull (craniofacial disjuncction) Floating face.

Question 8

What special investigations would you use?

Answer 8

Occipital mental facial views 15° and 30°

Question 9

How is a maxillary facture managed?

If it is hairline and then displaced

Answer 9

hairline fracture/not displaced, consider monitoring and pain relief
Open reduction and internal fixation under GA
Closed reduction and fixation

An open reduction internal fixation or ORIF is a surgical procedure to repair a fractured bone. The open reduction part of the operation involves restoring displaced bones to their correct position and the internal fixation is where the bones are fixed into place with rods, plates, and screws.

Question 10

Zygomatico-Obrital Complex Fracture-
1. What are 6 signs and symptoms of ZOC fractures involving the orbital floor?

Answer 10

• Double vision
• facial asymmetry (swelling followed by flattening)
• Alteration in sensation (infra-orbital damage)
• Numb cheek
• Black eyes
• Sub-conjunctival haemorrhage (biggest indicator)

Question 11

What imaging would you want to take to comfirm the ZOC fracture diagnosis?

Answer 11

Occipitalmental facial views at 15° and 30° (use campbells views to interpret)
Complex fractures or blow outs take CT scan

Question 12

3. What are the management options for ZOC fractures?

Answer 12

• No tx leave and monitor
• Exposure and repair of fracture - open reduction and internal fixation
• Closed reduction. Gillies lift (arch lifted out of realignment (or malar hook) (with FZ suture plate or malar butress plate)

Question 13

4. What post-operative advice should be given for ZOC fractue?

Answer 13

• Avoid nose blowing
• Eye observation overnight - if any suggestion of deterioration in visual acuity needs urgent attention (may be a sign of retrobulbar haemorrhage which is characterised by this along with severe pain, proptosis and ophthalmoplegia)
• Pain management
• Post operative steroids dexamethasone 4-8mg