09-09-2011-14H_PETER WARD-BOOTH
-
Upload
cobrac-2011 -
Category
Documents
-
view
219 -
download
0
description
Transcript of 09-09-2011-14H_PETER WARD-BOOTH
![Page 1: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/1.jpg)
XXI Oral and Maxillofacial Surgery Brazilian XXI Oral and Maxillofacial Surgery Brazilian Congress Congress
Vitória, ES, BrazilVitória, ES, Brazil
“Naso“Naso--ethmoid & ethmoid & ZygomaticZygomatic“Naso“Naso--ethmoid & ethmoid & ZygomaticZygomaticTrauma Trauma –– a personal a personal
perspective” perspective” peter ward booth fds frcs ukpeter ward booth fds frcs uk
![Page 2: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/2.jpg)
Most interesting facial Most interesting facial fractures?fractures?
•• NasoNaso--ethmoidethmoid––UncommonUncommon
•• ZygomaticZygomatic––Very commonVery common
![Page 3: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/3.jpg)
Why so interesting ?Why so interesting ?
Because the Because the outcomes are not outcomes are not always good enough always good enough always good enough always good enough
![Page 4: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/4.jpg)
Aetiology of mid face trauma in Aetiology of mid face trauma in the UKthe UK
•• Road traffic Road traffic accidentsaccidents
••WorkWork••WorkWork•• AssaultsAssaults•• “falls”“falls”•• sports sports
![Page 5: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/5.jpg)
Cars are much safer todayCars are much safer today
•• Pedestrians Pedestrians still at risk in still at risk in urban areasurban areasurban areasurban areas
•• Children at Children at risk in inner risk in inner citiescities
![Page 6: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/6.jpg)
Less heavy industry & much saferLess heavy industry & much safer
••Work related Work related facial injuries facial injuries very rarevery rarevery rarevery rare
![Page 7: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/7.jpg)
“falls”“falls”
•• Usually a Usually a medical medical problem in the problem in the problem in the problem in the elderlyelderly
•• Not common to Not common to get a facial get a facial injuryinjury
![Page 8: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/8.jpg)
sportssports
•• Increasing Increasing problemproblem
•• Nasal and Nasal and zygoma zygoma fracturesfractures
![Page 9: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/9.jpg)
assaultsassaults
•• Several studies Several studies in the UK by Jon in the UK by Jon ShepherdShepherdShepherdShepherd
•• Hutchison I, Magennis P, Shepherd JP, Brown AEHutchison I, Magennis P, Shepherd JP, Brown AE•• The BAOMS United Kingdom survey of facial The BAOMS United Kingdom survey of facial
injuries. Part I: aetiology and the association with injuries. Part I: aetiology and the association with alcohol consumption. Br J Oral Maxillofac Surg alcohol consumption. Br J Oral Maxillofac Surg 19981998
![Page 10: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/10.jpg)
Assaults main cause of facial Assaults main cause of facial injuries in the UKinjuries in the UK
•• Victims & culpritsVictims & culprits
––Young malesYoung males––Young malesYoung males––Unemployed or menial jobsUnemployed or menial jobs––Alcohol usually involved Alcohol usually involved
![Page 11: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/11.jpg)
NasoNaso-- ethmoid injuriesethmoid injuries
![Page 12: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/12.jpg)
My “key points”My “key points”
•• The injury is a “spectrum” & The injury is a “spectrum” & needs a good classificationneeds a good classification
•• Open access & fixation neededOpen access & fixation needed
•• immediate grafting should be immediate grafting should be consideredconsidered
![Page 13: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/13.jpg)
Nasoethmoid fracturesNasoethmoid fractures
•• Must be seen as Must be seen as a spectruma spectrum
•• Severity increases withSeverity increases with•• Severity increases withSeverity increases with–– ComminutionComminution–– Soft tissue damageSoft tissue damage–– displacementdisplacement
![Page 14: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/14.jpg)
Simple nasal fracture to severe nasoSimple nasal fracture to severe naso--ethmoid fractureethmoid fracture
![Page 15: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/15.jpg)
So we need a “helpful” So we need a “helpful” classificationclassification
•• Rowe & Williams (1994)Rowe & Williams (1994)––bibi--laterallateral––uniuni--laterallateral––uniuni--laterallateral–– isolatedisolated––with frontal #with frontal #
![Page 16: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/16.jpg)
classificationclassification
•• Gruss (1984) Gruss (1984) ––nasoethmoidnasoethmoid––nasoethmoid & central maxillanasoethmoid & central maxilla––nasoethmoid & central maxillanasoethmoid & central maxilla––+Le Fort II or III+Le Fort II or III––+Orbital dystopia+Orbital dystopia––+loss of bone+loss of bone
![Page 17: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/17.jpg)
classificationclassification
••Markowitz (1991) Markowitz (1991) ––goodgood••––single unit with canthussingle unit with canthus––single unit with canthussingle unit with canthus––comminution but not to canthuscomminution but not to canthus––comminution involving canthuscomminution involving canthus––uni or bi uni or bi --laterallateral
![Page 18: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/18.jpg)
classificationsclassifications
•• MarkowitzMarkowitz––recognises the importance recognises the importance of:of:of:of:••comminutioncomminution••canthal attachmentcanthal attachment
![Page 19: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/19.jpg)
a new classificationa new classification
•• Peter Ayliffe Peter Ayliffe (Consultant at Gt.Ormond St. (Consultant at Gt.Ormond St.
London)London)
•• aims to identify all the aims to identify all the •• aims to identify all the aims to identify all the aspects which are likely to aspects which are likely to produce a produce a POORPOOR outcome outcome ––i.e. “difficult case”i.e. “difficult case”
![Page 20: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/20.jpg)
Ayliffe’s classification of Ayliffe’s classification of Nasoethmoid fracturesNasoethmoid fractures•• Type 0Type 0•• Type IType I•• Type IType I•• Type IIType II•• Type IIIType III•• Type IVType IV
![Page 21: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/21.jpg)
•• Type 0Type 0UnUn--displaceddisplacedUnUn--displaceddisplaced
![Page 22: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/22.jpg)
•• Type IType IComminuted,Comminuted,Comminuted,Comminuted,but “platable”but “platable”
![Page 23: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/23.jpg)
•• Type IIType IIRequiringRequiringRequiringRequiringbone graftbone graft
![Page 24: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/24.jpg)
•• Type IIIType IIICanthal Canthal Canthal Canthal disruption,disruption,requiringrequiringcanthoplexycanthoplexy
![Page 25: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/25.jpg)
•• Type IVType IVLacrimal Lacrimal Lacrimal Lacrimal reconstructionreconstruction
![Page 26: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/26.jpg)
Should there be a V type?Should there be a V type?
Other fractures for example Other fractures for example orbitalorbital
![Page 27: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/27.jpg)
Why the need for Why the need for classification?classification?
•• Surgical planningSurgical planning•• Measuring outcomesMeasuring outcomes
![Page 28: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/28.jpg)
Examination & diagnosisExamination & diagnosis
![Page 29: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/29.jpg)
General appearanceGeneral appearance•• nasal nasal deformitydeformity–– “pig’s snout” !!“pig’s snout” !!–– “pig’s snout” !!“pig’s snout” !!
––DeviationDeviation
––broadeningbroadening
![Page 30: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/30.jpg)
Soft tissueSoft tissue•• inspect lacerations inspect lacerations for:for:–– foreign bodiesforeign bodies
–– damage to VII nerve or damage to VII nerve or lacrimal apparatuslacrimal apparatus
–– tissue losstissue loss
![Page 31: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/31.jpg)
Soft tissueSoft tissue
••mobility of canthusmobility of canthus
peter.wardbooth@btope
nworld.com
![Page 32: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/32.jpg)
Evaluate the orbitEvaluate the orbit
standard eye examinationsstandard eye examinations••visual acuityvisual acuity
••movements /diplopia (Hess movements /diplopia (Hess ••movements /diplopia (Hess movements /diplopia (Hess chart)chart)
••EnophthalmosEnophthalmos
•• intra ocular intra ocular
![Page 33: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/33.jpg)
Bone damageBone damage
•• Clinical Clinical examination examination still still examination examination still still importantimportant
•• radiologicalradiological
![Page 34: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/34.jpg)
radiological radiological
•• look for:look for:––fractures linesfractures lines––fractures linesfractures lines––comminutioncomminution––bone + canthal attachmentbone + canthal attachment––other relevant #, intracranial other relevant #, intracranial bleedsbleeds
![Page 35: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/35.jpg)
Radiological AFTER clinical Radiological AFTER clinical examinationexamination
•• basic screenbasic screen––occipital occipital mentalmental––occipital occipital mentalmental–– lateral skulllateral skull
![Page 36: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/36.jpg)
radiologicalradiological
•• if NOE # suspectedif NOE # suspected––C.T. essentialC.T. essential
––dycrocystogram rare in dycrocystogram rare in acute situationacute situation
![Page 37: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/37.jpg)
C.T. essential for NC.T. essential for N--E fractures?E fractures?
![Page 38: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/38.jpg)
DCR DCR
![Page 39: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/39.jpg)
It is said most audiences loose It is said most audiences loose concentration after 15 minutesconcentration after 15 minutes
•• But how do I get But how do I get •• But how do I get But how do I get the attention of the attention of females?females?
![Page 40: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/40.jpg)
SurgerySurgery
•• TimingTiming
•• AccessAccess
•• fixationfixation
![Page 41: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/41.jpg)
timingtiming
•• ? as soon as possible? as soon as possible––other injuries frequently other injuries frequently delaydelaydelaydelay–– let swelling reducelet swelling reduce
•• long delays = poor resultslong delays = poor results
![Page 42: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/42.jpg)
A delayed caseA delayed case
![Page 43: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/43.jpg)
accessaccess
•• Use lacerationsUse lacerations•• Coronal flap usually enoughCoronal flap usually enough
––Transconjunctival may be Transconjunctival may be needed for medial wall/floor needed for medial wall/floor of orbitof orbit
![Page 44: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/44.jpg)
operative sequenceoperative sequence
•• Commonsense! Build up from Commonsense! Build up from the foundations the foundations ––fix the mandiblefix the mandible––fix the mandiblefix the mandible––start laterally in the maxillastart laterally in the maxilla––central mid face lastcentral mid face last
![Page 45: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/45.jpg)
Have a logical plan!Have a logical plan!
•• The “pillars” for The “pillars” for reconstructionreconstruction–– These are obvious as the These are obvious as the bone is thickest and bone is thickest and bone is thickest and bone is thickest and easiest to plateeasiest to plate
•• Restoring the Restoring the zygomatic arch is zygomatic arch is more easily more easily “missed”“missed”
![Page 46: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/46.jpg)
fixationfixation
•• Use the smallest platesUse the smallest plates
![Page 47: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/47.jpg)
Supplementary fixationSupplementary fixation
•• The special problem of the The special problem of the completely detached canthuscompletely detached canthus
•• However most canthal However most canthal attachments remain if only to attachments remain if only to small fragments of bonesmall fragments of bone
![Page 48: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/48.jpg)
Complete canthal Complete canthal detachmentdetachment
•• Requires canthoplexyRequires canthoplexy––Is simple trans nasal wiring Is simple trans nasal wiring enough???enough???enough???enough???
![Page 49: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/49.jpg)
•• As shown in this diagram the As shown in this diagram the wire will:wire will:–– “cut through” the ligament“cut through” the ligament––And is too far forwardAnd is too far forward
![Page 50: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/50.jpg)
Trans nasal canthoplexyTrans nasal canthoplexy
––Wire Wire ––pullingpulling
––Acrylic Acrylic button button pushingpushing
![Page 51: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/51.jpg)
When to graftWhen to graft
•• Grossly comminuted boneGrossly comminuted bone
•• Missing boneMissing bone•• Missing boneMissing bone––Don’t delay and plan a Don’t delay and plan a secondary proceduresecondary procedure
![Page 52: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/52.jpg)
Missing or grossly Missing or grossly comminuted bonecomminuted bone
![Page 53: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/53.jpg)
Some casesSome cases
![Page 54: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/54.jpg)
•• Direct access to ensure good Direct access to ensure good reduction (via laceration)reduction (via laceration)
![Page 55: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/55.jpg)
•• Direct plating Direct plating onto lachrymal onto lachrymal bone bone bone bone
•• medial canthus medial canthus still attachedstill attached
![Page 56: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/56.jpg)
•• Check Check xx--rayray
•• C.T. C.T. --yes yes ideallyideallyideallyideally
![Page 57: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/57.jpg)
complicationscomplications
•• Poor reductionPoor reduction
•• Soft tissueSoft tissue•• Soft tissueSoft tissue••LidsLids••DrainageDrainage
•• (Orbital)(Orbital)
![Page 58: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/58.jpg)
telecanthustelecanthus
•• Poor canthal reductionPoor canthal reduction
![Page 59: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/59.jpg)
•• Lacerations will always be less Lacerations will always be less satisfactory satisfactory –– but they maturebut they mature
![Page 60: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/60.jpg)
Lachrymal damageLachrymal damage
•• Despite Despite immediate immediate canalisation canalisation canalisation canalisation of duct with of duct with tubestubes
![Page 61: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/61.jpg)
Zygoma traumaZygoma trauma
•• Zygoma & orbital Zygoma & orbital wallswalls
•• GlobeGlobe•• GlobeGlobe•• Soft tissueSoft tissue––Skin & periSkin & peri--orbital orbital tissuestissues
![Page 62: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/62.jpg)
My “key points”My “key points”••Ocular injury likely Ocular injury likely
•• Access, fixation & Access, fixation & •• Access, fixation & Access, fixation & reconstructionreconstruction
•• Don’t delay surgeryDon’t delay surgery
![Page 63: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/63.jpg)
Ocular injuryOcular injury
––A separate topic but covered A separate topic but covered well by Leo Stassen’s paperwell by Leo Stassen’s paper
alal--Qurainy IA, Stassen LF, Dutton GN, Moos KF, elQurainy IA, Stassen LF, Dutton GN, Moos KF, el--Attar A.Attar A.•• Br J Oral Maxillofac Surg. 1991 Oct;29(5):302Br J Oral Maxillofac Surg. 1991 Oct;29(5):302--77
![Page 64: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/64.jpg)
Leo Stassen BJOMS 1991Leo Stassen BJOMS 1991
••The definitive workThe definitive work••The definitive workThe definitive work––363 pts 363 pts (prospective study(prospective study
––2 year study2 year study
![Page 65: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/65.jpg)
Leo Stassen Leo Stassen --ocular injuriesocular injuries
••63% minor63% minor
•• 16% moderate16% moderate
•• 12% severe12% severe
![Page 66: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/66.jpg)
Most ocular problems resolveMost ocular problems resolve
––SwellingSwelling––DiplopiaDiplopia––Loss of Loss of ––Loss of Loss of motilitymotility
![Page 67: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/67.jpg)
Ocular injuriesOcular injuries
••Severity of injury Severity of injury increases riskincreases risk
••Reduction in visual acuity Reduction in visual acuity --main problemmain problem
••2.5% optic neuropathy2.5% optic neuropathy
![Page 68: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/68.jpg)
Conclusion:Conclusion:
•• Use a scoring systemUse a scoring system
•• Involve ophthalmologistInvolve ophthalmologist•• Involve ophthalmologistInvolve ophthalmologist
![Page 69: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/69.jpg)
My question!My question!
•• But how many injuries were But how many injuries were important and could be important and could be treated?treated?
•• DiplopiaDiplopiatreated?treated?
•• DiplopiaDiplopia•• Visual lossVisual loss––Retro bulbar hemorrhage Retro bulbar hemorrhage (0.5%)(0.5%)––Optic nerve compressionOptic nerve compression
![Page 70: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/70.jpg)
what should we do?what should we do?
••Examine and document the Examine and document the problemproblem
••Treat those who will Treat those who will ••Treat those who will Treat those who will benefit i.e.benefit i.e.••potentially reversible potentially reversible damagedamage
![Page 71: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/71.jpg)
reversible damagereversible damage
••Retro bulbar hemorrhage Retro bulbar hemorrhage ••BUT very rare <1%BUT very rare <1%
![Page 72: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/72.jpg)
At least you can At least you can say you have seen say you have seen one!one!
![Page 73: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/73.jpg)
Cook et al 1996Cook et al 1996
••Meta analysis of treatment Meta analysis of treatment of traumatic neuropathyof traumatic neuropathy––Treatment improves Treatment improves outcomeoutcome––Treatment improves Treatment improves outcomeoutcome––Unable to show benefit of Unable to show benefit of different treatmentsdifferent treatments
![Page 74: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/74.jpg)
The treatmentsThe treatments
••SteroidsSteroids
••SurgerySurgery
••Surgery & steroidsSurgery & steroids
![Page 75: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/75.jpg)
Zhonghua 2004Zhonghua 2004
•• 118 pts, 5 levels of 118 pts, 5 levels of neuropathy neuropathy ••BlindBlind••BlindBlind••Hand movementHand movement••Finger countFinger count••Light perceptionLight perception••Acuity lowest scoreAcuity lowest score
![Page 76: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/76.jpg)
Endoscopic Endoscopic decompressiondecompression
••50% of the blind 50% of the blind “effective”“effective”
•• 100% of those with 100% of those with minimal acuity minimal acuity “effective”“effective”
![Page 77: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/77.jpg)
“effective” means?“effective” means?
••Move up one or more Move up one or more grades ie not a “cure”grades ie not a “cure”
••Treat within 3 daysTreat within 3 days
••Steroids not usedSteroids not used
![Page 78: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/78.jpg)
The common “reversible” with The common “reversible” with treatment ocular problemstreatment ocular problems
•• DiplopiaDiplopia
––Loss of motilityLoss of motility––Loss of motilityLoss of motility
––Displaced globeDisplaced globe
![Page 79: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/79.jpg)
A “full house” A “full house” ––the perils of delaythe perils of delay
•• Loss of Loss of motilitymotility
•• DiplopiaDiplopia•• DiplopiaDiplopia•• DystopiaDystopia•• Ectropion Ectropion
![Page 80: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/80.jpg)
Management zygoma traumaManagement zygoma trauma
•• DiagnosisDiagnosis––ClinicalClinical––radiologicalradiological––radiologicalradiological
![Page 81: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/81.jpg)
clinicalclinical
•• OcularOcular
•• BoneBone•• BoneBone
•• neurologicalneurological
![Page 82: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/82.jpg)
Ocular examinationOcular examination
••visual acuityvisual acuity(Chart or paper!)(Chart or paper!)••Examine the eyeExamine the eye
![Page 83: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/83.jpg)
Eye examinationEye examination
•• Intra ocularIntra ocular––Specialist Specialist opinion?opinion?opinion?opinion?
![Page 84: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/84.jpg)
Diplopia & motility examinationDiplopia & motility examination
•• Record Record findingsfindings
•• Hess chartHess chart•• Hess chartHess chart
![Page 85: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/85.jpg)
Position of the globePosition of the globe
••Enophthalmos/ dystopiaEnophthalmos/ dystopia
![Page 86: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/86.jpg)
bonebone•• Most of the Most of the information you need information you need is at your finger tips!is at your finger tips!is at your finger tips!is at your finger tips!
![Page 87: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/87.jpg)
neurologicalneurological
•• SensorySensory––IO nerveIO nerve
•• MotorMotor––VII & ocular movementsVII & ocular movements
![Page 88: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/88.jpg)
radiologicalradiological
•• Plain filmPlain film––Occipital Occipital mental 30mental 30mental 30mental 30
•• CT (gold CT (gold standard)standard)
•• uu/sound MRI ??/sound MRI ??
![Page 89: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/89.jpg)
SurgerySurgery
![Page 90: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/90.jpg)
Timing Timing –– as soon as possible as soon as possible –– if if not before!not before!
![Page 91: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/91.jpg)
Surgical accessSurgical access
••All have potential All have potential complicationscomplications••Except intra oral Except intra oral ••Except intra oral Except intra oral approach, but inadequate approach, but inadequate accessaccess•• ?endoscopic approaches?endoscopic approaches
![Page 92: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/92.jpg)
Very traditional approachesVery traditional approaches
![Page 93: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/93.jpg)
Surgical access of choiceSurgical access of choice
•• LacerationsLacerations•• TransTrans--conjunctival +conjunctival +-- lateral lateral extension extension extension extension
![Page 94: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/94.jpg)
Surgical Access To The Surgical Access To The OrbitOrbitOrbitOrbit
Mr Kenneth SneddonMr Kenneth SneddonFDSRCS, FRCSFDSRCS, FRCS
![Page 95: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/95.jpg)
Surgical Approaches to the Surgical Approaches to the Orbital SkeletonOrbital Skeleton
Transconjunctival + Transconjunctival + Orbital SkeletonOrbital Skeleton
Transconjunctival + Transconjunctival + canthotomycanthotomy
![Page 96: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/96.jpg)
FollowFollow--upupComplete followComplete follow--up to 6 months up to 6 months 4949 80.3%80.3%
Ongoing followOngoing follow--upupOngoing followOngoing follow--upup10 16.4%10 16.4%
Lost to followLost to follow--upup2 3.3%2 3.3%
![Page 97: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/97.jpg)
ChemosisChemosis
ImmediateImmediate 1 month 3 months1 month 3 months
27.8%27.8% 0%0% 0%0%
![Page 98: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/98.jpg)
Scleral ShowScleral Show
1 1 monthmonth 3 3 monthsmonths 6 6 monthsmonths
18%18% 6.4%6.4% 3.2%3.2%
(11pts)(11pts) (4 pts)(4 pts) (2 pts)(2 pts)
![Page 99: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/99.jpg)
Other ComplicationsOther ComplicationsWebbing at outer canthusWebbing at outer canthus 1pt1pt
Canthal malpositionCanthal malposition 1pt1pt
Temporary weakness upperTemporary weakness upper 1pt1ptbranch of VII nervebranch of VII nerve
![Page 100: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/100.jpg)
•• Avoids two separate incisionsAvoids two separate incisions
•• Superior surgical accessSuperior surgical access
•• Simultaneous visualisation of Simultaneous visualisation of •• Simultaneous visualisation of Simultaneous visualisation of FZ & orbital rimFZ & orbital rim
•• Excellent cosmesis & low Excellent cosmesis & low morbiditymorbidity
![Page 101: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/101.jpg)
surgical accesssurgical access•• lacerationslacerations•• subsub--conjunctivalconjunctival•• coronal flap for displaced coronal flap for displaced malar/multi wall injuriesmalar/multi wall injuriesmalar/multi wall injuriesmalar/multi wall injuries
![Page 102: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/102.jpg)
•• quick ‘n easyquick ‘n easy
•• still needs to be still needs to be
coronal flapcoronal flap
•• still needs to be still needs to be in the right in the right place!place!
•• Only needed in Only needed in complex casescomplex cases
![Page 103: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/103.jpg)
coronal flapcoronal flap
![Page 104: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/104.jpg)
fixationfixation
![Page 105: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/105.jpg)
Internal fixationInternal fixation
••OrbitoOrbito--zygoma trauma zygoma trauma needs the smallest plate in needs the smallest plate in the box???the box???the box???the box???
•• Don’t remove themDon’t remove them
![Page 106: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/106.jpg)
Degradable platesDegradable plates
•• “degradable” plates “degradable” plates ????••Large screwsLarge screws••Large screwsLarge screws••Swell before Swell before degradingdegrading
![Page 107: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/107.jpg)
Orbital wall repairOrbital wall repair
••Close the holesClose the holes
••Maintain the volumeMaintain the volume••Maintain the volumeMaintain the volume
••Which material?Which material?
![Page 108: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/108.jpg)
Orbital wall repairsOrbital wall repairs
•• Are we over obsessed by Are we over obsessed by precise reconstructions?precise reconstructions?
•• Does not need to be exactly Does not need to be exactly the correct volume +the correct volume +--5%?5%?
![Page 109: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/109.jpg)
What really matters?What really matters?
•• Good motilityGood motility
•• No diplopiaNo diplopia•• No diplopiaNo diplopia
•• Position of globe Position of globe –– least least importantimportant
![Page 110: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/110.jpg)
Poor motility reasonable positionPoor motility reasonable position
![Page 111: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/111.jpg)
Poor position good motility & no Poor position good motility & no diplopiadiplopia
![Page 112: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/112.jpg)
Know your anatomyKnow your anatomy
![Page 113: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/113.jpg)
key pointskey points•• optic nerve optic nerve to rimto rim
•• the “ridge” in the “ridge” in orbital floororbital floor
![Page 114: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/114.jpg)
Lecturer’s nightmareLecturer’s nightmare
![Page 115: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/115.jpg)
bonebone
•• BiocompatibleBiocompatible•• CheapCheap•• CheapCheap
![Page 116: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/116.jpg)
other materialsother materials
••Titanium meshTitanium mesh••Effect of further Effect of further trauma?trauma?trauma?trauma?••Usually in young Usually in young people and difficult to people and difficult to removeremove••effectiveeffective
![Page 117: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/117.jpg)
other materialsother materials
••SiliconeSilicone••Well provenWell proven••Minimal tissue Minimal tissue ••Minimal tissue Minimal tissue reactionreaction••Only small defectsOnly small defects••May get infected, but May get infected, but easy to removeeasy to remove
![Page 118: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/118.jpg)
other materialsother materials
•• “degradable” materials“degradable” materials••F.B. reaction F.B. reaction --?scarring?scarring?scarring?scarring••Shrink on degradationShrink on degradation••Swell before shrinkingSwell before shrinking••Not rigid for large Not rigid for large defectsdefects
![Page 119: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/119.jpg)
other materialsother materials
•• MedporeMedpore••ExpensiveExpensive••Lot of fibrosisLot of fibrosis••Lot of fibrosisLot of fibrosis••RigidRigid
•• Polyether ether ketone (PEEK) Polyether ether ketone (PEEK) –– can be custom madecan be custom made
![Page 120: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/120.jpg)
Increasing the accuracy of Increasing the accuracy of the reconstructionthe reconstruction
![Page 121: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/121.jpg)
If you want a perfect If you want a perfect reconstruction (+ orreconstruction (+ or-- 1mm) 1mm) then get a navigation systemthen get a navigation system
![Page 122: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/122.jpg)
Surgical navigation in Surgical navigation in craniomaxillofacial Surgery: craniomaxillofacial Surgery: expensive toy or useful toolexpensive toy or useful tool
Lubbers JOMS 2011Lubbers JOMS 2011
•• A very good question !A very good question !•• A very good question !A very good question !
•• But does not give the answer !!But does not give the answer !!•• Invaluable in oncologyInvaluable in oncology
![Page 123: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/123.jpg)
Computer Assisted PlanningComputer Assisted PlanningBell B et al JOMS 2009Bell B et al JOMS 2009
•• Describes his experienceDescribes his experience
•• AND acknowledges the problems AND acknowledges the problems •• AND acknowledges the problems AND acknowledges the problems of scarring in fully correcting of scarring in fully correcting dystopia & diplopiadystopia & diplopia
![Page 124: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/124.jpg)
Or use a 3Or use a 3--D modelsD models
••Much cheaperMuch cheaper•• Also allows titanium Also allows titanium plate to be made plate to be made prepre--opopplate to be made plate to be made prepre--opop
––Reduces Reduces operating timeoperating time
![Page 125: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/125.jpg)
Still limitationsStill limitations
•• Rely on “mirroring”Rely on “mirroring”
•• Artefacts with thin bonesArtefacts with thin bones•• Artefacts with thin bonesArtefacts with thin bones
•• In secondary reconstruction In secondary reconstruction scar tissue may prevent rescar tissue may prevent re--positioningpositioning
![Page 126: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/126.jpg)
![Page 127: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/127.jpg)
But is it that simple ?But is it that simple ?
![Page 128: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/128.jpg)
Why are children a Why are children a special problemspecial problem
••Can we learn Can we learn from them?from them?
![Page 129: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/129.jpg)
Remember what’s happeningRemember what’s happening
•• Plast. Reconstr Surg 57:233Plast. Reconstr Surg 57:233--235, 1976. 3. Korneef L: 235, 1976. 3. Korneef L: Orbital septa: Anatomy and function. Ophthalmology 86: Orbital septa: Anatomy and function. Ophthalmology 86: 876876--. 880, 1979. 880, 1979
![Page 130: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/130.jpg)
Early diagnosis & Early diagnosis & treatment essentialtreatment essential
![Page 131: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/131.jpg)
mid face trauma is mid face trauma is fascinatingfascinating
andandwe do not have all the we do not have all the we do not have all the we do not have all the
answersanswers
![Page 132: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/132.jpg)
I am very grateful to your I am very grateful to your President & Committee for their President & Committee for their kind invitation & hospitalitykind invitation & hospitality
muito obrigadomuito obrigado
![Page 133: 09-09-2011-14H_PETER WARD-BOOTH](https://reader033.fdocuments.in/reader033/viewer/2022051219/568bd5e31a28ab20349a18ad/html5/thumbnails/133.jpg)
Thank you Thank you