How will you manage.....??? (case discussion)

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DENTALmd

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Hi all this is my frist post here...and I woud like to share a case to see the defferant ways for treatment and vairous approch
case No:1 Residual deformity of gun shot wound to the left zygoma, orbit and nasoethmoidal region.

http://www.rp4baghdad.org/cases/maxillofacial/case025/img/b3.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case025/img/b1.jpg
those are pic of the Stereolithography model
so please post your way of handling such a case?😉

i'll take a shot at it (no pun intended) even though it's difficult to say without
1. seeing (frontal, profile, birds eye) pictures of the patient
2. without scrolling through coronal, axial, and saggital CTs

I'd imagine this pt has L enophthalmos which makes this a functional and cosmetic repair (if he didnt lose his eye with the GSW which it doesn't look like he would have)

Your deformities include discontinuous zygoma, depressed orbitozygomatic (OZ) complex, downward and inward rotation of the orbitozygomatic complex. I don't see much of an issue with the NOE region as you have alluded to.

Goals of treatment: Restore orbital volume and facial symmetry

My treatment would include: Perform model surgery on the orbitozygomatic complex with fronto-zygomatic, sphenozygomatic, and zygomaticomaxillary osteotomies (the zygomaticotemporal area already discontinuous) Place the OZ complex in the desired position and make a custom implant that will span the discontinuity (or you couldtake the easier route of planning on just plating/meshing across that discontinuity). Intraoperatively, use a hemicoronal and intraoral approach, mobilize the OZ complex with osteotomies, rotate upward and outward, fixate, apply the custom implant to span the defect, explore the floor and place filler (such as calvarium since you have a hemicoronal already) to additionally help restore volume of not already done with just rotating the OZ complex.

why did you not include the entire maxilla in your model (zygomaticomaxillary buttress)? My treatment is by no means the only way to treat this case. there are less invasive ways to providing purely functional treatment that are less involved. Your zygoma projection really isn't all that bad. It's mostly an issue of orbital volume. But what do i know. I'm just a dentist.

I bet the stereolithography business is loving the war there.
 
i'll take a shot at it (no pun intended) even though it's difficult to say without
1. seeing (frontal, profile, birds eye) pictures of the patient
2. without scrolling through coronal, axial, and saggital CTs

I'd imagine this pt has L enophthalmos which makes this a functional and cosmetic repair (if he didnt lose his eye with the GSW which it doesn't look like he would have)

Your deformities include discontinuous zygoma, depressed orbitozygomatic (OZ) complex, downward and inward rotation of the orbitozygomatic complex. I don't see much of an issue with the NOE region as you have alluded to.

Goals of treatment: Restore orbital volume and facial symmetry

My treatment would include: Perform model surgery on the orbitozygomatic complex with fronto-zygomatic, sphenozygomatic, and zygomaticomaxillary osteotomies (the zygomaticotemporal area already discontinuous) Place the OZ complex in the desired position and make a custom implant that will span the discontinuity (or you couldtake the easier route of planning on just plating/meshing across that discontinuity). Intraoperatively, use a hemicoronal and intraoral approach, mobilize the OZ complex with osteotomies, rotate upward and outward, fixate, apply the custom implant to span the defect, explore the floor and place filler (such as calvarium since you have a hemicoronal already) to additionally help restore volume of not already done with just rotating the OZ complex.

why did you not include the entire maxilla in your model (zygomaticomaxillary buttress)? My treatment is by no means the only way to treat this case. there are less invasive ways to providing purely functional treatment that are less involved. Your zygoma projection really isn't all that bad. It's mostly an issue of orbital volume. But what do i know. I'm just a dentist.

I bet the stereolithography business is loving the war there.


It's really hard to evaluate this case based on the lithographic models alone. You really need to see the soft tissue available to work with as well, because that will affect how you need to reconstruct the bony skeleton. Is there malposition of the medial canthus? Are there any soft tissue avulsions? Is the nasolacrimal apparatus intact? Is the tissue all scarred down - This could affect how easy it is to mobilize the osteotomized zygoma.

In general I would want to approach this from 2 perspectives: Restore the orbital aperture, and restore the orbital floor and walls.

The orbital aperture I would approach in a similar method as Scalpel, perhaps without the intraoral approach. I think you could cheat a little with your osteotomies and only mobilize a portion of the superior aspect of the orbital aperture and ZM complex, and leave the ascending aspect of the zygomatic process of the maxilla where it is. It also looks like you might need to remove bone at the FZ region in order to move the inferolateral aspect of the orbital aperture superiorly. It looks like there is new bone bridging a bony gap at the FZ. You need to bring the osteotomy on the medial aspect of the inferior rim quite nasally. Though I agree from the photos provided it does not appear to involve the medial canthal attachment. More views would be helpful.

Once that is done, I would move to grafting the internal orbit. You'll need alot of bone. I agree with calvarium. A preformed implant would also be reasonable. Or if you have access to navigation assisted equipment, that'd be REALLY sexy. You should probably graft the arch as well, for aesthetics and restoration of transverse facial support/dimensions. Are there any injuries to the condyle?

PS. Or you could wait 'til next week when the Silver Surfer shows up and get him to use his Power Cosmic to fix it for you.
 
Hi all..... this is a new case and I think this well be a big challange for any max fax team:meanie: here some info about the Pt.
The history of trauma due to war injury since 25 years ago, previous soft tissue reconstruction of sub mental region, lower lip and floor of the mouth had been done,Mandible bony defect from angle to angle.😱
here some of the model:
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b1.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b2.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b3.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b4.jpg
and here some pic of the Pt.
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/a1.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/c2.jpg

N.B. I bet the stereolithography business is loving the war there.....you do'nt tell me!!!!😉




I'll start my approach with evaluating the soft tissue which i belive there is good volume to allow for reconstructive surgery, note the lesion on the R cheek of the Pt. I think is't Keratoacanthoma that needs surgical excision!!!
now for the mandibular recon. I think this well require two team approach the frist explor the defect the 2nd harvus fibula free flap we well get access from sub mand. incision after proper dissection of soft tissue and expose of the bone defects bilateraly then try to adapt the graft and anastimos the vessals the fallowed by placing some implants to restor the function, regarding the maxillary anterior defect in another stage reconstruct with illiac crest graft and also place cauple of implants in there and case is close:hardy:
 
Hi all..... this is a new case and I think this well be a big challange for any max fax team:meanie: here some info about the Pt.
The history of trauma due to war injury since 25 years ago, previous soft tissue reconstruction of sub mental region, lower lip and floor of the mouth had been done,Mandible bony defect from angle to angle.😱
here some of the model:
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b1.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b2.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b3.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/b4.jpg
and here some pic of the Pt.
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/a1.jpg
http://www.rp4baghdad.org/cases/maxillofacial/case033/img/c2.jpg

N.B. I bet the stereolithography business is loving the war there.....you do'nt tell me!!!!😉




I'll start my approach with evaluating the soft tissue which i belive there is good volume to allow for reconstructive surgery, note the lesion on the R cheek of the Pt. I think is't Keratoacanthoma that needs surgical excision!!!
now for the mandibular recon. I think this well require two team approach the frist explor the defect the 2nd harvus fibula free flap we well get access from sub mand. incision after proper dissection of soft tissue and expose of the bone defects bilateraly then try to adapt the graft and anastimos the vessals the fallowed by placing some implants to restor the function, regarding the maxillary anterior defect in another stage reconstruct with illiac crest graft and also place cauple of implants in there and case is close:hardy:

I agree with your treatment plan completely. I think free fibula is the way to go here. My biggest concern was the soft tissue envelope but if you think there's enough then you should be fine. Maybe error on the side of a lower profile 2.0 plate rather than a recon bar that may decide to extrude through the soft tissues with stretch. Or you could harvest an osteomyocutaneous composite flap and provive additional tissue although this will certainly affect cosmesis.

One thing I would certainly add to your treatment plan is a left coronoidectomy. Looking at your picture http://www.rp4baghdad.org/cases/maxillofacial/case033/img/a1.jpg
The left ramus/condylar segment is rotated medially and your coronoid process is medial and about an inch above your zygoma because of the unopposed temporalis muscle. When you fan this segment out to get your mandibular angle definition this coronoid will interefere with the zygoma, limiting opening. This has happened to such an extent that your left condyle isn't even in the fossa anymore. That might complicate things but I would try an relocate the condyle into the fossa intraop and the coronoidectomy should help with that. I don't know what the right coronoid is like but it might pose a similar problem. So I would add bilateral coronoidectomies.
That being said it will beinteresting to see what has happened to your muscles of mastication (especially your masseters, medial pterygoids, and anterior digastrics over the past 25 years since they didnt have any insertions). They will be quite atrophic. He may have a hard time with with jaw movement but with good physical therapy I would think he would regain some muscle attachments to allow this.
 
Thanks for dissing my "sticky" thread... OMFS CASE DISCUSSIONS up top.

anyway, i like this thread...nice cases 🙂
 
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