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International Association of Maxillofacial Surgeons in Training (IAMFST), Amsterdam, The Netherlands, 8–9 September 1995
Int. J. Oral Maxillofac. Surg. 1996; 25:326-329 Printed in Denmark. All rights resen'ed
Copyright © Munksgaard 1996 InternationalJournal of
Oral& MaxillofacialSurgery ISSN 0901-5027
Abstracts from internationalmeetings International Association of Maxillofacial Surgeons in Training (IAMFST), Amsterdam, The Netherlands, 8-9 September 1995 The fifth symposium of the IAMFST, which took place in Amsterdam, The Netherlands, on 8-9 September 1995, dealt with post-traumatic and congenital periorbital reconstructions. Like its predecessors, this symposium included an element of teaching, giving the residents (and others present) an overview of upto-date "knowledge and surgical methods centered on one topic, as presented by outstanding speakers. Dr G. J. Groen (Utrecht, The Netherlands) started the morning session on the first day with an anatomic journey through the periorbital region by CD-I. A newly developed, interactive audiovisual system was used to show crosssectional anatomy, histology, and radiology and their application in planning reconstructive procedures. Dr de Vries (Amsterdam, The Netherlands) explained the function and physiology of the nose. The nose is an essential respiratory organ because of its humidity and temperature regulation, and its cleansing, protective, and olfactory functions. Dr H. Kfircher (Graz, Austria) explained the various methods of radiodiagnostics of the orbit and midface and their advantages in surgical planning. Dr H. P. M. Freihofer (Nijmegen, The Netherlands) explained the various options in treatment of periorbital trauma, including access to the fracture and the sequence of the operative steps. Dr B. Hammer (Basel, Switzerland) demonstrated the principles of treatment of severe comminutive midfacial fractures. Both suggested that the treatment of periorbital trauma should be undertaken as early as feasible and as completely as possible. The prerequisite for successful treatment is the correct positioning of the maxilla, especially the zygomata. All lesions should be tackled during the primary treatment
with the exception of trauma to the lacrimal duct. Dr P. J. W. Stoelinga (Arnhem, The Netherlands) ended the morning session with a presentation on the recent developments and future prospects of the International Guidelines for Training in Oral and Maxillofacial Surgery, as described in the hltemational Journal of Oral attd Maxillofacial Surgery (I 992: 21: 129-32). The second session concentrated on the sequelae of post-traumatic periorbital deficiencies. It began with Dr H. Kfircher's presentation of the planning of secondary correction of the midface with 3-D models. The transfer from a 3D model to clinical surgery was proposed for the most difficult procedures because the associated soft-tissue response of movements of the bony underground structure is unpredictable. Dr S. Morax, of the Department of Plastic Ophthalmologic Surgery, Paris, France, gave an overview of oculomotor disturbances in orbital fractures. A permanent oculomotor mechanical disturbance by musculoaponeurotic incarceration and/or fibrosis in orbital fractures during the first days is an absolute indication of orbital exploration and reconstruction of the defect. There may be severe oculomotor disturbances in old fractures operated or neglected. 1) If the fracture has been operated and the oculomotor disturbance is permanent, the treatment must begin with prismation. In general, oculomotor surgery must be done 6 months after surgery. 2) If the fracture has been operated and has resulted in postoperative diplopia, this common complication (if persisting after 3 months) may call for an orbital floor revision with removal of the implant or bone graft.
Oculomotor surgery may be done secondarily. 3) If the fracture has not been operated, or has been insufficiently reduced, orbital surgery becomes necessary (e.g., correction of enophthalmos). With superb illustrations, Dr S. A. Wolfe (Miami, FL, USA) presented the secondary post-traumatic correction of enophthalmos. This requires thorough exploration of the orbital cavity, a procedure which often entails circumferential orbital dissection by the coronal approach. Autogenous material should be used for this correction. In his view, enophthalmos is a preventable deformity if appropriate primary bone grafting of the orbital defect and orbital reconstruction are performed. Dr Ph. A. van Damme (Nijmegen, The Netherlands) spoke on disturbances of smell and taste after severe frontal and midfacial trauma. In a retrospective study of 278 patients with a frontal/frontonasal and/or orbitonasal-ethmoidal fracture, he found that smell disturbances occurred in 44-48%, characterized as permanent hyposmia, and not as anosmia. Taste disturbances diminish in time and occur concomitantly with smell disturbances in over 50% of the cases. Dr N. de Vries reviewed all post-traumatic impaired functions of the nose such as rhinorrhea, uni- or bilateral obstruction, epistaxis, partial or complete loss of smell (and taste), headache, snoring, and sleep apnea. Dr R. P. van Oort (Groningen, The Netherlands) emphasized the role of the facial prosthesis and implantology of defects in the periorbital region and the orbit. Dr Ch. Ioannides (London, UK).ended this second session with a classification of the fractures of the frontal sinus and the modes of surgical treatment. The third session concentrated on
327 post-traumatic and congenital periorbital deformities. First, Dr H. P. M. Freihofer spoke on the effectiveness of secondary post-traumatic periorbital reconstructions, concluding that corrections after fractures of the zygoma showed good results in 80% of cases, while midfacial reconstructions had only acceptable results upgraded by tertiary operations. Dr S. Morax presented the general principles of treatment of the congenital malformations of the eye and its adnexa, which are multiple and can affect the whole eyeball or any part of it, as well as the orbit, eyelids, lacrimal ducts, extraocular muscles, and conjunctiva. In his second presentation, Dr S. A. Wolfe reviewed the technical points of congenital orbital hypertelorism reconstruction with particular reference to the nasal bridge and the management of the medial cantal tendon. In his last contribution, Dr H. P. M. Freihofer proposed a new, individually tailored, three-stage correction of Treacher Collins' syndrome. The first stage is osteotomized reconstruction of the malar bones and genioplasty, followed by reorientation of the maxillomandibular complex in a second stage. Small tertiary corrections of skeletal contour or soft tissues may be desirable. Dr M. Y. Mommaerts (Bruges, Belgium) emphasized the role o f malar "sandwich" osteotomy in developmental, post-traumatic, and congenital deformities. In a video demonstration, he explained the surgical steps. Dr S. A. Wolfe completed this topic by speaking on corrections of craniofacial dysostosis (Crouzon's syndrome and Apert's syndrome). In general, he still performs early synosteotomy and fronto-orbital advancement, although this may be a debatable procedure in Apert's syndrome. The best result generally comes from intracranial monobloc fronto-orbital advancement with or without facial bipartition, performed ideally at 4--8 years of age. The fourth session was dedicated to free papers submitted by members (see the following abstracts). The sixth symposium will take place in Zurich, Switzerland, in 1997. W e hope that it will be of the same standard, scientifically as well as socially, as the Amsterdam meeting. M. A. W. MERKX J. C. BEI~'qE A. W. P. J. ROOSErqBER~
Abstracts Classification and treatment of orbital fractures J. Kleinheinz, U. Joos
In a retrospective study, 326 orbital fractures treated in our department between 1992 and 1995 were analyzed to devise a new classification of orbital fractures and to demonstrate our treatments of the various types. The patients were assigned to a new classification according to the number of invoh'ed walls, type of fracture, and involvement of the periorbita. In addition, concomitant injuries of the periorbital tissues were listed. Bony defects were reconstructed either with autologous bone transplants (iliac crest or tabula extema) or with allogenic materials (PDS membranes or hydroxyapatite blocks). The ethmoid cells and the frontal sinus were not operated on except when decompression of the optic nerve was necessary. The results showed that central and centrolateral midface fractures of two orbital wails are predominant, 85.4% of all fractures having orbital involvement. The best functional and aesthetic results were achieved after complete primary reconstruction of soft tissue and bone. Secondary reconstructions were more difficult and showed worse results than primary reconstruction. Avoidance of transethmoidal operations resulted in fewer cases of postoperative diplopia or enophthalmos. A classification of medial canthal injuries R R. Ayliffe, B. T. Evans
Historically, the classification of midface trauma has concentrated on bony injuries; e.g., those of the maxilla, zygomatic complex, nose, and nasoethmoid complex. On the basis of the observation of over 50 patients with midface trauma, the senior author (B. T. E.) proposes a classification of medial canthal injuries. This classification allows the management of the injury to be based on a more diagnostic approach, and successful functional and cosmetic results can be obtained in a more predictable manner in this challenging area of craniofacial trauma.
use, lack of radiation, and low cost are arguments for routine use of sonography in orbital trauma. A radiologic and anatomic study of the lateral orbital wall osteotomy in orbital surgery M. S. Dover, T. K. Mellor
Accurate reconstruction of the orbital walls depends on visualization of the entire bony defect. A lower eyelid approach, with preservation of the orbital rim, can limit surgical exposure and compromise repair, particularly of larger defects. For these larger orbital wall defects, we have used a bicoronal flap and lateral wall osteotomy to approach the orbit laterally. Surgical exposure is thereby much improved, and the calvarium is available as a bone graft donor side. Assessment of 50 axial CT scans of adult patients has shown the anterior limit of the temporal lobe to be relatively constant with respect to the orbit. These results, together with dried skull examination and model surgery, have shown that it is safe to place the vertical osteotomy cut 15 mm behind the orbital rim. The dura and temporal lobe are then not at risk. A self-stabilizing osteotomy can be used, with a microplate and reattachment of the temporalis muscle for stability. This approach has been successfully used over the past 18 months on eight patients for correction of early and late enophthalmos. The theoretic and practical implications of this study are discussed. Transorbital penetrating injuries of the skull base J. Birbe, X. Rodrlguez, C. Bassas, G. Raspall
Transorbital penetrating injuries of the anterior or medial fossae of the skull base are not common. For appropriate treatment, a multidisciplinary team approach is mandatory. We present three cases treated in our service. The etiology, presentation, therapeutic approach, and prophylaxis of complications are analyzed and discussed. Reconstruction techniques and aesthetic repercussions are emphasized. We propose a diagnostic and therapeutic protocol for these patients.
Orbital sonography: a valuable Investigation in mtdface trauma H. Thuau
Therapeutic concept and management of complex midfaee trauma N. D. Kalavrezos, C. K. Oechslin, K. W. Gr~itz, H. F. Sailer
Orbital sonography has significantly benefited from recent advances in ultrasound imaging. High-resolution ultrasound offers the major advantage of aUowing static as well as dynamic scanning. It enables the surgeon to assess the integrity of the orbital walls, and also to visualize the soft tissues during ocular movement. Standardization of the orbital scanning planes is proposed, and the first results of a prospective study comparing computed tomography/surgical exposure and ultrasound imaging, with a 7.5-MHz curvilinear array probe and a closed-eyelid technique, is discussed. Accuracy, simplicity of
Severe trauma to the midface often results in fractures of the naso-orbito-ethmoidal (NOE) complex. Early surgical management is the only therapy by which to avoid post-traumatic defects in the fragile periorbital region that may lead to inadequate secondary procedures. Fifty-five patients with major midface trauma, treated in the University Hospital of Zurich from January 1990 to December 1994, are reviewed. The fractures were mainly caused by traffic and work accidents, but also by gunshot wounds and sports accidents. The therapeutic planning included wide exposure of the fractured area by a coronal incision,
Copyright © Munksgaard 1996 InternationalJournal of
Oral& MaxillofacialSurgery ISSN 0901-5027
Abstracts from internationalmeetings International Association of Maxillofacial Surgeons in Training (IAMFST), Amsterdam, The Netherlands, 8-9 September 1995 The fifth symposium of the IAMFST, which took place in Amsterdam, The Netherlands, on 8-9 September 1995, dealt with post-traumatic and congenital periorbital reconstructions. Like its predecessors, this symposium included an element of teaching, giving the residents (and others present) an overview of upto-date "knowledge and surgical methods centered on one topic, as presented by outstanding speakers. Dr G. J. Groen (Utrecht, The Netherlands) started the morning session on the first day with an anatomic journey through the periorbital region by CD-I. A newly developed, interactive audiovisual system was used to show crosssectional anatomy, histology, and radiology and their application in planning reconstructive procedures. Dr de Vries (Amsterdam, The Netherlands) explained the function and physiology of the nose. The nose is an essential respiratory organ because of its humidity and temperature regulation, and its cleansing, protective, and olfactory functions. Dr H. Kfircher (Graz, Austria) explained the various methods of radiodiagnostics of the orbit and midface and their advantages in surgical planning. Dr H. P. M. Freihofer (Nijmegen, The Netherlands) explained the various options in treatment of periorbital trauma, including access to the fracture and the sequence of the operative steps. Dr B. Hammer (Basel, Switzerland) demonstrated the principles of treatment of severe comminutive midfacial fractures. Both suggested that the treatment of periorbital trauma should be undertaken as early as feasible and as completely as possible. The prerequisite for successful treatment is the correct positioning of the maxilla, especially the zygomata. All lesions should be tackled during the primary treatment
with the exception of trauma to the lacrimal duct. Dr P. J. W. Stoelinga (Arnhem, The Netherlands) ended the morning session with a presentation on the recent developments and future prospects of the International Guidelines for Training in Oral and Maxillofacial Surgery, as described in the hltemational Journal of Oral attd Maxillofacial Surgery (I 992: 21: 129-32). The second session concentrated on the sequelae of post-traumatic periorbital deficiencies. It began with Dr H. Kfircher's presentation of the planning of secondary correction of the midface with 3-D models. The transfer from a 3D model to clinical surgery was proposed for the most difficult procedures because the associated soft-tissue response of movements of the bony underground structure is unpredictable. Dr S. Morax, of the Department of Plastic Ophthalmologic Surgery, Paris, France, gave an overview of oculomotor disturbances in orbital fractures. A permanent oculomotor mechanical disturbance by musculoaponeurotic incarceration and/or fibrosis in orbital fractures during the first days is an absolute indication of orbital exploration and reconstruction of the defect. There may be severe oculomotor disturbances in old fractures operated or neglected. 1) If the fracture has been operated and the oculomotor disturbance is permanent, the treatment must begin with prismation. In general, oculomotor surgery must be done 6 months after surgery. 2) If the fracture has been operated and has resulted in postoperative diplopia, this common complication (if persisting after 3 months) may call for an orbital floor revision with removal of the implant or bone graft.
Oculomotor surgery may be done secondarily. 3) If the fracture has not been operated, or has been insufficiently reduced, orbital surgery becomes necessary (e.g., correction of enophthalmos). With superb illustrations, Dr S. A. Wolfe (Miami, FL, USA) presented the secondary post-traumatic correction of enophthalmos. This requires thorough exploration of the orbital cavity, a procedure which often entails circumferential orbital dissection by the coronal approach. Autogenous material should be used for this correction. In his view, enophthalmos is a preventable deformity if appropriate primary bone grafting of the orbital defect and orbital reconstruction are performed. Dr Ph. A. van Damme (Nijmegen, The Netherlands) spoke on disturbances of smell and taste after severe frontal and midfacial trauma. In a retrospective study of 278 patients with a frontal/frontonasal and/or orbitonasal-ethmoidal fracture, he found that smell disturbances occurred in 44-48%, characterized as permanent hyposmia, and not as anosmia. Taste disturbances diminish in time and occur concomitantly with smell disturbances in over 50% of the cases. Dr N. de Vries reviewed all post-traumatic impaired functions of the nose such as rhinorrhea, uni- or bilateral obstruction, epistaxis, partial or complete loss of smell (and taste), headache, snoring, and sleep apnea. Dr R. P. van Oort (Groningen, The Netherlands) emphasized the role of the facial prosthesis and implantology of defects in the periorbital region and the orbit. Dr Ch. Ioannides (London, UK).ended this second session with a classification of the fractures of the frontal sinus and the modes of surgical treatment. The third session concentrated on
327 post-traumatic and congenital periorbital deformities. First, Dr H. P. M. Freihofer spoke on the effectiveness of secondary post-traumatic periorbital reconstructions, concluding that corrections after fractures of the zygoma showed good results in 80% of cases, while midfacial reconstructions had only acceptable results upgraded by tertiary operations. Dr S. Morax presented the general principles of treatment of the congenital malformations of the eye and its adnexa, which are multiple and can affect the whole eyeball or any part of it, as well as the orbit, eyelids, lacrimal ducts, extraocular muscles, and conjunctiva. In his second presentation, Dr S. A. Wolfe reviewed the technical points of congenital orbital hypertelorism reconstruction with particular reference to the nasal bridge and the management of the medial cantal tendon. In his last contribution, Dr H. P. M. Freihofer proposed a new, individually tailored, three-stage correction of Treacher Collins' syndrome. The first stage is osteotomized reconstruction of the malar bones and genioplasty, followed by reorientation of the maxillomandibular complex in a second stage. Small tertiary corrections of skeletal contour or soft tissues may be desirable. Dr M. Y. Mommaerts (Bruges, Belgium) emphasized the role o f malar "sandwich" osteotomy in developmental, post-traumatic, and congenital deformities. In a video demonstration, he explained the surgical steps. Dr S. A. Wolfe completed this topic by speaking on corrections of craniofacial dysostosis (Crouzon's syndrome and Apert's syndrome). In general, he still performs early synosteotomy and fronto-orbital advancement, although this may be a debatable procedure in Apert's syndrome. The best result generally comes from intracranial monobloc fronto-orbital advancement with or without facial bipartition, performed ideally at 4--8 years of age. The fourth session was dedicated to free papers submitted by members (see the following abstracts). The sixth symposium will take place in Zurich, Switzerland, in 1997. W e hope that it will be of the same standard, scientifically as well as socially, as the Amsterdam meeting. M. A. W. MERKX J. C. BEI~'qE A. W. P. J. ROOSErqBER~
Abstracts Classification and treatment of orbital fractures J. Kleinheinz, U. Joos
In a retrospective study, 326 orbital fractures treated in our department between 1992 and 1995 were analyzed to devise a new classification of orbital fractures and to demonstrate our treatments of the various types. The patients were assigned to a new classification according to the number of invoh'ed walls, type of fracture, and involvement of the periorbita. In addition, concomitant injuries of the periorbital tissues were listed. Bony defects were reconstructed either with autologous bone transplants (iliac crest or tabula extema) or with allogenic materials (PDS membranes or hydroxyapatite blocks). The ethmoid cells and the frontal sinus were not operated on except when decompression of the optic nerve was necessary. The results showed that central and centrolateral midface fractures of two orbital wails are predominant, 85.4% of all fractures having orbital involvement. The best functional and aesthetic results were achieved after complete primary reconstruction of soft tissue and bone. Secondary reconstructions were more difficult and showed worse results than primary reconstruction. Avoidance of transethmoidal operations resulted in fewer cases of postoperative diplopia or enophthalmos. A classification of medial canthal injuries R R. Ayliffe, B. T. Evans
Historically, the classification of midface trauma has concentrated on bony injuries; e.g., those of the maxilla, zygomatic complex, nose, and nasoethmoid complex. On the basis of the observation of over 50 patients with midface trauma, the senior author (B. T. E.) proposes a classification of medial canthal injuries. This classification allows the management of the injury to be based on a more diagnostic approach, and successful functional and cosmetic results can be obtained in a more predictable manner in this challenging area of craniofacial trauma.
use, lack of radiation, and low cost are arguments for routine use of sonography in orbital trauma. A radiologic and anatomic study of the lateral orbital wall osteotomy in orbital surgery M. S. Dover, T. K. Mellor
Accurate reconstruction of the orbital walls depends on visualization of the entire bony defect. A lower eyelid approach, with preservation of the orbital rim, can limit surgical exposure and compromise repair, particularly of larger defects. For these larger orbital wall defects, we have used a bicoronal flap and lateral wall osteotomy to approach the orbit laterally. Surgical exposure is thereby much improved, and the calvarium is available as a bone graft donor side. Assessment of 50 axial CT scans of adult patients has shown the anterior limit of the temporal lobe to be relatively constant with respect to the orbit. These results, together with dried skull examination and model surgery, have shown that it is safe to place the vertical osteotomy cut 15 mm behind the orbital rim. The dura and temporal lobe are then not at risk. A self-stabilizing osteotomy can be used, with a microplate and reattachment of the temporalis muscle for stability. This approach has been successfully used over the past 18 months on eight patients for correction of early and late enophthalmos. The theoretic and practical implications of this study are discussed. Transorbital penetrating injuries of the skull base J. Birbe, X. Rodrlguez, C. Bassas, G. Raspall
Transorbital penetrating injuries of the anterior or medial fossae of the skull base are not common. For appropriate treatment, a multidisciplinary team approach is mandatory. We present three cases treated in our service. The etiology, presentation, therapeutic approach, and prophylaxis of complications are analyzed and discussed. Reconstruction techniques and aesthetic repercussions are emphasized. We propose a diagnostic and therapeutic protocol for these patients.
Orbital sonography: a valuable Investigation in mtdface trauma H. Thuau
Therapeutic concept and management of complex midfaee trauma N. D. Kalavrezos, C. K. Oechslin, K. W. Gr~itz, H. F. Sailer
Orbital sonography has significantly benefited from recent advances in ultrasound imaging. High-resolution ultrasound offers the major advantage of aUowing static as well as dynamic scanning. It enables the surgeon to assess the integrity of the orbital walls, and also to visualize the soft tissues during ocular movement. Standardization of the orbital scanning planes is proposed, and the first results of a prospective study comparing computed tomography/surgical exposure and ultrasound imaging, with a 7.5-MHz curvilinear array probe and a closed-eyelid technique, is discussed. Accuracy, simplicity of
Severe trauma to the midface often results in fractures of the naso-orbito-ethmoidal (NOE) complex. Early surgical management is the only therapy by which to avoid post-traumatic defects in the fragile periorbital region that may lead to inadequate secondary procedures. Fifty-five patients with major midface trauma, treated in the University Hospital of Zurich from January 1990 to December 1994, are reviewed. The fractures were mainly caused by traffic and work accidents, but also by gunshot wounds and sports accidents. The therapeutic planning included wide exposure of the fractured area by a coronal incision,