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Osteotomy
Dr. Meka Sridhar
PROFESSOR
Dept Of OMFS
Content
• Introduction
• History
• Advantages and dis advantages
• classification
• Access to cranial base
• Access to infra temporal region
• Access to naso pharynx
• Access to base of tongue and oropharynx
• Access to parapharyngeal spaces
• Post op care
• Complications
Introduction
• A plethora of various pathologies occur in the skull base and deep spaces
of the neck.
• The surgical resection of these hidden lesions often poses a great surgical
challenge owing to the anatomical complexity, difficulty in accessibility and
proximity of vital structures.
• The choice and type of access osteotomy to these hidden lesions of the
cranial base like Infratemporal fossa/ Sphenopalatine fossa and /or dee p
spaces of neck is most often based on
• the maxilla and the zygomatic bone can be removed in one piece as
described by McGurk and Lello.
• Salins PC introduced the trans naso-orbito-maxillary approach to
the anterior and middle skull base in 1998
Classification
• A variety of transfacial surgical approaches to midline skull base lesions
can be organized in a simple classification scheme of six techniques or
levels.
The transfacial approaches to midline skull base lesions: A classification scheme. Operative Techniques in
Neurosurgery Volume 2, Issue 4, December 1999, Pages 201–217
• Three extracranial approaches use a more inferior trajectory and variable
2.The primary blood supply to the "facial units" is through the external carotid
Classification of facial translocation approach to the skull base IVO P. JANECKA, MD, FACS, [OTOLARYNGOL
HEAD NECK SURG 1995;I 12:579-85.
4. Displacement of facial units for an approach to the cranial base offers much
good reconstruction.
• Modification:
Le Fort Maxillary Swing Procedure for Posterior Maxilla Tumor Extirpation Deepak
Kademani, DMD, MD*J Oral Maxillofac Surg 65:1055-1058, 2007
• Modification: two piece lefort 1
• The Le Fort I osteotomy as a maxillotomy,
with midline split of the hard and soft
palate, can be used safely in certain clinical
situations for lesions of the nasal cavity,
nasopharynx, upper anterior cervical spine
and base of skull, for which direct
visualization is required
• Lefort 2 osteotomy
Maxillary SwingProcedure
• This surgical approach is most
suitable for lesions that are
located on the medial aspect of
the infra temporal fossa in the
pterygomaxillary region or in the
lateral wall of the nasopharynx.
Maxillary removal andreinsertion
exposure to ACB.
Maxillary removal and reinsertion: A favorable approach for extensive anterior cranial base
tumorsOtolaryngology–Head and Neck Surgery (2010) 142, 322-326
Approaches to infra temporalregion-
lesion
• Zygomatic arch osteotomy can be combined with vertical ramus
infratemporal space.
approach
Transpalatal approach
Medial MaxillectomyApproach
• Modification: mandibulotomy
with paralingual extension and
mandibular swing
Access to para-pharyngealspaces
• The styloid process, the
stylomandibular ligament and the
mandible impede access to
parapharyngeal region. Division of
the mandible was first proposed by
Ariel et al.
• The most important maneuvers and
osteotomies that have been proposed
to improve surgical access to the
parapharyngeal space
Double mandibular osteotomy with coronoidectomy for tumoursin the parapharyngeal space N.
Lazaridis, ∗ K. Antoniades † British Journal of Oral and Maxillofacial Surgery (2003) 41, 142–146
Stylomandibular tenotomy
mandibular function or the sensory supply of the face or oral cavity. The
• Airway
placed at the time of surgery to retain a natural draining passage for tears
deep vein thrombosis are used while the patient is still confined to bed and
early ambulation is not feasible. Once the patient is able to sit up, gradual
resulting from postoperative pain and discomfort, and later, trismus occurs
as a result of fibrosis around the TMJ and the masticator group of muscles.
period, and the patient is instructed to self execute jaw exercises during the
sudden onset and are most serious. They include vasospasm, thrombosis,
and hemorrhage.
• tongue dysfunction
• TMJ dysfunction
• Malunion
• epiphora
• The surgery of access should have minimal morbidity and introduce minimal
additional operating time.
• Patient specific osteotomy approach need to be carried out based on the site,
size, type of tumour, adjacent anatomical structure, anticipated complication
references
• 1.Head and neck oncology Jatin P Shah
• 2. Operative oral and maxillofacial surgery- Langdon patel
• 3.. The transfacial approaches to midline skull base lesions: A classification
scheme. Operative Techniques in Neurosurgery Volume 2, Issue 4,
December 1999, Pages 201–217
• 4. The Le Fort I osteotomy as a surgical approach for removal of tumours
of the Midface Hermann F. Sailer, Piet E. Haers, Klaus W. Grfitz Journal of
Cranio-MaxillofaciaI Surgery (1999) 27, 1~
• 5. Oral Maxillofac Surg 59:1292-1296, 2001 Functional and Aesthetic
Results of Various Lip-Splitting Incisions: A Clinical Analysis of 60 Cases
Alexander D. Rapidis, MD, DDS, Dr Dent, Oral Maxillofac Surg 59:1292-
1296, 2001 *
• 6. CRANIOFACIAL OSTEOTOMIES FOR HIDDEN HEAD & NECK LESIONS
• Mohammad Akheel, Suryapratap Singh Tomar2 Craniofacial osteotomies
for hidden head & neck lesions, Journal of Head & Neck physicians and
surgeons, 2013;1(1):1-3
•
• 7. Classification of facial translocation approach to the skull base IVO P.
JANECKA, MD, FACS, Pittsburgh, Pennsylvania OTOLARYNGOL HEAD NECK
SURG 1995;I 12:579-85.
• 8. Journal of Cranio-Maxillofacial Surgetlv (1997) 25, 285-293 Craniofacial
access to the anterior and middle cranial fossae and skull base G. Lello 1, R
Statham 2, J. Steers 2, M. McGurk 3 . Journal of Cranio-Maxillofacial
Surgetlv (1997) 25, 285-293
• 9. G. K. B. Sandor, D. A. Charles, V. G. Lawson, C. H. Tator: Trans oral
approach to the nasopharynx and clivus using the Le Fort I osteotomy with
midpalatal split. Int. J. Oral MaxiIlofac. Surg. 1990; 19:352 355.
• 10. A new external approach to the pterygomaxillary fossa and
parapharyngeal space. Attia EL, Bentley KC, Head T, Mulder D. Head Neck
Surg. 1984 Mar-Apr;6(4):884-91.
• 11. Maxillary-fronto-temporal approach for removal of recurrent
malignant infratemporal fossa tumors: Anatomical and clinical study Yuxing
Guo, Chuanbin Guo* Journal of Cranio-Maxillo-Facial Surgery 42 (2014)
206e212
• 12. Double mandibular osteotomy with coronoidectomy for tumours in the
parapharyngeal space N. Lazaridis, ∗ K. AntoniadesBritish Journal of Oral
and Maxillofacial Surgery (2003) 41, 142–146
Thankyou…