Presentor-

Dr. Gireesha Reddy

1st Year PG
 Takagi first used the technique in 1918
 The endoscope has been described as an ‘‘extra set of
eyes’’
 As a teaching tool
 describe the procedure in real time
 Surgical procedures may also be completed
with less morbidity, hence greater margin of
safety
 Can be used as surgical adjunct
 One can easily identify the location and size of the
defect without invading the content of the orbit
 Traditional periorbital approaches - significant
manipulation of the orbital tissues- Ectropion/
Entropion
 Visualization is difficult, especially posterior limit
 Using endoscope- disadvantages are minimized
 Approach used – transantral approach
Strong EB. Endoscopic repair of orbital blow-out fractures. Facial Plast Surg
2004;20(3):223–30.
 Technique
 Use of a pure periorbital approach, a purely transantral
approach, or a combination of the two
 Purely transantral approach- effective for orbital blow-
out fracture
 Maxillary vestibular incision is placed
 Osteotomy in the anterior antral wall is performed.
 The endoscope is placed into the sinus, which acts as a
natural optical cavity.
 A 30, 4-mm-diameter endoscope (Karl Storz,
Tuttlingen, Germany) with a xenon light source is
preferred
 A sinusotomy of the sinus roof/orbit floor is completed
 Margins of the fracture are identified.
 Each shelf is carefully dissected and the orbital contents
replaced back into the orbit.
 Fracture segments reduced and stabilised with titanium
mesh
 Intraoral approach, it may be difficult to position
fixation with precision
 Extra oral approach- risk of injury to the facial
nerve
 Endoscopic assistance
- above disadvantages are nullified
- allowing the patient to function immediately
- less pain & scar than with extra oral incisions
 Technique
 standard intraoral incision
 A subperiosteal dissection is performed for creation of
the optical cavity
 The 30, 4-mm-diameter endoscope, xenon light
source, and a standard mandibular fracture
instrumentation tray are used
 A recommended specialized instrument is a retractor
with an endoscopic sleeve to improve visualization and
decrease instrumentation in the cavity
 Superior tension and inferior fixation plates are
positioned and fixated using a single transbuccal trocar
technique.
 Locking cannula is preffered as it aids in precise
placement of the fixation hardware.
 Once optimal fixation is placed and the reduction is
confirmed with the scope
Advantages of endoscope assisted ORIF of sub-
condylar fractures
- performed through- intra oral incision- less
external scar, facial nerve injury, salivary fistula
formation
Miloro reported that the technique improved
- visibility in an illuminated and magnified field of
view with decreased bleeding, and better anatomic
reduction
- decreased postoperative pain, oedema, and
limited mouth opening
Miloro M. Endoscopic-assisted repair of subcondylar fractures. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2003;96(4):387–91
 Technique
 Can be performed as an extra oral or a transoral
procedure
 incision for the transoral approach consists of a
lateral vestibular incision similar to that for a
sagittal split osteotomy.
 A subperiosteal dissection to the proximal
mandibular segment is performed for creation of
the optical cavity.
 A 30, 4-mm-diameter endoscope and a xenon
light source is used
 The Synthes subcondylar fracture tray (Synthes,
ADI/AO Development Institute, Davos, Switzerland)
has helpful retractors and instruments designed
specifically for this procedure.
 It is important not to place the patient into
maxillomandibular fixation to allow for manipulation of
the proximal and distal segments of the mandible to
facilitate reduction.
 Use of the specialized curved retractors, reduction-
manipulation forceps, and placement of a clamp at the
angle of the mandible percutaneously for control of the
distal segment.
 A trocar is used to deliver the drill and screws for rigid
fixation

Schon R, Gutwald R, Schramm A, et al. Endoscopy assisted open treatment of

condylar fractures of the mandible: extraoral vs intraoral approach. Int J Oral
Maxillofac Surg 2002;31:237
 Isolated anterior table fracture that is minimally
displaced and lacks comminution, endoscopic approach
is ideal
 The endoscopic approach avoids
- large incisions (alopecia, paresthesia, scarring,
nerve injuries)
- visualization of the sinus wall fracture, and can
be used to evaluate the integrity of the
nasofrontal duct and posterior wall of the
sinus.
Cole P, Kaufman Y, Momoh A, et al. Techniques in frontal sinus
fracture repair. Plast Reconstr Surg 2009;123(5):1578–9.
 The approaches available are
1. Trans nasal approach
 After frontal sinusotomy and insertion of a balloon
catheter for reduction and support of the fractured
segments
2. Brow lift procedure
 Incision through the eyebrow and a trephine bur
hole into the sinus with endoscopic examination of
the frontal sinus and subsequent reduction of the
fracture.
Yoo MH, Kim JS, Song HM, et al. Endoscopic transnasal reduction of an
anterior table frontal sinus fracture: technical note. Int J Oral Maxillofac Surg
2008;37(6):573–5.
 A subperiosteal dissection to the fracture followed
by reduction with endoscopic instruments and
plating may be performed for stability.
 With traditional techniques, there can be
- an unfavorable fracture anterior to the lingula
leaves the inferior alveolar nerve in the
proximal segment
- A poorly oriented medial osteotomy puts the
coronoid process at risk of fracture
Iwai T, Matsui Y, Tohnai I, et al. Endoscopic-assisted medial osteotomy
during sagittal split ramus osteotomy. J Plas Reconstr Aesthet Surg 2008;
61(12):1547–8.
- Insufficient osteotomy in inferior border often
leads to a buccal cortical plate fracture
Turvey TA. Intraoperative complications of sagittal osteotomy of the
mandibular ramus. J Oral MaxillofacSurg 1985;43:504–9.
 Kim and McCain reported the use of an endoscope
during mandibular orthognathic surgery
 After dissecting medially and visualizing the lingula
with the endoscope soft-tissue protection is
applied and angulation of the medial cut is
directed with appropriate anatomic cues
 Helps to verify the inferior border osteotomy with
the help of number 3 myringotomy suction.
 The surgeon can reduce complications at this site
by visualizing a completed inferior border
osteotomy, thereby reducing the possibility of a
buccal plate fracture
 Traditional techniques may have
* bleeding- transection of the
inferior alveolar, masseteric, or
maxillary arteries
* nerve damage- transection of the inferior
alveolar nerve as it enters
the mandible, secondary to
an osteotomy completed
too far anteriorly
 In an effort to protect these structures the
osteotomy is placed too far posteriorly leading to
subcondylar osteotomy
 The approaches include
1. modified Risdon approach
2. intraoral incisions
- improved visualization
- medial aspect of the ramus can be explored
and appropriate protection of neurovascular
structures improves accuracy of the osteotomy

Troulis MJ, Kaban LB. Endoscopic vertical ramus osteotomy: early clinical results. J
Oral Maxillofac Surg 2004;62:824–8.
 Lefort I osteotomy is a predictable operation for
repositioning the mid-face and upper arch of
dentition.
 With 30 and 70 degree endoscopes, the
pterygomaxillary junction, ptyergoid plates, nasal
septum, and other relevant anatomic points can be
visualized.
 A 0 degree scope can be used to visualize the
posterior maxillary wall and the neurovascular
bundles
 Sialoendoscopy provides the ability to diagnose
and treat obstructive salivary gland disease without
subjecting the patient to redundant testing and
more invasive procedures
 Was first described in 1991 by Katz, and significant
contributions were made by Nahlieli, Marchal
 Arzoz reported success using a rigid urethroscope
to navigate the duct
 Marchal introduced the semiflexible design in 1998
 The irrigation channel was introduced to the design
in 1999 by Nahlieli.

Nahlieli O. Endoscopic techniques for the diagnosis and treatment of salivary

gland disease. Carl Stortz: Silver Books; 2009. p. 23.

Marchal F. The endoscopic approach to salivary gland ductal pathologies. Carl

Stortz: Silver Books; 2005.
 The most used designs are semiflexible
 Components include
* irrigating channel- 0.25-mm
* workingchannel- 0.8-mm
* scope diameter- 1.6mm(0.8–2.7 mm)

The authors prefer an endoscope that has a

- 0.90-mm optic
- 1.3-mm channel
 Non obstructive sialadenitis that resolves with
antibiotics
 Spontaneous expulsion of the obstruction
 Large stone size
 Proximal location of a stone
 Stones within the gland, or extra glandular. (managed
by surgical excision of gland)
 Mucous plugs
 Strictures
 radiolucent stones
 Small stones or obstructions
 For larger stones usually sialoendoscopy is
contraindicated, but lithotripsy can be considered

Lithotripsy is of two types

1. Extra corporeal

2. Intra carporeal
Lithotripsy is of two types
1. Extra carporeal
2. Intra carporeal

Extra carporeal Intra carporeal

 lithotripsy uses shock wave  Intracorporeal lithotripsy

therapy to ablate the (endoscopically assisted) is
obstruction a minimally invasive
 Disadvantages technique used in the
treatment of salivary gland
- need for repeat treatment
stones
and the need for retrieval of
the stones that do not flow
freely out of the system

Iro H, Waitz G, Nitsche N, et al. Arzoz E, Santiago A, Esnal F, et al.

Extracorporeal piezoelectric shock-wave Endoscopic intracorporeal lithotripsy for
lithotripsy of salivary gland stones. sialolithiasis. J Oral Maxillofac Surg
Laryngoscope 1992;102:492. 1996;54:847–50.
 Technique
 Pt evaluation
 local anaesthesia/ intravenous sedation/general
anaesthesia
 Localisation of duct- methylene blue
 Dialatation of duct- if cannot dialate papillotomy
can be used
 Evaluation and necessary treatment
 To prevent ductal stenosis, a 2-mm polyethelene
stent is placed into the duct and stabilized with a
temporary nonresorbable suture for 4 weeks
 Complications
 Incidence is less than 10%, usually minor
 Swelling of the gland secondary to the copious
irrigation process.
 Extravasation of irrigation into the floor of the
mouth andsurrounding tissues.
 Transient paresthesia to lingual nerve
 Iatrogenic ranula or infection
 Stricture of the duct- in 4% of cases
 Trauma or ulceration to the papilla
 Indications
 Mild synovitis or other inflammatory-type pathosis,
synovectomy and reducing inflamed tissuewith
laser
Koslin M. Advanced arthroscopic surgery. Oral Maxillofac Surg Clin North
Am 2006;18:329–43.
 For antiinflammatory therapy- endoscopically
assisted injection of corticosteroids or hyaluronic
acid into the retrodiscal tissue
 Removal of adhesions, fibrocartilagenous scuff
 Sculpting of disk perforation margins
 Hypermobile joint with open lock
- injection of a sclerosing agent
- injection of autologous blood into the joint
space
- posterior contraction procedure.
 Complications
 Rate of complications- 1.3%
 scuffing of the fibrocartilage
 Trauma to this tissue- hypomobility of the joint.
 Extravasation of fluid The periorbital tissues,like
masseter, and soft palate
 Temporary facial nerve paresis
 Damage to the cartilaginous or bony ear canal
 Bleeding- in 2% of cases
 Perforation into the glenoid fossa
 Failure of instrumentation
 As with many new technologies there is a
steep learning curve.
 Operative times can be expected to double
when first attempting
 Nevertheless the scope of oral and
maxillofacial surgery is increasing and will be
more with endoscopic assisstance