text: 24 Secondary Osteotomies and Bone Grafting David Richardson Introduction (Fig. 24.1), a craniofacial syndrome including stigmata of residual frontal and nasoethmoidal fractures, a maxillary syn- Modern techniques of fracture management allow easy access drome with occlusal abnormalities, and a nasal syndrome to the whole craniofacial skeleton, accurate fracture reduc- characterized by naso-orbital dislocation. Other workers such tion, internal fixation with mini and microplating systems and as Manson3 and Gruss4 have devised systems related to the primary bone grafting where necessary to replace missing previous location of bone fractures, comprising frontobasilar, bone. The goal of primary treatment is to restore normal Le Fort I, II and III fractures of the maxilla, naso-orbito- anatomy and therefore normal form and function of the ethmoid, zygomatic, nasal, mandibular, complex and pan- craniofacial complex. However, patients may present with facial deformities. posttraumatic deformity for a variety of reasons. They may fail to present in the acute phase or injuries may go undiag- nosed if specialist expertise is not available. Other serious Principles of Management injury or medical conditions may preclude or compromise The principles underlying management of secondary post- immediate treatment of facial injuries and the results of traumatic skeletal deformity include: primary treatment may be unsatisfactory if the extent of the injury is underestimated or in the more severe comminuted ■ accurate assessment by history, clinical examination and panfacial fractures (Fig. 24.1).1 special investigations ■ treatment planning ■ surgery, utilizing a variety of techniques for management Classification of soft and hard tissue deficits or deformities, including There is no entirely satisfactory system for classification of osteotomies and bone grafting. posttraumatic facial deformity which incorporates the neces- sary mix of hard and soft tissue deficits or takes account of resultant esthetic or functional difficulties. Tessier2 proposed Assessment a system based on the major esthetic aspects of the disfigure- Assessment of any deformity requires a detailed history, ment and included an orbital syndrome with enophthalmos examination and special investigations. (a) (b) Fig. 24.1: Residual nasal and zygomatic deformity with enophthalmos and restricted ocular motility following untreated midfacial injury. (a) Facial appearance. (b) Restricted eye movement. 2 Secondary Osteotomies and Bone Grafting History degree of soft tissue response to the underlying bony move- ment and leave a persisting esthetic or functional deficit even A full history is essential in diagnosis of secondary post- if a perfect underlying skeletal position can be achieved. This traumatic deformity. Of particular importance is documenta- should be appreciated in the planning phase so that soft tissue tion of the patient's complaints or concerns. A number of adjustment can be carried out at the appropriate time, potentially correctable deformities may be present, but it is usually subsequent to the skeletal reconstruction.1,4 In addi- important to assess which of these require correction in order tion, what may seem to be a bony asymmetry may be solely to address the concerns of the patient. A brief assessment of due to soft tissue problems and surgical technique for correc- the psychosocial effect of the deformity may help to highlight tion is likely to be different from that chosen where the important areas, since relatively minor physical abnormalities underlying problem is truly skeletal in nature. When consid- may give rise to significant psychological, social or occupa- ering complaints of orbitozygomatic deformity, soft tissues of tional problems. The history of the original injury, whether the bony orbit are of paramount importance. Globe displace- any primary surgery was carried out and if so what this ment in the vertical or anteroposterior plane needs to be involved are important in order to plan secondary surgery and accurately assessed and the presence of characteristic stig- anticipate potential difficulties or complications (e.g. previous mata of enophthalmos, such as pseudoptosis, implies a degree craniotomy with or without dural repair will make subsequent of displacement of the orbital tissues (Fig. 24.1). craniotomy more difficult due to dural adhesions, thus predis- Examination of eye movement and forced duction test will posing to increased risk of dural tear and subsequent CSF allow assessment of tethering of the extraocular muscles leak. Eye injury or visual loss will increase the significance of (Fig. 24.2) and traction on the insertions of the medial and the risk to vision in operating on the contralateral orbit). Time lateral recti (usually under general anesthetic prior to surgery) elapsed between the original injury or its primary management will give an indication of the potential for improvement in and presentation of secondary deformity may be significant anteroposterior eye position following enophthalmos correc- because timing of secondary surgery may be important. Some tion. On occasion, intraorbital fibrosis may preclude anterior problems are better corrected early, whilst in others the eye repositioning despite good orbital volume correction. The timing may be less critical (e.g. correction of enophthalmos position of the lateral and medial canthi should be assessed, and orbital and nasal reconstruction). intercanthal distances measured and note made of any abnor- mality of eyelid position such as retraction or ectropion. Examination Hard tissues A comprehensive clinical examination of the craniofacial A thorough assessment of any bony distortion, deficiencies or complex is mandatory and should include assessment of both asymmetry must be carried out by inspection and palpation. hard and soft tissues. Techniques used for assessing the bony (and cartilaginous) craniofacial skeleton are well documented in the craniofacial, Soft tissues rhinoplasty and orthognathic literature. Assessment should Whilst not directly the subject of this chapter, mention must be applied in a logical way and must include all areas of the be made of the soft tissues. The presence of cutaneous scars, craniofacial skeleton, including the calvarium and forehead, soft tissue deficiency and distortions or subcutaneous fat frontal sinus, orbits, zygomas, external and internal nose, atrophy may limit the extent of bony movement and/or the temporomandibular joints, mandible, upper and lower dental (a) (b) Fig. 24.2: Forced duction test. (a) Tethering of inferior rectus. (b) Normal contralateral eye. Principles of Management 3 arches and dental occlusion. Assessment should be made of displacements in each area examined in the three planes of space, anteroposterior, vertical and transverse, and should include assessment of asymmetries in each of these three planes. Special investigations These may include plain films, dental study models, photo- graphs and CT or MR scanning, with three-dimensional stereo- lithographic modeling where appropriate. Plain films Plain films will demonstrate the site and extent of the original injuries, the presence of bone plates and grafts used in pri- mary treatment. Detailed measurements to assess malposi- Fig. 24.3: Three-dimensional CT scan of malunited fracture of tion and asymmetries, including AP and lateral cephalometry, left zygoma with measurement of displacement. may be useful both in delineating the underlying problem and in planning surgical correction. This particularly applies to fractures of the mandible where plain films will demonstrate ing has been a major advance in the management of patients a fibrous or non-union, the direction and extent of displace- with complex posttraumatic bony deformity. ments and major occlusal abnormalities such as anterior open bite or mandibular asymmetry. Treatment planning Dental study models Having identified the concerns of the patient, established treat- Dental study models are mandatory for assessment of post- ment goals and documented all areas of anatomical and func- traumatic deformity involving the tooth-bearing segments tional abnormality, detailed operative planning is required. If a of the maxilla or the mandible. Where a posttraumatic mal- portion of a craniofacial skeleton is malpositioned or deficient occlusion exists, an assessment can be made of the achievable and is giving rise to patient concerns or complaints, it should be occlusion and whether any secondary dentoalveolar compen- restored to its normal anatomical position, shape or volume. satory changes have occurred, which may result in a need for However, in planning treatment, it must be borne in mind that orthodontic or restorative correction or segmental surgery. correction of one deformity may result in accentuation of Face bow recording and anatomical articulation may be useful another, which may not have been previously noticed by the particularly in cases of bilateral condylar malunion, where patient, e.g. malar osteotomy may make a previously mild vertical face height changes are planned and mandibular enophthalmos more obvious or correction of mandibular asym- autorotation is anticipated. metry may exaggerate an ipsilateral mild nasal deviation. In this situation, the milder unnoticed defects may require simultane- CT scanning ous or subsequent correction even though they may not be of CT scanning in the axial and coronal planes yields very useful direct concern to the patient initially. information, particularly in complex midface and orbito- Detailed planning of surgical interventions and movements zygomatic deformity and calvarial defects. Two-dimensional depends on the information gathered from the history and imaging is useful in delineating areas of deformity or defi- examination, but in particular the special investigations. ciency and, as with plain films, accurate measurements taken When planning bony surgery, it is essential that an accurate from stable and unaffected portions of the craniofacial skele- plan of surgery and movements is established prior to opera- ton can give an assessment of degree of displacement or defor- tion. This entails a detailed assessment of the extent of mity. However, an additional benefit of CT scanning is its movement required in the three planes of space, i.e. antero- ability to generate three-dimensional images which allow the posterior, vertical and transverse. If onlay grafts are to be surgeon to visualize all aspects of the deformity at the same used, the site and extent of augmentation should be similarly time and can sometimes reveal the underlying cause of a established preoperatively. Intraoperative judgment of the deformity or discrepancy, which is difficult to assess by extent of necessary bone movement or augmentation to two-dimensional scans (Fig. 24.3). In addition, the recent achieve symmetry is extremely difficult, due to distortion of introduction of stereolithographic modeling allows direct visu- overlying soft tissues as a result of the surgical access, edema, alization of the defect. Direct measurement of required bony presence of an endotracheal tube and inaccessibility of nor- movements or augmentation is possible and if necessary, surgi- mal reference points beneath sterile drapes. Where three- cal simulation may be carried out. It also facilitates prefabrica- dimensional modeling is available, prebending of plates, tion of alloplastic implants and production of templates as a preforming of implants or production of bone graft templates guide for size and shape of bone grafts, as well as prebending helps to facilitate accurate correction of the deformity and of plates or mesh for graft fixation. Stereolithographic model- may reduce operating time. 4 Secondary Osteotomies and Bone Grafting It is important to insure a co-ordinated approach to the cor- can be carried out using small osteotomies medial and lateral rection of both bony and soft tissue abnormalities. This to the nerves. The calvarium, forehead, supraorbital rim, usually means correcting the bony abnormality first and then orbital roof and lateral orbital rim are exposed and after mobi- carrying out any necessary soft tissue revision subsequently. It lization and reflection of the temporalis muscle, access is is essential to discuss with the patient the proposed correction gained to the lateral wall of the orbit and the temporal fossa. and insure a realistic expectation of outcome, including both At the end of the operation, the temporalis muscle must be the positive and negative effects of any proposed surgery. anchored to the lateral orbital rim with sutures, if necessary fol- lowing anterior mobilization of the muscle, to prevent postoper- ative retraction and temporal hollowing (Fig. 24.4). Access to Treatment Techniques the infraorbital margin and orbital floor is possible through a Surgical access bicoronal flap but is limited and fixation of osteotomy cuts or grafts can be difficult from this approach without a lower eyelid Surgical access to the entire craniofacial skeleton is afforded incision. In addition, if at the start of the operation the medial by bicoronal flap, lower eyelid or transconjunctival and intra- canthal ligament is intact and attached to the anterior lacrimal oral buccal sulcus incisions. In addition, a variety of intra- and crest, it should never be detached during elevation of the flap, extraoral incisions are available for access to the mandible, in since this requires the use of a transnasal canthopexy on closure, particular the vertical ramus and condyle. the results of which are often disappointing. The attachment of the medial canthal ligament can therefore limit access to the Bicoronal flap medial orbital wall. If full access to the medial orbital wall is necessary, a lower eyelid incision is required in addition to A bicoronal flap gives excellent surgical exposure of the upper access gained via the orbital roof exposure of the bicoronal flap. craniofacial skeleton. Pre-auricular extension of the incision and dissection in the temporal region immediately adjacent to the deep temporal fascia allow excellent exposure down to Lower eyelid incision and including the zygomatic arches. If the dissection is kept on Transconjunctival, subciliary or midtarsal incisions, with the surface of the deep temporal fascia, there is no need to retro-orbicular preseptal dissection, all give excellent access pass deep to the superficial layer of the deep temporal fascia to the infraorbital rim, orbital floor, infraorbital foramen and and the frontal branch of the facial nerve is elevated with the anterior surface of the maxilla. We avoid the infraorbital inci- flap, resulting in little risk of nerve injury and easy dissection sion for cosmetic reasons. Occasionally, postoperative lower in a single surgical plane (subgaleal), leaving pericranium eyelid retraction and increased scleral show may occur but attached to the outer table of the skull. Once the flap is raised this is unusual and amenable to correction if it fails to resolve to within a centimeter of the supraorbital margins the pericra- spontaneously (Fig. 24.5). nium can be incised along the temporal crest each side and across the vertex of the skull posteriorly. The pericranial flap pedicled anteriorly can be raised to expose the underlying Intraoral buccal sulcus incisions skull and is available as vascularized tissue for dural repair if A horseshoe incision in the upper buccal sulcus gives excel- needed. Freeing the supraorbital nerves from their foramina lent access to the lower half of the maxilla and zygomatic (a) (b) Fig. 24.4: Postoperative retraction of temporalis muscle. (a) Before treatment. (b) After treatment by onlay augmentation of temporal fossa and correction of lower eyelid tethering. Treatment Techniques 5 buttress, and limited access to the infraorbital rim. It should be placed at the height of the sulcus, extending from first molar to first molar, and be directed out into the cheek poste- riorly to avoid tearing and insure maintenance of a good vas- cular pedicle to the maxilla. Repair of the paranasal muscles at the end of the procedure may reduce the risk of alar flaring postoperatively.5 Extraoral approach to the mandible While lower buccal sulcus incisions give good intraoral access to the horizontal ramus and angle of the mandible, on some occasions avoidance of the transoral route is necessary. In addition, intraoral access to the vertical ramus and mandibu- lar condyle is poor and surgical procedures on these areas of the lower jaw often require an extraoral approach. (a) The submandibular approach gives good access to the hori- zontal ramus and angle and allows limited access to the verti- cal ramus of the mandible. The marginal mandibular branch of the facial nerve must be protected, either by dissection deeply on the cervical fascia or by dissection on the deep surface of platysma and formal identification of the nerve in the subplatysma fascial layer. Excessive traction may result in temporary paralysis of the lower lip due to stretching of the marginal mandibular branch of the facial nerve but perma- nent weakness should be uncommon through this approach. However, nerve injury is more likely if the submandibular approach has been used previously, with fibrosis, loss of surgi- cal planes and distortion of the local anatomy. Retromandibular incision with blunt dissection between the buccal and marginal mandibular branches of the facial nerve can give excellent access to the vertical ramus and condylar neck and a pre-auricular incision with temporal extension allows access to the condylar head and temporo- mandibular joint. As with the bicoronal flap, dissection on the surface of the temporalis fascia will avoid injury to the frontal branch of the facial nerve. Other incisions Other local incisions such as the upper eyelid blepharoplasty incision, lateral eyebrow incision or use of existing scars may be indicated in selected cases, where more extensive expo- sure is not necessary. Correction of deformity Correction of bony deformity may be carried out by using osteotomy, onlay grafting or a combination of both tech- niques. If an individual component of the facial skeleton is of normal morphology but in abnormal position (displacement), osteotomy is usually the technique of choice. If the bulk of the bone is in normal position but there is abnormal morphol- (b) ogy, e.g. localized contour deficit (deficiency) then onlay grafting may be appropriate.4 If both displacement and deficiency exist, then both techniques may be required. Fig. 24.5: Postoperative lid retraction. (a) Before treatment. However, the choice of technique must take account of the (b) Following correction by placement of auricular cartilage graft. concerns of the patient, as well as the nature and degree of 6 Secondary Osteotomies and Bone Grafting deformity, the extent of surgery required, potential complica- ralis muscle or the superficial temporal vessels and temporo- tions and a realistic assessment of the likely outcome. These parietal fascia provide an excellent source of vascularized considerations may necessitate a departure from or modifi- bone for midface and mandibular reconstruction.11 A disad- cation of the basic principles outlined above. vantage in mandibular reconstruction is the possibility of postoperative restriction in mouth opening. In cases where a Osteotomy large bulk of vascularized bone is required, microvascular free flap transfer is the treatment of choice, with a variety of A variety of osteotomies are available and are well docu- potential donor sites, including iliac crest (deep circumflex mented.1–4 These effectively recreate the original fracture iliac artery) and fibula. In selected cases, bone regeneration pattern in the area of concern. Secondary osteotomies for by distraction osteogenesis may be an option6 but has cur- trauma patients are usually carried using conventional surgical rently not been widely applied to treatment of posttraumatic techniques with use of interpositional bone grafting if deformity. required to fill gaps created by the bony movements, to The disadvantages of autogenous bone grafting include pro- insure primary bone healing, stability of the bony movement longation of operating time and the creation of a graft donor and support for overlying soft tissues. Osteogenic distraction site, with its potential associated morbidity. Variability of cal- of the craniofacial skeleton is becoming more widespread and varial thickness may result in inadvertently cutting into the may offer another treatment option in selected cases.6 intracranial space during graft harvesting,12 but complications However, its role in the correction of posttraumatic deform- are rare. ity has yet to be established. Cartilage Onlay grafting Autogenous cartilage is an excellent material for reconstruc- tion in some situations.13 It is biocompatible, maintains its Onlay grafting to correct bone deficiencies may be carried out viability, is dimensionally stable and is easy to carve and using a number of materials. Autografts, homografts, hetero- shape. It can be fixed with wires or sutures. Although its grafts and alloplastic materials have been described and each resistance to infection is limited, it has been proved to be a has its advantages and disadvantages. The 'ideal' characteris- reliable material when implanted into a vascular bed, espe- tics of onlay grafts have been outlined by a number of authors cially when used in the orbit and nose. It is an excellent space but include the following: biocompatible, no risk of disease filler but not rigid and therefore unsuitable for load bearing. transmission, resistant to infection, dimensionally stable, easy Potential donor sites are auricular concha and nasal septum, to shape or mold, amenable to skeletal fixation, long shelf which give a relatively thin sheet with limited area and life, cheap. volume, or costal cartilage, which has an abundant supply and can provide large volume. As with autogenous bone, prolon- Autogenous materials gation of operating time and donor site morbidity, particularly if costal cartilage is used, are relative disadvantages. Bone Autogenous bone may be used as an interpositional graft or for onlay augmentation. It has several advantages over other Other materials materials, including its biocompatibility and lack of risk of A variety of homografts, heterografts and alloplastic materials disease transmission. Resistance to infection is good, particu- are available and the reader is referred to Chapters 8 and 31 larly if the bone is vascularized.7 Dimensional stability is vari- for discussion of these. In principle, we prefer to use autoge- able and depends on the vascularity (vascularized being better nous materials in most situations to minimize the risk of than non-vascularized),8,9 embryological origin (membranous disease transmission, peri-implant infection or late extrusion. bone being better than cartilaginous bone),10 fixation (rigid Exceptions to this are large calvarial defects, where sufficient fixation better than non-rigid fixation),10 graft site (interposi- autogenous bone may not be available, temporal or forehead tional graft better than onlay) and functional loading (func- contour defects, where bone graft substitutes (e.g. tricalcium tional loading is better than no functional loading). A number phosphate) may be used, and minor malar deficiencies where of donor sites including tibia, iliac crest, mandible and calvar- alloplastic onlay grafts are an option. ium are available. The author's preferred donor site is iliac crest for cancellous or corticocancellous bone grafting to mandibular non-union and calvarial bone grafting for almost Follow-up all other situations where osteotomy gaps or bony deficiency Postoperative follow-up is essential, not only to monitor the exist, where masticatory loading is expected and where results of treatment but to assess the need for further proce- dimensional stability is important. dures. It is not uncommon for several reconstructive proce- The use of non-vascularized grafts requires a healthy, well- dures to be necessary in order to achieve the best possible vascularized graft bed. This is usually present in secondary result. Cohen & Kawamoto1 presented a series of complex posttraumatic deformity patients, but occasionally the graft posttraumatic deformity cases, with an average of 3–4 proce- bed may be of sufficiently poor quality to require vascularized dures per patient in order to obtain optimal correction and a bone grafts. Vascularized calvarial bone pedicled on tempo- range of 1–15. It is also important to appreciate the limita- Treatment Techniques 7 tions of corrective surgery and to accept that some patients Full-thickness calvarial defects cannot be restored to complete normality. There is a danger that unrealistic expectations of outcome on the part of the Background patient or the surgeon may result in increasing numbers of Full-thickness calvarial defects may be seen in a number of surgical interventions yielding diminishing returns. If this situations such as following gunshot wounds, after loss of point is reached, psychological counseling may be appropriate osteoplastic craniotomy flaps or as a result of a growing skull in order to help the patient accept and cope with any residual fracture. Growing skull fracture is a specific and unusual deformity. variant on the full-thickness calvarial defect. These may be linear or non-linear skull fractures, which enlarge with The principles of secondary correction of posttraumatic time and are usually seen in children below the age of 3 deformity will be discussed in the following areas. (Fig. 24.6).14 Ninety percent occur under the age of 3 years ■ Cranial vault deformity but the process may be observed in older children and ■ Orbitozygomatic injuries adults.15 The incidence of 'growth' as a delayed complica- ■ Nasoethmoidal injuries tion of skull fracture is rare and occurred in only 0.6% ■ Posttraumatic malocclusion of the cases in one large series. 16 They present with soft ■ Complex cases involving bone deficiency swelling in the region of a previous skull fracture with clini- cal and radiographic evidence of increased width and length of a previous fracture. The predominant factor responsible Defects and deformity of the skull for increase in the size of the fracture seems to be a dural These will be discussed under the headings of calvarial defect17 with abnormal growth of the underlying cerebral defects, frontal sinus fractures and orbital roof fractures. tissues,18 usually in the form of a leptomeningeal cyst but (a) (b) Fig. 24.6: Clinical presentation of growing skull fracture. (a) Frontal. (b) Lateral. 8 Secondary Osteotomies and Bone Grafting also from herniated cerebrum or dilated underlying ventri- cle with porencephalic cyst. Full-thickness calvarial defects may require treatment for a number of reasons. The patient may be at risk from further trauma, either from blunt injury or penetrating objects, and a significant cosmetic defect may be apparent (Fig. 24.6). In addition, infections of the scalp present a significant risk of intracranial spread due to loss of the natural barrier of the calvarial bone, with potentially serious consequences.19 Reconstruction using alloplastic prostheses has historically been the most commonly used method for correction of the larger full-thickness calvarial defect. In the early 20th century active interest developed in autogenous cranioplasty from various donor sites, such as tibia, ilium, ribs or skull. More recently, however, the trend has been to use split-thickness calvarial bone grafting. Calvarial bone grafts have become Fig. 24.7: Three-dimensional model of skull defect and more popular because of their greater dimensional stability prefabricated implant. and lower donor site morbidity compared with other bone graft donor sites. However, harvesting of these grafts still involves small risks of dural tears, meningitis, brain abscess, cover the defect, without leaving a deficiency in the donor encephalitis and sagittal sinus tears. These risks depend upon area. Large full-thickness calvarial defects therefore are the size of the graft harvested and whether full-thickness or usually reconstructed using acrylic or titanium implants, split-thickness grafts are used,20 the location of the donor site whilst smaller defects are amenable to the use of split cal- and the skill and experience of the operator. varial bone grafts. Assessment Operative technique A full history of the cranial defect should be established Surgery is performed using a standard coronal flap approach. together with previous surgical details, including any prior Great care is needed when elevating the flap in the region of attempts at reconstruction, in order to anticipate potential the bony defect in order that a dural tear is not produced. surgical complications such as dural tears or the need to The margins of the defect are carefully exposed by subperi- remove plates or other implants placed previously. As always, cranial and extradural dissection and any soft tissues within a thorough clinical examination is required. Special attention the fracture line or defect are excised or replaced. Excision of should be given to the site and size of the skull defect. The non-viable cerebral tissue and dural repair is carried out position of previous surgical scars should be noted and the where necessary. quality of the soft tissues overlying the bony defect assessed. If calvarial bone graft is to be used, a template of the Plain X-rays show a characteristic irregular oval or elliptical defect is cut out using sterile paper to aid in accurate harvest- skull defect which may be demonstrated on anteroposterior ing of the graft. The exact form of the calvarial bone graft and lateral films. However, more detailed images are gained depends on the size of the defect being reconstructed. Shave from CT scans, which in addition give useful information grafts consist of fine strips of bone harvested from the outer about the underlying brain. This is of special relevance where table with osteotomes. Their advantage is that multiple grafts growing skull fractures are being managed and an MRI study can be harvested from a wide area without leaving a is often used in addition because of its excellent soft tissue significant donor defect. However, their small size means that imaging characteristics. Reformatting of axial and coronal CT they cannot be rigidly fixed in their new position. images can be performed to create three-dimensional images Sliding bone grafts are in many ways analogous to the which give excellent visualization of the cranial defect. advancement flaps used in skin surgery. An area of bone is Modern software allows the milling of an exact model of the exposed adjacent to the defect and a bone graft somewhat skull and defect. This is particularly useful for very large larger in size than the defect is marked out using saws or defects as it allows the fabrication of a custom-made allo- burrs. The outer table of the skull is then harvested through plastic cranioplasty implant (Fig. 24.7). the diploic layer as a partial-thickness graft. The bone graft is then slid across the defect in such a manner that it still par- Treatment planning tially lies across the inner table of the donor site. Such The decision to reconstruct a full-thickness calvarial defect overlap allows increased primary stability and may possibly depends on a number of factors including age, risk of injury, lead to earlier bony union. size of defect, any underlying pathology and the cosmetic Transposition calvarial bone grafts are now the most widely consequences of the defect. The decision to operate is taken accepted method of reconstructing sizeable full-thickness on the merits of each individual case. Whether calvarial bone skull defects.20 Following complete exposure of the edges of graft or alloplastic implant is used depends largely on the size the bony defect, a temporary template is fashioned and a of the defect and the availability of sufficient calvarial bone to suitable area for the harvest of calvarial bone is identified. Treatment Techniques 9 Outcome of calvarial defect reconstruction The outcome of reconstruction of simple calvarial defects using split calvarial bone grafts is excellent. In a follow-up study of 27 patients, Posnik et al21 found minimal complica- tions with no infections, graft exposures or intracranial injuries. However, a growing skull fracture is a different clinical entity. In a study of 41 patients with growing skull fractures Gupta et al16 reported a death rate of 7%, postop- erative CSF leaks in 7% and local wound infection in 14%. In a review of 132 cases reported in the literature, Pezzota et al22 found a high incidence of seizures and focal neurolog- ical deficit, with functional recovery being linked to the clinical presentation and early diagnosis. Reconstruction of simple calvarial defects is therefore associated with a better outcome than growing skull fractures, in which the postop- Fig. 24.8: Split calvarial bone graft showing outer and inner erative morbidity is largely related to abnormalities of the tables separated. underlying brain. Frontal sinus fractures This is most usually in the parietal region on the contralateral side to the pre-existing defect. A full-thickness piece of cal- Background varial bone slightly larger in dimensions than the template is Frontal sinus fractures are most commonly managed in the removed, taking great care not to damage the underlying acute setting where open reduction and internal fixation of dura. Once this has been achieved the bone graft is split using the disrupted bone is performed together with any necessary fine osteotomes and saws along the diploic layer, thus produc- maxillofacial or neurological surgery.23 Where the posterior ing two similarly sized pieces of bone consisting of the inner wall of the frontal sinus is fractured, cranialization of the and outer table respectively (Fig. 24.8). Once this has been sinus and stripping of the lining mucosa together with obliter- done, the outer table bone graft can be returned to the donor ation of the frontonasal duct with muscle, fat or cancellous site, leaving the inner table graft which can then be adapted bone chips are necessary to prevent late complications of to reconstruct the bony defect. CSF leakage, mucopyoceles, osteomyelitis and meningo- Fixation is achieved for the bone at the donor and the encephaloceles.24 A dural repair is generally required where grafted sites using micro or miniplates (Fig. 24.9). In growing the posterior wall is fractured. On occasion, however, skull fractures in pediatric patients, consideration should be patients may present for late correction of a depressed frac- given to use of resorbable plates to avoid drift of the plate ture of the frontal bone, usually for reasons of cosmesis. from the outer to the inner aspect of the calvarium with con- tinued skull growth. The donor site should be covered with a Assessment layer of Surgicel, the pericranial layer closed and the scalp A thorough history of the injury and its subsequent manage- repaired over a suction drain if necessary. ment should be taken. If the posterior table was involved in (a) (b) Fig. 24.9: Split calvarial bone graft. (a) Outer table replaced at donor site. (b) Inner table reconstructing defect. 10 Secondary Osteotomies and Bone Grafting the original fracture it is important to know if a cranialization Treatment planning procedure was performed as this will have important conse- There are two principal methods of management, both quences for the reconstruction of the bony defect. In this sit- usually through a coronal approach. First, the bone may be uation, fibrosis and adhesions will increase risk of further re-osteotomized along the previous fracture lines and the dural tear and avoidance of extradural dissection is desirable. bone fragment(s) fixed in their original position with mini- Onlay bone graft or use of an alloplastic filler material may be plates or microplates. If the posterior table has been involved more appropriate than osteotomy in order to reduce risk of this is likely to involve a formal craniotomy. Alternatively the complications. defect can be masked with an onlay bone graft or, if the Examination of the frontal bone contour together with contour defect is minor, it may be corrected more simply the condition of the overlying skin is performed. The sensa- using a calcium triphosphate bone replacement material tion subserved by the supraorbital and supratrochlear nerves keyed to the bone with microscrews or fine titanium mesh. should be assessed prior to raising the coronal flap. Plain films can give useful information especially with Operative technique regard to the presence and location of metalwork from pre- Figure 24.10 illustrates the operative technique. vious surgical procedures. CT scans are required to show greater detail of the anatomy of the anterior and posterior Outcome walls of the frontal sinus. The presence or otherwise of active Outcome of secondary osteotomy or bone grafting for frontal sinus disease can also be assessed and if present, displaced anterior wall fractures is excellent. Most complica- should be treated prior to reconstruction. tions are associated with the original injury and are depend- (a) (c) (b) Fig. 24.10: Frontal sinus fracture. (a) Bicoronal flap. (b) Osteotomy and fixation of fragments. (c) Augmentation with tricalcium phosphate bone cement. Treatment Techniques 11 ent on whether the posterior wall is involved with dural tear, CSF leaks, involvement of the nasofrontal duct and whether adequate treatment including, where necessary, dural repair, cranialization or obliteration of the sinus and nasofrontal duct were carried out. In a series of 33 patients with frontal sinus fracture,25 long-term complications occurred in four patients, with only two being cosmetic. The requirement for second- ary surgery is therefore small in well-managed frontal sinus fractures. Orbital roof fractures Background Orbital roof fractures are a consequence of severe trauma and are associated with a considerable likelihood of neurological and ophthalmological injury. In general such injuries are managed in the acute phase but where they are not treated or where treatment is inadequate, the patient may present with a significant secondary deformity. Below the age of 3, the orbital roof may be the site of a growing skull fracture.15 Assessment A full history of the original injury is taken together with a history of previous treatment. Original notes, X-rays and scans are of great help in shedding light on previous treat- ment and planning surgery. A full assessment of the external bony contour should be made. Irregularity or asymmetry of the supraorbital rims should be noted. An assessment of enophthalmos or exo- phthalmos (including pulsating exophthalmos indicative of orbital roof defects) should be made. Sensory function of the supraorbital and supratrochlear nerves should be assessed. As with any orbital reconstruction, an ophthalmological opinion should be sought before any surgery is performed to docu- ment vision and ocular motility preoperatively to identify (a) problems and to act as a baseline for postoperative follow-up. Where the orbital roof itself has been depressed, ocular dystopia with inferior displacement of the globe is a common finding (Fig. 24.11). Larger defects of the orbital roof put the patient at risk of dural herniation which may result in pulsat- ing exophthalmos and disturbance of ocular function. Special investigations Fine cut axial and coronal CT scans should be obtained to give detailed images of the orbital roofs of both orbits (Fig. 24.12). This allows accurate surgical planning and meas- urements can be made of bony displacement, deficiency or asymmetry. Operative technique In the great majority of cases a coronal flap will be the most appropriate approach. Occasionally it may be possible to access the surgical area via an existing scar and for small defects confined to the supraorbital rim, this approach (b) may be adequate. However, more major deformities and any significant displacement or deficiency of the orbital roof Fig. 24.11: Orbital roof fracture. (a) Inferior displacement of eye. will require a transcranial approach with unilateral frontal (b) Proptosis. 12 Secondary Osteotomies and Bone Grafting Deformity of the zygomaticoorbital region Background The treatment of fractures of the orbit and fractures of the zygoma will be dealt with together due to the great overlap of these topics. Injuries to this area can produce complex deform- ities and careful planning is required when secondary correc- tive surgery is contemplated. In general, deformity is due to inadequate primary surgery28 and is related in part to the underlying bony skeletal abnormality and in part to the soft tissue component including scarring, thickening and incor- rect draping of the soft tissue envelope on the facial bones. Deformities of upper and lower eyelids may be seen, often as a result of the initial trauma but also occasionally resulting from a previous surgical approach. Patient complaints may be related to the cosmetic or functional deficit that they are experiencing or both. It is important to establish from the outset the specific concerns of the patient and his expectation of the outcome of treatment. This will allow surgery to be tailored to the patient's concerns rather than the surgeon's view of the defor- mity and will give the opportunity to dispel any unrealistic expectations that the patient may have. Assessment A full history should be taken including the mechanism of the original injury, the treatment previously received and the current concerns of the patient. A number of factors con- tribute to unsatisfactory appearance following orbitozygo- matic injuries and give rise to cosmetic complaints. Fig. 24.12: CT scan of orbital roof fracture showing significant Enophthalmos is common due to increased orbital volume displacement of fracture segment. or herniation of orbital contents through defects in the orbital walls, usually inferior or medial (Fig. 24.13). Ocular dystopia may occur with inferior displacement of the globe when craniotomy, retraction of frontal lobe and on occasion Whitnall's tubercle is inferiorly displaced as a result of zygo- may require removal of the supraorbital bar. This obviously matic malunion following an inferiorly displaced fracture. requires joint neurosurgical/maxillofacial management. Loss of zygomatic prominence leading to cheekbone asymme- Where small depressions or contour irregularities exist try is common and increased facial width due to bowing of they may be masked by bony recontouring with burrs and by the zygomatic arch may occur secondary to an inadequately the application of small onlay bone grafts or alternatively one reduced posteriorly displaced zygomatic fracture. Telecan- of the proprietary bone cements now available. Large dis- thus may be present if the original fractures involved the placements or defects in the orbital roof require accurate portion of bone bearing the medial canthal ligament or if the reduction or reconstruction with split-thickness calvarial ligament has been detached during surgical access for primary bone graft, if necessary following dural repair. Where a treatment. frontal craniotomy has been performed, the graft can be har- Esthetic concerns with regard to the periorbital soft tissues vested from the inner table of the frontal bone flap, thus are frequently related to the position of the eyelids and avoiding any visible or palpable donor site defect.26 canthi. Lid retraction and/or true ectropion may be seen, usually as a result of previous treatment (see Fig. 24.5). Outcome Functional deficits following orbital trauma frequently There is very little in the literature regarding secondary cor- relate to injury to the globe itself and are thus within the pre- rection of orbital roof fractures.27 With accurate reconstitu- serve of the ophthalmological surgeon. Tethering and scarring tion of the anatomy, the outcome should be good in both of the periorbita and extraocular muscles may cause diplopia pediatric and adult patients. However, some inaccuracy in which, if severe, can be disabling (see Fig. 24.1). Epiphora is a vertical and AP globe partitioning may occur, as well as post- frequent complaint and may be due to damage to the bony or operative diplopia. soft tissue component of the lacrimal drainage apparatus, Treatment Techniques 13 (a) Fig. 24.14: Three-dimensional CT scan showing overreduction of the fracture of the left zygoma. including abnormalities of lower lid and therefore lacrimal punctum position. Where epiphora persists, corrective surgery may be necessary. Clinical examination should include assessment of the degree of enophthalmos, which should be assessed sub- jectively by clinical examination and objectively by exo- phthalmometry. The classic signs of enophthalmos, including (b) obvious ocular retrusion, hypoglobus, deep supratarsal fold, pseudoptosis and narrowing of the palpebral fissure, may be apparent (Fig. 24.14). Normal anterior projection of the globe relative to the lateral orbit rim is between 12 and 16 mm. Whilst formal exophthalmometry would seem likely to give a more objective assessment than clinical examination, it should be remembered that it is comparing the position of the globe with that of the lateral orbital wall and if this bony landmark has been altered by the original trauma, the subse- quent reading may be unreliable. Any asymmetry of the malar prominences should be noted. The malar eminence on the injured side may be displaced medially, posteriorly or inferiorly or combinations of these. Rarely, if previous surgery has overreduced the zygomatic complex, it may be lateral to its normal position and there- fore overprominent. Facial width should be assessed by com- paring the relative prominence of the zygomatic arch on the injured and uninjured side. If the zygoma is displaced poste- riorly, this results in a 'bowing out' of the zygomatic arch, thus increasing the facial width on the injured side. (c) An assessment of the overlying soft tissues should be made. Fig. 24.13: Enophthalmos. (a,b) Clinical appearance. The quality and thickness of the tissues should be noted. (c) CT scan showing large floor blow-out. Scarred, contracted tissues may require correction either at 14 Secondary Osteotomies and Bone Grafting (a) (b) Fig. 24.15: Surgical planning on CT scans. (a) Anteroposterior measurement. (b) Vertical measurement. the time of osteotomy or subsequently. Loss of sensation in measurements from unaffected fixed points such as the the distribution of the infraorbital nerve is common following pterygoid plates or contralateral uninjured orbit, a quantita- orbital trauma, whilst loss of supraorbital and supratrochlear tive measurement of the bony deformity can be established nerve sensation is less frequently seen. There is no evidence with respect to the contralateral uninjured side. These meas- to suggest that secondary surgery will have a beneficial effect urements should be established in three planes so that the on compromised nerve function and indeed, the patient necessary movements or augmentations of the zygomatico- should be aware that surgery carries the risk of further nerve maxillary complex can be predicted in the vertical, medio- damage. lateral and posteroanterior planes. These movements should be accurately established before surgery is undertaken (Fig. 24.15). Special investigations MR scans are little used in the planning of facial bone Plain X-rays have a limited role in surgical planning of osteotomies at the present time but they do have a role in midface deformity. They are useful in identifying the type assessing the nature and quality of the overlying soft tissues and position of internal fixation used in previous operations, and may be a useful investigation in difficult cases. The as this will almost certainly need to be removed if further degree of herniation of tissues through the medial, inferior surgery is performed. A submento-vertex radiograph will and to a lesser extent the lateral orbital walls may be assessed show the form of the zygomatic arches. Subtle variations in with MRI scanning. It may also be possible to image trapping the shape of the zygomatic arches can have a profound effect or tethering of extraocular muscles. on facial width and overall facial balance. Dental study casts have little role to play in the manage- CT scans are invaluable in surgical planning. Images should ment of zygomatico-orbital deformity unless there is going to be obtained in the coronal and axial planes and 3D images can be a simultaneous osteotomy of the maxilla or mandible to be particularly useful in orbitozygomatic injuries. By taking correct a malocclusion. The advent of computer-generated Treatment Techniques 15 Surgical technique For successful correction of the zygomatico-orbital deformity, complete regional exposure is required28 although some authors advocate a more conservative approach.30,31 This is per- formed through a bicoronal flap, combined with a lower eyelid incision, and an upper buccal sulcus incision. The bicoronal flap gives excellent access to the orbit and zygomatic arch and body and permits harvesting of calvarial bone graft. Stripping of the temporalis muscle facilitates exposure of the lateral orbital wall. Lower eyelid approach gives access to the infraorbital rim and orbital floor and allows visualization and protection of the infraorbital nerve. It may be through a skin incision (blepharo- plasty, midtarsal or infraorbital) or via a transconjunctival incision. The transconjunctival incision, which is usually com- bined with a lateral canthotomy, is technically more difficult to perform but has the advantage of leaving less facial scarring compared with the cutaneous approaches and may be associ- ated with a lower incidence of lid retraction. The combination of bicoronal flap and lower lid approach allows circumferential subperiosteal dissection within the orbit. The lateral canthal ligament and should be tagged and reattached at the end of the procedure. Conversely, the medial canthal ligament, which is notoriously difficult to reattach, should have its origin carefully preserved. The orbital floor must be dissected with great care as the infraorbital nerve is frequently embedded in dense scar tissue and may easily be damaged. A similar situation applies where gaps in the bony skeleton, for example in the lateral orbital wall, have led to fusion of the intra- and extraorbital soft tissues. The buccal sulcus incision gives access to the anterior surface of the maxilla, zygomatic buttress and, via the maxil- lary sinus, the inferior aspect of the orbital floor. (c) Correction of bony deformities in the zygomatico-orbital Fig. 24.15: (c) Transverse measurement. area is dependent upon the performance of several key maneuvers. Zygomatic osteotomy will reproduce the fracture lines of the original injury. Following exposure, bone cuts are made from the infraorbital rim just lateral to the nerve 3D models of the bony facial skeleton milled or cast using extending down the anterior maxillary wall, passing poste- information derived from CT scans has been a major step riorly, to the zygomatic buttress. The bone cut is continued forward in this regard. Exact measurements can be made on around the lower extent of the buttress onto its posterior the models and the surgery accurately preplanned. If alloplas- face. Within the orbit the cut passes from the infraorbital rim tic materials are to be used they can be custom made on the posteriorly to the anterior end of the inferior orbital fissure. 3D models. Recent advances in computer software are likely The cuts are then continued superiorly through or just ante- to allow much more specific surgical planning in relation to rior to the greater wing of the sphenoid and continued to the the hard or soft tissue movements. zygomatico-frontal suture. Completion of the osteotomy at Sinus endoscopy is a relatively recent innovation and may the posterior aspect of the buttress is best performed using a be useful to assess the condition of the orbital floor. In the fine, curved osteotome, inserted via the coronal approach acute situation, some success with definitive fracture man- behind the lateral orbital rim within the temporal fossa, and agement has been achieved but whether endoscopically extends from the anterior end of the inferior orbital fissure to assisted surgery will have any role in the management of the join with the cut already made in the inferior part of the but- secondary deformity is unclear. One case has been reported tress. The root of the zygomatic arch is sectioned, resulting in of correction of enophthalmos secondary to a medial wall complete freeing of the zygoma from its bony attachments. defect using alloplastic material inserted via an endoscopic For the less experienced operator, appreciation of the exact approach medial to the lacrimal caruncle.29 three-dimensional anatomy is enhanced if a dry skull or a Where surgery is being considered a full ophthalmic and three-dimensional model is available in the operating theater. orthoptic assessment is required as a baseline. This is espe- Before the zygoma is mobilized, the bony movements cially important in those cases where the patient is experienc- should be marked at the infraorbital rim, the zygomatico- ing diplopia. frontal suture and the zygomatic arch. The most common 16 Secondary Osteotomies and Bone Grafting (a) (b) Fig. 24.16: Zygomatic osteotomy with calvarial bone graft to orbit. (a,b) Preoperative photographs showing enophthalmos, hypoglobus and loss of zygomatic prominence. posttraumatic displacement of the zygoma involves impaction occur as a result of repositioning. This increased orbital volume posteriorly, inferiorly and medially. Usually, bone removal is predisposes towards the development of enophthalmos. The required at the zygomatico-frontal suture to permit superior inferior orbital fissure should be exposed and the soft tissues repositioning of the zygoma, whereas advancement and lateral divided (no significant structures pass through it) and it should movement will create bony gaps. The zygoma is fixed into its be obliterated with a graft. Bone grafting is essential to treat new position with microplates. Repositioning of the body of pre-existing enophthalmos and to prevent its occurrence fol- the zygoma will often produce contour deformities and steps lowing osteotomy. Contoured calvarial bone is used for this in the zygomatic arch and the arch itself may require local purpose. Calvarial bone graft exhibits considerably less ten- osteotomies to allow it to be recontoured. dency for resorption than the previously used rib or iliac crest Anterior, lateral and superior movement of the osteotomized grafts, particularly when rigid fixation techniques are utilized.10 zygoma will create bony gaps and step deformities at several Calvarial bone should now be considered as the 'gold standard' sites and these require bone grafting in order to insure bony for grafting in and around the orbit. The bone is readily avail- union, stability and soft tissue support and to avoid palpable able and does not require a separate incision for its harvest. irregularities and edges beneath the thin periorbital skin. Gaps Enough bone is available for the great majority of cases and the occur at the infraorbital margin, orbital floor, the frontozygo- morbidity associated with its harvest has been shown to be matic cut, lateral orbital wall, zygomatic arch and zygomatic very low.32 The technique has been described elsewhere but buttress. In addition, the zygomatic repositioning may have the bone is usually obtained as thin rectangular strips, which created an orbit larger in volume than before and allow hernia- are ideally suited for grafting orbital defects. tion of periorbital tissues through bony defects of the orbital For the correction of enophthalmos it is important that the walls. Considerable widening of the inferior orbital fissure may bone graft is largely situated behind the equator of the globe Treatment Techniques 17 tion. Bone grafts placed posteriorly within the orbit do not generally require fixation although a number of specifically designed plates are available for this purpose. Where grafts are more anteriorly placed, fixation is recommended to mini- mize the amount of resorption and prevent migration. Where possible, the metalwork should be placed within the orbital margin so that it is not subsequently palpable through the thin infraorbital skin. A forced duction test is performed immediately before and after placement of bone graft to insure that ocular motility has not been jeopardized (see Fig. 24.2). In cases where a bone graft is being placed to correct a pre- existing enophthalmos, overcorrection is advisable at the time of surgery in order to allow for swelling and a degree of bone graft resorption.28 Bone graft is carefully placed until a degree of exophthalmos has been achieved. Some authors have rec- ommended incisions within the scarred periorbital tissues in order to allow the globe to take up a more anterior position. It is likely, however, that the scarring will recur and this maneuver is not recommended. Advancement of the dis- placed zygoma and orbital rim is dependent on the ability to simultaneously correct the enophthalmos as otherwise the appearance of the enophthalmos itself may be worsened (Fig. 24.16). Onlay grafting Onlay grafting may be used in mild cases of malar asymmetry and can usually be carried out easily through a lower eyelid incision. Calvarial bone, bone substitutes or alloplastic implants may be used (Fig. 24.17). Nasoethmoid fractures (c) Detachment of the medial canthal ligaments together with their bony insertion is relatively common following orbital and nasoethmoidal fractures. Inadequate primary management leads to telecanthus and blunting of the medial canthal angle. Osteotomy and repositioning of the nasoethmoidal segment may be required. Complete correction of the medial canthal position is notoriously difficult and overcorrection should be the aim. In those cases where the medial canthal ligament is not attached to an identifiable bone fragment, a transnasal canthopexy is required (Fig. 24.18). Where a nasoethmoidal fracture has been a significant part of the orbital injury a graft will almost invariably be needed to the dorsum of the nose to recreate the degree of nasal projection present before the injury. Calvarial bone has been widely used in the past but although it gives a satisfactory appearance, its 'feel', espe- cially towards the nasal tip, is too solid to be natural and a (d) nasal dorsal graft of carved costal cartilage may be preferred (Fig. 24.19). Fig. 24.16: (c,d) Following operative correction. Outcome in order that the eye is displaced forwards. Hypoglobus may Long-term outcome depends on the extent of the secondary be corrected if the bone graft is placed in the orbital floor deformity, on detailed planning, choice of technique and beneath the globe, but care must be taken in placing orbital meticulous surgery. In a series published by Freihofer & bone grafts not to produce unwanted elevation in globe posi- Borstlap,33 osteotomy was found to give superior results 18 Secondary Osteotomies and Bone Grafting (a) (b) Fig. 24.17: Onlay augmentation of left zygoma utilizing vascularized calvarial bone pedicled on temporalis muscle. (a) Preoperative. (b) Post operative. (a) (b) Fig. 24.18: Secondary deformity following nasoethmoidal injury. (a) Medial canthal detachment. (b) Appearance following transnasal canthopexy. Treatment Techniques 19 (a) (c) Fig. 24.19: Nasal reconstruction following comminuted midfacial trauma. (a) Preoperative lack of nasal projection. (b) Carved costal cartilage graft. (c) Postoperative improvement (b) in nasal projection. compared with onlay techniques. In 16 posttraumatic cases, enophthalmos, two were corrected fully whilst three were only 14 were assessed as good or satisfactory, with only two being partially corrected. Infraorbital nerve sensory loss occurred in rated as unsatisfactory, due to undercorrection, overcorrection approximately half of the group. In a series of four cases, or persistence of enophthalmos. They found no decrease in Perino et al34 reported good results and low complication rate. visual acuity and in five cases with associated posttraumatic However, both these had a significant requirement for further 20 Secondary Osteotomies and Bone Grafting procedures to insure optimum outcome and in Cohen & mechanical joint derangement may result in severe deviation Kawamoto's series1 including 14 cases of orbitozygomatic or limitation of mouth opening. deformity, the average number of operations required was Assessment of temporomandibular joint function is manda- 3.76. Further procedures may be required to reduce overcor- tory, since restriction of mouth opening or severe deviation rected malar position, to correct medial and lateral canthal may necessitate surgery to the temporomandibular joint in dystopias, recurrence of enophthalmos and abnormalities of addition to osteotomies or bone grafting. It is important to eyelid position. check for mandibular displacement and insure that when the Hammer28 reported good or satisfactory esthetic results malocclusion is assessed, the mandible is fully retruded. following secondary zygomatico-orbital reconstruction in 20 Occasionally, a patient will present with occlusal complaints out of 26 patients. Where diplopia was present prior to sec- but will apparently show a good occlusion. This may be due ondary correction, improvement occurred in just over half of to a minor mandibular displacement, indicating a discrepancy the group. There was a complication rate of 15% including between the retruded condylar position of the mandible and visual loss due to displacement and bone graft, endoph- intercuspal position. In addition, fibrous union of a body frac- thalmitis, orbital abscess and exposure of a nasal bone graft. ture, allowing a very small degree of movement between Freihofer35 reported a series of patients who underwent segments, may allow good intercuspation but only at the secondary correction of fractured zygomas, with a good expense of bone movement at the site of the fibrous union. result obtained in 80%. Medial canthopexy was carried out It may be difficult to see obvious fracture mobility in this in 19 patients. Three required further procedures but all 19 situation by standard clinical examination but careful inspec- achieved satisfactory or good final outcome. tion of the fracture site whilst occluding and discluding the teeth may demonstrate movement. The use of articulating Posttraumatic malocclusion paper may help assessment in cases where the discrepancy is small. Background Investigation usually includes study models and plain radi- Posttraumatic malocclusion may present following malunion ographs. CT scans may occasionally help, particularly in of any fracture that directly or indirectly involves the alveolar assessment of condylar injuries. segments of the maxilla or mandible. These include isolated Dental study models are necessary to assess whether seg- dentoalveolar fractures of maxilla or mandible, maxillary mental surgery or whole-jaw surgery should be undertaken. If fractures including Le Fort I, II or III with or without palatal the pretraumatic occlusion is obtainable with the existing split, and mandibular fractures. arch form, then one-piece jaw surgery is indicated. If an Before the introduction of miniplating, stabilization of the acceptable occlusion is not obtainable, it may be indicative of occlusion by intermaxillary fixation (IMF) was the primary a malunited segmental fracture or a degree of dentoalveolar aim of treatment of facial fractures. The introduction of compensatory change secondary to the altered occlusion and internal fixation makes direct anatomical segment reduction jaw position. In this situation, one-piece jaw surgery alone the primary aim. If this is achieved, a normal occlusion will not establish the pretraumatic occlusion and adjunctive should automatically follow. This is indeed the case in the treatment is necessary. If the occlusal discrepancy is slight, majority of cases. However, in some comminuted maxillary selective occlusal grinding may allow a reasonable seating of or mandibular fractures, a perfect occlusion may be difficult the occlusion. If this is considered undesirable or will not to achieve and most fractures of the mandibular condyle tend achieve a satisfactory occlusion, then orthodontic treatment to be managed by closed techniques, with the potential for may be considered. However, a number of patients will be displacement following removal of the intermaxillary fix- unsuitable for orthodontics due to lack of anchorage, poor ation. In addition, large muscle forces in the mandible may oral hygiene or dental condition or lack of sufficient motiva- cause movement of the fracture site, resulting in fibrous or tion. If orthodontics is precluded for any of these reasons, non-union. Infection of mandibular fractures, particularly occlusal rehabilitation by restorative techniques may also be those involving the tooth-bearing segment of the mandible or considered but may also be limited by existing dental condi- angle, may result in non-union and segment displacement tion, oral hygiene or patient motivation. In this situation seg- with malocclusion. mental surgery may be the only viable option. Face bow recording and anatomical articulation are useful in planning treatment for correction of anterior open bite. Diagnosis They allow accurate assessment of the degree of posterior In the presence of small displacements of segments, patients maxillary impaction required and an approximate assessment usually complain of functional difficulties in biting and chew- of the degree of mandibular autorotation. This is helpful in ing and the inability to find a positive, comfortable inter- planning the need for mandibular osteotomy to correct cuspal position. In large displacements, an effect on facial anteroposterior jaw relationships. appearance may be added, particularly increases in mandibu- Plain X-rays, particularly OPG and lateral cephalogram, lar angle causing anterior open bite, and mandibular asymme- will demonstrate fibrous union, gross segment displacement, try, both usually due to mandibular condylar fracture site of previously inserted metalwork and if orthognathic malunion. Complaints related to temporomandibular joint techniques are being used, provide a basis for orthognathic dysfunction may follow malunion of condylar fractures and work-up. Treatment Techniques 21 Treatment planning ing this cut radially between the roots of the teeth either side of the site of the desired segmental cut. After segmentation, It is important to consider the need for multidisciplinary an acrylic palate retained with Adams cribs helps to control involvement before treatment is undertaken. This may the segments and temporary intermaxillary fixation is applied involve an orthodontist and occasionally a restorative dental using a prefabricated occlusal wafer to establish the desired surgeon, since some occlusal discrepancies may be amenable position of the maxilla relative to the mandible. Any areas to occlusal adjustment, restorative or orthodontic treatment. causing interference with establishment of the desired posi- As discussed above, other patients may require a joint ortho- tion of the maxilla are removed. This is particularly important dontic and surgical approach using standard orthognathic in the nasal septum to avoid postoperative septal deviation techniques, particularly if a pre-existing malocclusion or and at the posterior maxilla in cases of maxillary impaction. dental crowding existed or if sufficient time has elapsed since The maxilla is then fixed with miniplates, at the piriform the injury to allow some compensatory dentoalveolar changes apertures and zygomatic buttresses. to occur. On occasions, the amount of movement required at Once the maxilla is fixed, the intermaxillary fixation is osteotomy is relatively small and this gives only a small removed in order to check the newly established dental acceptable margin of error in jaw and segment positioning at occlusion. This must be exactly as planned and must be surgery. If positioning errors occur, then elastic traction may achievable by gentle upward pressure on the chin point, be adequate for correction in the early postoperative phase insuring that no distraction of the mandibular condyles out of but should this prove inadequate, an assessment of the feasi- the glenoid fossae has occurred. If this happens, an anterior bility of orthodontic or restorative solutions is useful. open bite will be detectable following removal of intraopera- With regard to the detailed surgical movements, these are tive intermaxillary fixation. If undetected at this stage, it of course dictated by the establishment of an acceptable would certainly become apparent in the early postoperative dental occlusion. Intraoperative occlusal wafers to assist accu- period. If on careful checking of the occlusion, any discrep- rate jaw and segment positioning are essential. Preformed ancy, in particular anterior open bite, is detected, then the arch bars facilitate intraoperative intermaxillary fixation and occlusal wafer and intermaxillary fixation must be reapplied if significant edentulous areas exist, especially posteriorly, and the maxilla repositioned and replated, following the then acrylic saddles should be incorporated within the arch removal of any persistent bony interferences, especially in the bars to facilitate jaw positioning and should be left in situ region of the maxillary tuberosity and pterygoid plates. postoperatively to improve jaw stability and prevent loss of Once the correct maxillary position is established, any posterior ramus height in the early postoperative period. significant bony gaps or deficiencies are bone grafted. This is particularly important at piriform and zygomatic buttresses Osteotomies and at the anterior maxillary wall. These insure union, stabil- ity and support for the overlying soft tissues of the cheek. Maxilla However, the use of bone grafts in Le Fort I osteotomies to Indications correct posttraumatic occlusion is uncommon due to the rela- In order to correct occlusal abnormalities due to maxillary tively small movements involved. malunion, Le Fort I osteotomy is indicated. Osteotomy at If segmental surgery is necessary to reposition a dento- Le Fort II or III level, or variations of these procedures alveolar segment only, then this is best carried out via a full tailored to the individual needs of the patient, may be Le Fort I down fracture in the manner described above. This required in some instances where simultaneous correction of approach facilitates access for bone cuts, particularly in the midface deformity is necessary. However, primary treatment palate, and removal of bony interferences between segments. by open reduction with internal fixation and primary bone Care must be taken to avoid injury to the dental roots adja- grafting have substantially reduced the need for more exten- cent to segmental bone cut, especially if preoperative ortho- sive maxillary osteotomies in the treatment of secondary dontic treatment has not been carried out. If palatal posttraumatic deformity. Le Fort I osteotomy is therefore expansion is carried out then bone graft may be placed in the indicated for most cases of maxillary occlusal abnormality, palatal osteotomy gaps to improve transverse stability.1 when segmental or one-piece maxillary repositioning is neces- Previously described local segmental maxillary osteotomies sary. In addition, maxillary osteotomy may be required in have largely been superseded by the Le Fort I down fracture order to close an anterior open bite following bilateral condy- technique. lar malunion. Outcome Operative technique There is very little literature devoted to the outcome of Standard Le Fort I down fracture is carried out via a horse- maxillary osteotomies for the correction of posttraumatic shoe-shaped buccal sulcus incision. Bone cuts of lateral deformity, either one-piece or segmental procedures. maxillary wall, zygomatic buttress, lateral nasal walls, pterygo- Stability following osteotomies for posttraumatic deformity maxillary dysjunction and nasal septum are carried out in a will be dependent to an extent on the nature of the original similar way to standard orthognathic surgery. Following down injury, its treatment and subsequent secondary procedures fracture, the maxilla is mobilized and if indicated, segmenta- and the presence of soft tissue scarring which, if present, is tion of the maxilla can be carried out from the nasal aspect by likely to increase relapsing forces, a phenomenon well known making a horseshoe-shaped cut in the bony palate and extend- in cleft osteotomy. Cohen & Kawamoto1 reported the results 22 Secondary Osteotomies and Bone Grafting of 25 patients with severe posttraumatic facial deformities, including 10 Le Fort I osteotomies. Although they present no detailed analysis of long-term outcome, they take the view that malocclusion following secondary correction should be rare. However, any adult non-orthodontic, orthognathic surgery demands meticulous technique and accurate posi- tioning of segments. Mandible Patients presenting with malocclusion following mandibular injuries may present with non-union, fibrous union or malunion. Non-union/fibrous union Non-union and fibrous union may occur following fracture of any part of the mandible but most commonly affect fractures of the mandibular angle. 36 In a study of 1432 mandibular fractures, Mathog et al37 found an incidence of non-union of 2.8%. They reported increased incidence in men, in fractures affecting the body of the mandible and in patients with multiple fractures. Inadequate stabilization or reduction and osteomyelitis were found to be common. Other contributory factors included lack of prophylactic antibiotics, delay in treatment, presence of teeth in the line of the fracture, alcohol and drug abuse, an inexperi- enced surgeon and lack of patient compliance. 37 Moreno et al38 found that the overall complication rate, postopera- tive infection and postoperative malocclusion were significantly correlated with the severity of the original frac- ture and similar risk factors were identified by Haug & Schwimmer.39 Treatment requires debridement of the fracture site and eradication of infection, with accurate reduction and (a) fixation. In the absence of significant bone deficit this treat- ment should result in successful union. Since infected non- unions present with a mandibular continuity gap, temporary fixation of fragments is desirable to allow resolution of infec- tion prior to bone grafting. Where there is intact overlying mucoperiosteum, this may be achieved by rigid internal fixation. However, in long-standing severe cases, the quality and availability of mucosal cover for the fracture may be poor. If internal fixation is used in these cases, dehiscence of the intraoral wound may occur with resultant plate expo- sure. In this situation immobilization is best achieved by use of an external fixator (Fig. 24.20). Once infection is eradi- cated and mucosal healing has occurred, cancellous or cortic- ocancellous bone graft and internal fixation in the form of mesh or plates is carried out usually via an extraoral approach to avoid contamination of the bone graft by intrao- ral bacteria. (b) Technique Fig. 24.20: Infected non-union of fractured mandible. The fracture site is approached by a standard intraoral or (a) External fixator in place. (b) Maintenance of occlusion with extraoral incision. The fracture is mobilized, bone ends cut fixator. back to healthy bleeding bone and segments repositioned with the aid of temporary intraoperative intermaxillary fixation and use of an occlusal wafer for accurate location of Outcome the teeth. Where little or no bone gap is present, bone grafts Outcome is usually good although sensory loss in the region may be unnecessary but in most cases cancellous or cortico- of the inferior dental nerve is common due to inevitable scar- cancellous bone harvested from the iliac crest will restore ring and damage as a result of the original injury, primary mandibular continuity defects and insure bony union. treatment and subsequent secondary bone grafting. Treatment Techniques 23 Malunion Malunion may occur in the horizontal or vertical ramus of the mandible. Horizontal ramus Malunion of a fracture of the horizontal ramus usually requires direct osteotomy to recreate the fracture, mobilization and repositioning of the segments and placement of internal fixation, with the expectation of an excellent outcome. Angle, ramus and condylar fractures Malunion of fractures behind the tooth-bearing segment of the mandible result in displacement of the whole dento- alveolar arch. Uncomplicated angle and ramus fractures rarely result in malunion because they are amenable to open reduc- tion with internal fixation. However, mandibular condyle frac- tures are often treated non-surgically by closed methods of reduction, intermaxillary fixation and elastic traction. Displacement of the mandible and resulting malocclusion may occur for a variety of reasons. Severe condylar malposition with dislocation allows vertical shortening of the ascending ramus and this may be associated with restricted mouth opening or deviation on opening due to mechanical disruption of the temporomandibular joint. The functional status of the temporomandibular joint is an important factor in the choice of technique adopted for correction of the occlusal deformity. If temporomandibular joint function is significantly compro- mised, reduction of the dislocation may be necessary, along with disc repositioning. If temporomandibular joint function is acceptable, ramus osteotomy is indicated in order to avoid joint surgery and the possibility of surgically induced limita- tion of mouth opening. Vertical ramus shortening may also occur following angular displacement of the condylar neck without dislocation if telescoping of the proximal and distal fragments occurs, particularly if the molar teeth are absent (a) and there is lack of posterior occlusal support. It may also be seen following condylar resorption.39 In unilateral condylar fractures, malunion results in shorten- ing of the ipsilateral ramus height, transverse cant of the lower occlusal plane, gagging of the occlusion on the ipsilateral pos- terior molars and contralateral open bite. In addition, there may be posterior displacement of the ipsilateral mandible resulting in obvious chinpoint asymmetry, as well as cross or scissors bite (Fig. 24.21). If bilateral malunion occurs, then both ascending rami shorten, with an increase in mandibular and lower occlusal plane angle, bilateral occlusal gagging on the posterior molars, anterior open bite, with class II jaw rela- tionship and, if severe, lip incompetence (Fig. 24.22). Treatment Unilateral (b) The aim of treatment in unilateral cases is to restore the pre- Fig. 24.21: Bilateral condylar malunion. (a) Obvious chinpoint traumatic ramus height and correct posterior mandibular dis- asymmetry. (b) Occlusal derangement with open bite. placement if present. This corrects the occlusal plane cant and restores a normal occlusion and can be achieved by either performing an osteotomy at the site of the original moid, inverted L or sagittal split osteotomy. Direct fracture fracture, repositioning and if necessary interpositional bone line osteotomy is appropriate where the fracture site involves grafting to maintain lengthening of the ramus, or by a ramus the angle or ascending ramus. However, if the fracture osteotomy distant from the fracture site, e.g. vertical subsig- involves the condylar neck, direct osteotomy and grafting can 24 Secondary Osteotomies and Bone Grafting (a) (b) (c) (d) (e) (f) Fig. 24.22: Vertical ramus osteotomy to correct posttraumatic malocclusion. (a) Preoperative malocclusion. (b) Retromandibular incision marked. (c) Vertical ramus osteotomy performed. (d) Temporary intermaxillary fixation with occlusal wafer. (e) Fixation of osteotomy. (f) Wound closure. Treatment Techniques 25 (a) (d) (b) (e) (c) (f) Fig. 24.23: Bilateral sagittal split osteotomy to correct postoperative malocclusion. (a) Preoperative malocclusion due to unilateral condylar fracture. (b) Preoperative cephalogram. (c) Preoperative OPG. (d) Postoperative occlusion following osteotomy. (e) Postoperative PA cephalogram. (f) Postoperative OPG. 26 Secondary Osteotomies and Bone Grafting be difficult and carry significant risk of postoperative trismus Bilateral or ankylosis. In this situation vertical subsigmoid osteotomy, Bilateral condylar malunion usually results in anterior open inverted L or sagittal split osteotomy is indicated where tem- bite and class II jaw relationship. This is best treated in the poromandibular joint function is adequate. Where temporo- same way as a developmental high angle class II anterior open mandibular joint function is compromised, reduction of the bite, utilizing standard orthognathic and if necessary ortho- condylar fragment and disc repositioning may be necessary dontic techniques. This approach effectively accepts the despite the surgical difficulty and risk of surgically induced reduced ramus height and therefore a reduced posterior face restriction of mouth opening postoperatively. height. The correction is achieved by adjusting the maxilla Where temporomandibular joint surgery or condylar reduc- to accommodate this reduced posterior face height by carry- tion is not necessary, the particular type of osteotomy chosen ing out a posterior maxillary impaction. This results in an is governed by the direction and extent of displacement. increase of the occlusal plane angle, but this is of little Rubens et al40 recommend that when horizontal movement significance and will result in a stable correction of the ante- is the primary goal, sagittal split osteotomy is appropriate. rior open bite component of the deformity, as a consequence Where vertical correction is required, they recommend use of of mandibular autorotation. Mandibular autorotation will also an intra- or extraoral ramus osteotomy. However, they also result in a degree of anterior mandibular projection and this point out that other factors such as facial scarring, ease of may be sufficient to correct the mild class II skeletal relation- condylar segment manipulation and available bone influence ship. The degree of anterior projection as a result of autorota- the approach selected. tion may be assessed preoperatively by surgical simulation (a) (b) Fig. 24.24: Bimaxillary osteotomy to treat anterior open bite and mandibular asymmetry following bilateral condylar fracture. See Fig. 24.21 for preoperative clinical appearance. (a,b) Pre and postoperative lateral cephalograms. Treatment Techniques 27 using an anatomical articulator. If autorotation is insufficient should err on the side of overcorrection if doubt exists. This to correct anteroposterior discrepancy, then bilateral sagittal maneuver will reveal the extent of the ramus height deficit. If split mandibular advancement is indicated. As in orthog- direct fracture osteotomy or inverted L osteotomy has been nathic cases, in some patients addition of advancement genio- carried out, a suitably sized bone graft is inserted into the plasty may enhance the esthetic result and improve lip osteotomy gap and internal fixation applied. If vertical ramus competence where needed. osteotomy or sagittal split has been carried out, no bone graft is necessary and having repositioned the proximal segment, Operative technique fixation is applied (see Fig. 24.22e). In some cases of uni- lateral injury, a contralateral sagittal split osteotomy may be Unilateral required in order to achieve the preplanned occlusion. This Access is gained via a posterior intraoral buccal sulcus incision can be assessed preoperatively using an anatomical articulator or submandibular, retromandibular (see Fig. 24.22b) or pre- and intraoperatively, when the occlusion can be assessed fol- auricular extraoral incisions. Depending on the technique lowing osteotomy on the injured side. If a satisfactory occlu- chosen, the old fracture line is osteotomized or a ramus sion is achieved, contralateral osteotomy may be unnecessary. osteotomy carried out distant from the fracture site (see If satisfactory occlusion cannot be achieved contralateral Fig. 24.22c). Once this has been done, temporary, intraopera- osteotomy must be carried out. tive intermaxillary fixation with an occlusal wafer is applied (see Fig. 24.22d). Following this, posterior and upward trac- Bilateral tion on the proximal fragment will keep the condyle in its Posterior maxillary impaction, mandibular autorotation and retruded position. The condyle may be located in the glenoid advancement are well described in the orthognathic literature fossa or outside the confines of the glenoid fossa if dislocated. and the use of these techniques in a posttraumatic situation In this situation, intraoperative judgment of the correct usually demands little or no modification (Figs 24.23, 24.24). condylar position is a little more difficult but the surgeon Outcome The techniques described are effective in correcting the esthetic and functional problems associated with post- traumatic malocclusion. In a study of 21 patients, Becking et al 41 reported stable dental and cephalometric results in 20 patients. Similarly, Spitzer et al 42 reported occlusal correction and normal mandibular movement in a group of 14 patients. Rubens et al40 presented four cases with suc- cessful outcome, including correction of occlusion and reso- lution of temporomandibular joint and muscle pain. Traumatic tissue loss Severe posttraumatic tissue loss is uncommon in civilian prac- tice. It may occasionally be encountered following gunshot (d) (c) Fig. 24.24: (c,d) Postoperative facial appearance and occlusion. 28 Secondary Osteotomies and Bone Grafting (a) (b) (c) Fig. 24.25: Road traffic accident with severe lower third facial injury involving bilateral mandibular fracture, severe soft tissue disruption and complete traumatic glossectomy. (a,b) Appearance on presentation. (c) Tracheotomy, plating of fracture and soft tissue repair, defect in floor of mouth dressed with Whitehead varnish pack. (d) OPG showing mandibular fixation. (d) Treatment Techniques 29 (g) (h) (e) (f) (i) Fig. 24.25: (e) Radial forearm free flap to repair floor of mouth and tongue defect. (f,g) Avascular necrosis of right mandibular body treated by removal of fixation, debridement and application of external fixator. (h) Mandibular defect following non-union. (i) Reconstruction with DCIA free vascularized bone flap. 30 Secondary Osteotomies and Bone Grafting (j) (n) (k) (l) (o) Fig. 24.25: (j) OPG showing mandibular reconstruction. (k) Endosseous implants placed into DCIA bone graft. (l) Lingual movement of lower incisors due to lip pressure following loss of tongue. (m) Appearance following orthodontic treatment using implants as anchorage. (n) Intraoral appearance of radial forearm flap. (o) Facial appearance at commencement of orthodontic (m) treatment. References 31 wounds, high-speed road traffic accidents or industrial acci- 20 Hunter D, Baker S, Sobol SM 1990 Split calvarial grafts in maxillofacial dents. Often there is a combination of hard and soft tissue loss reconstruction. Otolaryngology Head and Neck Surgery 102(4): 345–350 demanding a variety of primary and secondary reconstructive 21 Posnick JC, Goldstein JA, Armstong D, Rutka JT 1993 Reconstruction techniques with multiple operations in order to restore lost of skull defects in children and adolescents by the use of fixed cranial form and function. Initial management usually follows tradi- bone grafts: long-term results. Neurosurgery 32(5): 785–791; discussion tional principles of trauma management and subsequent cor- 791 rection may involve pedicle or free tissue transfer to replace , 22 Pezzota S, Silvani V, Gaetani P Spanu G, Rondini G 1985 Growing skull fractures of childhood. Journal of Neurosurgical Sciences 29(2): hard and soft tissue. The recent development of osteogenic 129–135 distraction in the craniofacial skeleton gives another option for , 23 Ionnides Ch, Freihofer HP Friens J 1993 Fractures of the frontal sinus: replacement of tissue deficits along with their closely associ- a rationale of treatment. British Journal of Plastic Surgery 46: 208–214 ated soft tissues. Each case will be different and must be 24 Luce EA 1987 Frontal sinus fractures: guidelines to management. planned and treated on its own merits, but Figure 24.25 shows Plastic and Reconstructive Surgery 80(4): 500–510 25 Gonty AA, Marciani RD, Adornato DC 1999 Management of frontal a case which illustrates many of the principles and problems sinus fractures: a review of 33 cases. Journal of Oral Maxillofacial involved in these patients. Surgery 57(4): 372–379; discussion 380–381 26 Penfold CN, Lang DD, Evans B 1992 The management of orbital roof References fractures. British Journal of Oral Maxillofacial Surgery 30: 97–103 27 Horowitz JH, Persing JA, Winn HR, Edgerton MT 1984 The late 1 Cohen SR, Kawamoto HK 1992 Analysis and results of treatment of treatment of vertical orbital dystopia resulting from an orbital roof established post traumatic facial deformities. Plastic and Reconstructive fracture. Annals of Plastic Surgery 13(6): 519–524 Surgery 90(4): 574–584 28 Hammer B, Prein J 1995 Correction of post traumatic orbital 2 Tessier P 1971 Total osteotomy of the middle third of the face for deformities: operative techniques and review of 26 patients. Journal of faciostenosis or for sequelae of Le Fort III fractures. Plastic and Craniomaxillofacial Surgery 23: 81–90 Reconstructive Surgery 48: 533 29 Barone CM, Gigantelli JW 1998 Endoscopic repair of posttraumatic 3 Manson PN 1990 Facial injuries. In: McCarthy JG (ed) Plastic surgery. enophthalmos using medial transconjunctival approach: a case report. WB Saunders, Philadelphia, pp 867–1141 Journal of Craniomaxillofacial Trauma 4(1): 22–26 4 Gruss JS 1982 Frontonaso-orbital trauma. Clinics in Plastic Surgery 9: 30 Watzinger F, Wanschitz F, Wagner A et al 1997 Computer-aided 557 navigation in secondary reconstruction of post traumatic deformities of 5 Schendel SA, Lewis W, Williamson DDS 1983 Muscle reorientation the zygoma. Journal of Craniomaxillofacial Surgery 25(4): 198–202 following superior repositioning of the maxilla. Journal of Oral and 31 Jones RH, Ching M 1995 Intraoral zygomatic osteotomy for correction Maxillofacial Surgery 41: 235–240 of malar deficiency. Journal of Oral Maxillofacial Surgery 53(4): 6 Shvykov MB, Shamsudinov AK, Sunarckov DD, Shvyrkova II 1999 483–485 Non-free osteoplasty of the mandible in maxillofacial gunshot wounds; 32 Frodel JL, Marentette LJ, Quatela VC et al 1993 Calvarial bone graft reconstruction by compression-osteodistraction. British Journal of Oral harvest – techniques, considerations and morbidity. Archives of and Maxillofacial Surgery 37(4): 261–267 Otolaryngology Head and Neck Surgery 119(1): 17–23 7 McCarthy J, Zide BM 1984 The spectrum of calvarial bone grafting: 33 Freihofer PM, Borstlap WA 1989 Reconstruction of zygomatic area. A introduction of the vascularized calvarial bone flap. Plastic and comparison between osteotomy and onlay techniques. Journal of Reconstructive Surgery 74: 10 Craniomaxillofacial Surgery 17 (6): 243–248 8 Berggren A, Weiland AJ, Dorfman M 1982 Free vascularized bone 34 Perino KE, Zide MF, Kinnebrew MC 1984 Late treatment of malunited grafts: factors affecting their survival and ability to lead recipient bone malar fractures. Journal of Oral and Maxillofacial Surgery 42(1): 20–34 defects. Plastic and Reconstructive Surgery 69: 19 35 Hans PM, Freihofer P 1995 Effectiveness of secondary post-traumatic 9 Paskest JP Yaremchuk MJ, Randolph MA et al 1987 Prolonging survival , periorbital reconstruction. Journal of Oral and Maxillofacial Surgery 23: in vascularized bone allograft transplantation: developing specific immune 143–150 unresponsiveness. Journal of Reconstructive Microsurgery 3: 254 36 Ellis E 3rd 1999 Treatment methods for fractures of the mandibular 10 Zins JE, Whitaker LA 1983 Membranous versus endochondral bone angle. International Journal of Oral and Maxillofacial Surgery 28(4): autografts: implications for craniofacial reconstruction. Plastic and 243–252 Reconstructive Surgery 72(6): 778–785 37 Mathog RH, Toma V, Clayman L, Wolf S 2000 Nonunion of the 11 Yaremchuk MJ 1989 Vascularized bone grafts for maxillofacial mandible: an analysis of contributing factors. Journal of Oral and reconstruction. Clinics in Plastic Surgery 16(1): 29–39 Maxillofacial Surgery 58(7): 746–752; discussion 752–753 12 McCarthy JG, Cutting CC, Shaw WW 1987 Vascularized calvarial flap. 38 Moreno JC, Fernadez A, Ortiz JA, Montalvo JJ 2000 Complication Clinical Plastic Surgery 14(1): 37–47 rates associated with different treatment for mandibular fractures. 13 Zalzal GH, Cotton RT, James McAdams AMD 1986 Cartilage grafts – Journal of Oral Maxillofacial Surgery 58(3): 273–280; discussion present status. Head and Neck Surgery 8(5): 363–374 280–281 14 Yen CP Cheung CM, Loh JK, Jong YJ, Howng SL 1999 Growing skull , 39 Haug RH, Schwimmer A 1994 Fibrous union of the mandible: a review fracture. Kaohsiung Journal of Medical Sciences 15(3): 175–181 of 27 patients. Journal of Oral and Maxillofacial Surgery 52(8): 15 Colak A, Akbasak A, Biliciler B, Erten SF. Kocak A 1998 An unusual 832–839 variant of a growing skull fracture in an adolescent. Paediatric 40 Rubens BC, Stoelinga PJW, Weaver TJ, Biijdorp PA 1990 Management Neurosurgery 29(1): 36–39 of malunited mandibular condylar fractures. International Journal of 16 Gupta SK, Reddy NM, Khosla VK et al Growing skull fractures: a Oral Maxillofacial Surgery 19: 22–25 clinical study of 41 patients. Acta Neurochirurgica 139(10): 928–932 41 Becking AG, Zijerveld SA, Tuinzing DB 1998 Management of post 17 Sener RN 1995 Growing skull fracture in a patient with cerebral traumatic malocclusion caused by condylar process source. Journal of hemiatrophy. Paediatric Radiology 25(1): 64–65 Oral and Maxillofacial Surgery 56(12): 1370–1374; discussion 18 Scarfo GB, Mariottini A, Tomaccini D, Palma L 1989 Growing skull 1374–1375 fractures. Child's Nervous System 5(3): 163–167 42 Spitzer WJ, Vanderborght G, Dumbach J 1997 Surgical management of 19 Hunter PD, Pelofsky S 1995 Classification of autogenous skull grafts in mandibular malposition after malunited condylar fractures in adults. cranial reconstruction. Journal of Craniomaxillofacial Trauma 1(14): 8–15 Journal of Craniomaxillofacial Surgery 25(2): 91–96


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Patriots rookie TE Zach Sudfeld 1-on-1
It's certain Aaron Hernandez won't be with the Patriots this year, and there are still questions pertaining to the health of Rob Gronkowski and Jake Ballard. The Patriots used to be incredibly strong at tight end, but have a lot of questions at the position this year.
Undrafted rookie tight end Zach Sudfeld could be one of Tom Brady's newest assets. CSNNE's Kevin Walsh spoke to Sudfeld at training camp to go over Sudfeld's progress.
"It's a very intense process, but it's great to be out here," said Sudfeld, who saw some time practicing with the first team.
Sudfeld, a 6-foot-7, 253-pound tight end who played at Nevada, will be competing with Michael Hoomanawanui, Daniel Fells and Ballard to be a tight end this season, but Sudfeld said he is focused on improving throughout the preseason in all aspects.
"My job is just to come out here and compete, and wherever they put me, I got to do my job," Sudfeld said. "It doesn't matter who it's with. I'm going to go out there and do my best and continue to improve."