Malposition of the Resorbable Sheet in Medial Orbital Wall Fractures: Frequency and Techniques for Prevention.

The aim of this report is to discuss malposition of the resorbable sheet in medial orbital wall fractures and how to prevent this problem. After making an incision through the skin and orbicularis oculi muscle, a skin-muscle flap was elevated just superficial to the orbital septum, extending to the arcus marginalis. Dissection was extended just below the anterior lacrimal crest to increase the exposure. Fracture site in medial orbital wall was visualized. A resorbable sheet (poly- l -lactide, d -lactide sheet, 0.5-mm thickness) was trimmed and molded in an L shape, with the vertical portion used to cover the medial wall defect and the horizontal portion for stability in the orbital floor. An extended part, measuring roughly 1 cm, was bent across on the infraorbital rim, and this part was fixed with absorbable screws to prevent the sheet from crumpling. After the molded plate was put in position, the periosteum and skin were closed. From 2011 to 2021, the authors operated on 152 orbital floor or medial wall fractures. Among 152 patients who underwent surgery to reconstruct orbital floor or medial wall fracture, of whom 27 patients had both floor and medial wall fractures, the authors experienced 2 cases of medial orbital wall fractures where the resorbable sheet was malpositioned, requiring reoperation. To prevent malposition of the sheet in medial wall reconstruction, the inferomedial angle of the vertical portion and the horizontal portion of the sheet should be about 135°. Before fixing the sheet on the bony part, a complete tension-free forced-duction test is mandatory.

Change of the Inclination Angle in a Pediatric Bilateral Condylar Fracture Treated With Intermaxillary Fixation and an Occlusal Stop.

ABSTRACT: This paper presents the outcomes of a pediatric bilateral condylar fracture treated with intermaxillary fixation (IMF) and an occlusal stop.A 6-year-old girl presented with the complaint of pain on her chin. She had fallen down, whereas riding a bicycle and her face hit the road. She had limited mouth-opening (10 mm). Panoramic radiography and computed tomography confirmed a bilateral con-dylar fracture. The inclination of the fractured condyle (IFC) was 39.2° and 42.4° on the left and right sides, respectively. On the third post-trauma day, arch bars were applied and IMF was performed with a prefabricated wafer (occlusal stop) and rubber bands. The rubber bands were changed to wires on post-IMF day (PMF) 4.Immediately after IMF, the IFCs increased (left: 50.1° and right: 68.1°). On PMF 1, the IFCs had improved (44.5° and 46.9°, respectively). On PMF 3, 12, 28, and 35, the left and right IFCs were 46.9° and 70.7°,38.9° and 72.0°,38.0° and 56.5°, and 36.4° and 44.6°, respectively. On PMF 42, the IFCs had changed to 34.5° and 36.1 °, and wires were changed to rubber bands. On PMF 49, the IFCs were 34.0° and 36.5°, and rubber bands were applied at night only. On PMF 56, the IFCs had improved to 35.0° and 34.8°, and the arch bars were removed. The changes of IFC were fitted to an exponential regression model (left: y = 44.134e 0.005x and right: y = 11.378e 0.043x ).This case shows that pediatric bilateral mandibular condyle fractures can be treated by vertical lengthening using an occlusal stop and IMF.

Overcorrection of Nasal Bone Fracture Reduction Can Be Minimized by Packing Removal.

ABSTRACT: We experienced 16 cases of overcorrection among 524 cases of packing following nasal bone fracture (NBF) reduction. In these cases, the packing was removed immediately.From July 2017 to October 2020, 535 cases of NBF were reduced by closed reduction. Nasal packing was applied in 524 cases (97.9%). In all cases, postoperative X-rays (both nasal bone lateral view and Water's view) were taken. The degree of overcorrection was measured in the nasal bone lateral views.Among the 524 patients who underwent nasal packing, overcorrection was noted in 16 cases (3.1%). The average degree of overcorrection was 2.09 ±â€Š0.70 mm. In these patients, the packing was removed immediately and X-rays were taken directly after packing removal. The degree of overcorrection decreased; however, no significant difference was found (1.83 ±â€Š0.71 mm, P   =  0.081, [paired t test]).In this study, overcorrection was noted in 3.1% of patients in whom nasal packing was applied. After packing removal, the degree of overcorrection decreased but was not significant. Postoperative X-rays should be taken after reduction of NBF and nasal packing, and if overcorrection is noticed, the packing should be removed immediately.

Inclination Angle in Greenstick Fracture of Mandibular Subcondyle Treated with Intermaxillary Fixation in an Elderly Patient.

This study presents the outcomes of a conservative approach to greenstick condylar fracture treatment in an elderly patient. Serial changes of the inclination angle were measured in a greenstick fracture of the mandibular subcondyle treated with intermaxillary fixation (IMF). A 64-year-old woman presented to an outpatient clinic complaining of pain on her chin. While waiting for an elevator, she lost consciousness and hit her face on the floor. She had a limited mouth-opening of 13 mm. Panoramic radiography and computed tomography confirmed a greenstick (incomplete) fracture of the left condyle, in which the lateral side of the bone was fractured and the medial side was bent. The medial inclination was approximately 40.4 degrees. On the second post-trauma day, IMF was performed using arch-bars and a prefabricated occlusal stop. Serial Towne's views were taken. The inclination of the fractured condyle was measured and compared with the contralateral side. The difference in inclination angles (DI) between the fractured and contralateral sides was plotted over time. In SPSS version 19.0, an exponential regression model was constructed. In this patient, a greenstick (incomplete) fracture of the condyle (40.4 degree inclination) was treated with IMF and a pre-fabricated occlusal stop. On day 42 post-IMF, the inclination angle had decreased to 15.6 degrees, only 5.4 degrees greater than the contralateral side. The DI was fitted to exponential regression model (y = 25.111e-0.028x, P = 0.004). This case shows that even in an elderly patient, a greenstick fracture of the mandibular condyle can be treated by vertical lengthening using an occlusal stop and IMF.

A Nasal Bone Fracture Caused by a Dog Bite in an Adult.

ABSTRACT: The authors report a case of nasal bone fracture caused by a dog bite in a 25-year-old woman.A 25-year-old woman presented with lacerations of the face caused by a dog bite. When visiting her friend's house, a malamute attacked her. The dog's maxillary teeth bit her right canthal area and right infraorbital area, and the mandibular teeth traversed her left cheek through the buccal mucosa. She had full-thickness lacerations on the left cheek from the skin to the buccal mucosa, and deep lacerations in the right infraorbital area and the right medial canthal area. She had tenderness on the dorsum and right side of her nose. Computed tomography revealed a depressed nasal bone fracture on the right side. The wound was irrigated using betadine solution, and antibiotics were injected. On the seventh post-trauma day, closed reduction and delayed primary repair were performed.The biting force of German shepherds, huskies, and malamutes is approximately 320 pounds per square inch. The nasal bones are the most fragile facial bones, and their tolerance levels for minimal fractures are in the 25 to 75 lbs range. The maxilla has low tolerance level (140-445 lbs). The zygomatic arch is relatively fragile (tolerance level, 208-475 Ibs), while the zygomatic body has higher tolerance level (200-450 lbs). Thereafter, the biting strength of these dogs suffices to fracture the nasal bone, maxilla, or even zygoma.When a dog bite injury occurs near the orbit, nose, and cheek, facial fracture should be suspected in both children and adults.

Change of the Inclination Angle in a Greenstick Fracture of the Mandibular Subcondyle Treated With Intermaxillary Fixation in a Child.

ABSTRACT: This paper presents the outcomes of a conservative approach to greenstick condylar fracture treatment in a child. Serial changes of the inclination angle were measured in a greenstick fracture of the mandibular subcondyle treated with intermaxillary fixation (IMF).A 7-year-old girl presented with the complaint of pain on her chin. She had fallen from a 3-m height and hit her face on the floor. She had limited mouth-opening of one finger breadth. Panoramic radiography and computed tomography confirmed a green-stick (incomplete) fracture of the right condyle, in which the lateral side of the bone was fractured and the medial side was bent. The medial inclination was approximately 67.9°. On the second posttrauma day, IMF was performed using arch-bars and a prefabricated occlusal stop. Serial Town's views were taken. The inclination of the fractured condyle was measured and compared with the contralateral side. The difference in inclination angles (DI) between the fractured and contralateral sides was plotted over time. In SPSS version 19.0, an exponential regression model was constructed.In this child, a green-stick (incomplete) fracture of the condyle (68.0° inclination) was treated with IMF and a prefabricated occlusal stop. On day 321 post-IMF, the inclination angle had decreased to 31.1°, only 6.8° greater than the contralateral side. The DI was fitted to an exponential regression model (y = 37.019e-0.006x, R2 = 0.703, P < 0.001).This case shows that even in children, a greenstick fracture of the mandibular condyle can be treated by vertical lengthening using an occlusal stop and IMF.

Use of a Monoblock Gunning Splint in a Bilateral Condylar Fracture in an Edentulous Patient.

ABSTRACT: This paper presents the outcomes of a conservative approach to a bilateral condylar fracture in an edentulous patient. Serial changes of the inclination angle were measured in an edentulous mandibular fracture treated with a monoblock Gunning splint.After being hit by a motor vehicle, a 67-year-old man fell onto his face. He had been edentulous for 7 years and did not use dentures. His mouth-opening was 28 mm between the edentulous maxilla and the mandible. X-rays and computed tomography revealed a comminuted mandibular angle fracture and bilateral condylar fractures. Stone casts were made from maxillary and mandibular alginate impressions. Maxillary and mandibular labiolingual splints were constructed using an autopolymerizing acrylic resin. In the most comfortable jaw position, the wax-bite was inter-positioned between the upper and lower splints and the vertical dimension was measured. Using a calibration resin, the inter-positional segment containing the eyelet wire was fixed between the splints with glue. A monoblock Gunning splint was applied and intermaxillary fixation (IMF) was performed with circummandibular and circumzygomatic wiring. The inclination of the fractured condyle was compared with the contralateral side. The difference in inclination between the fractured and contralateral sides was plotted over time.On post-IMF day 34, the inclination angle had decreased to 22.9°, only 3.2° greater than the contralateral side. The difference in inclination was fitted to an exponential regression model (y = 11.378e-0.043x, R2 = 0.766, P = 0.022).This case shows that a condylar fracture in an edentulous patient can be treated by vertical lengthening using a monoblock Gunning splint and IMF.

Reconstruction of a Gunshot-Caused Mouth Floor Defect Using a Nasolabial Flap and a De-Epithelialized V-Y Advancement Flap.

ABSTRACT: We present reconstruction of a gunshot-caused mouth floor defect using a nasolabial flap and a de-epithelialized V-Y advancement flap.A 58-year-old man presented 14 days after bullet injury passed from anterior chin to the right postauricular area. Upon examination, the central incisors, alveolar bones, and soft tissues of the mouth floor were lost. Bone fragments and failed miniplates were exposed. Pus discharge filled the defect.On the 23rd post-trauma day, right unilateral nasolabial flap was used to cover the oral side of the mouth floor. This flap was centered on the nasolabial fold and its base was situated on the commissure of the lips. The flap was raised in the soft tissue, just superficial to the facial muscles, transferred into the oral cavity through an incision made in the cheek mucosa, and sutured to the margin of the defect. A de-epithelialized dermal and subcutaneous flap was used to reconstruct the deep portion of the mouth floor through the V-Y advancement method. At the lower border of the mandible, a 3-cm-wide V-Y advancement flap was designed. The de-epithelized portion was inserted into the mouth floor and sutured to the defect margin. On 30th post-trauma day, left commissure-based buccal mucosal flap was used for the gingivobuccal sulcus defect. The apex was near the retromolar trigone. The elevated flap was transferred to the lower gingivobuccal sulcus defect. On POD 28, the nasolabial flap and commissure-based buccal myomucosal flap was divided and inset respectively.These flaps can be used for moderate-sized mouth floor defects.

Early surgical correction of microstomia following Stevens-Johnson syndrome.

Stevens-Johnson syndrome (SJS) is a rare disease in which extensive toxic epidermolysis occurs after medication. Skin and mucous membranes are involved in about 90% of SJS cases, and webbing of mouth corners (microstomia) may occur when they are affected. Few reports have been issued on microstomia in SJS, and no consensus has been reached regarding treatment methods, timings, or results. We encountered a case of microstomia following SJS after ofloxacin medication in a 22-year-old woman treated by commissuroplasty using a lozenge-shaped excision. We present an appropriate correction method and surgical timing for microstomia following SJS.

Osteotomy and iliac bone graft for the treatment of malunion caused by failed mandibular fracture reduction.

This report describes osteotomy and iliac bone graft for malunion caused by failed mandibular fracture reduction. A 27-year-old man was referred 3 months after a motor vehicle accident. At another hospital, two operations had been performed for symphyseal fracture using two resorbable plates. Malocclusion was noted, and panoramic radiography and computed tomography revealed a misaligned dental arch, with a 9.37-mm gap between the central and the lateral incisor of the left mandible. A wafer was made from the patient's dental model, and a maxillary arch bar was applied. Through a lower gingivolabial incision, osteotomy was performed between the malunited symphyseal fracture segments. Both segments were reduced to their original position using the wafer and fixed with titanium miniplates via intermaxillary fixation (IMF). The intersegmental gap was filled with cancellous bone from the iliac crest. The gingival defect was covered with a mucosal transposition flap from the gingivolabial sulcus. IMF and the wafer were maintained for 5 and 9 weeks, respectively. At postoperative week 13, the screws were removed from the mandible and satisfactory occlusion was noted. His mouth opening improved from 2.5 to 3 finger breadths (40 mm). This case demonstrates the need for sufficient IMF when using resorbable plates.

Release of the Lateral Pharyngeal Mucosa Using a Palatal Elevator.

The aim of this paper is to present how to release the nasal mucosa from the hard palate and from the lateral pharyngeal wall using palatal elevator.After mucoperiosteal flap is raised, the nasal mucosa is detached with an instrument pushed laterally behind the palatine vessels to meet the medial pterygoid plate. The palatal elevator is passed around the spine at the posterior medial border of the bony palate and then moved forward in the cleft to separate the nasal mucosa from bone. The palatal elevator is now introduced behind the greater palatine vessels, maintaining contact with the medial pterygoid plate. The elevator is pushed deeply up toward the base of the skull to elevate the lateral pharyngeal mucosa medially. When this mucosa is freed, the elevator can be moved anteriorly to separate the nasal mucosa from nasal side wall and upper surface of the hard palate. After closure of the buccal layer, 2 posterior flaps are joined to the small anterior flap. Finally, an A suture is made to hold the buccal layers together with the nasal mucosa and lateral pharyngeal mucosa to obliterate dead space.Herein, the authors present how to completely free the nasal mucosa from the hard palate and from the lateral pharyngeal wall before medial shifting and suturing. In our series of 60 cases of complete or incomplete cleft palate, fistula rate was low (6.7%), which the authors suggest was due to the low tension of the sutured nasal lining with the released lateral pharyngeal wall.

Treating skin graft donor sites: a comparative study between remnant skin use and polyurethane foam.

OBJECTIVE: Excess remnant skin is retained for use in additional grafting in case of split-thickness skin graft (STSG) failure. We hypothesise that regrafting with remnant skin offers greater efficacy and advantages in wound healing and donor site appearance. METHODS: Skin graft donor sites were assessed by comparing those regrafted with remnant skin with those treated with polyurethane foam dressing. Healing time, pain, patient satisfaction, itching sensation, skin stiffness and irregularity between regrafting and foam dressing were compared. The aesthetic satisfaction of donor site was evaluated by four board-certified plastic surgeons. The differences were tested statistically. RESULTS: A total of 39 patients received a STSG due to skin or soft tissue wounds caused by burn, trauma and cancer reconstruction. The donor site healing time was shorter with remnant skin regrafting compared with foam dressing. There was no difference with respect to donor site pain between the two treatment groups. At two weeks after skin graft, patient satisfaction was higher in those treated with remnant skin than in those treated with foam dressing. Aesthetic assessment was improved after 12 weeks. CONCLUSION: Donor site dressing using remnant skin appears to improve wound healing and enhance the aesthetic outcome of donor sites.

Unplanned change from double free flap to a chimeric anterolateral thigh flap in recurrent laryngeal cancer.

Reconstruction method choice in recurrent head and neck cancer depends on surgical history, radiation therapy dosage, conditions of recipient vessels, and general patient condition. Furthermore, when defects are multiple or three dimensional in nature, reconstruction and flap choice aimed at rebuilding the functional structure of the head and neck are difficult. We experienced successful reconstruction of recurrent laryngeal cancer requiring reconstruction of esophageal and tracheostomy stroma defects using a chimeric two-skin anterolateral thigh flap with a single pedicle.