Surgical approach

The entrances to the facial bone are different according to their location and presence of muscles and vital organs and vascular and nerve. In general all types of incisions are made to reach facial bone should have: Adequate exposure. Good post operative aesthetic. Good post operative function. Preservation of essential structures. Maintenance of adequate nutrition. Should not leave traumatic scarring affect the esthetic and functions.

The approach to the facial bone either:

1. Intra – oral approach 2. Extra – oral approach

Intra – oral incision: Reflection of mucoperiosteium for exposure of bone or dental structure and direct the incision to take shortest distance to the bone, e.g.:Semilunar flap.Mucogingival flap.2sided, 3sided flaps….. The most common used in apicectomy. This buccal flap also used anteriorly and posteriorly according to offending tooth. 1. Intra – oral approach

The gingival flap or buccal flap, in case of impaction, alveoplasty and other minor operation.This type of flap is simple and the reflection reach to the sulcus only but the intra – oral approach to mandible or maxilla through the superiosteal dissection from the buccal aspect and extended under the vestibule

Incisions in Mandible

From the buccal aspect of the lower third molar and forward or from canine to canine according to lesion or access that we need to expose the anterior part of mandible: Labial incision. Mucogingival incision. Transoral incision.

Incisions in Mandible

In edentulous, the incision should be placed parallel to the crest of the ridge and keeping a good flanges for dentures.

Incisions in Mandible

To expose the body of mandible, ramus and angle of mandible: The incision should follow the line of third molar to retromolar area and extend up ward and out ward and back ward over the external oblique ridge.

Incisions in Mandible

Access to the T.M.J.: Intraorally, the incision is continued along the anterior surface of the coronoid process to about (1 Cm) below the tip. Ramus: Is exposed well by dissected medially in position of lingula with good retraction medially and laterally.

Incisions in Mandible

Intra – oral incision posteriorly to treat fractures of body of mandible, ramus and body, the incision extend from the lower wisdom tooth until reach the fracture side.

Incisions in Mandible

Intra – oral incision access for some surgical facial correction like receding chin: Anteriorly, the incision is made on buccal side of gingival margin.

is used in orthognathic surgery; - Sliding Genoplasy - Correction of occlusion from intra – oral approach by vertical incision down to anterior aspect of the ramus from just below the tip of coronoid process across the retromolar fossa into the buccal sulcus, also the body of mandible can expose well from this approach in addition, to ramus Obwegeser incision


This approach used in most mandibular deformity correction; Horizontal osteotomy of ramus. Oblique and vertical subsigmoid osteotomy in ascending ramus. Sagittal splitting technique.
Obwegeser incision


The incision is made around the gingival margins buccally and lingually from the retromolar area to the lower canine and on the buccal side anteriorly
Body Osteotomy:



Maxilla
In case of minor oral surgery the incision to reach the bone also by buccal incisions to reflect the periosteum either posteriorly or anteriorly in case of apicectomy or cysts or others.

Maxilla

Anterior opening to reach the maxillary sinus from the buccal sulcus (Could – Well Luk).Vertical incision posteriorly to remove impacted teeth or fracture of tuborocity.Palatal incision to reflect mucosa and expose the palate in case of impacted teeth or cystic lesion

Maxilla

Also the incisions are made to treat the maxillary sinus fistula: Buccal advancement flap. Palatal transposition flap. Rotation flap. Buccal horizontal incision to remove buccally impacted canine or other teeth.


Other incision to reach bone of maxilla intra – orally: 1. Anterior maxila A. Wassmund Approach: It is safe and maintained labial and palatal pedicle.
The incision from the mucosa of premolar vertical vestibular incision on the lateral aspect of the premaxilla and from the palatal from premolar region to the mid line around the neck of 1st premolar and midline of the palate.


Other incision to reach bone of maxilla intra – orally: A. Wassmund Approach: This type has: Good blood supply Good healing Osteotomy is easy (midline) But can not enter through this approach to nasal cavity or nasal septum.

Other incision to reach bone of maxilla intra – orally: 1. Anterior maxila B. Wanderer Approach: Two vertical vestibular premolar incision being combined with transpalatal incision. This incision has access to nasal area and septum, floor of the nose but it may lead to oronasal fistula.


Other incision to reach bone of maxilla intra – orally: 1. Anterior maxila C. Horseshoe Incision: Expose of maxilla for total osteotomy with out raised palatal flap through buccal periosteal around the antrum



Other incision to reach bone of maxilla intra – orally: 2. Posterior maxila Buccally; through the buccal incision: from premolar area until reach tuborosity area like in impaction or periapical lesion and buccal alveolar bone reduction in case of edentulous patient. Also, buccally; Kufner horizontal incision above the apices of the involved teeth and access palatally. Shuchard corresponding incision palatally to have direct vision. Incision along the midline of palate and direct laterally through the surgical side and could be Y shaped if bilateral.

Incision to reach bone of maxilla Extra – oral Approach: The incision should be with hair lines eye brow and relaxed skin lines. 2. At right angle to the skin surface avoid beveling. 3. Adequate incision to minimize the scar.

Access to the Mandibular Joint T.M.J.

1. Preauricular approach
2. Submandibular approach
3. Postauricular approach
4. Endaural approach
5. Intra – oral approach

Access to the Mandibular Joint T.M.J.

Good access
Control bleeding
Decrease the risk of facial nerve damage
1. Preauricular approach

Access to angle, ramus, condyle and coronoid process

Difficult to avoid the facial nerve
Incision (5 Cm in length) behind and parallel to the lower border about 1.5 finger
2. Submandibular approach

Below the chin

3. Submental approach

Access to the Mandibular Joint T.M.J.

4. Risedon Flap

a. Infra – orbital incisions 5. Periorbital approaches

b. Subcilliary incision
c. Eye brow incision
d. Lateral incision
e. Paranasal incisions
f.Transconjuctival incision

Periorbital approaches

Subcilliary incision; access to
orbital floor
medial half of zygoma
Upper part of anterior maxilla

Periorbital approaches

Lateral ( Crow’s Foot) Incision In older patient for placement of frontal suspension wire and bone graft placement

Periorbital approaches

Paranasal Incision
Used to access of Lefort II osteotomy. The incision obliquely between lower medial angle of the eye and bridge of the nose. This incision enter to the nasal bone, glabuler region and anterior maxilla

Periorbital approaches

Transconjunctival Incision
Give access to lateral orbital wall

Extaoral approachular

5. Bicoronal Flap
To expose the orbit, zygoma, frontal area, frontonasal, nasoethmoid. It is the choice for Lefort III osteotomy The incision is hidden in the hair line.


6. Open – Sky approach Used in nasal fracture when direct access to the bony valt is required and for nasal – orbital – ethmoid region fractures.


Zygomatic Fracture
1. Temporal approach: (Gillies approach); Temporal facia is attached to the zygomatic arch and the temporal muscle, to be attached to the coronoid process. The incision made in temporal facia to elevate the segment.

Zygomatic Fracture

2. Direct Extra – Oral Elevation:The incision directly below and behind the prominence of zygomatic bone and replaced the segment by hook.

Zygomatic Fracture

3. Incision made above the outer Canthus on the line of outer aspect of eye brow ( to avoid damage to facial nerve). 4. Antrum opening (to treat fracture of zygoma through maxillary antrum).


Other Extra – Oral Approaches used for Removal of Oral Cavity Tumors Weber – Fergusen Incision In Tumor of Maxilla

Other Extra – Oral Approaches used for Removal of Oral Cavity Tumors Lower cheek flap

In mandibular tumor and tongue with neck dissection


Other Extra – Oral Approaches used for Removal of Oral Cavity Tumors Mandible sparing surgical approach
In mandibular tumor and tongue with neck dissection



Other Extra – Oral Approaches used for Removal of Oral Cavity Tumors Supraomohyoid neck dissection
In mandibular tumor and tongue with neck dissection