2 surgical approach

Surgical Approach to the Facial Bones

The entrances to the facial bone are different according to;
Their location.
Presence of muscles.
Vital organs.
Vascular and nerve.

Face boundary; Extra-orally (hair line chin tragus of the ears),

Intra-orally (lips cheeks - ?)

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:

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 (limited area, small region, and scar area-gathering pain).
This flap is the result of a curved incision, which begins just beneath the vestibular fold and has a bow shaped course with the convex part towards the attached gingiva. The lowest point of the incision must be at least 0.5 cm from the gingival margin, so that the blood supply is not compromised. Each end of the incision must extend at least one tooth over on each side of the area of bone removal.
The semilunar flap is used in apicectomy and removal of small cysts and root tips.
Advantages;
Small incision.
Easy reflection.
No recession of gingivae around the prosthetic restoration.
No intervention at the periodontium.
Easier oral hygiene compared to other types of flaps.
Disadvantages;
Possibility of the incision being performed right over the bone lesion due to miscalculation.
Scarring mainly in the anterior area.
Difficulty of re-approximation and suturing due to absence of specific reference points.
Limited access and visualization.
Tendency to tear.


Mucogingival flap.
2sided, 3sided flaps (partial or full thickness flap).. The most common used in apicectomy. This buccal flap also used anteriorly and posteriorly according to offending tooth.
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The mucogingival flap; buccal & lingual 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 sub-periosteal dissection from the buccal aspect and extended under the vestibule.

Trapezoidal Flap (3 sided flap):

The trapezoidal flap is created after a Π-shaped incision, which is formed by a horizontal incision along the gingivae, and two oblique vertical releasing incisions extending to the buccal vestibule. The vertical releasing incisions always extend to the interdental papilla and never to the center of the labial or buccal surface of the tooth. This ensures the integrity of the gingiva proper, because if the incision were to begin at the center of the tooth, contraction after healing would leave the cervical area of the tooth exposed.
(1)-A satisfactory surgical field is ensured when the incision extends at least one or two teeth on either side of the area of bone removal.
(2)-The fact that the base of the resulting flap is broader than its free gingival margin ensures the necessary adequate blood supply for the healing process.
(3)-The trapezoidal flap is suitable for extensive surgical procedures, especially when the triangular flap would not provide adequate access.
Advantages;
Provides excellent access, allows surgery to be performed on more than one or two teeth.
Produces no tension in the tissues.
Allows easy re-approximation of the flap to its original position and hastens the healing process.

Disadvantages; Produces a defect in the attached gingiva (recession of gingiva).

Triangular Flap (2 sided flap):

This flap is the result of an L-shaped incision, with a horizontal incision made along the gingival sulcus and a vertical or oblique incision.
The vertical incision begins approximately at the vestibular fold and extends to the interdental papilla of the gingiva. The triangular flap is performed labially or buccally on both jaws and is indicated in the surgical removal of root tips, small cysts, and apicectomy.
Advantages;
Ensures an adequate blood supply.
Satisfactory visualization.
Very good stability and re-approximation.
It is easily modified with;
Small releasing incision.
An additional vertical incision.
Even lengthening of the horizontal incision.


Disadvantages;
Limited access to long roots.
Tension is created when the flap is held with a retractor.
It causes a defect in the attached gingiva.

Incisions in Mandible; used in case;

Fracture of body of mandible.
Sub-periosteal implant.
Cystic lesion.
Note; mental nerve should be avoided except in the removal of tumor.

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.
Muco-gingival incision.
Trans-oral incision.

Incisions in Mandible

In edentulous; the incision should be placed parallel to the crest of the ridge and keeping good flanges for dentures.
Note; scar formation utilizing good retention of denture.


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.
Notes;
The incision should follow the external oblique ridge at the level of occlusal surface of 3rd molar upward to avoid the pterygoid venous plexus.
The lingual nerve is located 5mm from the distal side of the 3rd molar, therefore the reflection of mucoperiosteal flap started posteriorly to avoid the nerve.
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Incisions in Mandible
Access to the T.M.J.:
Intra-orally; the incision is continued along the anterior surface of the coronoid process to about (1 cm.) below the tip. (Treatment of condylar neck fracture)
Ramus:
Is exposed well by dissected medially in position of lingula with good retraction medially and laterally.
Intra oral incision posteriorly; to treat fractures of body of mandible and ramus, the incision extend from the lower wisdom tooth until reach the fracture side.
Intra oral incision anteriorly; access for some surgical facial correction like receding chin: the incision is made on buccal side of gingival margin.


Note; mental mental full thickness flap with bucco-lingual extension; lead to compromise of blood supply resulted in the bone necrosis & floating of the teeth.
This approach used in most mandibular deformity correction;
Horizontal osteotomy of ramus.
Oblique and vertical subsigmoid osteotomy in ascending ramus.
Sagittal splitting technique (Obwegeser).

Obwegeser Incision: 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.
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Body Osteotomy:

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.

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


Also the incisions are made to treat the maxillary sinus fistula:
Buccal advancement flap.
Palatal transposition flap.
Rotation flap.

Flap resulting from Y- shaped Incision: An incision is made along the midline of the palate, as well as two anterolateral incisions, which are anterior to the canines. This type of flap is indicated in surgical procedures involving the removal of small exostoses.
Flap resulting from double Y -shaped Incision: This type of flap is used in larger exostoses, and is basically an extension of the Y -shaped incision. The difference is that two more postero-lateral incisions are made, which are necessary for adequate access to the surgical field. This flap is designed such that major branches of the greater palatine artery are not severed.






Surgical Technique; In order to remove the lesion surgically, an incision is made along the midline of the palate, which is composed of two anterior and posterior oblique incisions. The incision is designed so as to avoid injuring branches of the palatine artery, but also so that there is adequate visualization of, and access to, the surgical field without tension and injurious manipulations during the procedure. After reflection, the flaps are retracted with the aid of sutures or broad periosteal elevators. After complete exposure of the lesion, it is sectioned with a fissure bur and the segments are individually removed using a monobevel chisel. More specifically, the chisel is positioned at the base of the exostoses with the bevel in contact with the palatal bone and, thereafter, each segment of the lesion is removed after a slight blow with the mallet. After smoothing the bone surface, excess soft tissue is trimmed and, after copious irrigation with saline solution, the flaps are repositioned and sutured with interrupted sutures. If the torus palatinus is small in size, the incision for creation of the flap is again made along the midline, but only with anterior oblique releasing incisions. The procedure is then performed in exactly the same way as that already mentioned.

Flaps made to treat the oro-antral fistula:

Pedicle Bridge Flap (Sliding Flap); this flap is palate-buccal and is perpendicular to the alveolar ridge. After creation, the flap is moveed posteriorly or anteriorly, to cover the orifice of the oroantral communication, without compromising the vestibular fold. This type of flap is used only on edentulous parts of the alveolar ridge.


Buccal Flap; This is a typical trapezoidal flap created buccally, corresponding to the area which is to be covered, and is usually used on dentulous patients. It is the result of two oblique incisions that diverge upwards, and extend as far as the tooth socket. After creating the flap, the periosteum is incised transversally, making it more elastic so that it may cover the orifice that results from the tooth extraction. The oblique buccal flap is a variation of the buccal flap. It is the result of an antero-posterior incision, so that its base is perpendicular to the buccal area, posterior to the wound. The flap is rotated about 7080 and is placed over the socket. Both cases require that, before placing the flap, the wound margins must be debrided.
Palatal Flap; this type of flap is used in edentulous patients so that the vestibular depth is maintained. The resulting palatal mucoperiosteal flap is rotated posteriorly and buccally, always including the vessels that emerge from the corresponding greater palatine foramen. After rotation, the flap is placed over the orifice of the socket, the wound margins are debrided, and the flap is sutured with the buccal tissues. A gingival dressing is applied for a few days at the void created and healing is achieved by secondary intention.

Other incision to reach bone of maxilla intra orally:

1. Anterior maxilla
A. Wassmund Approach:
It is safe and maintained labial and palatal pedicle.
This type has:
Good blood supply
Good healing
Osteotomy is easy (midline)
But cannot enter through this approach to nasal cavity or nasal septum.


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B. Wanderer Approach:

Two vertical vestibular premolar incisions 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.

C. Horseshoe Incision:

Expose of maxilla for total osteotomy without raised palatal flap through buccal periosteal around the antrum.


2. Posterior maxila

Buccally; through the buccal incision from premolar area until reach tuberosity area like in impaction or periapical lesion and buccal alveolar bone reduction in case of edentulous patient.
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.
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Incision to reach bone of maxilla Extra oral Approach:
The incision should be with hair lines - eye brow and relaxed skin lines.
At right angle to the skin surface avoid beveling.
Adequate incision to minimize the scar.


Access to the Mandibular Joint T.M.J.
Pre-Auricular Approach;
Good access
Control bleeding.
Decrease the risk of facial nerve damage.
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Submandibular 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 fingers.
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Submental approach; below the chin.



Risedon Flap;

Peri-orbital approaches.

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Peri-orbital approaches;
Infra orbital incisions.
Subcilliary incision; access to;
Orbital floor
Medial half of zygoma.
Upper part of anterior maxilla.
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Eye brow incision.
Lateral incision.
Paranasal incisions.
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
Transconjuctival incision; Give access to lateral orbital wall.
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Lateral (Crows Foot) Incision; in older patient for placement of frontal suspension wire and bone graft placement.

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Extaoral approachular
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.
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Pericoronal approach

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

Zygomatic Fracture

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.

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Direct Extra Oral Elevation: The incision directly below and behind the prominence of zygomatic bone and replaced the segment by hook.
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Incision made above the outer Canthus on the line of outer aspect of eye brow (to avoid damage to facial nerve).
Antrum opening; (to treat fracture of zygoma through maxillary antrum).


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Other Extra Oral Approaches used for Removal of Oral Cavity Tumors;

In Tumor of Maxilla; (Weber Fergusen Incision).

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In mandibular tumor and tongue with neck dissection;
Lower cheek flap.
Mandible sparing surgical approach).
Supraomohyoid neck dissection.
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Oral Surgery Dr. M. Kh. Hassoni
Lec.1

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