Lecture 3 maxillofacial trauma part 3

Maxillofacial Surgery 1
Dental Students Fifth Year First semester
Lecture Name maxillofacial trauma Part 3
Al Azhar University Gaza Palestine
Dr. Lama El Banna

1. Basic Principles of Treatment of a Fracture 1

2. Anatomic consideration The craniofacial skeleton is made up of 22 bones. These bones surround different cavities that form the skull such as orbital cavity, nasal cavity, oral cavity, maxillary sinuses, etc. In the craniofacial skeleton, thin bony walls are connected by thicker bony portions. These thick bony portions are referred to as ‘buttresses’ and are a key factor in the reconstruction of panfacial fractures. They were described by Sicher and Tandler (1928), Merville (1974) and later expanded by Gruss and Mackinnon (1986). These buttresses maintain the various dimensions of the face such as height, width, anteroposterior projection, etc. They are also the lines along which the masticatory forces and other dynamic forces are distributed. The reduction and fixation of panfacial fractures is done at the various buttresses to maintain the architecture of the facial skeleton. 2

3. Principles in managing panfacial fractures There are two main theories in the management of panfacial fractures: Bottom up and inside out This sequence involves reduction of all the fractures keeping the mandible as base. Mandibular fracture is first reduced and the rest of the fractures are reduced sequentially from down upwards and at each level the fixation is done from the innermost bone proceeding outward, e.g. a nasal bone fracture is reduced first and a zygomatic fracture is reduced next. 3

4. Top down and outside in In this sequence the calvarium is used as a base. The fixation of other bones is done from the topmost proceeding downward, e.g. a frontal bone fracture is first addressed before a maxillary fracture. The mandibular fracture is reduced last and at each level the fixation is done from the most lateral bone inwards, e.g. a mandibular angle fracture reduction precedes the reduction of a body or symphysis fracture. 4

5. Bottom up and inside out Top down and outside in 1. Tracheostomy 1. Tracheostomy 2. Repair of palatal fracture 2. Repair of frontal sinus fracture 3. Maxillomandibular fixation 3. Repair of zygomaticomaxillary complex 4. Repair of condylar fractures (including arches) 4. Repair of naso -orbito-ethmoidal fractures 5. Repair of mandibular fractures (angle, symphysis, ramus) 5. Repair of Le Fort fractures (including midpalatal split) 6. Repair of zygomaticomaxillary complex fractures (including arches) 6. Maxillomandibular fixation 7. Repair of frontal sinus fracture 7. Repair of condylar fractures 8. Repair of naso -orbito-ethmoidal bone fracture 8. Repair of mandibular fractures (symphysis, body, ramus) 9. Repair of maxilla 5

6. Principles of fracture repair This includes: Reduction Fixation Immobilisation Early return of function 6

7. Reduction Reduction: Restoration of the fractured fragments to their original anatomical position. The restoration of the fragments to their correct position may be brought about by: Closed reduction Open reduction 7

8. Closed reduction Closed reduction refers to reduction of the fracture segments to their previous anatomic and functional position by manipulation without direct visualisation of the fracture. Closed reduction is often followed by closed fixation. Healing of the bone occurs by secondary intention with callus formation. 8

9. Closed manipulation The dentulous fracture segments especially of mandible can be reduced by closed manipulation unless extremely displaced from muscular forces. These segments guided by the occlusion of teeth can be reduced and fixed by closed method. 9

10. External reduction devices When the fractured segments do not override much, manipulation using instruments can be employed to bring the segments to occlusion. For example: Rowe’s disimpaction forceps can be used to disimpact the fractured maxilla and bring it to occlusion. Midpalatal split maxillae are reduced by Hayton William forceps . Walsham forceps can be used to manipulate certain nasal fractures. Asch forceps for septal fracture reduction. 10

11. Fracture reduction using Rowe’s maxillary disimpaction forceps. Septal fracture reduction with Asch forceps. (C)Walsham forceps for nasal bone fracture reduction. 11

12. (1) Reduction of maxillary fracture using disimpaction forceps, (2) Walsham’s disimpaction forceps 12

13. Intraoral or extraoral traction They are employed in cases where reduction has been delayed or in cases where muscular forces prevent effective manipulation. Intraoral traction involves fixation of prefabricated arch bars to the maxillary and mandibular arches and traction of the segments to normal occlusion using elastics. Extraoral traction , on the other hand, involves anchorage from the intact skull for traction. The process of traction is extremely slow and the patient is encouraged to open and close the mouth to facilitate the elastic traction. When satisfactory occlusion is achieved, elastics are removed and intermaxillary fixation is done using wires. 13

14. Intraoral traction, (2)Intraoral fixation/ligation with wires-IML or IMF 14

15. Advantages of closed reduction Inexpensive Only stainless steel wires needed (usually arch bars also) Easy availability, convenient Short procedure, stable Gives occlusion some “leeway” to adjust itself Generally easy, no great operator skill needed Conservative, no need for surgical tissue damage No foreign object or material left in the body No operating room needed in most cases, outpatient treatment Callus formation (secondary bone healing) allows bridging of small bony gaps 15

16. Disadvantages of closed reduction Cannot obtain absolute stability (contributing to nonunion and infection) Noncompliance from patient due to long period of IMF Difficult (liquid) nutrition Complete oral hygiene impossible Possible temporomandibular joint sequelae (MPDS) Muscular atrophy and stiffness Denervation of muscles; alteration in fibre types Myofibrosis Changes in temporomandibular joint cartilage Weight loss Irreversible loss of bite force Decrease range of motion of mandible Impaired pulmonary function, may be problematic for patient with premorbid pulmonary condition Risks of wounds to operators manipulating wires 16

17. Open reduction Open reduction is the surgical intervention for reduction of the fractured segments. After introduction of antibiotics, possibility of surgical opening of facial bone fractures increased significantly. This is especially important with respect to the facial skeleton, where an exact reduction results in an optimal functional and aesthetic result. Healing takes place by primary intention where no callus formation occurs during healing. Usually it is followed by direct fixation of the fracture fragments with internal fixators. 17

18. Advantages of open reduction with rigid internal fixation Early return to normal jaw function Normal nutrition Normal oral hygiene after a few days Avoidance of airway problem Can get absolute stability, promotes primary bone healing Bone fragments re-approximated exactly by visualization Avoids detrimental effects to muscles of mastication Does not require patient’s compliance or supervision Permits the physical therapy early postsurgically Avoids IMF for patient with occupational benefits in avoiding mandible fixation, e.g. lawyers, teachers, sales people, seizure disorders 18

19. Advantages of open reduction with rigid internal fixation Helpful in special nutritional requirements (diabetics, alcoholics, psychiatric disorders, pregnancy) Easy oral access (for example in intensive care unit patients) Decreased patient discomfort, greater patient satisfaction Less myoatrophy Decreased hospital time Substantial savings in overall cost of treatment Lower risk of major complications Lower infection rates, improved overall results Lower rate of malunion /nonunion 19

20. Disadvantages of open reduction with rigid internal fixation Most obvious; need for an open surgical procedure Significant operating room time Prolonged anaesthesia Expensive hardware Some risk to neuromuscular structures and teeth Need for secondary procedure to remove hardware “Unforgiving procedure”, the rigidity of the plate means no manipulation is permissible 20

21. Disadvantages of open reduction with rigid internal fixation Needs much operator skill, meticulous technique needed Directly compared to maxillomandibular fixation Higher frequency of malocclusion Higher frequency of facial nerve palsy Scarring ( extraoral and intraoral) Needs sophisticated material No bridging of small bone defect (absence of callus) 21

22. Fixation In this phase the fractured fragments (after reduction) are fixed, in their normal anatomical relationship to prevent displacement and achieve proper approximation. Fixation devices can be placed internally or externally. 22

23. a. Direct skeletal fixation Consists of: (i) Direct external skeletal fixation, where the device is outside the tissues, but inserted into the bone percutaneously (ii) Direct internal skeletal fixation—by devices which are totally enclosed within the tissues and uniting the bone ends by direct approximation. In direct external fixation, bone clamps or pin fixation can be used, while direct internal skeletal fixation is carried out with transosseous or intraosseous wiring or using bone plating system. 23

24. b. Indirect skeletal fixation Here, the control of bone fragments is done via the denture bearing area. By means of arch bars and IML or Gunning splint, if the patient is edentulous. It can be extraoral or intraoral method. 24

25. Indirect fixation (Closed Reduction) A. Intermaxillary fixation or maxillomandibular fixation (IMF or MMF). B. Craniomaxillary or craniomandibular suspension C. External fixation. D. Bone Clamps E. Kirshner wires F. Haloframes G. Plaster of Paris head cap H. Box frame 25

26. Immobilization During this phase, the fixation device is retained to stabilize the reduced fragments into their normal anatomical position, until clinical bony union takes place. The fixation device is utilized for a particular period to immobilize the fractured fragments. Immobilization period will depend on the type of fracture and the bone involved. For maxillary fractures 3 to 4 weeks of immobilization period is sufficient, while for mandibular fracture it can vary from 4 to 6 weeks. In condylar fracture the recommended immobilization period is 2-3 weeks only, for prevention of ankylosis of TMJ. 26

27. Next steps Prevention of infection and gradual rehabilitation of function 27

28. In order to stabilize the reduced facial fractures, some type of anchoring device is applied to maxillary dental arch and mandibular dental arch and intermaxillary fixation is carried out by applying wires or elastic bands between the upper and lower dental arch anchoring devices. The main methods for such fixation are dental wiring, arch bars and splints. 28

29. There are various methods available for anchoring the dental arches. The type of device to be chosen will depend on the type of fracture, site of fracture, number of teeth present and their periodontal status and availability of the anchoring device. 29

30. The anchoring devices can be fitted on the dental arches under local anaesthesia with or without sedation, prior to surgical procedure (if at all it is planned) to cut down the total operating time. In case of multiple fractures or extremely uncooperative patient, it can be done under general anaesthesia at the time of surgery. 30

31. Different Types of Dental Wiring Techniques i. Essig’s wiring ii. Gilmer’s wiring iii. Risdon’s wiring iv. Ivy eyelet wiring v. Col. Stout’s multiloop wiring 31

32. 1. Direct dental wiring Direct interdental wiring (Gilmer wiring) Risdon’s wiring Button wiring 32

33. 2. Interdental eyelet wiring (Ivy loop method) 3. Continuous or multiple loop wiring 4. Arch bars i . Prefabricated . ii. Custom made—prepared individually for a specific patient. 5. Cap splints 6. Gunning splint 7. Bonded modified orthodontic brackets 8. Intermaxillary fixation screws 33

34. Direct interdental wiring . Direct interdental wiring (Gilmer wiring) 34

35. Gilmer’s wiring 35

36. Risdon’s wiring. 36

37. Risdon’s wiring 37

38. Interdental eyelet wiring (Ivy loop method) 38

39. Ivy eyelets wiring 39

40. Maxillomandibular fixation using Ivy eyelets for angle fracture 40

41. Continuous or multiple loop wiring 41

42. Essig’s wiring 42

43. Col. Stout’s multiloop wiring 43

44. Arch Bars Many types of prefabricated arch bars are available. But the most popular one and commonly used is the Erich‘s arch bar. It is a prefabricated arch bar with hooks incorporated on the outer surface with flat malleable stainless steel metal strip. 44

45. Indications for use 1. When the remaining teeth are insufficient to allow efficient eyelet wiring. 2. When the distribution of the teeth in the arch is such that efficient intermaxillary fixation is not possible. 3. In cases of simple dentoalveolar fractures or where multiple toothbearing fragments in either jaw requires reduction into an arch form before intermaxillary fixation is applied. 4. As an integral part of internal skeletal suspension in the treatment of fractures involving the middle third of the facial skeleton. 5. In cases where external skeletal fixation is planned, an anterior projection bar is attached to an individually made arch bar. 6. Where laboratory and technical facilities are inadequate or nonexistent. 45

46. Operative technique The fracture is first reduced and the teeth in the main fragments of the fracture are tied to a metal bar which is adapted to the dental arch. Various types of arch bar available are Erich type, German silver and Jelenko type. It is wise to place the wires for securing the arch bar around the teeth away from the fracture in order to prevent subluxation of the teeth involved in the fracture line. To be retentive, the wires holding the bar must lie below the contact points and, if possible, around the necks of the teeth. The arch bars have hooks or other provisions for maintenance of intermaxillary fixation. Small notches created on the bar with the help of a file prevent the wires from slipping. The hooks in the upper jaw face in an upward direction whereas the hooks in the lower jaw face downward direction. 46

47. The arch bars have hooks or other provisions for maintenance of intermaxillary fixation. Small notches created on the bar with the help of a file prevent the wires from slipping. The hooks in the upper jaw face in an upward direction whereas the hooks in the lower jaw face downward direction. The arch bar is adapted to the buccal surface of the lower and upper jaws by bending first at the buccal surface of the last teeth on one side and passing across the midline to the opposite side. Now the arch bar is secured to each tooth using a 0.35 mm soft stainless steel wire. Each wire passes over the bar mesially , around the tooth and under the bar distally. The ends of the wire are twisted on the buccal side. 47

48. Once the fragments have been tightly secured to the arch bar, it is difficult to correct any errors in a vertical displacement of the occlusion. It is advisable, therefore, not to tighten any ligatures until all have been inserted and any vertical displacement has been corrected by articulating the jaws. Intermaxillary fixation is achieved by passing tie wires around the lower arch bar and inserting them either through hook, around the upper arch bar. A more rigid fixation can be achieved by threading the tie wire through the wire loop, which will secure the arch bar to the teeth. The tie wires are first pulled, tightened and then cut so that the end can be bent over the bar into an interdental space where it will not cause soft tissue damage. 48

49. On the upper jaw, the hooks are arranged in an upward direction. The bar is attached to the lower jaw with the hooks in a downward direction. The arch bar should be adapted to the buccal surface of each arch by giving a shape of the arch by bending it. Bending of the arch bar should start at the buccal side of the last tooth progressing past the midline and finishing at the other end. The arch bar is fixed to each tooth, with 26 gauge stainless steel wire, which is passed from the mesial surface of a tooth to the lingual side and back on the buccal side from the distal surface of the tooth. 49

50. It provides an effective, quick and inexpensive method of fixation. The bar is available in spool form. The bar should be cut accurately to the length of the dental arch. Accuracy in this regard will prevent injury to the adjacent soft tissues by protruding ends. Each arch bar is to be fixed to the upper and lower dental arches. 50

51. Erich arch bar. 51

52. One end of the wire is above the bar and the other below. By twisting the two ends of wire together, the bar is attached securely and firmly to the necks of the teeth on the buccal surface of the arch. The twisting of the wires should be always done in a clockwise manner, so that later on removal of wires can be done in anticlockwise manner. Improper adaptation of the bar, ligation of an insufficient number of teeth and inefficient tightening will result in inadequate stability of the arch bar. Advantages of the arch bar include less trauma because of the thin wire and greater stability in an arch, even if some teeth are missing, because the edentulous gaps can be spanned by this rigid appliance. 52

53. Arch bar fixation 53

54. Maxillomandibular fixation using arch bars to preserve dental occlusion 54

55. Cap splints For many years, cap splints were used as a significant means of immobilisation. The possible indications for their use in the present days are confined to the following: 55

56. For prolonged fixation on the mandibular teeth in a patient with fracture of the tooth-bearing segment of the mandible and bilateral displaced fractures of the condylar neck. In a case, where a portion of the mandible is missing with considerable soft tissue loss. Here the cap splint helps in maintaining the correct relationship of remaining tooth-bearing segments till the reconstruction is completed. In patients with severe periodontal disease in which case temporary retention is essential for proper fracture healing. Here the cap splint helps to splint the loose teeth together and facilitates the application of the intermaxillary fixation. Cap splints are also used for extraoral fixation in case of complicated midfacial fractures which particularly involves mandible. 56

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58. Bonded modified orthodontic brackets Orthodontic brackets can be bonded onto teeth and intermaxillary fixation applied with the help of elastic bands. This type of intermaxillary fixation can be used for fractures with minimum displacement. The orthodontic brackets have to be modified by attaching small hooks on them for application of the elastic bands. 58

59. Intermaxillary fixation screws Arch bars and wires have a chance of accidental skin puncture causing risk of HIV/hepatitis transmission. Karlis first described the use of cortical bone screw fixation for treating mandible. 59

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61. Advantages Ease of application. Decreased operating time—decreased overall cost. Decrease risk of disease transmission. Armamentarium Local anaesthesia 24 g wire IMF screws Screwdriver Disadvantages Lacks tension band effect. May interfere with internal fixation plates, so recommended for only minimally displaced fracture. 61

62. Technique Local anaesthesia medial to canine (upper and lower). Self-tapping IMF screw 8–14 mm length is inserted in transmucosal fashion/mucosa incised with No. 15 blade. Care taken to avoid iatrogenic injury to mental nerve branches. 24 g wires used for MMF. 62

63. IMF screws. Note the head is double headed with a hole for gaining entry of wire. Wire passed through the hole in the IMF screw head. MMF done using IMF screws. 63

64. Length of Fixation Traditionally the length of IMF used for adult mandibular fractures has been 6 to 8 weeks. It appears that each individual case must be judged on its merits but that most uncomplicated fractures in children are united in 2 to 3 weeks, in adults 3 to4 weeks, and in older patients in 6 to 8 weeks. Several other factors should be taken into account when deciding on the appropriate regime for a particular patient. The following situations generally require longer periods of IMF: comminuted fractures; fractures in alcoholics, particularly those with nutritional problems; fractures in patients with psychosocial handicaps; fractures treated late; and fractures with teeth removed in the line of the fracture. 64

65. In condylar fracture IMF is used for a maximum of 2 to 3 weeks in adults and 10 to 14 days in children, after which there is a period of aggressive functional rehabilitation. Longer periods of IMF can lead to bony ankylosis or fibrosis and severe limited mouth opening. 65

66. Custom made Splints Custom made appliances are fabricated for individual patient. The splints can be constructed using acrylic material or cast metal. Indications 1. When the wiring of the teeth will not provide adequate fixation. 2. When horizontal splinting across the fracture zone is required without closing the patient’s mouth. 3. When both the jaws are edentulous. 4. In case of growing children, where mixed dentition is present and number of firm teeth for anchorage are not adequate. 5. In case of pregnant women and mentally challenged patients, where IML is not desirable. 66

67. Acrylic Splints i. Lateral compression splint. ii. Gunning splint 67

68. Lateral compression splint : It is made for the stabilization of mandibular arch. Mainly used in case of children, where there is mixed dentition and presence of developing teeth buds (open reduction and direct fixation is contraindicated). It can be also used in adult mandibular body fracture, where the stability cannot be obtained by means of other type of horizontal wiring methods. 68

69. Lateral compression splint 69

70. Gunning splint: In edentulous jaws, patient’s own dentures, suitably modified can be used or specially constructed Gunning splint can be used. Circumferential wiring is used to fix the splint to the mandibular bone and upper denture or splint is fixed to the maxilla by means of peralveolar wiring. 70

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72. Obwegeser’s method of circummandibular wiring 72

73. Methods of Fixation Treatment without Any Form of Fixation This method is reserved for the following: i. Fractures exhibiting minimal displacement and mobility; without occlusal discrepancy or with very minimal occlusal discrepancy. ii. Green stick fractures. iii. Elderly edentulous patients who are in the high/ poor risk category and who have no gross displacement. 73

74. Treatment with Intraoral Fixation Alone This method can be employed for the treatment of the following: Dentoalveolar fractures Unilateral fracture—maxilla Dentulous mandibular body fracture with minimal displacement or no displacement Edentulous mandibular body fractures 74

75. This fixation can be achieved by the following: 1. The use of an arch bar or suitable type of wiring methods described earlier. 2. Cap splints with locking plates and a connecting bar. 3. Acrylic splints – lateral compression or Gunning type splint. 4. Intermaxillary ligation or fixation IML/IMF – whenever required the jaws are rigidly fixed to each other in centric occlusion. Both the jaws are united as a block, must be fixed to the skull in case of maxillary fractures. 75

76. External Fixation The intact skull serves as a fixation point for the fixation of facial fractures. Usually a plaster of Paris head cap is applied for external skeletal fixation. 76

77. External skeletal fixation with plaster of Paris skull cap 77

78. The metallic ‘Halo frame’ devised by Crewe in 1943 is directly secured to the skull by multiple screw pins inserted into the external cortex of the skull. Vertical rods, bilateral check wires, side bars can be added to the central Halo frame, which is a versatile apparatus of great stability 78

79. The metallic ‘Halo frame’, devised by Crewe 79

80. Extraoral fixation device consisting of metallic halo frame, possible combination of rods and universal joints 80

81. Internal Fixation This type of fixation is achieved entirely or primarily by passing wires within the tissues. 81

82. Direct suspension In this method the same principle, as extraoral fixation is used except, the wires are passed subcutaneously from stable skeletal points into the oral cavity and are fixed on both sides to the arch bars under traction (craniofacial suspension). Depending on the type of fracture, the point of fixation may vary. The wires are always passed from a stable point above the fracture line. 82

83. The various areas for direct suspension of wires can be chosen. a. Pyriform fossa b. Zygomatic buttress c. Zygomatic arch d. Infraorbital rim e. Zygomatic process of the frontal bone. 83

84. Direct suspension wires at different locations 84

85. Pyriform aperture suspension wiring along with wiring at anterior nasal spine. (B) Suspension wiring from the infraorbital rims on either side to arch bar 85

86. Indirect support Craniomandibular suspension is brought about by sandwiching the fractured areas between the mandible and some part of the facial skeleton above the fracture line through the medium of suspensory wires connected to a mandibular arch bar. The appropriate sites can be chosen as indicated in direct suspension procedure. 86

87. Transosseous or intraosseous wiring It can be used at various sites. Open reduction is needed. Here the fractured fragments are approximated in their normal anatomical position after reduction and the holes are drilled on either sides of the fracture line and 26 or 28 gauge stainless steel wire is passed to interconnect the holes and both the ends of the wires are grasped on the outer cortex and twisted, cut and finished. This type of direct internal fixation offers semirigid stability. 87

88. Transosseous wiring at various sites in the facial area 88

89. Transosseous or intraosseous wiring can be done at the following sites: a. Zygomaticofrontal b. Zygomaticomaxillary c. Zygomatic bone (comminuted) d. Palatal processes e. Frontonasal f. Mandibular angle at superior border or inferior border g. Edentulous mandible at the site of fracture h. Condylar fractures— subcondylar or high condylar Wire osteosynthesis is the oldest, simplest and most popular method for internal fixation. 89

90. Disadvantages: Intermaxillary fixation is always needed There is no three-dimensional stability to the fragments Interfragmentary pressure cannot be controlled Under-functional stress, the wire synthesis lacks adequate rigidity, direction control and surface contact Delayed healing as compared to bone plate system, because of micromovement at the fracture side. 90

91. Direct support This may be employed in the case of a comminuted orbital floor by utilizing an antral pack or balloon. It can be also used for stabilizing zygomatic complex fractures. 91

92. Antral pack 92

93. Miniplate osteosynthesis The extraordinarily good results with compression osteosynthesis with plates or lag screws in the mandible have led to the development of similar procedure for the midface. Champy and Michelet introduced miniplate osteosynthesis suitable for facial fracture fixation. 93

94. Miniplate osteosynthesis 94

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96. Internal Fixation by Means of Bone Plate Osteosynthesis Indications Cases where there is absolute contraindications to IMF, i.e. in epileptics, mentally retarded uncooperative patients, asthmatics, alcoholics, drug abusers, pregnant women, etc. When the patient wants to return back to work early. Edentulous patients with loss of bone segments, which need the maintenance of the gap or grafting, if indicated. In subcondylar and angle fractures of the mandible, early mobilization of the joint is required. Atrophic mandible requiring additional reinforcement. 96

97. Contraindications In heavily contaminated fractures, where there is active infection and discharge. However, some surgeons advocate the use of compression osteosynthesis in such cases. In badly comminuted fracture, where open reduction may pose risk of compromising vascularity. In children having mixed dentition, where there is a danger of injuring the developing teeth buds. Presence of gross pathological abnormalities in the bone. 97

98. Advantages Simple technique. Decreased intraoperative time. Most of the time, intraoral approach is sufficient. However, in certain cases extraoral approach may be required. Direct control of occlusion in intraoral technique. Postoperative intermaxillary fixation is not needed or period of IMF is reduced. Early return of function. Reduced hospital stay. Better aesthetics and function, better three dimensional stability. Minimization of immediate postoperative complications, as mouth is not locked. Better maintenance of oral hygiene Nutritional intake does not suffer. Psychological advantage. No weight loss No speech problem. 98

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104. Treatment of Fractures of the Zygomatic Bone In majority of cases early operation is advisable, provided that there are no ophthalmic or cranial complications. Whenever there is a gross periorbital oedema and ecchymosis, postponement of the operation for 3 to 5 days can be done, but it should not be prolonged more than two weeks. 104

105. Gillies Temporal Approach 105

106. 106

107. Keen’s approach Intraoral Procedure 107

108. Alternate methods like intranasal elevation via intranasal antrostomy or oroantral elevations were suggested. 108

109. Direct extraoral elevation can be done by inserting a sharp curved hook directly through the skin below and above the prominence of the zygomatic bone. 109