13 ACCESS OSTEOTOMY - Aligarh Muslim UniversityABSTRACT : Mandibular access osteotomy allows...

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ABSTRACT : Mandibular access osteotomy allows mobilization of craniofacial skeleton and replacements of bony fragments either pedicled on their soft tissues or as free bone segments. This provides increased and direct exposure of posterior region and surrounding vital structures and avoid the need to resect uninvolved structures. Roux in 1836 suggested the division of the lower lip and mandible for improved access to the tongue carcinoma.In this paper we review various circumstances like tumors of posterior one third of tongue , tumors of infra temporal fossa and parapharyngeal tumors where access osteotomy was thought to be the preferred choice of treatment because of lack of adequate access to the surgical site. 1 2 Madhumati Singh, Auric Bhattacharya 1 Professor & Hod, Department of Oral & Maxillofacial Surgery Rajarajeswari Dental College & Hospital, Bangalore, Karnataka 2 Post Graduate, Department of Oral & Maxillofacial Surgery Rajarajeswari Dental College & Hospital, Bangalore, Karnataka INTRODUCTION : The optimum access to the site of malignancy of the oral cavity and oropharynx is imperative to allow three- dimensional assessment and resection of the lesion. Incomplete surgical resection or rupture, due to poor access, predispose to tumor recurrence. Transoral resection is often possible for anterior tumours, but for posterior tumors an access osteotomy is required.Roux's 1836 description of division of the lower lip and mandible for improved access to the tongue carcinoma has often been cited as the original description for access osteotomy. Various methods have been described and splitting the lip in conjunction with an access osteotomy of the mandible has become the gold standard. ACCESS OSTEOTOMY: Access osteotomy was first introduced in 1836 by Roux to improve access in floor of mouth and base of tongue of tongue surgeries.It was repeated in 1959 by Head and neck oncology group of Sloan- Kettering Cancer Hospital.In 1981, Spiro et al proposed the translabial access with mandibulotomy. In 1984, Attia et al described translabial access with mandibular osteotomy anterior to mental foramen, thus preserving the ipsilateral lip sensation. Access osteotomy is indicted in areas were the visualization and access is a challenge to the surgeon, specially in such areas were the access is hindered by other anatomical structures of the region.Access osteotomy is mainly indicated in areas like tumors of posterior floor of mouth ,base of tongue, ,nasopharynx ,oropharynx, parapharyngeal space & skull base. ACCESS OSTEOTOMY FOR TUMORS OF POSTERIOR ONE THIRD OF TONGUE: A male patient aged thirty two years came to our Department of Oral and Maxillofacial Surgery, Raja Rajeswari Dental College, with the chief complain of burning sensation and difficulty in swallowing from last six month. On inspection , a roughly oval 2 x 2 cm ulceroproliferative lesion on the ventral surface of tongue was seen in the right posterior region with everted margins. On palpation , all inspectory ACCESS OSTEOTOMY FOR TUMORS OF THE OROPHARYNGEAL REGION - A REVIEW Keywords : Access osteotomy, Ulcero-proliferative lesion, Source of support : Nil Conflict of interest: None Swiss Cheese Appearance Journal of Dental Sciences University University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 75 University J Dent Scie 2016; No. 2, Vol. 1 Review Article

Transcript of 13 ACCESS OSTEOTOMY - Aligarh Muslim UniversityABSTRACT : Mandibular access osteotomy allows...

Page 1: 13 ACCESS OSTEOTOMY - Aligarh Muslim UniversityABSTRACT : Mandibular access osteotomy allows mobilization of craniofacial skeleton and replacements of bony fragments either pedicled

ABSTRACT : Mandibular access osteotomy allows mobilization of craniofacial skeleton and replacements of

bony fragments either pedicled on their soft tissues or as free bone segments. This provides increased and

direct exposure of posterior region and surrounding vital structures and avoid the need to resect uninvolved

structures. Roux in 1836 suggested the division of the lower lip and mandible for improved access to the

tongue carcinoma.In this paper we review various circumstances like tumors of posterior one third of tongue

, tumors of infra temporal fossa and parapharyngeal tumors where access osteotomy was thought to be the

preferred choice of treatment because of lack of adequate access to the surgical site.

1 2Madhumati Singh, Auric Bhattacharya1Professor & Hod, Department of Oral & Maxillofacial SurgeryRajarajeswari Dental College & Hospital, Bangalore, Karnataka2Post Graduate, Department of Oral & Maxillofacial SurgeryRajarajeswari Dental College & Hospital, Bangalore, Karnataka

INTRODUCTION :The optimum access to the site of malignancy of the oral cavity and oropharynx is imperative to allow three-dimensional assessment and resection of the lesion. Incomplete surgical resection or rupture, due to poor access, predispose to tumor recurrence. Transoral resection is often possible for anterior tumours, but for posterior tumors an access osteotomy is required.Roux's 1836 description of division of the lower lip and mandible for improved access to the tongue carcinoma has often been cited as the original description for access osteotomy. Various methods have been described and splitting the lip in conjunction with an access osteotomy of the mandible has become the gold standard.

ACCESS OSTEOTOMY:Access osteotomy was first introduced in 1836 by Roux to improve access in floor of mouth and base of tongue of tongue surgeries.It was repeated in 1959 by Head and neck oncology group of Sloan- Kettering Cancer Hospital.In 1981, Spiro et al proposed the translabial access with

mandibulotomy. In 1984, Attia et al described translabial access with mandibular osteotomy anterior to mental foramen, thus preserving the ipsilateral lip sensation.Access osteotomy is indicted in areas were the visualization and access is a challenge to the surgeon, specially in such areas were the access is hindered by other anatomical structures of the region.Access osteotomy is mainly indicated in areas like tumors of posterior floor of mouth ,base of tongue, ,nasopharynx ,oropharynx, parapharyngeal space & skull base.

ACCESS OSTEOTOMY FOR TUMORS OF POSTERIOR ONE THIRD OF TONGUE:A male patient aged thirty two years came to our Department of Oral and Maxillofacial Surgery, Raja Rajeswari Dental College, with the chief complain of burning sensation and difficulty in swallowing from last six month. On inspection , a roughly oval 2 x 2 cm ulceroproliferative lesion on the ventral surface of tongue was seen in the right posterior region with everted margins. On palpation , all inspectory

ACCESS OSTEOTOMY FOR TUMORS OF THE OROPHARYNGEAL REGION - A REVIEW

Keywords :Access osteotomy,Ulcero-proliferative lesion,

Source of support : NilConflict of interest: None

Swiss Cheese Appearance

Journal of Dental Sciences

University

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University J Dent Scie 2016; No. 2, Vol. 1

ReviewArticle

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findings were confirmed. The lesion was tender, indurated with irregular margins & everted edges.An incisional biopsy was done .The histopathological report suggested Adenocarcinoma of tongue . Adenocarcinoma occurs mostly in fifth and sixth decade of life. Many of these patients exhibit clinical manifestation of typical malignant salivary gland tumours like early local pain, facial nerve paralysis , fixation to deeper structures and local invasion. Morphologically three growth patterns have been described : cribriform, tubular and solid. The swiss cheese appearance, is the most classic and best recognised histologic pattern. The treatment plan consisted of supra omohyoid neck dissection and resection of the tumour with access osteotomy.

Pre–operative View Swiss Cheese Appearance

MRI with contrast MRI without contrast

A lateral utility incision was given and supraomohyoid neck dissection was done preserving the spinal accessory nerve and internal jugular vein.

After the completion of supra- omohyoid neck dissection, a lip splitting incision was given.Lip splitting incision is of various types as shown in fig 1. Out of all the designs of lip splitting incision .Haytel's modification of Mcgregor's lip splitting incision is considered best, because of least post operative complications of facial scarring,loss of sensation & lower lip function.The lip splitting incision consists of a chin pad extension with two grooves in mentolabial sulcus and vermillion border of lower lip.

Haytel's type lip splitting incision given with chin pad extension and a full thickness labial periosteal flap reflected. The lip splitting incision joins with the lateral utility incision below.

Acsess osteotomy of mandible can be basically classified into two types- 1) Access osteotomy anterior to mental foramen.2) Access osteotomy posterior to mental foramen.Access osteotomy anterior to mental foramen has the advantage of preserving the ipsilateral lip sensation because of non – involvement of the mental nerve.It is further subdivided into two types – median & paramedian osteotomy.

In case of median osteotomy ,the osteotomy cut is given in between the lower central incisors.The disadvantage of this type of osteotomy cut is that the muscular attachment of genial tubercles is transected, i.e geniohyoid and geniossus.Hence , the paramedian osteotomy is preferred in which the cut in given distal to canine and anterior to mental foramen.

MEDIAN AND PARAMEDIAN OSTEOTOMY

Paramedian osteotomy cut given between lateral incisor and canine region and mandible swung laterally exposing the posterior region of tongue.Access osteotomy posterior to mental foramen is further classified into three types –

Sagittal split osteoetomy

vertical subsigmoid osteotomy

inverted L osteotomy

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Access osteotomy has definite advantages of greater and easier access to areas where visibility is difficult.As a result of greater access ,a complete three dimensional resection can be planned, and thus greatly reduces chance of tumor spillage & recurrence .Another advantage is preserving neurovascular ,vascular and muscular anatomic structures in the nearby viscinity of the tumor, beacause of greater access and visualization.Thus improving the post –operative living condition of the patient. The procedure of access osteotomy also is helpful is restoring the normal anatomy & function of mandible with least cosmetic disability.The disadvantages of access osteotomy include facial scars and loss of lower lip function due to lip splitting incision. But, the incidence of such complications are very less in Haytel's modification type of lip splitting incision. Another disadvantage is the risk of mini plate fracture at a later stage. This occurs mainly as a result of too much stress on a single plate.This can be avoided by placing two mini plates( one 4 hole and other 2 hole) and giving a step cut in the paramedian osteotomy cut.The step cut helps in better three dimensional approximation of surfaces and redistribution of forces .Thus reducing chances of miniplate fracture.

ACCESS OSTEOTOMY FOR TUMORS OF INFRATEMPORAL FOSSA

The transmandibular approach to the retromaxillary region was introduced by Barbosa. However this approach did not gain popularity. Use of a transmandibular approach to the skull base was described in 1981 by Biller et al and adopted by Krepsi and Sisson in 1984. This approach provided good exposure to the lateral and middle compartments of the middle cranial base and offered good vascular control in the neck.Shaheen described alternative approaches to the infratemporal fossa, concluding that the route of access is determined by the position, extent, and nature of the disease in question. His preferred access to the maxillary tumors invading the infratemporal fossa was the extended anterolateral approach, which combined mandibulotomy with the classical Weber-Fergusson incision. Attenborough in 1980 and Obwegeser in 1985 also described the temporal approach for lesions in the infratemporal fossa and pterygomaxillary area. Both procedures involved multiple osteotomy of the zygomatic arch and the ramus of the

mandible, with the disadvantage beingseparation of masseter and temporalis muscle fibers multiple osteotomy sites, and dissection in a highly vascular zone.The Lip split mandibulotomy for access to the maxilla and infratemporal fossa combined with sublabial degloving was successfully used for resection of tumors of the maxilla including the infratemporal fossa and the advantages of this technique included achievement of disease-free surgical margins especially in the region of the infratemporal fossa &access to the palatal aspect in patients with trismus with good vascular control from the external carotid artery feeders .In conclusion, mandibulotomy to access tumors of the maxilla and those involving the infratemporal fossa is an ideal choice, with minimal morbidity.

PRE – OPERATIVE VIEW

INTRA–OPERATIVE VIEW post excision defect with orbital extention : Acess osteotomy of mandible done to approach the infra temporal region.

ACCESS OSTEOTOMY FOR TUMORS OF PARAPHARYNGEAL SPACE

Surgical access is the primary dif?culty during the resection of tumors of the parapharyngeal space. The parapharyngeal space which is shaped like a5-sided inverted pyramid extending from the skull base to the greater cornu of the hyoid bone and between the pterygomandibular raphe and prevertebral fascia. The parapharyngeal space contains a numberofvital structures including the carotid artery, jugular vein, cranial nerves IX, X, and XII, and the sympathetic chain. Tumors withinthe parapharyngeal space are bounded laterally by the mandibular condyle and ramus. The superior and medial access to the parapharyngeal space is restricted by mandibular ramus. Incomplete surgical resection or rupture, particularly of neoplasms of salivary gland origin,will lead to to tumor recurrence. Multiple surgical approaches to the parapharyngeal space utilizing mandibular osteotomies have

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been described. In 1970, Dingman et al introduced the lateral approach to the pterygomaxillary space, whereas, in 1984, Attia et al are credited for the description of a double mandibular osteotomy for the same purpose.If surgical exposure is inadequate for a given tumor or if safe tumor removal without rupture is not deemed to be feasible then a decision is made to perform a mandibulotomy.

In an article by Kolokythus he describes that through an intraoral approach the buccal and lingual gingiva are reflected inferiorly for approximately 5 mm at the planned osteotomy site. Subperiosteal dissection is performed for exposure of the lateral aspect of the mandibular ramus from the angle to the sigmoid notch. Subperiosteal dissection is also performed on the buccal and lingual aspect between the ipsilateral canine and premolar . The extraoral dissection is made continuous with the intraoral and interdental dissection that had been created previously. The mental nerve is identified and protected . The planned osteotomy site is approximately 5 mm anterior to the mental foramen. . For the anterior osteotomy, the osteotomy is started at the inferior border of the mandible with the reciprocating saw. The mandible is then retracted superiorly with preservation of the inferior alveolar nerve, allowing for access to the tumor . Following tumor extirpation the rigid fixation plates are placed and the wound closed.

ACCESS OSTEOTOMY FOR NASOPHARYNGEAL TUMORSNasopharyngeal tumors present with progressive obstruction of nasal respiration, bleeding, obstruction, invasion of paranasal sinuses, and in advanced cases due to intracranial extension. Intraorbital extension of tumor can lead to vision loss or ophthalmoplegia. Surgery remains the main treatment modality for this tumor. The choice of a surgical approach is still controversial. Maxillary swing approach is one of the commonly accepted approaches for removal of nasopharyngeal tumors but it provides exposure to only ipsilateral infratemporal fossa. Gupta et al adopted a extended approach called nasomaxillary swing for the large nasopharyngeal tumors involving bilateral sinuses and infratemporal fossa with intracranial extension .In this procedure a modified Weber-Fergusson incision was made beginning from the zygomatic arch and passing just below ipsilateral ciliary line, nasofrontal suture and contralateral nasomaxillary groove with lip split.. Osteotomies were made and the nasal bone, nasal septum, hard palate and maxillary bone were swung laterally and anterior skull base, postero-superior wall of nasopharynx and anterior part of clivus were fully exposed . The medial, lateral and superior margins of the tumor were fully exposed. Dissection was done at the anterior skull base and tumor removed in toto after releasing its peripheral lateral attachments.

Lefort one osteotomy done and naso maxillary swing performed

CONCLUSION –Thus we would like to conclude that access osteotomy allows the surgeon a better view and a better access of the surgical field to resect the tumor completely with safer margins.Thus, in the process helping to preserve vital structures, pre-operative function and reduce post operative complications.

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CORRESPONDING AUTHOR :Dr. Madhumati SinghDepartment of Oral & Maxillofacial surgeryRajarajeswari Dental College & HospitalNo.14, Mysore Road, Ramohalli crossP.O – Kumbakgodu - 560074.Bangalore, Karnataka

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