MAXILLARY ORTHOGNATHIC PROCEDURES AND SOFT TISSUE CHANGES-2.pptx

orthognathic procedures are used to correct facial deformity of jaws

1. PRESENTED BY- DR. SAHANA M.S MAXILLARY ORTHOGNATHIC PROCEDURES AND SOFT TISSUE CHANGES

2. CONTENTS INTRODUCTION AIMS & OBJECTIVES HISTORY ANATOMICAL CONSIDERATIONS ANTERIOR AND POSTERIOR MAXILLARY SEGMENTAL OSTEOTOMY SARME LEFORT -I OSTEOTOMY MAXILLARY QUADRANGULAR LEFORT I AND QUADRANGULAR LEFORT II OSTEOTOMY HIGH LEVEL MIDFACE OSTEOTOMY CLEFT OSTEOTOMIES COMPLICATIONS CONCLUSION REFERENCES

3. INTRODUCTION Dentofacial deformities affect 20%of the population. The incidence of Transverse Maxillary Deficiency is estimated to be between 8% & 18% Patients with dentofacial deformities may demonstrate various degrees of functional and aesthetic compromise. Such deformities may be limited to either one jaw or both the jaws. Tremendous advancement in field of orthognathic surgery have been made since 1970s.

4. AIMS & OBJECTIVES Fonseca vol 2- Orthognathic surgery

5. HISTORY 1859 : Von- Langenback did the first orthognathic procedure. 1921 :Cohn-Stock introduced the anterior maxillary osteotomy . 1927 :Wassmund reported the first total maxillary osteotomy . Bells research- biologic basis for orthognathic surgery.

6. GOALS

7. ANATOMICAL CONSIDERATIONS

8. ANATOMICAL CONSIDERATIONS VASCULAR ANATOMY:

9. ORTHOGNATHIC PROCEDURES IN MAXILLA

10. ANTERIOR SEGMENTAL OSTEOTOMY INDICATIONS

11. ANTERIOR SEGMENTAL OSTEOTOMY TECHNIQUES:

12. WUNDERER TECHNIQUE : ANTERIOR SEGMENTAL OSTEOTOMY

13. WASSMUND TECHNIQUE: ANTERIOR SEGMENTAL OSTEOTOMY

14. CUPAR TECHNIQUE : ANTERIOR SEGMENTAL OSTEOTOMY Cupar technique is the most commonly used technique for AMO. A buccal vestibular incision is created. Direct access to the anterior lateral maxillary walls. Nasal mucosa is elevated from the maxilla. Horizontal osteotomy is completed followed by vertical osteotomy between teeth.

15. ANTERIOR SEGMENTAL OSTEOTOMY

16. POSTERIOR MAXILLARY OSTEOTOMY INDICATIONS

17. POSTERIOR MAXILLARY OSTEOTOMY CONTRAINDICATIONS: Damage to the vital structures. When repositioning of the entire maxilla is recommended.

18. COMBINED ANTERIOR AND POSTERIOR MAXILLARY OSTEOTOMY

19. SURGICALLY ASSISTED MAXILLARY EXPANSION Brown- 1938- midpalatal split Timms – major resistance to expansion is midpalatal suture. Kennedy –lateral maxillary osteotomy with midpalatal split Shetty -all bony buttress contribute resistance for expansion but midpalatal suture followed by pterygomaxillary articulations were the primary areas of resistance.

20. SURGICALLY ASSISTED MAXILLARY EXPANSION INDICATIONS

21. SURGICALLY ASSISTED MAXILLARY EXPANSION

22. SURGICALLY ASSISTED MAXILLARY EXPANSION TECHNIQUE

23. TECHNIQUE SURGICALLY ASSISTED MAXILLARY EXPANSION Maxilla should remain stationary – 5 days then 0.5mm /day 0.5mm-1mm/day –Expansion > this causes gingival recession

24. LEFORT I OSTEOTOMY INDICATIONS

25. LEFORT I OSTEOTOMY

26. LEFORT I OSTEOTOMY

27. LEFORT I OSTEOTOMY DESIGN OF OSTEOTOMY Low level osteotomy Osteotomy approaching Infraorbital rims Osteotomy including Cheek prominence Low level horizontal osteotomy

28. LEFORT I OSTEOTOMY SURGICAL TECHNIQUE:

29. LEFORT I OSTEOTOMY

30. LEFORT I OSTEOTOMY

31. LEFORT I OSTEOTOMY

32. LEFORT I OSTEOTOMY

33. LEFORT I OSTEOTOMY

34. LEFORT I OSTEOTOMY To Summarize.......

35. SURGICAL COMPLICATIONS OF SEGMENTAL LEFORT I OSTEOTOMY M.W.Ho , M.A.Boyle , J.C.Cooper , M.D.Dodd , D.Richardson CONCLUSION: The overall complication rate was 27%. There was no segmental loss of bone or teeth. Our results show that complications in this cohort were relatively low, and that segmental maxillary surgery is safe as an adjunct in carefully selected cases. British Journal Of Oral & Maxillofacial Surgery, 23 Sep 2010

36. QUADRANGULAR LEFORT-I OSTEOTOMY INDICATIONS

37. QUADRANGULAR LEFORT-I OSTEOTOMY

38. QUADRANGULAR LEFORT-II OSTEOTOMY

39. QUADRANGULAR LEFORT-II OSTEOTOMY TECHNIQUE:

40. LEFORT II OSTEOTOMY INDICATIONS

41. LEFORT II OSTEOTOMY 1)General anesthesia 2)Intraoral and oblique paranasal skin incisions 3) Osteotomy in infraorbital rim 4)Connected with intraoral osteotomy cuts 5)Nasal bridge osteotomy 6)Mobilisation of maxilla 7)Splint fixation 8) Intermaxillary fixation 9)Grafts placement 10)Mini plate fixation SURGICAL STEPS:

42. LEFORT III OSTEOTOMY INDICATIONS:

43. LEFORT III OSTEOTOMY

44. ORTHOGNATHIC SURGERY IN CLEFT PATIENTS Most patients with cleft express some amount of mid face deficiency. Problems due to cleft:- Nasal breathing Speech, hearing and olfaction. Sometimes exorbitism and eyelid in adequacy.

45. IN CLEFT PATIENTS Maxillofacial growth in children

46. ORTHOGNATHIC IN CLEFTS OSTEOTOMY CUTS INCISIONS

47. ORTHOGNATHIC IN CLEFTS LATERAL VIEW

48. ORTHOGNATHIC IN CLEFTS DOWNFRACTURING THE MAXILLA CLOSURE

49. ORTHOGNATHIC IN CLEFTS BONE GRAFTING

50. SOFT TISSUE CHANGES Most important aspect at end of the surgery –achievement of an aesthetically pleasing facial soft tissue envelope . With the refinement of surgical procedures and the advent of rigid fixation techniques the surgeon can predict the final outcome of osseous and soft tissue changes .

51. SOFT TISSUE CHANGES NASAL CHANGES

52. SOFT TISSUE CHANGES Direction Maxillary Movement Alar Bases Nasal Tip Nasolabial Angle Superior Increase Increase Decrease Anterior Increase Increase Decrease Inferior Inferior Decrease Increase Posterior None Decrease Increase

53. SOFT TISSUE CHANGES LABIAL CHANGES ANTERIOR SEGMENTAL REPOSITIONING- SETBACK ANTERIOR SEGMENTAL REPOSITIONING- ADVANCEMENT Increase in nasolabial angle Decrease in nasolabial angle Lengthning of upper lip Slight shortening and thinning of lip(2mm) Decrease in interlabial gap Alar base widening Uncurling and retraction of lower lip Advancement of upper lip,subnasale and nose

54. SOFT TISSUE CHANGES SUPERIOR REPOSITIONING INFERIOR REPOSITIONING Elevation of nasal tip Loss of nasal tip support  polybeak deformity Widening of alar base (2-4mm) Downward repositioning of the columella and alar base Decrease in Nasolabial angle Increase in Nasolabial angle No change in the angulation of the upper lip. Thinning of lip

55. COMPLICATIONS

56. COMPLICATIONS VASCULAR COMPROMISE: Incidence is low To look for - Cyanosis and Ischaemia Venous congestion TREATMENT: Removal of maxillomandibular fixation Removal of splints Angiographs to detect site of spasm or occlusion Administration of Anticoagulants, Beta blockers, Vasodilators, Hyperbaric oxygen therapy After irreversible damage debridement of necrotic tissue is undertaken followed by intraoral free graft

57. COMPLICATIONS HAEMORRHAGE: During intraop period- Internal maxillary artery,Posterior superior alveolar artery, Greater palatine artery. Postop period - Nasopalatineartery,nasoseptal,sphenopalatine artery. TREATMENT - Nasal packing, decongested with a LA with a vasoconstrictor. LA in the nose and around the greater palatine foramen. Therapeutic transcatheter arterial embolization .

58. COMPLICATIONS NEURAL:- Injury to the nerve is more common in mandibular procedures after BSSO than in cases of total down fracture of maxilla Study conducted by Kari Panula et al states that incidence of infraorbital nerve injuries is about 6% on 12 months follow up when tested objectively. During Le Fort osteotomy it is recognized that the nasopalatine and posterior, middle, and anterior superior alveolar nerves are completely severed as an intrinsic part of the surgical procedure. Despite ligation and division of the neurovascular bundle, sensory recovery does occur and is most likely to represent collateral axonal sprouting from adjacent nerves.

59. COMPLICATIONS INFECTIONS:- Overall, the incidence of infection is reported to be between 0% and 18% with either a perioperative or a combined perioperative and postoperative antibiotic course. Rates of infection between 0% and 53% have been reported without antibiotics. Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242 231

60. COMPLICATIONS RELAPSE:- Relapse is usually three dimensional, with vertical, horizontal, and sagittal components that may occur concurrently. On comparison mandibular procedures>maxillary procedures Relapse tends to be proportionately greater with greater advancements. Bone grafting large advancements (>8 mm) may help to reduce relapse.

61. COMPLICATIONS TEMPOROMANDIBULAR DISORDERS : - Researchers believe that malocclusion plays some role in TMD. Numerous studies support the notion that orthognathic surgery decreases the overall prevalence of TMD signs and symptoms. With respect to orthognathic surgery patients with preexisting TMD, subjective improvement ranges from 0% to 75%, with a mean of 18% Objective improvement ranges from 7% to 72%, with a mean of 48% . R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242

62. COMPLICATIONS- RARE Permanent Blindness Nasolacrimal obstruction or injury Orbital compartment syndrome Avascular necrosis (most of which were segmental) False aneurysm of sphenopalatine artery False aneurysm of maxillary artery Carotid-cavernous sinus fistula Vomerosphenoidal dysarticulation Cranial nerve III palsy Keratitis

63. SEQUENCING MANDIBLE FIRST:- Timothy Turvey journal of oral and maxillofacial surgery 2011 august 69(8):2217-2224

64. CONCLUSION Esthetic appearance is critical and of utmost importance in our society Dentofacial and craniofacial deformities not only have a significant psychological effect on individuals but also on general health status of same. Correction of these deformities cannot be done always by same protocol and requires indepth knowledge of the subject and can involve other specialities also.

65. REFERENCES Oral & maxillofacial surgery-Fonseca vol 2 Oral & maxillofacial trauma-Rowe & Williams vol 2 Principles of Oral & maxillofacial surgery-Peterson vol 2 Killeys - 5 th Edition Maxillofacial trauma & facial reconstruction-Peter Ward Booth vol 1 Essentials of Orthognathic surgery- Reyneke