Maxillary Osteotomy Procedures

orthognathic surgery is very intresting and well knowing branch in oral surgery ....this presentation is dealing with jaw correction surgery in upper jaw.

1. By :dr. nikil jain KIIT UNIVERSITY Maxillary Osteotomy Procedures

2. Introduction Dentofacial deformities affect 20%of the population. Orthognathic surgery is a team work. This team must Correctly diagnose existing deformities Establish an appropriate treatment plan Execute recommended treatment . Basic theraputic goals Function Aesthetics Stability Minimizing the treatment time.

3. History In 1859 by Von Langenbeck -- for the removal of nasopharyngeal polyps . The first American report -- Cheever in 1867 -- for the treatment of complete nasal obstruction secondary to recurrent epistaxis for which a right hemimaxillary downfracture was used . In 1927 Wassmund -- LeFort I osteotomy for the correction of the midfacial deformities and used orthopedic force postsurgically In 1934 Axhausen described total mobilization of the maxilla with immediate repositioning for an open bite case

4. In 1942 Schuchardt first advocated the pterygomaxillary dysjunction . In 1949 Moore and Ward -- horizontal transaction of the pterygoid plates for advancement In 1965 Obwegeser -- complete mobilization of the maxilla so that repositioning could be accomplished without tension. Bone grafting to enhance stabilization for LeFort and anterior osteotomies -- by Cupar , Gilles and Rowe and Obwegeser . Early description of the rigid fixation of maxillary osteotomies were published by Michelet and colleagues in 1973 , Horster in 1980, Drommer and Luhr in 1981, and Luyk and Ward-Booth in 1985.

5. SEQUENCE OF TREATMENT PLANNING 1} Dental and periodontal treatment 2} Extractions 3} Presurgical orthodontics Position teeth over their respective basal bone Align and level the teeth Adjust for tooth size discrepancies Connect related teeth Divergence of roots adjacent to surgical sites.

6. 4} Orthognathic surgery 5} Post-surgical orthodontics Final tooth alignment and root parallelism Maximal interdigitation Ideal over bite and overjet Centric occlusion - centric relation

7. Various Maxillary O steotomies Segmental maxillary surgeries i . Single tooth dento -osseous osteotomies . ii. Corticotomy iii. Anterior segmental maxillary osteotomy iv.Posterior segmental maxillary osteotomy v.Horse shoe osteotomy . Total maxillary osteotomies : I) Le Fort I osteotomies II) Le Fort II osteotomies III) Le Fort III osteotomies

8. Surgicaly assisted maxillary expansion Quadraangular lefort I and lefort II osteotomy High level midface osteotomy

9. Surgical anatomy of maxilla Osseous structures Maxillary sinus Infraorbital rim Anterior nasal spine Palate Maxillary tuberosity Pyramidal process of palatine bone Pterygomaxillary junction

10. Vascularization Pathway of the Ascending palatine, Ascending pharyngeal , and Descending palatine arteries as they continue into the greater palatine arteries.

11. Reference Marks, and IntraoperativePositioning At surgery, slots are made in the piriform rim and holes in the buttress to simulate points A and P bilaterally. The gingival cuffs of the canines and first molars represent points B and C. Following mobilization of the maxilla it is placed so that the differences between lines A–B and A–B' are the same as they were on the models.

12. Biological basis of maxillary osteotomy Revascularization studies of bell and fonseca indicates that’ the maxilla may be mobilized and repositioned and survival continue as long as mobilized maxilla attached to a broad soft tissue pedicle’ . Healing occur even if maxilla segmented into several pieces . Necrosis occurs only when vascular pedicles are damaged

13. Mucoperiosteal arterial system –cortical bone- supply maxilla Vascular connections- arteries and veins The multiple sources of blood supply to maxilla and the abundant vascular communications between the hard and soft tissues constitute the biologic foundations for maintaining dento -osseous viability despite transcetion of medullary blood supply after osteotomies

14. The soft tissue of the palate ,lateral pharyngeal walls and buccal mucosa provide the vascular network that permits the healing. The rich ,freely anastomosing vasculature of the face is responsible for this healing Loss of bony segments due to vascular ischemia is result of poor surgical technique or violation of basic biological principles.

15. Poor incision design ,extensive detachment of palatal mucoperiosteum , excessive pressure by splint, excessive and continue manipulation of surgical site, traumatic manipulation of maxilla during down fracture also associated with post operative complications.

16. Blood flow in gingival tissue after osteotomy Soft palatal, ascending pharyngeal, and ascending palatal vessels anastomose with the greater palatine artery. Major vessels have been sectioned and tied. The arrows signify direction of blood flow.

17. Bell et.al (1970s) – early osseous union and minimal osteonecrosis You et.al (1991) -- no histologic evidence of osteonecrosis Siebert et.al (1997) – ascending palatine and pharyngeal artery major contribution to palatal blood supply

18. In segmental maxillary osteotomy the blood supply is via the buccal and palatal mucoperiosteum and the intraalveolar vessels

19. Technique to preserve the vascular supply Horizontal incision ,through buccolabial mucoperiosteum above the level of keratinized gingiva or attached gingiva margin at the level of maxillary teeth apices,extending from first molar one side to first molar contralateral side

20. The superior tissues are reflected subperiosteally , first at the piriform aperture margins . Progressively more superior exposure lateral to the nasal aperture will expose the infraorbital nerve exiting from its foramen. Posterior reflection proceeding from the delineated infraorbital foramen reveals the zygomaticomaxillary suture, zygomatic buttress, and the most anterior aspect of the zygomatic arch. Inferiorly, with subperiosteal tunneling, the lateral aspect of the maxillary tuberosity and its junction with palatine bone and pterygoid plates of the sphenoid bone are identified

21. The nasal mucosa is elevated beginning on the superolateral surface of the piriform rim.

22. Curved Freer elevator used for this dissection,angles inward and downward,keeping in mind that nasal cavity is greater in volume interiorly than at the piriform apprature Dissection carried out up to 15 to 20 mm The mucoperiosteum is reflected from the nasal floor, lateral nasal wall, and nasal crest of the maxilla. The dissection should continue superiorly for a centimeter up the vertical nasal walls to prevent tearing during osteotomy or down-fracture of the maxilla, particularly at the superior reflections of the nasal floor medially and laterally

23. Osteotomy Obtaining appropriate access to maxillary segment ,apices of root identified by the bony protuberance or by using peria apical or panoramic radiographs Osteotomy kept 5-6 mm apical to apical to roots of maxillary teeth, it means 30- 35 mm from the tip of the crown During osteotomy lateral nasal wall,great attension to protect nasal mucosa medially, so osteotomy terminated after 20 mmto avoid injury to descending palatine artery.

24. Pterygomaxillary dysjunction - Obwegeser osteotome to separate the maxillary tuberosity and pterygoid plates, as previously described by ROBINSON & HENDY The osteotome was positioned parallel to the occlusal plane

25. Relationship between maxillary artery & maxillary osteotomies • Turvey & Fonseca ( J.Oral Surg. 1980; 38: 92-95) 16 cadavers/32 sides Measured distance from inf. pterygomax . junc. to max. artery Mean distance25mm (range 23-28mm) Mean height of pterygomax junc. 14.6mm (range 11-18mm) Width of pterygoid chisel 10-15mm

26. Curved pterygomaxillary osteotome was used except that the pterygomaxillary dysjunction was achieved through the maxillary tuberosity itself, rather than between the maxillary tuberosity and the pterygoid plates, by the technique advocated by TRIMBLE,STOELINGA JOMS VOL 41 ISSUE 8 1983,544-546

27. No incision was made and the osteotome was placed on the tuberosity , distal to the second molar, and approximately 0.5-1.0 cm above the crest of the tuberosity . Better visibility and easier access were achieved by this approach than by attempting to position the osteotome through the tunnel created under the posterior buccal soft-tissue pedicle

28. Care must be taken to angulate the osteotome properly, so that it does not penetrate too far anteriorly ; this could cause a separation at the junction of the horizontal process of the palatine bones and the palatal process of the maxilla, or create a fracture through the greater palatine foramen which could damage the descending palatine artery.

29. Surgically Assisted Maxillary Expansion Assists to correct deformities in transverse dimension . First described by Angell in 1860 This procedure is in essence combination of distraction osteogenisis and controlled soft tissue expansion .

30. Diagnosis and clinical evaluation: paranasal hallowing narrowed alar base deepening of nasolabial folds zygomatic difficiancy

31. Treatment options : Based on skeletal maturity Slow dentoalveolar expansion Orthopedic rapid maxillary expansion SAME Segmental maxillary osteotomy

32. Advantages of SAME improved stability non extraction alignment of dentition elimination of negative space improved periodontal health and nasal respiration

33. Indications: skeletal discrepancy greater than 5mm assossiated with wide mandible failed orthodontic expansion extremely thin, delicate gingival tissue significant nasal stenosis .

34. Technique: First the mandibular dentition should be decompensated Expansion appliance should be placed preoperatively

35. Steps: Bilateral osteotomy from pyriform rim to pterygomaxillary fissure Release of nasal septum Midline palatal osteotomy Osteotomy of the anterior 1.5mm lateral nasal wall Bilateral release of pterygoid plates Activation of appliance by 1 to 1.5mm Soft tissue closure

36. S A M E-PROCEDURE

37. APPLIANCE IN PLACE

38. Maxilla should remain stationary for 5 days postoperatively. Pt should feel discomfort while activation. Expansion at a rate of 0.5 mm/day Over correction is not recommended. Retention: 6 to 12 months after expansion

39. Modified SAME Unilateral or asymmetric deformities Osteotomy done on one side Non operated site buccal bone bending and dental tipping Relapse occure non operated site Six month for midpalatal healing

40. Complications : a)Those due to inadequate surgery: pain dental tipping periodontal breakdown post orthodontic relapse b)Those due to expansion lack of appliance expansion deformation of the appliance due to processing errors stripping or loosening of midpalatal screw

41. Segmental Osteotomies Single tooth osteotomy : Indicated in tooth mal position . Dental ankylosis . closure of diastema .

42. Two vertical cuts,1-2mm either side of proposed bony cut. Mucoperiosteum not elevated over the tooth. Labial bone scored. Horizontal cut is made 3mm above the apex. ( when nasal floor is relatively low, cuts may be extended into it )

43. Advantages : Reduction in the treatment time. Lower incidance of relapse. Disadvantages : Injury to teeth Periodontal compromise Devitalization of teeth

44. Corticotomy Cortical bone remove both labialy and palatally Supra apical region , 5mm above the apices of teeth palatal bone is removed in radial fashion, taking out the cortex in wide strips between each tooth Repositioning of teeth with in arch obtained in 6-12 weeks

45. Anterior maxillary osteotomy Cohn Stock 1921- first report Indications: Bimaxillary protrusion Protruded maxillary teeth with normal inclination to alveolar bone. Anterior open bite. When orthodontic teeth movement not possible. To reduce the prominence of the upper lip.

46. Wassmund technique(1935) Preserves both buccal and palatal pedicle. Buccal as well as anterior verticle incision Tunneling between anterior and buccal incisions Trans palatal osteotomy through buccal vertical osteotomy . Occasional mid palatal sagittal incision.

47. Wunderer method(1963) Relies on intact buccal pedicle. Transpalatal incision combined with buccal verticle incision. Modification: Midline vertical incision combined with buccal vertical incision .

48. Cupar method Buccal vestibular incision Nasal septum is first released Horizontal osteotomy followed by vertical buccal osteotomy . Trans palatal osteotomy under direct vision .

49. Advantages: Direct access to the nasal structures and superior maxilla Preservation of the palatal pedicle Ease of placement of rigid fixation Ability to remove bone from palate.

50. Complications of the AMO: Loss of teeth vitality. Persistant periodontal defects Communication with nasal cavity or antrum Occlusal steps formation.

51. Posterior maxillary osteotomy Schuchardt 1959 first report Indications: Posterior maxillary hyperplasia. Distal repositioning of the posterior segment. Posterior open bite. Transverse excess or deficiancy Spacing in the dentition.

52. Surgical technique: Buccal vestibular incision below the buttress. Platal osteotomy through the buccal osteotomy site. Occasional palatal incision. Principles are same as for the total maxillary osteotomies .

53. Complications: Same as that for other osteotomies . Blind procedure. Technically challenging

54. POSTERIOR SEGMENTAL OSTEOTOMY

55. PTERYGO MAXILLARY DISJUNCTION

56. Summary: Segmental osteotomies are indicated for isolated dento facial deformities when there is good dento skeletal relationships in the non affected areas . Decreased morbidity when compared to total maxillary osteotomies . For isolated dentofacial deformities and prosthetic problems, the segmental osteotomies should be in the armamentarium of the surgeon.

57. Lefort I Line Line runs horizontally above the floor of nasal cavity, involves the lower third of septum ,palate ,alveolar proces sof maxilla and lower third of pterygoid plates of sphenoid

58. Le-Fort 1 osteotomy Work horse of the orthognathic surgical procedures. Broad application to resolve many functional and aesthetic problems . Biologic basis: Rich anastamosing vasculature of the face. Maxilla is clothed by wide soft tissue. Osteotomised segment should remain attached to soft tissue pedicle.

59. Indications Vertical maxillary excess in bimax protrusion. Superior re positioning of the maxilla to correct open bites. To advance maxilla in cleft palate and post traumatic patients. To correct open bites when combined with mandibular procedures. Correction of cants. Advancement of the maxilla in class III patients .

60. Surgical technique Patient position: head end elevation by 10degree . Reference pins should be placed when vertical changes are planned . Incision: Maxillary vestibular incision high in the muco buccal fold . Incision traverses the mucosa, muscles and the periosteum .

61. LE FORT I OSTEOTOMY

62. Sub periosteal dissection . Infra orbital nerve identified and preserved Nasal mucosa dissected from nasal wall and floor . Dissection in buttress region kept inferiorly . Vertical reference points placed in pyriform aperture and buttress.

63. VESTIBULAR INCISION OSTEOTOMY MARKINGS

64. Osteotomy should be kept below the pyriform aperture region. Initial cuts in the buttress region progressing towards the nose. Next the posterior cuts in the pterygo maxillary region kept inferiorly. Minimum of 5mm above the root apices. The next cut in the sinus from inside out. Same procedure for the opposite side.

65. POSTERIOR CUTS SINUS CUTS USING RECIPROCATING SAW

66. SEPTAL OSTEOTOMY LATERAL NASAL OSTEOTOMY

67. SEPTAL CLEARANCE

68. Septal cartilage and the septum freed from the maxilla. Lateral nasal cut is then performed all the way till perpendicular plate of palatine bone. Final step is seperation of maxilla from pterygoid plate. Care should be taken to preserve the descending palatine vessels.

69. PTERYGO MAXILLARY DISJUNCTION

70. In case of superior repositioning of the maxilla sufficient bone and cartilage should be removed from the septum. Mobilization of the maxilla is done. Occlusal splint b/n maxilla and mandible is then fixed. Maxillo mandibular complex is rotated supporting the condyles in the fossa.

71. CONDYLAR REPOSITIONING

72. Correct vertical re positioning is ensured using reference pins. Stabilization: Small bone plates (1.5mm) or intra osseous wiring applied at pyriform aperture and buttress region.

73. WIRE FIXATION PLATE FIXATION

74. Segmenting the maxilla: Indications : Transverse discrepancies between the dental arches Vertical steps in the maxillary occlusal plane Space remaining in the maxillary arch.

75. Two para median osteotomies and one transverse osteotomy are used. Midline sectioning of the palate is avoided. Osteotomised segments should never be stripped off the nourishing mucosa.

76. SEGMENTING THE MAXILLA

77. Bone grafts: Indicated when large defects in the walls of maxilla are present. Critical in buttress and lateral walls. Advantages: Greater stabilization promote healing and Consolidation of the osteotomy sites.

78. Autogenous bone grafts preferred Cranial bone, iliac crest and sometimes mandibular buccal cortex.

79. BONE GRAFTING

80. Wound closure: Done in layers Periosteum and muscle layer closed first in buttress and nasal base. Mucosa of the lip closed with a horizontal mattress suture in v-y pattern. This helps to maintain the height of the exposed vermilion and lip length.

81. V-Y CLOSURE

82. Alar sinch Suture

83. MODIFIED LE FORT I OSTEOTOMIES Quadrangular osteotomy - ( Kufner 1971)

84. This technical note should be kept in mind whenever an anterior and downward movement is planned and vertical stability might be compromised.

85. LE FORT II OSTEOTOMY (HENDERSON AND JACKSON, 1973 Indications Naso -maxillary hypoplasia , such as Binder syndrome Retruded naso -maxillary complex resulting from mal or non treated Le Fort II fracture Cleft lip and palate deformity

86. INCISIONS Nasal root and medial orbital wall approached by a coronal incision or paranasal incision or medial brow incision

87. Coronal incision runs from upper anterior attachment of helix over the cranial vault passing behind the hair line Dissection carried forward in loose connective tissue plane deep to galea Incision to pericranium 3 cm posterior to supraorbital rim to expose supraorbital rim and orbit Conjunctival or subciliary incision is required to gain access to infraorbital rim and orbital floor Subperiosteal dissection through subciliary incision should join the dissection above to enable bone cut under direct vision Access to canine fossa and posterior maxilla by routine buccal vestibular incision

88. OSTEOTOMIES Horizontal cut over nasal bridge passing below the anterior ethmoidal foramen Vertical cut is continued by a cut in the orbital floor medial to the exit of infraorbital nerve Bony nasal septum is split at nasal bridge by a forked septum chisel Posterior separation by pterygomaxillary dysjunction

89. Bone cut around zygomatic buttress downward and posteriorly A Sagittal cut by thin fissure bur passing behind the lacrimal sac to the orbital floor

90. Repositioning of maxilla Fixation

91. MODIFIED LE FORT II OSTEOTOMY Psillakis , Lapa and Spina (1973) designed modified Le fort II, which leaves tooth bearing area behind

92. LE FORT III OSTEOTOMY (GILLIES , 1940 ) INDICATIONS Naso -maxillary hypoplasia along with underdevelopment of malar bone A retruded midface due to trauma Pseudo- exophthalmos as a result of shallow orbit Mild hypertelorism and telecanthus

93. Incision Orbit and nasal root is approached by coronal incision Subperiosteal dissection from FZ suture to expose lateral orbital wall Periosteum is split vertically at nasal root and malar area to accommodate anticipated advancement Orbital floor is approached by separate conjunctival or subciliary incision Buccal vestibular incision to complete osteotomy in posterior maxillary area

94. Osteotomy Ostoetomy starts at lateral orbital wall by reciprocal saw extending to the inferior orbital fissure Cut extended through orbital floor crossing the pathway of infraorbital nerve Bone cut at nasal bridge links up with osteotomy in the floor behind lacrimal duct Osteotomy in lateral orbital wall carried downward tangentially through zygomatic bone passing below the buttress Posterior separation by pterygomaxillary dysjunction

95. Complications 1 } Relapse: most commonly with advancements and downgrafts patients with parafunctional habits prevention – rigid fixation grafting control of parafunctional habits 2} Settling: differs from relapse movement regardless of original position seen with # grafts and wire osteosynthesis prevention – rigid fixation control of parafunctional habit s

96. 3} Transverse relapse : -- common with segmental osteotomies and transverse expansion -- lack of soft tissue mobilization at the time of expansion -- inadequate grafting and stabilization along the palatal midline -- poorly adapted bone plates -- unstable presurgical orthodontic movements -- hyperfunctional buccinator muscle activity Prevention -- a bone plate placed across the nasal floor -- a heavy guage circumferential arch wire in the molar head gear bracket tubes -- a transpalatal arch bar to maintain the palatal width -- an occlusal coverage splint -- a palatal splint without occlusal coverage

97. 4} Condylar distraction: -- occurs when there are interferences in the tuberosity or pterygoid plate area P revention -- elimination of bony interferences 5} Bleeding: -- common areas include – descending palatine vessels and anterior or posterior palatine vessels ; PSA vessels; pterygoid plexus; incisive canal vessels; internal maxillary artery; vessels associated with the nasal septum and turbinates .

98. 6 } Avascular necrosis: -- initially – gingiva – dusky appearance -- no refill after tissue blanching -- sloughing within 12 to 24 hrs -- exposure of bone/ roots without infection Prevention and management -- careful flap design and surgery -- HBO therapy – 20 to 30 dives -- conservative debridement and good oral hygiene -- reconstructive procedures if needed

99. 7 } Periodontal defects: -- trauma to adjacent soft tissues and bone -- avascular necrosis -- tearing of interdental soft tissue through the papilla -- removal of the bony collar around the neck of the teeth -- vertical incisions at interdental areas 8} Nerve injury 9} Infection 10} Non-union

100. Epiphora

101. Illustration of lateral wall, showing the distance from the anterior attachment of the inferior turbinate to the nasolacrimal canal orifice OLD- ostium of nasolacrimal duct OL- high lefort 1 osteotomy line IT- inferior turbinate MT- medial turbinate

102. The meatal portion of the nasolacrimal duct can be protected by detaching the mucosa from the lateral nasal wall and placing and elevator between the mucosa and the lateral nasal wall as the osteotomy is accomplished. IT- inferior turbinate MT- medial turbinate

103. SOFT TISSUE CHANGES Several investigators have suggested that the etiology of these soft tissue changes is attributable to three factors Elevation of the periosteum and muscle attachments adjacent to nose without adequate replacement Postsurgical edema Increased bony support in advancement cases

104. TECHNIQUES TO CONTROL THE SOFT TISSUES V-Y CLOSURE

105. ALAR CINCH

106. CONTOURING THE ANS

107. DOUBLE V-Y CLOSURE

108. Conclusion Orthognathic surgery has made it possible to reposition of either or both jaws in all possible directions. This has provided solution for the patients with severe dentofacial problems and malocclusion. Thorough evaluation and assessment of the defect and efficient execution of the surgery is needed for effective result. Repeated assessment and rectification of the technique are required to improve the outcome of these aesthetic surgical procedures.

109. References Fonseca – Oral and Maxillofacial Surgery – Vol. 2 Dentofacial Deformities – Bruce N Epker John P Stella, Leward C Fish Orthognathic Surgery – Varghese Mani Principles of oral and maxillofacial surgery – Peterson Surgery of mouth and jaw – Moore Text book of otrhognathic surgery - Reyenke

110. THANK YOU