Maxillary Orthognathic Procedures.ppt / orthodontic courses by Indian dental academy

Maxillary Orthognathic Maxillary Orthognathic Procedures Procedures

INDIAN DENTAL ACADEMY

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• IntroductionIntroduction• Applied vascular anatomyApplied vascular anatomy• SAMESAME• Segmental OsteotomiesSegmental Osteotomies• Le-Fort 1 OsteotomyLe-Fort 1 Osteotomy


IntroductionIntroduction• Dentofacial deformities affect 20%of the population.Dentofacial deformities affect 20%of the population.• Orthognathic surgery is a team work. Orthognathic surgery is a team work. • This team mustThis team must• Correctly diagnose existing deformitiesCorrectly diagnose existing deformities• Establish an appropriate treatment planEstablish an appropriate treatment plan• Execute recommended treatment.Execute recommended treatment.• Basic theraputic goals Basic theraputic goals • FunctionFunction• AestheticsAesthetics• StabilityStability• Minimizing the treatment time.Minimizing the treatment time.


HistoryHistory• 1859: Von-Langenback did the first 1859: Von-Langenback did the first

orthognathic procedure.orthognathic procedure.• 1921:Cohn-Stock introduced the 1921:Cohn-Stock introduced the

anterior maxillary osteotomy.anterior maxillary osteotomy.• 1927:Wassmund reported the first total 1927:Wassmund reported the first total

maxillary osteotomy.maxillary osteotomy.• Bells research- biologic basis for Bells research- biologic basis for

orthognathic surgery.orthognathic surgery.www.indiandentalacademy.comwww.indiandentalacademy.com

• Vascular anatomy:Vascular anatomy:• All the vessels are All the vessels are

branches of the ECA.branches of the ECA.• Anastamosed ascending Anastamosed ascending

palatine and ascending palatine and ascending pharyngeal artery joins the pharyngeal artery joins the lesser palatine artery, also lesser palatine artery, also the greater palatine artery. the greater palatine artery.

• Sphenopalatine, posterior Sphenopalatine, posterior superior alveolar and superior alveolar and infraorbital arteries are the infraorbital arteries are the others others

•


• Bell et al 1995 –Bell et al 1995 –• proved the proved the

excellent collateral excellent collateral circulation of the circulation of the maxilla. maxilla.


Surgically Assisted Maxillary Surgically Assisted Maxillary ExpansionExpansion• Assists to correct deformities in transverse Assists to correct deformities in transverse

dimension.dimension.• First described by Angell in 1860First described by Angell in 1860• This procedure is in essence combination of This procedure is in essence combination of

distraction osteogenisis and controlled soft tissue distraction osteogenisis and controlled soft tissue expansion.expansion.

• Diagnosis and clinical evaluation:Diagnosis and clinical evaluation:• paranasal hallowingparanasal hallowing• narrowed alar basenarrowed alar base• deepening of nasolabial folds deepening of nasolabial folds • zygomatic difficiancyzygomatic difficiancy


• Treatment options: based on skeletal maturityTreatment options: based on skeletal maturity• Slow dentoalveolar expansionSlow dentoalveolar expansion• Orthopedic rapid maxillary expansionOrthopedic rapid maxillary expansion• SAMESAME• Segmental maxillary osteotomySegmental maxillary osteotomy• Advantages of SAMEAdvantages of SAME• improved stabilityimproved stability• non extraction alignment of dentitionnon extraction alignment of dentition• elimination of negative spaceelimination of negative space• improved periodontal health and nasal respirationimproved periodontal health and nasal respiration


• Indications:Indications:• skeletal discrepancy greater than 5mm skeletal discrepancy greater than 5mm

assossiated with wide mandibleassossiated with wide mandible• failed orthodontic expansionfailed orthodontic expansion• extremely thin, delicate gingival tissueextremely thin, delicate gingival tissue• significant nasal stenosis.significant nasal stenosis.• Technique:Technique:• First the mandibular dentition should be First the mandibular dentition should be

decompensateddecompensated• Expansion appliance should be placed Expansion appliance should be placed

preoperatively preoperatively


• Steps:Steps:• Bilateral osteotomy from pyriform rim to Bilateral osteotomy from pyriform rim to

pterygomaxillary fissurepterygomaxillary fissure• Release of nasal septumRelease of nasal septum• Midline palatal osteotomyMidline palatal osteotomy• Osteotomy of the anterior 1.5mm lateral Osteotomy of the anterior 1.5mm lateral

nasal wallnasal wall• Bilateral release of pterygoid platesBilateral release of pterygoid plates• Activation of appliance by 1 to 1.5mmActivation of appliance by 1 to 1.5mm• Soft tissue closure Soft tissue closure


S A M E-PROCEDURE


APPLIANCE IN PLACE


• Maxilla should remain stationary for 5 Maxilla should remain stationary for 5 days postoperatively.days postoperatively.

• Pt should feel discomfort while Pt should feel discomfort while activation.activation.

• Expansion at a rate of 0.5 mm/dayExpansion at a rate of 0.5 mm/day• Over correction is not recommended.Over correction is not recommended.• Retention:Retention:• 6 to 12 months after expansion6 to 12 months after expansion


• ComplicationsComplications::• Those due to inadequate surgery:Those due to inadequate surgery:• painpain• dental tippingdental tipping• periodontal breakdownperiodontal breakdown• post orthodontic relapsepost orthodontic relapse• Those due to expansion Those due to expansion • lack of appliance expansionlack of appliance expansion• deformation of the appliance due to processing deformation of the appliance due to processing

errorserrors• stripping or loosening of midpalatal screw stripping or loosening of midpalatal screw


Segmental OsteotomiesSegmental Osteotomies• Single tooth osteotomy:Single tooth osteotomy:• Indicated in tooth mal position.Indicated in tooth mal position.• Dental ankylosis.Dental ankylosis.• closure of diastema.closure of diastema.• Advantages: Advantages: • Reduction in the treatment time.Reduction in the treatment time.• Lower incidance of relapse.Lower incidance of relapse.• Disadvantages:Disadvantages:• Injury to teethInjury to teeth• Periodontal compromisePeriodontal compromise• Devitalization of teeth. Devitalization of teeth.


Anterior maxillary Anterior maxillary osteotomyosteotomy• Cohn Stock 1921- first reportCohn Stock 1921- first report• Indications:Indications:• Bimaxillary protrusionBimaxillary protrusion• Protruded maxillary teeth with normal Protruded maxillary teeth with normal

inclination to alveolar bone.inclination to alveolar bone.• Anterior open bite.Anterior open bite.• When orthodontic teeth movement not When orthodontic teeth movement not

possible.possible.• To reduce the prominence of the upper lip. To reduce the prominence of the upper lip.


• Wunderer method:Wunderer method:• Relies on intact buccal Relies on intact buccal

pedicle.pedicle.• Transpalatal inncision Transpalatal inncision

combined with buccal combined with buccal verticle incision.verticle incision.

• Modification:Modification:• Midline vertical Midline vertical

incision combined with incision combined with buccal vertical incision. buccal vertical incision.


Wassmund techniqueWassmund technique• ;;• Preserves both buccal and Preserves both buccal and

palatal pedicle.palatal pedicle.• Buccal as well as anterior Buccal as well as anterior

verticle incisionverticle incision• Tunneling between Tunneling between

anterior and buccal anterior and buccal incisionsincisions

• Trans palatal osteotomy Trans palatal osteotomy through buccal vertical through buccal vertical osteotomy.osteotomy.

• Occasional mid palatal Occasional mid palatal sagittal incision. sagittal incision.


• Buccal vestibular incisionBuccal vestibular incision• Nasal septum is first releasedNasal septum is first released• Horizontal osteotomy followed by vertical buccal Horizontal osteotomy followed by vertical buccal

osteotomy.osteotomy.• Trans palatal osteotomy under direct vision.Trans palatal osteotomy under direct vision.• Advantages:Advantages:• Direct access to the nasal structures and Direct access to the nasal structures and

superior maxillasuperior maxilla• Preservation of the palatal pediclePreservation of the palatal pedicle• Ease of placement of rigid fixationEase of placement of rigid fixation• Ability to remove bone from palate.Ability to remove bone from palate.

CUPAR METHOD


CUPAR METHOD


• Complications of the AMO:Complications of the AMO:• Loss of teeth vitality.Loss of teeth vitality.• Persistant periodontal defectsPersistant periodontal defects• Communication with nasal cavity or Communication with nasal cavity or

antrumantrum• Occlusal steps formation. Occlusal steps formation.


Posterior maxillary Posterior maxillary osteotomyosteotomy• Schuchardt 1959 first reportSchuchardt 1959 first report• Indications:Indications:• Posterior maxillary hyperplasia.Posterior maxillary hyperplasia.• Distal repositioning of the posterior Distal repositioning of the posterior

segment. segment. • Posterior open bite.Posterior open bite.• Transverse excess or deficiancyTransverse excess or deficiancy• Spacing in the dentition. Spacing in the dentition.


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

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


POSTERIOR SEGMENTAL OSTEOTOMY


PTERYGO MAXILLARY DISJUNCTION


• Summary:Summary:• Segmental osteotomies are indicated for Segmental osteotomies are indicated for

isolated dento facial deformities when isolated dento facial deformities when there is good dento skeletal relationships there is good dento skeletal relationships in the non affected areas.in the non affected areas.

• Decreased morbidity when compared to Decreased morbidity when compared to total maxillary osteotomies.total maxillary osteotomies.

• For isolated dentofacial deformities and For isolated dentofacial deformities and prosthetic problems, the segmental prosthetic problems, the segmental osteotomies should be in the osteotomies should be in the armamentarium of the surgeon. armamentarium of the surgeon.


Le-Fort 1 osteotomyLe-Fort 1 osteotomy

• Work horse of the orthognathic surgical Work horse of the orthognathic surgical procedures.procedures.

• Broad application to resolve many Broad application to resolve many functional and aesthetic problems.functional and aesthetic problems.

• Biologic basis:Biologic basis:• Rich anastamosing vasculature of the face.Rich anastamosing vasculature of the face.• Maxilla is clothed by wide soft tissue.Maxilla is clothed by wide soft tissue.• Osteotomised segment should remain Osteotomised segment should remain

attached to soft tissue pedicle.attached to soft tissue pedicle.


• Indications:Indications:• Vertical maxillary excess in bimax protrusion.Vertical maxillary excess in bimax protrusion.• Superior re positioning of the maxilla to correct Superior re positioning of the maxilla to correct

open bites.open bites.• To advance maxilla in cleft palate and post To advance maxilla in cleft palate and post

traumatic patients.traumatic patients.• To correct open bites when combined with To correct open bites when combined with

mandibular procedures.mandibular procedures.• Correction of cants.Correction of cants.• Advancement of the maxilla in class III patients. Advancement of the maxilla in class III patients.


• Surgical technique:Surgical technique:• Patient position: head end elevation by Patient position: head end elevation by

10degree.10degree.• Reference pins should be placed when Reference pins should be placed when

vertical changes are planned.vertical changes are planned.• Incision: Maxillary vestibular incision high Incision: Maxillary vestibular incision high

in the muco buccal fold.in the muco buccal fold.• Incision traverses the mucosa, muscles Incision traverses the mucosa, muscles

and the periosteum. and the periosteum.


LE FORT I OSTEOTOMY


• Sub periosteal dissection.Sub periosteal dissection.• Infra orbital nerve identified and preservedInfra orbital nerve identified and preserved• Nasal mucosa dissected from nasal wall Nasal mucosa dissected from nasal wall

and floor.and floor.• Dissection in buttress region kept Dissection in buttress region kept

inferiorly.inferiorly.• Vertical reference points placed in Vertical reference points placed in

pyriform aperture and buttress.pyriform aperture and buttress.


VESTIBULAR INCISION

OSTEOTOMY MARKINGS


• Osteotomy should be kept below the Osteotomy should be kept below the pyriform aperture region.pyriform aperture region.

• Initial cuts in the buttress region Initial cuts in the buttress region progressing towards the nose. progressing towards the nose.

• Next the posterior cuts in the pterygo Next the posterior cuts in the pterygo maxillary region kept inferiorly.maxillary region kept inferiorly.

• Minimum of 5mm above the root apices.Minimum of 5mm above the root apices.• The next cut in the sinus from inside out.The next cut in the sinus from inside out.• Same procedure for the opposite side. Same procedure for the opposite side.


POSTERIOR CUTS

SINUS CUTS USING RECIPROCATING SAW


SEPTAL OSTEOTOMY

LATERAL NASAL OSTEOTOMY


SEPTAL CLEARANCE


• Septal cartilage and the septum freed from Septal cartilage and the septum freed from the maxilla.the maxilla.

• Lateral nasal cut is then performed all the Lateral nasal cut is then performed all the way till perpendicular plate of palatine way till perpendicular plate of palatine bone.bone.

• Final step is seperation of maxilla from Final step is seperation of maxilla from pterygoid plate.pterygoid plate.

• Care should be taken to preserve the Care should be taken to preserve the descending palatine vessels. descending palatine vessels.


PTERYGO MAXILLARY DISJUNCTION


• In case of superior repositioning of the In case of superior repositioning of the maxilla sufficient bone and cartilage maxilla sufficient bone and cartilage should be removed from the septum.should be removed from the septum.

• Mobilization of the maxilla is done.Mobilization of the maxilla is done.• Occlusal splint b/n maxilla and Occlusal splint b/n maxilla and

mandible is then fixed.mandible is then fixed.• Maxillo mandibular complex is rotated Maxillo mandibular complex is rotated

supporting the condyles in the fossa.supporting the condyles in the fossa.


CONDYLAR REPOSITIONING


• Correct vertical re positioning is Correct vertical re positioning is ensured using reference pins.ensured using reference pins.

• Stabilization: Stabilization: • Small bone plates (1.5mm) or intra Small bone plates (1.5mm) or intra

osseous wiring applied at pyriform osseous wiring applied at pyriform aperture and buttress region.aperture and buttress region.


WIRE FIXATIONPLATE FIXATION


• Segmenting the maxilla:Segmenting the maxilla:• IndicationsIndications::• Transverse discrepancies between the Transverse discrepancies between the

dental archesdental arches• Vertical steps in the maxillary occlusal Vertical steps in the maxillary occlusal

planeplane• Space remaining in the maxillary arch. Space remaining in the maxillary arch.


• Two para median osteotomies and Two para median osteotomies and one transverse osteotomy are used.one transverse osteotomy are used.

• Midline sectioning of the palate is Midline sectioning of the palate is avoided.avoided.

• Osteotomised segments should Osteotomised segments should never be stripped off the nourishing never be stripped off the nourishing mucosa. mucosa.


SEGMENTING THE MAXILLA


• Bone grafts:Bone grafts:• Indicated when large defects in the walls Indicated when large defects in the walls

of maxilla are present.of maxilla are present.• Critical in buttress and lateral walls.Critical in buttress and lateral walls.• Advantages:Advantages:• Greater stabilizationGreater stabilization• promote healing and promote healing and • Consolidation of the osteotomy sites. Consolidation of the osteotomy sites.


• Autogenous bone grafts preferredAutogenous bone grafts preferred• Cranial bone, iliac crest and Cranial bone, iliac crest and

sometimes mandibular buccal cortex.sometimes mandibular buccal cortex.


BONE GRAFTING


• Wound closure:Wound closure:• Done in layersDone in layers• Periosteum and muscle layer closed Periosteum and muscle layer closed

first in buttress and nasal base.first in buttress and nasal base.• Mucosa of the lip closed with a Mucosa of the lip closed with a

horizontal mattress suture in v-y pattern.horizontal mattress suture in v-y pattern.• This helps to maintain the height of the This helps to maintain the height of the

exposed vermilion and lip length.exposed vermilion and lip length.


V-Y CLOSURE


NASAL STINT SUTURE


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Maxillary Orthognathic Procedures.ppt / orthodontic courses by Indian dental academy

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