Maxillary procedures and soft tissue changes /certified fixed orthodontic courses by Indian dental academy


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  • Maxillary procedures and soft tissue changes /certified fixed orthodontic courses by Indian dental academy

    1. 1. Maxillary procedures and soft tissue changes INDIAN DENTAL ACADEMY Leader in continuing dental education
    2. 2. Contents :  History  Anatomic considerations  Maxillary deformities  Midface osteotomies  Surgical procedures  Complications  references
    3. 3. Introduction  Orthognathic surgery  correct both facial deformity and oral dysfunction.  Facial beauty is difficult to define in precise terms  subtle differences between individuals can produce marked aesthetic contrasts.  Different racial forms of beauty are not comparable and so ethnic norms are required to correct the abnormality.  skeletal abnormality is recognisable, measurable.
    4. 4. History
    5. 5. History 1859 – Von Langenbeck – nasophyrngeal angiofibroma. 1867 – David Cheever – Le fort 1 osteotomy- nasal obstruction 20th century :-dentofacial deformities 1921 – Cohn Stock – A M O 1950 – Gillies & Harrison – Le fort 111 1959 – schuchardt- post maxillary osteotomy 1969 -75 – Bell – Biologic basis 1970’s – Kufner, Henderson & jackson – L 1
    6. 6. History Initial Days..  Segmental osteotomies  Complete mobilization was avoided  High incidences of relapse
    7. 7.  1965- Obwegeser complete mobilization of maxilla  repositioning could be accomplished without tension  Until 1960-pedicle of soft tissue on buccal side  *Bell 1969-75-as long as maxilla is pedicled to palatal mucosa ,labial gingiva and mucosa ,down fracture of the maxilla with complete mobilization can be accomplished with adequate vascular supply *JOS-1969;27;249-Revascularization after lefort 1 osteotomy
    8. 8. Anatomic considerations :  External carotid artery : Maxillary artery Facial artery Ascending pharyngeal artery
    9. 9. Anatomic considerations :
    10. 10. Anatomic considerations : Bell et al 1975, Quejada -1986 B/L descending palatine artery can be transected –if basic principles are followed
    11. 11. Anatomic considerations :  Bell et al 1995-proved the excellent collateral circulation of the maxilla.  Restoration of blood supply 1 week post operatively-Dodson -1994
    12. 12.
    13. 13. Mid face osteotomies Segmental maxillary osteotomy Total maxillary osteotomy Single tooth Anterior segmental Posterior segmental Horseshoe
    14. 14. Total maxillary osteotomy Le Fort 1 SAME Classic down fracture Quadrangular Le Fort 11 Le Fort 111 Anterior L F 11 Pyramidal L F 11 Quadrangular L F 11 Mid face Zygomatic Malar maxillary
    15. 15. Transverse maxillary deficiencies  Complete and accurate evaluation - transverse dimension .  Treated with orthodontic expansion  relapse after appliance removal  Orthopedic /rapid maxillary expansion  Predictable and stable results (Angell -1860 using expansion screw )  1960- Haas reintroduced teq, as age increases resistance to expansion  This led to SAME
    16. 16. Transverse maxillary deficiency :  Incidence : 8%  Etiology :Congenital, Developmental (thumb sucking ) Traumatic Iatrogenic (cleft palate)  Diagnosis : dental cross bite skeletal cross bites (Jacobs-JAO1980) high arched palate paranasal hollowing and narrow alar base P A cephalogram frontal tomography C T scans.
    17. 17. Rocky mountain analysis*  10+/-1.5mm -TMD  Total transverse deficiency <5mm orthopedic expansion >5mmsurgical expansion Ricketts –angle orthodontics 1981;51;115-50
    18. 18. Transverse maxillary deficiency  Treatment : 1. S D E (slow dento alveolar expansion )2-4months 2. O R M E (orthopedic rapid maxillary expansion) 1-4 weeks 3. S A M E(surgically assisted maxillary expansion )1-2 weeks 4. S M O (segmental maxillary osteotomy)  * “To achieve the desired expansion and stability ,transverse maxillary expansion should be accomplished by sutural adjustments in the craniofacial complex not by alveolar bending and dental tipping.” *Starnbaatch –angle orthodontics 1966
    19. 19. SAME  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 *Bjoms 1981;9;180 *JOMS 1994-;52;742
    20. 20. SAME: Indications of S A M E :  Skeletal maxillomandibular transverse discrepancy > 5mm  Significant TMD asstd with a narrow maxilla and wide mandible  Failed orthodontic expansion  Necessity for a large amount > 7mm of expansion  Extremely thin and delicate gingival tissues with buccal gingival recession  Significant nasal stenosis
    21. 21. Benefits of S A M E :  Skeletal and dental stability  Non-extraction orthodontic alignment of teeth  Esthetics by eliminating negative space  Periodontal health  Nasal respiration
    22. 22. SAME: Technique of S A M E :  Mandibular dentition should be decompensated  Maxillary expansion appliance – preoperatively Surgical technique : 1 Incision
    23. 23. B/L maxillary osteotomy with step at buttress Release of nasal septum
    24. 24. Midline palatal osteotomy
    25. 25. Lateral nasal wall osteotomy (anterior 1.5mm) B/L release of the pterygoid plates
    26. 26. Activation of the appliance : 3-4mm then 1-1.5 mm
    27. 27.  Soft tissue closure  Alar base Cinch with non resorbable suture + v-y closure  SAME can be used for unilateral asymmetries
    28. 28. SAME:  Maxilla should remain stationary – 5 days then 0.5mm /day  Ilzarovs principle- “healing period of 5 days allows for capillary healing across the bony gap”  0.5mm-1mm/day –expansion > this causes gingival recession
    29. 29. During expansion  discomfort  severe increase in pain then bony interferences Tightness and minor discomfort
    30. 30. During expansion
    31. 31. Clinical signs of SAME  Immature attached gingival tissue - medial to each central incisor tooth  Expansion exceeds the ability of the attached gingiva to remodel  sign of success (if b/l and symmetric)  Recession / gaping occurs then rate should be decreased  Over correction is not required  Palatal expansion should achieve – 4 weeks  Skeletal retention 6-12 months.
    32. 32. Complications :  Similar to Le Fort 1  Inadequate release of the maxilla (dental tipping, periodontal breakdown, pain, necrosis)  Problems with expansion device (lack of appliance expansion, processing error, stripping of screw.
    33. 33. Modifications of SAME Age Palatal tori Skeletal open bite / open bite When future Lefort 1
    34. 34. Palatal tori At the time of SAME Modifications of incisions Tori excision After six months SAME
    35. 35. Skeletal open bite / open bite Ramped cut Angled cut Vertical step At the buttress
    36. 36. segmental osteotomies :  Performed many years before total maxillary osteotomies  Allows for improvement in occlusion but at the expense of facial esthetics  Past decade the versatility and reliability of total maxillary osteotomies  AMO - Isolated anterior open bite /bimaxillary protrusion  PMO- pre prosthetic surgery
    37. 37. Single tooth osteotomy : Indications tooth malposition Dental ankylosiss Closure of diastema Initially some surgeons were reluctant to do this teq  Soft tissue necrosis  Tooth devitaliztion  Pulpal necrosis *Variety of studies & bell -5mm and above the apices – adequate to maintain the vitality Anterior& posterior Subapical osteotomies -3mm is adequate(sheideman-joms.1985;43;408 ) *yoshida-biologic responses of the pulp to single tooth osteotomy OOOO-1996;82 Bell-revsclstion & bone healing after AMO. JOS1969;27;249,1978
    38. 38. Single tooth osteotomy Benefits : reduction in treatment time lower incidence of dental relapse Drawbacks : Injury to adjacent tooth, periodontal compromise, devitalization of teeth, need for endodontic therapy. Technique : Incision – transverse incision on either side of the tooth. Osteotomy – 3-5mm apical to root apex separated with fine osteotomies fixed to the adjacent teeth with interdental wires.
    39. 39. Anterior maxillary osteotomies : 1921 – Cohn Stock. Transverse palatal incision Wedge shaped osteotomy green stick fracture retracted the anterior segment Relapsed within 4 weeks Various incision designs for desired osseous movements . *Bell- overall procedure is predictable from standpoint of dental stability and soft tissue changes. * Stability and soft tissue changes in anterior part of jaw surgery A J ORDNTCS;1973
    40. 40. Anterior maxillary osteotomies : Indications :  Correction of bimaxillary protrusion.  Marked protrusion of the maxillary teeth (normal incisor axial inclination to alveolar bone)  Anterior open bite  To retract the anterior teeth when that cannot be accomplished by conventional orthodontic treatment.(pt noncomplience)  When orthodontic tooth movement is inadvisable.(ankylosiss, root resorption)  Improvement in appearance.
    41. 41. Anterior maxillary osteotomies :  *Radioactive microsphere teq used assess the blood flow in AMO in macaque monkeys.  Variation in flap design didn’t affect the postop blood supply to ant maxillary segment.  This study gives scientific credence to different incisions for AMO  Blood supply can be maintained by- labial-buccal & palatal tissues , labial –buccal tissues alone palatal tissues alone *Nelson –quantation of blood flow after AMO in three teq-JOS;1978;36;108
    42. 42. A M O Techniques :  Wunderer  Wassmund  Cupar
    43. 43. Wunderer-AMO  When posterior movement of A M segment  Transpalatal incision  Can be combined with buccal vertical incision in the region of the planned extractions /interdental osteotomies
    44. 44. Wunderer teq-AMO  Advantages-direct palatal access transverse palatal osteotomy through molar site This teq relies on intact buccal pedicle Modifications of Wunderer teq -midline vertical incision +incisions at extractions sites  horizontal osteotomy separation of nasal septum from maxillary segment performed directly
    45. 45. Wassmund technique : 1935  vertical incision – planned extraction or interdental osteotomy.  Preserves both buccal & palatal soft tissues. Anterior nasal spine incision.  Osteotomy : buccal horizontal osteotomy Transpalatal osteotomy if required midpalatal sagittal split repositioning of entire segment.
    46. 46. Cupar method : Technique : A buccal vestibular incision is created, allowing direct access to the anterior lateral maxillary walls, piriform aperture, nasal floor and septum. Most commonly used for AMO* *Epker joms a modifed AMO 1977 ;5; 35
    47. 47. Cupar method : Advantages : Direct access to the nasal structures Unhampered access – bone grafting Ability to remove bone under direct visualization Preservation of blood supply Ease of placement of rigid internal fixation.
    48. 48. Posterior maxillary osteotomy : Schudart in 1959 : Indications :  Posterior maxillary alveolar hyperplasia  Total maxillary hyperplasia  Distal repositioning(guiding the eruption of impacted teeth )  Spacing in the dentition  Transverse excess or deficiency  Posterior open bite. Surgical technique : Incision : buccal vestibular incision from 3-6 Vertical incision in the region of anterior and posterior osteotomy sites. Parasagittal palatal incision.
    49. 49. Posterior maxillary osteotomy : Osteotomy :  Horizontal osteotomy 5 mm above the root apices.  Vertical osteotomy through the extraction sites.  Posterior vertical osteotomy at Pterygomaxillary junction(3 rd molor extraction site or like lefort I osteotomy )  Palatal osteotomy – curved osteotome.  Acrylic splint  Fixation.
    50. 50. Horizontal osteotomy 5 mm above the root apices. Vertical osteotomy through the extraction sites.
    51. 51. Palatal osteotomy – curved osteotome.
    52. 52. Combination anterior and posterior maxillary osteotomy :  Horseshoe osteotomy  Historical purpose  Maxillary alveolar hyperplasia with or with out anterior open bite deformity  Transverse maxillary hypoplasia.
    53. 53. SAME Segmental maxillary osteotomy Relapse Pogrel-11.8%(molar) Greco-8.8%(canine) 7.7%(molar) Stephens-30%(canine) 23%(molar) Phillips-30% premolar 51% molar Pattern of expansion More at canine region Less at molar region Less at canine region More at molar region Osteotomy of articulations Not all articulations are not osteotomised superiorly and inferiorly extraction no yes
    54. 54. SAME All direction movement Two surgical procedures Segmental single Difficult Teq sesnsitive Potentially more morbid Total theater timings SAME+ Lefort I
    55. 55. Which one to select? SAME /Segmental osteotomy
    56. 56.  Only in transverse SAME  When pt requires anterior posterior and vertical movements if >6mm SAME if <7mmsegmental  If two separate surgical procedures are planned then SAME should be performed
    57. 57.