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Maxillary procedures and soft tissue
changes
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentala...
Contents :
 History
 Anatomic considerations
 Maxillary deformities
 Midface osteotomies
 Surgical procedures
 Compl...
Introduction
 Orthognathic surgery
 correct both facial deformity and oral dysfunction.
 Facial beauty is difficult to ...
History

www.indiandentalacademy.com
History
1859 – Von Langenbeck – nasophyrngeal angiofibroma.
1867 – David Cheever – Le fort 1 osteotomy- nasal obstruction
...
History
Initial Days..


Segmental osteotomies



Complete mobilization was
avoided



High incidences of relapse

www....
 1965- Obwegeser complete mobilization of maxilla  repositioning

could be accomplished without tension
 Until 1960-pe...
Anatomic considerations :


External carotid artery :
Maxillary artery
Facial artery
Ascending pharyngeal artery

www.ind...
Anatomic considerations :

www.indiandentalacademy.com
Anatomic considerations :

Bell et al 1975,
Quejada -1986
B/L descending
palatine artery can
be transected –if
basic princ...
Anatomic considerations :
 Bell et al 1995-proved the

excellent collateral circulation of
the maxilla.
 Restoration of ...
www.indiandentalacademy.com
Mid face osteotomies
Segmental maxillary osteotomy

Total maxillary osteotomy

Single tooth
Anterior segmental
Posterio...
Total maxillary osteotomy
Le Fort 1

SAME
Classic down fracture
Quadrangular

Le Fort 11 Le Fort 111

Anterior L F 11
Pyra...
Transverse maxillary deficiencies
 Complete and accurate evaluation - transverse dimension .
 Treated with orthodontic e...
Transverse maxillary deficiency :
 Incidence : 8%
 Etiology :Congenital,

Developmental (thumb sucking )
Traumatic
Iatro...
Rocky mountain analysis*
 10+/-1.5mm -TMD
 Total transverse deficiency

<5mm orthopedic expansion
>5mmsurgical expansi...
Transverse maxillary deficiency

 Treatment :

1. S D E (slow dento alveolar expansion )2-4months
2. O R M E (orthopedic ...
SAME
 Brown-1938- midpalatal split
 Timms – major resistance to expansion is midpalatal suture.*
 Kennedy –lateral maxi...
SAME:
Indications of S A M E :
 Skeletal maxillomandibular transverse discrepancy > 5mm
 Significant TMD asstd with a na...
Benefits of S A M E :


Skeletal and dental stability



Non-extraction orthodontic alignment of teeth



Esthetics by ...
SAME:

Technique of S A M E :
 Mandibular dentition should be
decompensated
 Maxillary expansion appliance
– preoperativ...
B/L maxillary osteotomy with step at buttress

Release of nasal septum

www.indiandentalacademy.com
Midline palatal osteotomy

www.indiandentalacademy.com
Lateral nasal wall osteotomy (anterior 1.5mm)

B/L release of the pterygoid plates

www.indiandentalacademy.com
Activation of the appliance : 3-4mm then 1-1.5 mm

www.indiandentalacademy.com
 Soft tissue closure

 Alar base Cinch with non resorbable suture + v-y closure

 SAME can be used for unilateral asymm...
SAME:
 Maxilla should remain stationary – 5 days then 0.5mm /day

 Ilzarovs principle- “healing period of 5 days allows ...
During expansion
 discomfort
 severe increase in pain then bony

interferences

Tightness and minor discomfort

www.ind...
During expansion

www.indiandentalacademy.com
Clinical signs of SAME
 Immature attached gingival tissue - medial to each central incisor tooth
 Expansion exceeds the ...
Complications :
 Similar to Le Fort 1
 Inadequate release of the maxilla (dental tipping, periodontal

breakdown, pain, ...
Modifications of SAME
Age
Palatal tori
Skeletal open bite / open bite
When future Lefort 1

www.indiandentalacademy.com
Palatal tori
At the time of SAME
Modifications of incisions

Tori excision
After six months
SAME

www.indiandentalacademy....
Skeletal open bite / open bite
Ramped cut
Angled cut

Vertical step
At the buttress

www.indiandentalacademy.com
segmental osteotomies :
 Performed many years before total maxillary osteotomies
 Allows for improvement in occlusion bu...
Single tooth osteotomy :
Indications
tooth malposition
Dental ankylosiss
Closure of diastema
Initially some surgeons were ...
Single tooth osteotomy
Benefits :
reduction in treatment time
lower incidence of dental relapse
Drawbacks :
Injury to adja...
Anterior maxillary osteotomies :
1921 – Cohn Stock.
Transverse palatal incision
Wedge shaped osteotomy green stick fractu...
Anterior maxillary osteotomies :
Indications :
 Correction of bimaxillary protrusion.
 Marked protrusion of the maxillar...
Anterior maxillary osteotomies :
 *Radioactive microsphere teq used assess the blood flow in AMO

in macaque monkeys.
 V...
A M O Techniques :
 Wunderer
 Wassmund
 Cupar

www.indiandentalacademy.com
Wunderer-AMO
 When posterior movement of A

M segment
 Transpalatal incision
 Can be combined with buccal

vertical inc...
Wunderer teq-AMO
 Advantages-direct palatal access transverse palatal osteotomy through

molar site
This teq relies on in...
Wassmund technique : 1935
 vertical incision – planned

extraction or interdental osteotomy.
 Preserves both buccal & pa...
Cupar method :
Technique :
A buccal vestibular incision
is created, allowing direct
access to the anterior lateral
maxilla...
Cupar method :

Advantages :
Direct access to the nasal structures
Unhampered access – bone grafting
Ability to remove bon...
Posterior maxillary osteotomy :
Schudart in 1959 :
Indications :
 Posterior maxillary alveolar hyperplasia
 Total maxill...
Posterior maxillary osteotomy :
Osteotomy :
 Horizontal osteotomy 5 mm above the root apices.
 Vertical osteotomy throug...
Horizontal osteotomy 5 mm
above the root apices.
Vertical osteotomy through the
extraction sites.
www.indiandentalacademy....
Palatal osteotomy – curved osteotome.

www.indiandentalacademy.com
Combination anterior and posterior
maxillary osteotomy :
 Horseshoe osteotomy
 Historical purpose
 Maxillary alveolar h...
SAME

Segmental maxillary
osteotomy

Relapse

Pogrel-11.8%(molar)
Greco-8.8%(canine)
7.7%(molar)

Stephens-30%(canine)
23%...
SAME
All direction movement Two surgical
procedures

Segmental
single

Difficult
Teq sesnsitive
Potentially more
morbid
To...
Which one to select?
SAME /Segmental osteotomy

www.indiandentalacademy.com
 Only in transverse SAME
 When pt requires anterior posterior and vertical movements

if >6mm SAME
if <7mmsegmental
...
www.indiandentalacademy.com
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Maxillary procedures and soft tissue changes /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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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 www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Contents :  History  Anatomic considerations  Maxillary deformities  Midface osteotomies  Surgical procedures  Complications  references www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  4. 4. History www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  6. 6. History Initial Days..  Segmental osteotomies  Complete mobilization was avoided  High incidences of relapse www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  8. 8. Anatomic considerations :  External carotid artery : Maxillary artery Facial artery Ascending pharyngeal artery www.indiandentalacademy.com
  9. 9. Anatomic considerations : www.indiandentalacademy.com
  10. 10. Anatomic considerations : Bell et al 1975, Quejada -1986 B/L descending palatine artery can be transected –if basic principles are followed www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  12. 12. www.indiandentalacademy.com
  13. 13. Mid face osteotomies Segmental maxillary osteotomy Total maxillary osteotomy Single tooth Anterior segmental Posterior segmental Horseshoe www.indiandentalacademy.com
  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 www.indiandentalacademy.com 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 www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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.” www.indiandentalacademy.com *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 www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  22. 22. SAME: Technique of S A M E :  Mandibular dentition should be decompensated  Maxillary expansion appliance – preoperatively Surgical technique : 1 Incision www.indiandentalacademy.com
  23. 23. B/L maxillary osteotomy with step at buttress Release of nasal septum www.indiandentalacademy.com
  24. 24. Midline palatal osteotomy www.indiandentalacademy.com
  25. 25. Lateral nasal wall osteotomy (anterior 1.5mm) B/L release of the pterygoid plates www.indiandentalacademy.com
  26. 26. Activation of the appliance : 3-4mm then 1-1.5 mm www.indiandentalacademy.com
  27. 27.  Soft tissue closure  Alar base Cinch with non resorbable suture + v-y closure  SAME can be used for unilateral asymmetries www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  29. 29. During expansion  discomfort  severe increase in pain then bony interferences Tightness and minor discomfort www.indiandentalacademy.com
  30. 30. During expansion www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  33. 33. Modifications of SAME Age Palatal tori Skeletal open bite / open bite When future Lefort 1 www.indiandentalacademy.com
  34. 34. Palatal tori At the time of SAME Modifications of incisions Tori excision After six months SAME www.indiandentalacademy.com
  35. 35. Skeletal open bite / open bite Ramped cut Angled cut Vertical step At the buttress www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  42. 42. A M O Techniques :  Wunderer  Wassmund  Cupar www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  50. 50. Horizontal osteotomy 5 mm above the root apices. Vertical osteotomy through the extraction sites. www.indiandentalacademy.com
  51. 51. Palatal osteotomy – curved osteotome. www.indiandentalacademy.com
  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. www.indiandentalacademy.com
  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 www.indiandentalacademy.com yes
  54. 54. SAME All direction movement Two surgical procedures Segmental single Difficult Teq sesnsitive Potentially more morbid Total theater timings SAME+ Lefort I www.indiandentalacademy.com
  55. 55. Which one to select? SAME /Segmental osteotomy www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  57. 57. www.indiandentalacademy.com

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