Anatomy of the maxilla and its surgical implications /cosmetic dentistry courses

ANATOMY OF THE MAXILLA AND ITS
SURGICAL IMPLICATIONS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
 Gross anatomy
 Surgical anatomy
 Development
 Maxilla in fractures
 Maxillary osteotomies
 Maxillectomy
 Infections of maxilla

INTRODUCTION
 Paired bone
 Second largest bone of face
 Contributes to formation of several
structures
 Whole of upper jaw
 Roof of oral cavity
 Floor and lateral wall of nasal cavity
 Floor of each orbit
 Infratemporal and pterygopalatine
fossae
 Inferior orbital and pterygomaxillary
fissures

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

GROSS ANATOMY OF MAXILLA
 Body
 Processes :
 Frontal
 Zygomatic
 Alveolar
 Palatine

BODY OF MAXILLA
 Incisive fossa
 Canine fossa
 Canine eminence
 Infraorbital
foramen
 Nasal notch
 Anterior nasal
spine
 Posterior dental
canals
 Maxillary tuberosity

 Infra orbital groove and canal
 Inferior orbital fissure

 Maxillary hiatus
 Greater palatine
groove
 Inferior meatus

PROCESSES OF MAXILLA
 Frontal
 Zygomatic
 Alveolar

PALATINE PROCESS

SURGICAL LAYERS
SMAS is a meshwork of fibrous septae
Which envelopes fat lobules Overlies
fascia
Blends into facial muscles

MUSCLE GROUPS

BLOOD VESSELS ENCOUNTERED IN MAXILLA

MAXILLARY ARTERY

VENOUS DRAINAGE IN MAXILLAwww.indiandentalacademy.com

INNERVATION OF MAXILLARY REGION - MOTOR
 Predominantly
zygomatic and
buccal branches
of facial nerve
 Proximal trunks
located relatively
deep to skin
 Several
anastomoses of
branches

INNERVATION OF MAXILLARY REGION - SENSORY
 Infra orbital nerve

DEVELOPMENT OF MAXILLA
 Develops from the mesenchyme of the
maxillary process (derivative of first arch)
 Cartilages:
 No primary cartilage seen
 Associated closely with cartilage of nasal
capsule
 Secondary cartilage: zygomatic or malar
cartilage aids in growth

 Centre of ossification appears at angle between
anterior superior alveolar nerve and infraorbital nerve

CENTRE OF
OSSIFICATION
(B/W 2 NERVES)
FRONTAL
PROCESS
TOWARD
DEVELOPING
ZYGOMA
TOWARD FUTURE
INCISOR REGION
LATERAL ALVEOLAR PLATE
BONY TROUGH FOR
NERVE
PALATINE
PROCESS
MEDIAN ALVEOLAR PLATE
Sinus – develops by sixteenth week by pneumatization

FRACTURES OF MAXILLA
 Maxilla varies from mandible in geometric
distribition of bone
 Thin laminae
 Increased surface area : bone volume ratio
 Good blood supply – excellent healing
potential

BUTTRESSES OF MIDFACE ARCHITECTURE
 Was elucidated by Le fort in fracture lines
 Sicher and Tandler in 1928 gave concept of
vertical buttresses
 These help in transmission of forces
 3 buttresses are identified:
 Pterygomaxillary
 Zygomatic
 nasomaxillary

 Nasomaxillary buttress:
 From maxillary canine area
 Through lateral piriform rim
 Through frontal process of maxilla
 To superior orbital rim

 Zygomaticomaxillary buttress:
 From zygomaticoalveolar crest
 Through the zygoma
 To posterior aspect of superior orbital rim and
temporal bone

 Pterygomaxillary buttress:
 Through palatine bone
 To pterygoid plates
 Base of sphenoid

SURGICAL APPROACHES FOR # FIXATION
 Intra oral approach preferred – esthetics
 Vestibular
 Palatal
 Midface degloving approach

VESTIBULAR
 Access to anterolateral aspect of maxilla
 Extent can vary – unilateral or bilateral

PALATAL
 Midline split of maxilla – severe injuries

MIDFACE DEGLOVING APPROACH
 Le fort II fractures

 Lower eyelid/ subciliary
incision
 Transconjunctival/ lateral
canthotomy approach

 Upper eyelid blepharoplasty

 Coronal approach

FIXATION OF MAXILLARY #
 Le fort I : lateral
and medial
buttress

 Le fort II :
 nasofrontal
suture,
 orbital rim

 Le fort III :
 nasoethmoid,
 fronto -
zygomatic
suture,
 orbital rim,
 zygoma

PATHOLOGIES OF MAXILLA
 Squamous cell carcinoma of sinus and oral
mucosa
 Desmoplastic ameloblastoma
 Adenomatoid odontogenic tumor
 Squamous odontogenic tumor
 Melanotic neuroectodermal tumor
 Osteosarcoma – secondary to Paget’s disease
 Chondrosarcoma

LATEARL RHINOTOMY APPROACH
 Tumors of lower part
of nasal cavity/maxilla
 Polyps, papillomas
 Starts at philtrum
 Around vestibule, ala
 Nasolabial crease

WEBER FERGEUSON INCISION (DIEFFENBACH)
 More exposure
 partial/total maxillectomy
 Midline upper lip
 Philtrum columella
 Around vestibule, ala
 Nasolabial crease
 Medial canthus

LYNCH EXTENSION
 Exposure of ethmoid
air cells
 Extends till medial
edge of eyebrow

LATERAL SUBCILIARY EXTENSION SUBCILIARY AND
SUPRACILIARY EXTN.
 Total and radical maxillectomy
 Along tarsal margin of lower eyelid to lateral canthus
 Along upper eyelid

MIDFACE DEGLOVING INCISION

PARTIAL MAXILLECTOMY
 Tumors in floor of sinus
 Lower half of maxilla
 Intra oral incision
 Antral lining is removed
to prevent chronic
inflammation

SUBTOTAL MAXILLECTOMY
 Tumors extending to superior part of sinus
 Tumors extending beyond the sinus borders
 Weber fergeuson approach
 Palatine vessels and maxillary artery

MEDIAL MAXILLECTOMY
 Tumors of:
 lateral wall of nasal
cavity
 medial wall of maxillary
sinus
 Infra orbital nerve is
preserved
 Medial canthal ligament
is detatched
 Lacrimal duct
transected
 Anterior ethmoidal
artery ligated

TOTAL MAXILLECTOMY
 Complete removal
 Primary
mesenchymal
tumors
 Subciliary extension
 Periosteum
elevated from floor
of orbit

RADICAL MAXILLECTOMY
 Orbital exenteration is done
 For tumors that have spread into orbit
through orbital periosteum
 Weber fergeuson approach with subciliary
and supraciliary extension

MAXILLARY OSTEOTOMIES
 Le fort I osteotomy
 Segmental osteotomy
 High level osteotomies – le fort II and III

ANATOMICAL CONSIDERATIONS IN LE FORT 1
OSTEOTOMY
 Incision – intraoral
from
zygomaticomaxillary
buttress anteriorly
across the midline
 Posterior maxilla –
dissection is tunneled
to preserve an intact
mucosal pedicle

 Infra orbital nerve exposed
on subperiosteal
dissection
 Descending palatine
vessels – usually ligated
as they are source of
bleeding
 Internal maxillary artery –
may be damaged during
downfracture. Posterior
osteotomy is directed
inferiorly to prevent this.

SEGMENTAL OSTEOTOMIES
 Wunderer method – buccal pedicle intact
 Wassmund method – both buccal and palatal
pedicle intact
 Cupar method

WUNDERER METHOD
 Incisions –
transpalatal
buccal vertical
incisions
 Midline incision
over anterior nasal
spine

WASSMUND METHOD
 Two buccal verical incision
 No transpalatal incision

CUPAR METHOD
 Only vestibular incision
 Non vitality of teeth – minimum 1mm of bone over
roots
 Oronasal & oroantral communication.

LE FORT II OSTEOTOMY
 Indications :
 Cleft palate, binder’s
syndrome
 Dish face deformity due
to trauma
 Incision – mucogingival
 Anatomical structures :
 Infraorbital nerve
 Nasolacrimal duct

LE FORT III OSTEOTOMY
 Total midface hypoplasia:
craniofacial synostosis
 Degree of proptosis and
hypoplasia
 Incision – coronal
 Anatomical structures:
 Infraorbital nerve
 Lacrimal apparatus and orbit
 Pterygoid venous plexus

INFECTIONS OF MAXILLA
 Sinus infections
 Space infections
 Infantile osteomyelitis

CHRONIC MAXILLARY SINUSITIS
 Approaches:
 Caldwell Luc approach
 incision over canine fossa
 Exposes anterolateral wall of sinus
 Above – infraorbital foramen and nerve
 Below – apex of premolar teeth, middle superior
alveolar nerve
 Posteriorly – zygomatic buttress

 Intranasal antrostomy:
 Antrum punctured through inferior meatus
 The inferior turbinate must be protected
 Denker’s procedure:
 Antrum exposed via caldwell luc approach
 The lateral nasal wall is trephined and nasal mucosa sutured to
the sinus

SPACE INFECTIONS
 Canine space
 Infected maxillary
canine
 Between maxilla and
muscles of face
 Drainage – intraoral
through vestibule

INFANTILE OSTEOMYELITIS
 Rare but involves maxilla
 Etiology :
 Due to perinatal trauma
 use of suction bulb or contaminated fingers
 May involve eye, dural sinuses and teeth
 Maxilla is swollen both buccally and
palatally

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