Maxillary osteotomy procedures and soft tissue changes

1. Presented by-
Dr Shibani Sarangi
Postgraduate III year
Pacific Dental college
Guided by-
Dr A. Bhagvandas Rai
Dr Himanshu Gupta
Dr Prachod Krishnan
Dr Gargi Jadaun

3. Wassmund -- LeFort I osteotomy

4. Schuchardt pterygomaxillary dysjunction

5. Dental and periodontal treatment
Extractions
Presurgical orthodontics

6. Orthognathic surgery
Post-surgical orthodontics

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

9. Midface
Osteotomies
Segmental Maxillary
osteotomies
Single tooth
osteotomy
Anterior
osteotomy
Wassmund
Wunderer
Cupar
Posterior
osteotomy
Schuchardth Kufner
Horseshoe
osteotomy
Total Maxillary
osteotomies

10. Total Maxillary
osteotomies
Lefort I
osteotomy
SAMEClassic
Downfracture
Quadrangular
Lefort II
Osteotomy
Anterior LF I
Pyramidal LF II
Quadrangular LF II
Lefort III
Osteotomy
Midface
Osteotomy
Zygomatic
osteotomy
Malar
osteotomy

11. 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
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

13. Technique to preserve the vascular supply

14. Osteotomy
5-6 mm apical
Obwegeser
osteotome
ROBINSON & HENDY

15. Relationship between maxillary artery & maxillary
osteotomies
14.6mm
Turvey & Fonseca Relationship between maxillary artery & maxillary osteotomies: (Journal of Oral Surg. 1980; 38: 92-95)

17. Transverse Maxillary deficiency

18. Transverse
deficiency
SDE
ORME
SAME
Segmental
osteotomy
• Orthodontic appliance used
• Results takes 2-4 months .
• Dental stability is compromised
• Orthopedic appliance
can achieve results in
2-4 weeks.
• Effective before
growth ceases
Results are achieved even
after cessation of growth.

19. ORME(Orthopedic rapid maxillary expansion)
males- 14-15
Female-15-16

20. Distraction Osteogenesis
• Introduction

21. Illizarov principle
“ILLIZAROV EFFECTS”
SURGICAL
PHASE
DISTRACTION
PHASE
LATENCY
PHASE
CONSOLIDATION

22. Surgically Assisted Maxillary Expansion(SAME)

23. • Indications:
>5mm
(>7 mm)
• Advantages of SAME

25. Technique for SAME
• B/L Maxillary ostetomy from pyriforn to the pterygomaxillary fissure
• Release of nasal septum
• Midpalatal osteotomy interdentally b/w Maxillary incisor and
anterior nasal spine

26. APPLIANCE IN PLACE
Activation of appliance with a total widening of 1-1.5mm

27. • Healing period of 5 days allows capillary healing across bony gaps. Reestablishment
of this blood supply leads to faster and more complete ossification of the expanded
defects.
• Retention period-

29. • Complications:

31. SegmentalOsteotomies

34. Anterior maxillary osteotomy
• Cohn Stock 1921- first report
• Indications:

35. Wassmund technique(1935)

36. Wunderer method(1963)
• Modification:

37. Cupar method

38. • Advantages:

39. • Complications of the AMO:

40. Posterior maxillary osteotomy
• Schuchardt 1959 first report
• Indications:
Schuchardt
Petko Bell
Kufner

41. • Surgical technique:

42. • Complications:

43. PTERYGO MAXILLARY DYSJUNCTION

44. Lefort I Osteotomy

45. • Biologic basis:

46. Indications

47. Various
designs of
Osteotomy

48. Surgical technique
.(5 mm superior to attached
gingiva).

49. POSTERIOR CUTS
SINUS CUTS USING
RECIPROCATING SAW

50. SEPTAL
OSTEOTOMY
LATERAL NASAL
OSTEOTOMY

51. PTERYGO MAXILLARY
DYSJUNCTION

52. SEPTAL CLEARANCE

53. • Stabilization:

54. WIRE FIXATIONPLATE FIXATION

55. • Segmenting the maxilla:

59. BONE GRAFTING DONE

60. • Wound closure:

61. V-Y CLOSURE ALAR CINCH SUTURE

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

64. Lefort II Osteotomy
Anterior
Pyramidal
QuadrangularConverse - 1971 Henderson & Jackson-1973
Kufner 1971

65. 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

66. Posterior lacrimal crest down towards
the orbital floor

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

70. 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
• Crouzens/Aperts syndrome
• Craniostenotic syndroms

71. 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

72. Osteotomy
 Osteotomy 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

78. 1} Relapse:
2} Settling:

79. 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

80. 4} Condylar distraction:
-occurs when there are interferences in the tuberosity or
pterygoid plate area
Prevention
-- 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.

81. 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

82. 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

84. • Nasal structures-
• Maxillary movements affects the nasal dorsum.
• Alar base widening
• Decrease in nasal tip height
• Widening of philtral columns.
• Decrease in Nasolabial angle
• Supratip break in ANS

85. • Labial changes-

86. For posterior repositioning-

87. V-Y CLOSURE

88. ALAR CINCH

89. CONTOURINGTHE ANS

90. DOUBLEV-Y CLOSURE

91. Conclusion

92. • Textbooks
• Articles