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Maxillary procedures and soft tissue changes
1) The document discusses various maxillary osteotomies including Lefort I, Lefort II, Lefort III, segmental osteotomies, and surgically assisted rapid maxillary expansion. 2) Complications of maxillary osteotomies are discussed such as relapse, settling, transverse relapse, condylar distraction, bleeding, avascular necrosis, periodontal defects, and nerve injury. 3) Techniques to preserve vascular supply and prevent complications are presented.
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Presented by Dr. Shibani Sarangi; Guided by Dr. Rai, Dr. Gupta, Dr. Krishnan, Dr. Jadaun.
Discusses Wassmund LeFort I osteotomy and Schuchardt pterygomaxillary dysjunction.
Covers dental and periodontal treatments, including extractions and orthodontics before and after orthognathic surgery.
Pathway of relevant arteries and various maxillary osteotomy techniques including segmental and total maxillary osteotomies.
Details on maxillary osteotomies including Lefort I, II, and III, and mentions the surgical techniques.
Discusses blood supply to maxilla, techniques to preserve vascular integrity during osteotomies.
Transverse maxillary deficiencies and orthodontic options like ORME and distraction osteogenesis.
Introduces SAME with techniques indicated for maxillary expansion and healing processes involved.
Segmental osteotomies, approaches to anterior/posterior maxillary osteotomy, and potential complications.Methods and stabilization techniques related to pterygo-maxillary dysjunction and surgical closures.
Details on modified osteotomy techniques, indications for methods by historical figures, including Cohn Stock and Kufner.
Discusses Le Fort II and III indications including syndromes affecting the maxillary structures and surgical techniques.
Complications of maxillary osteotomy including relapse, nerve injury, bleeding, and avascular necrosis.
How maxillary movements affect nasal and labial structures, with techniques for closure and contouring.
Concludes the presentation with referenced textbooks and articles for further reading.
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Maxillary procedures and soft tissue changes
- 1. Presented by- Dr ShibaniSarangi Postgraduate III year Pacific Dental college Guided by- Dr A. Bhagvandas Rai Dr Himanshu Gupta Dr Prachod Krishnan Dr Gargi Jadaun
- 3. Wassmund -- LeFortI osteotomy
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- 5. Dental and periodontaltreatment Extractions Presurgical orthodontics
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- 7. Pathway of the Ascendingpalatine, 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 SchuchardthKufner Horseshoe osteotomy Total Maxillary osteotomies
- 10. Total Maxillary osteotomies Lefort I osteotomy SAMEClassic Downfracture Quadrangular LefortII Osteotomy Anterior LF I Pyramidal LF II Quadrangular LF II Lefort III Osteotomy Midface Osteotomy Zygomatic osteotomy Malar osteotomy
- 11. Biological basis ofmaxillary 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 preservethe vascular supply
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- 15. Relationship between maxillaryartery & maxillary osteotomies 14.6mm Turvey & Fonseca Relationship between maxillary artery & maxillary osteotomies: (Journal of Oral Surg. 1980; 38: 92-95)
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- 18. Transverse deficiency SDE ORME SAME Segmental osteotomy • Orthodontic applianceused • 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 maxillaryexpansion) males- 14-15 Female-15-16
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- 22. Surgically Assisted MaxillaryExpansion(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 Activationof appliance with a total widening of 1-1.5mm
- 27. • Healing periodof 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-
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- 34. Anterior maxillary osteotomy •Cohn Stock 1921- first report • Indications:
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- 39. • Complications ofthe AMO:
- 40. Posterior maxillary osteotomy •Schuchardt 1959 first report • Indications: Schuchardt Petko Bell Kufner
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- 48. Surgical technique .(5 mmsuperior to attached gingiva).
- 49. POSTERIOR CUTS SINUS CUTSUSING RECIPROCATING SAW
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- 55. • Segmenting themaxilla:
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- 61. V-Y CLOSURE ALARCINCH SUTURE
- 63. MODIFIED LE FORTI OSTEOTOMIES • Quadrangular osteotomy - (Kufner 1971)
- 64. Lefort II Osteotomy Anterior Pyramidal QuadrangularConverse- 1971 Henderson & Jackson-1973 Kufner 1971
- 65. LE FORT IIOSTEOTOMY (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 crestdown towards the orbital floor
- 69. MODIFIED LE FORTII OSTEOTOMY Psillakis, Lapa and Spina (1973) designed modified Le fort II, which leaves tooth bearing area behind
- 70. LE FORT IIIOSTEOTOMY(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 andnasal 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 startsat 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
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- 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: -occurswhen 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
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Editor's Notes
- #12 EVEN IF IT IS SEGMENTED
- #17 An upward and posteriorly oriented osteotome will not reliably separate the maxilla from the pterygoid plates. It is also associated with increased risk of bleeding from the pterygoid plexus and internal maxillary artery.
- #26 Osteotomy ii to occlusal plane Step made in buttress
- #31 To avoid open bite
- #37 Adv- direct palatal access
- #42 2 step procedure for open bite correction
- #48 Low level osteotomy Ostetomy approaches infraorbital rim Osteotomy including cheek prominence Ramped cut
- #50 Posterior osteotomy directed inferiorly as it safeguards the Max artery
- #52 Final step Index finger kept on palte while malleating
- #53 Rongeur used to remove remaining vomer or nasal crest of maxilla. Descengin palatine neurovasc. Bundle seen postero-medial aspect of Max sinus
- #56 PARAMEDIAN OSTEOTOMY
- #57 THIN OSTEOTOME TO REVISE BONE GRAFTS PLACEE
- #60 WQEDGING GRAFT IN PLACE
- #74 Subgaleal dissection done