maxillary osteotomies & associated surgical complications
TRANSCRIPT
MAXILLARY OSTEOTOMIES &
SURGICAL COMPLICATIONS
Presented by- Dr. Varun Mittal PG Maxillofacial Surgery Dept., SRM Dental College,
Chennai, INDIA
• HISTORY
• BIOLOGICAL BASIS
• WOUND HEALING
• SURGICAL APPROACHES
• MAXILLARY PROCEDURES
• MAXILLARY DEFORMITIES
• INDICATIONS
• COMPLICATIONS
1859 → von Langenback, nasopharyngeal polyps
1867 → David Cheever, hemimaxillarydownfracture for complete nasal obstruction
1921 → Cohn-Stock, AMO (mainly occlusion)
1927 → Wassmund, Lefort I without PMD
1934 → Axhausen, Complete mobilization 1st time
1942 → Schuchardt, PMD
1950 → Gillies & Harrison, 1st Lefort II osteotomy
1950 → Gillies & Harrison, 1st midfaceadvancement using Lefort III osteotomy cuts
1965 → Obwegeser, suggested complete mobilization
1969-75 → Bell, Lefort I downfracture & formed the BIOLOGICAL BASIS
1971 → Converse et al; 1971 → Kufner et al & 1973 → Henderson & Jackson Lefort II as classified by Steinhauser in 1980
1985 → Bennet & Wolford; Lefort 1 Step-osteotomy
BIOLOGIC BASIS..Bell et al; “Wound healing after multisegmental
Lefort I osteotomy and transection of the descending palatine vessels”, J Oral & Maxillofacial Surg 1995
• Study examined Le Fort I osteotomy wound healing after downfracture in 9 rhesus monkeys through circumvestibular incisions later, killed at 0, 3, 7, 14, and 28 days after surgery. Revascularization and bone healing were studied & proposed that the palatal mucosa or labial-buccal gingiva and mucosa provide adequate nutrient pedicles for Le Fort I osteotomies accomplished through a circumvestibular type incision.
• Siebert et al; 1997, “Blood Supply of the Le Fort I Maxillary Segment: An Anatomic Study” performed study on 10 fresh cadavers by injecting standard latex technique.
• Demonstrated interruption of the descending palatine arteries with preservation of the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal artery within the attached posterior palatal soft-tissue pedicle in all specimens following Le Fort I maxillary osteotomy.
Lateral view of right face on a fresh cadaver with posterior half of mandible & zygomaremoved. Within the right temporal and pterygoid fossae, the internal maxillary artery and its branches are demonstrated (large arrow). The facial artery is seen crossing the mandible and continuing up toward the orbit (curved arrow). The anastomotic network between branches of the facial artery and branches of the internal maxillary artery on the inner surface of the gingival mucosa
• The ascending palatine br. of the facial artery was 1 to 1.5 mm in diameter ; entered soft palate by crossing over the L.V.palatinimuscle.
• Anterior br. of ascending pharyngeal artery ; 0.8 to 1.2 mm in dia entered soft palate slightly more cephalad compared with ascending palatine by coursing over T.V. palatini and L.palatinimuscles.
• Both branches entered soft palate posterior to pterygoid muscles & rich anastomotic network existed within the maxilla between the ascending palatine branch, the anterior branch of the ascending pharyngeal artery, and the alveolar branches of the internal maxillary artery.
• Dale Bloomquist -1995 studied blood flow in human gingiva & pulp during 1st 24 hrs. following Lefort 1 osteotomy by laser dopplerflowmetry
• Dodson -1993 measured intraoperativemaxillary gingival blood flow during Lefort I osteotomy (JOMS; 1993)
Healing after osteotomy• Transient ischemia → Fibrinous clot formation
incorporated with RBC’s & some WBC’s
• 1st week postop - increased periosteal-endosteal vascular supply reducing osseous & pulpal ischemia.
• Granulation tissue formation in Space between bones
• 2 weeks post-op- Tissue matures & numerous blood vessels develop with early sign of osteophytic bone fromation
• 4 weeks post-op →proliferated endostealvessels restore circulation between bone segments, fibrous callus formed
• 6 weeks post-op →bony bridges connect the osseous segments
• 12 weeks →maturation of soft & hard tissue continues upto 12 weeks
Syndromes with maxillary deformity
Aperts syndrome
Crouzons syndrome
Pfeifer syndrome
Binders syndrome
Achondroplasia
Cleidocranial dysplasia
Mid face osteotomies-
Segmental maxillary osteotomy
• Single tooth osteotomy
• Corticotomy
• Anterior segmental osteotomy :Wassmund – 1935Wunderer – 1963Epker & walford – 1980
• Posterior segmental osteotomy :Shushardt – 1959Kufner – 1971
• Horseshoe osteotomy :Walford and Epker - 1975
Total maxillary osteotomy :• Le Fort 1 osteotomy :
Classic down fracture ( Bell 1969-75 )SAMEQuadrangular (Keller and Sather – 1990)
• Le Fort 11 osteotomy :Anterior L F 11 ( converse et al – 1970 )Pyramidal L F 11 ( Henderson & Jackson - 1973)Quadrangular L F 11 ( Kufner – 1971)
• Le Fort 111 osteotomy : Killies 1940’s , Tessier 1950’s
• Mid face osteotomies :Zygomatic osteotomiesMalar maxillary osteotomy
Transverse maxillary deficiency • Incidence : 8%
• Etiology : congenital, developmental, traumatic, Iatrogenic
• Diagnosis : clinical and radiographic examination.dental cross biteskeletal cross bitesP A cephalogramfrontal tomographyC T scans.
S A M E :
Transverse maxillary deficiency
• Treatment :
1. S D E
2. O R M E
3. S A M E
4. S M O
• Selection of the technique depends upon the skeletal maturity of the patient.
S A M E :
Indications of S A M E :
• Skeletal maxillo-mandibular transverse discrepancy greater than 5mm
• Significant TMD with a narrow maxilla and wide mandible
• Failed or orthodontic expansion
• Necessity for a large amount more than 7mm of expansion
• Extremely thin and delicate gingival tissues with buccal gingival recession
• Significant nasal stenosis
S A M E :
Brown (1938); midpalatal splitTechnique of S A M E :
• Subtotal Le Fort 1 osteotomy• Mandibular dentition should be decompensated• Maxillary expansion appliance – preoperatively
Surgical technique : B/L maxillary osteotomy (pyriform rim to PTF) Release of nasal septum Midline palatal osteotomy Lateral nasal wall osteotomy B/L release of the pterygoid plates Activation of the appliance : 1-1.5 mm Soft tissue closure
S A M E :
• Maxilla should remain stationary – 5 days
• Palatal expansion should achieve – 4 weeks
• Skeletal retention 6-12 months.
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.
S A M E :
Single tooth osteotomy & Corticotomy
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.
Anterior and posterior maxillary segmental osteotomies :
1921 – Cohn Stock.
Indications :• Correction of bimaxillary protrusion
• Marked protrusion of the maxillary teeth
• Anterior open bite
• To retract the anterior teeth when that cannot be accomplished by conventional orthodontic treatment.
• When orthodontic tooth movement is inadvisable.
• Improvement in appearance.
A M O Techniques :
• Wunderer
• Wassmund
• Cupar
Anterior maxillary osteotomies :
Wassmund technique : 1935
• Preserves both buccal & palatal soft tissues.
• Incision : vertical incision – planned extraction or interdental osteotomy.
Anterior nasal spine incision.
• Osteotomy : buccal horizontal osteotomy
transpalatal osteotomy
repositioning of entire segment.
Wunderer technique : 1963
Similar to wassmund, except the palate is exposed by a transverse palatal incision with the margins away from the osteotomy site.
Anterior maxillary osteotomies :
Cupar method
Most commonly used
Technique :
A buccal vestibular incision is created, allowing direct access to the anterior lateral maxillary walls, piriformaperture, nasal floor and septum.
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.
Anterior maxillary osteotomies
Schuchardt in 1959 :
Indications :• Posterior maxillary alveolar hyperplasia
• Total maxillary hyperplasia
• Distal repositioning
• Spacing in the dentition
• Transverse excess or deficiency
• Posterior open bite.
Surgical technique :
Incision :
Buccal vestibular incision from 3-7
Vertical incision in the region of anterior and posterior osteotomy sites.
Parasagittal palatal incision.
Posterior maxillary osteotomy :
Osteotomy :• Horizontal osteotomy 5 mm above the root apices.
• Vertical osteotomy through the extraction sites.
• Posterior vertical osteotomy at Pterygomaxillary junction
• Palatal osteotomy – curved osteotome.
• Acrylic splint (6-8 weeks with bone plate fixation)
• Maxillomandibular Fixation.
Posterior maxillary osteotomy
• Horseshoe osteotomy
• Histological purpose
Maxillary alveolar hyperplasia with or with out anterior open bite deformity
• Transverse maxillary hypoplasia with vertical component
Combination anterior and posterior maxillary osteotomy
Indications of various procedures-Lefort I
Deformity in all 3 planes can be corrected.
AP → Setback (Total+AMO)
Advancement (Total)
Vertical → Setup (Total)
Downgraft (Total)
Transverse → Narrowing (Segmental+Total)
Widening (Segmental+ Total)
Surgical technique :
1. Positioning of the patient
2. Modified hypotension
3. Infiltration of the soft tissue with a vasoconstrictor.
4. Mucosal incision : blade / electrocautrey.
5. Subperiosteal dissection : complications -perforation of the periosteum, exposure of buccal pad of fat, perforation of the nasal mucosa.
6. Reference marks : vertical and horizontal
Le Fort 1 osteotomy
5. Anterior buccal osteotomy : using a reciprocating saw from buttress to the piriform rim. Osteotomyparallel to the occlusal plane.
6. Posterior buccal osteotomy : extending from buttress to the tuberosity. + / - 3mm lower than the anterior osteotomy. Step b/w ant/post osteotomy. Impacted 3rd molar should be removed. Connect anterior and posterior osteotomies.
Le Fort 1 osteotomy
Incision through the mucosa, submucosa, facial musculature, and periosteum
Subperiosteal dissection of the anterior maxilla
Submucosal dissection of the nasal cavity. Note the tip of the periosteal elevators inside
the piriform aperture
9. Place the holes for inter osseous wires :
10. Separation of the tuberosity from the pterygoidplates :
11. Complete the posterior osteotomy : damage to the descending palatine artery, palatal mucosa or contents of the pterygopalatine fossa.
12. Osteotomy of the lateral nasal wall : Resistance and audible change – palatine bone.
13. Repeat the osteotomies on opposite side :
14. Complete the Subperiosteal dissection of the nasal spine : ramus retractor, separate the septalcartilage from the anterior nasal spine.
Le Fort 1 osteotomy
15. Osteotomy of the septal cartilage and vomer :
16. Maxillary down fracture : several techniques : digital pressure, row’s maxillary disimpactionforceps, tessier spreader, smith 3 – prong spreader or turvey maxillary expander. Modified leverage technique. (JOMS 62 ; 112-114 : 2004). Failure to effect maxillary down fracture –redefine the osteotomies. Mobilize the maxilla.
17. Place a maxillary positioning wire : assist the final mobilization of the maxilla, pull the maxilla anteriorly for better vision and access to the posterior area of the maxilla.
Le Fort 1 osteotomy
18. Exposure of the posterior maxilla : helps in identifying descending palatine neurovascular bundle, osteotomies for refinement, to examine the maxillary sinus mucosal lining and to remove pathological mucosa.
19. Trim the lateral nasal wall :
20. Contouring of the piriform rim :
21. Reverse the hypotensive anesthesia and check for any hemorrhage.
22. Feed a wire through holes at the buttress.
23. Place a intermaxillary fixation with the teeth in the planned occlusion.
Le Fort 1 osteotomy
24. Maxillary reposistiong : rotate and check for reference points. Great care should be taken at this step. Both the mandibular condyles should be ideal relationship to the glenoid fossa.
25. Turbencetomy : soft tissue atrophy or hypertrophy of the bone. Ventral approach or tear
26. Check the position of the nasal antrum :
27. Tightening of the maxillary wire :
28. Placement of the bone plates : 1.5 mm plates.
29. Wound closure : cinch, v-y closure.
30. Apply a pressure dressing :
Le Fort 1 osteotomy
Effect of the alar cinch technique of the width of the
alar base. Note the difference after tying the suture.
Tip of the finger (or thumb) everts the lip and nasal base while suture is passed
V-Y closure of a lip incision. A skin hook is placed in the midline and tissue is gathered for approximately 1 cm with suture
The remainder of the incision is closed so that the superior edge is pulled anteriorly
Obwegeser
Keller and Sather – 54 patients
Indications :• Maxillary – zygomatic horizontal deficiency
• Class 111 skeletal malocclusion
• Maxillary vertical excess or deficiency
• Maxillary transverse deficiency
• Maxillary midline shifts.
Surgical procedure :
High level Le Fort 1 that incorporates almost all anterolateral aspects of maxilla below infraorbital nerve and parts of body of malar.
Quadrangular Le Fort 1 osteotomy
Steinhauser 1980
• Anterior L F 11 Osteotomies
• Pyramidal L F 11 Osteotomies
• Quadrangular L F 11 Osteotomies.
Anterior Le Fort 11 osteotomies :
Indication :
Nasomaxillary hypoplasia
Surgical procedure :
Pyramidal nasomaxillary osteotomies
Premaxillary osteotomy
Le Fort 11 osteotomy
Pyramidal Le Fort osteotomy :
Henderson and Jackson 1973
Indications : nasomaxillary hypoplasia
• Involving dentoalveolar segment
• Excluding dentoalveolar segment (binders syndrome)
• Cleft palate patients
• Pan facial problems.
Surgical procedure :
• similar to Le Fort 1
• Oblique Para nasal skin incision
• Infraorbital rim osteotomy
• Medial canthus – osteotomy over nasal bone
• Bone grafts and fixation.
Le Fort 11 osteotomy
Indications :
• Similar to quadrangular Le Fort 1 osteotomies.
• Patients with significant maxillary deficiency that includes the infraorbital rims and zygomas but also who have normal nasal projection.
• Surgical procedure : diagram…….
Quadrangular Le Fort 11 osteotomy
• Sir Harold Gillies – 1942
• Tessier
High level midface osteotomy surgery
Midface anteriorly or inferiorly or both
Indications :
Total midface hypoplasia primarily in anterioposterior and vertical dimension.
Syndromic patients (aperts, crouzens syndrome)
Timing :
Growth – completed
Earlier operation : dislocation of eyes, corneal exposure, sever functional or psychological problems
Le Fort 111 osteotomy
Surgical procedure :
Incision : Coronal flap
Intra oral incision – Le Fort 1
Osteotomies :
zygomatic arch, F-Z region, inferior orbital fissure, medial wall of the orbit, bridge of the nose. Pterygomaxillary dysjunction, Bone grafts and fixation.
Modifications : Le Fort 1 osteotomy
Le Fort 1111 osteotomy : advancement of frontal bone and anterior cranial fossa.
Le Fort 111 osteotomy
Incision placement for most female patients and males with no signs or family history of baldness. The incision
is kept approximately 4 cm behind the hairline
Malpositioning :• Accurate models,• Not to deviate the surgical treatment plan,
• position of the mandibular condyles.Bleeding :
• Anesthesia -• Head position -• Descending palatine artery -• Packing -• Embolization -• Postoperatively -• Arteriogram -
Complications of Maxillary Osteotomies
Perfusion deficiencies :• Laser Doppler flowmetry
• Ligation of D P A
• Palatal and posterior soft tissue
• HBO
• Removal of fixation and splints
• Necrosis
Periodontal defects :• Attached gingiva and interdental papilla
• Good hygiene and nutrition
• Periodontist consultation
Complications of Maxillary Osteotomies
Devitalized tooth :
• Osteotomies – 5mm
• Endodontic therapy
Nerve injury :
• Anatomy
• Neurosensory changes
• Careful retraction
• Reasses the patient
• Consider re-exploration
Complications of Maxillary Osteotomies
Nasolacrimal injuries:
• Epiphora
• Dacryocystorhinostomy
Oronasal and oroantral fistulas :
• Large expansion
• Intact nasal mucosa
• Decongestants, nasal sprays, antibiotics
• Oral hygiene
• Surgical closure.
Complications of Maxillary Osteotomies
Nasal septal deviation :• Pre op evaluation
• Nasolacrimal obstruction
• Septal crest
• Cinch suture
• Post op – treat as early as possible.
Maxillary sinusitis :• Decongestants,
• Antihistamines
• Antibiotics
• Nasal spray.
Complications of Maxillary Osteotomies
Effects of the maxillary vestibular approach if simple closure is performed :
the nasal tip loses projection, the alar bases widen, and the upper lip rolls inward
Unaesthetic soft tissue changes :
• Informed consent
• Down turned or unsupported oral commissures
• Excessive impaction should be avoided
• Periosteal suturing
• V-Y closure
Unfavorable fracture :
• Osteotomies,
• Ideal splitting.
Complications of Maxillary Osteotomies
Non union :
• R I F technique
• Occlusion
Eustachian tube dysfunction :
• Intubation
• Palatal muscles
• Decongestants, nasal sprays, reassure the patient.
A-V Fistula’s :
• Very rare
• Unexpected neurological signs.
Complications of Maxillary Osteotomies
• Rowe and Williams – vol 2
• Peterson –Oral & Maxillofacial Surgery
• Fonseca – vol 3
• Ward Booth – vol 1
• Edward Ellis- Surgical Approaches to Facial Skeleton
• Neelima Malik
• Articles-JOMS & IJOMS
References