Maxillary Orthognathic Procedures - PPT / Orthodontic Courses by Indian Dental Academy

Maxillary Orthognathic
Procedures

INDIAN DENTAL ACADEMY

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Introduction
Applied vascular anatomy
SAME
Segmental Osteotomies
Le-Fort 1 Osteotomy
Introduction
Dentofacial deformities affect 20%of the population.
Orthognathic surgery is a team work.
This team must
Correctly diagnose existing deformities
Establish an appropriate treatment plan
Execute recommended treatment.
Basic theraputic goals
Function
Aesthetics
Stability
Minimizing the treatment time.

History
1859: Von-Langenback did the first
orthognathic procedure.
1921:Cohn-Stock introduced the anterior
maxillary osteotomy.
1927:Wassmund reported the first total
maxillary osteotomy.
Bells research- biologic basis for
orthognathic surgery.
Vascular anatomy:
All the vessels are branches of
the ECA.
Anastamosed ascending
palatine and ascending
pharyngeal artery joins the
lesser palatine artery, also the
greater palatine artery.
Sphenopalatine, posterior
superior alveolar and
infraorbital arteries are the
others

Bell et al 1995
proved the
excellent collateral
circulation of the
maxilla.
Surgically Assisted Maxillary
Expansion
Assists to correct deformities in transverse dimension.
First described by Angell in 1860
This procedure is in essence combination of distraction
osteogenisis and controlled soft tissue expansion.
Diagnosis and clinical evaluation:
paranasal hallowing
narrowed alar base
deepening of nasolabial folds
zygomatic difficiancy
Treatment options: based on skeletal maturity
Slow dentoalveolar expansion
Orthopedic rapid maxillary expansion
SAME
Segmental maxillary osteotomy
Advantages of SAME
improved stability
non extraction alignment of dentition
elimination of negative space
improved periodontal health and nasal respiration
Indications:
skeletal discrepancy greater than 5mm assossiated with
wide mandible
failed orthodontic expansion
extremely thin, delicate gingival tissue
significant nasal stenosis.
Technique:
First the mandibular dentition should be
decompensated
Expansion appliance should be placed preoperatively
Steps:
Bilateral osteotomy from pyriform rim to
pterygomaxillary fissure
Release of nasal septum
Midline palatal osteotomy
Osteotomy of the anterior 1.5mm lateral nasal
wall
Bilateral release of pterygoid plates
Activation of appliance by 1 to 1.5mm
Soft tissue closure
S A M E-
PROCEDURE
APPLIANCE IN
PLACE
Maxilla should remain stationary for 5
days postoperatively.
Pt should feel discomfort while activation.
Expansion at a rate of 0.5 mm/day
Over correction is not recommended.
Retention:
6 to 12 months after expansion
Complications:
Those due to inadequate surgery:
pain
dental tipping
periodontal breakdown
post orthodontic relapse
Those due to expansion
lack of appliance expansion
deformation of the appliance due to processing errors
stripping or loosening of midpalatal screw
Segmental Osteotomies
Single tooth osteotomy:
Indicated in tooth mal position.
Dental ankylosis.
closure of diastema.
Advantages:
Reduction in the treatment time.
Lower incidance of relapse.
Disadvantages:
Injury to teeth
Periodontal compromise
Devitalization of teeth.

Anterior maxillary osteotomy
Cohn Stock 1921- first report
Indications:
Bimaxillary protrusion
Protruded maxillary teeth with normal
inclination to alveolar bone.
Anterior open bite.
When orthodontic teeth movement not
possible.
To reduce the prominence of the upper lip.
Wunderer method:
Relies on intact buccal
pedicle.
Transpalatal inncision
combined with buccal
verticle incision.
Modification:
Midline vertical incision
combined with buccal
vertical incision.
Wassmund technique
;
Preserves both
buccal and palatal
pedicle.
Buccal as well as
anterior verticle
incision
Tunneling between
anterior and buccal
incisions
Trans palatal
osteotomy through
buccal vertical
osteotomy.
Occasional mid
palatal sagittal
incision.
Buccal vestibular incision
Nasal septum is first released
Horizontal osteotomy followed by vertical buccal
osteotomy.
Trans palatal osteotomy under direct vision.
Advantages:
Direct access to the nasal structures and superior
maxilla
Preservation of the palatal pedicle
Ease of placement of rigid fixation
Ability to remove bone from palate.
CUPAR METHOD
CUPAR METHOD
Complications of the AMO:
Loss of teeth vitality.
Persistant periodontal defects
Communication with nasal cavity or
antrum
Occlusal steps formation.
Posterior maxillary osteotomy
Schuchardt 1959 first report
Indications:
Posterior maxillary hyperplasia.
Distal repositioning of the posterior segment.
Posterior open bite.
Transverse excess or deficiancy
Spacing in the dentition.
Surgical technique:
Buccal vestibular incision below the buttress.
Platal osteotomy through the buccal osteotomy
site.
Occasional palatal incision.
Principles are same as for the total maxillary
osteotomies.
Complications:
Same as that for other osteotomies.
Blind procedure.
Technically challenging.
POSTERIOR SEGMENTAL OSTEOTOMY
PTERYGO MAXILLARY
DISJUNCTION
Summary:
Segmental osteotomies are indicated for
isolated dento facial deformities when there is
good dento skeletal relationships in the non
affected areas.
Decreased morbidity when compared to total
maxillary osteotomies.
For isolated dentofacial deformities and
prosthetic problems, the segmental osteotomies
should be in the armamentarium of the surgeon.
Le-Fort 1 osteotomy
Work horse of the orthognathic surgical
procedures.
Broad application to resolve many functional
and aesthetic problems.
Biologic basis:
Rich anastamosing vasculature of the face.
Maxilla is clothed by wide soft tissue.
Osteotomised segment should remain attached
to soft tissue pedicle.
Indications:
Vertical maxillary excess in bimax protrusion.
Superior re positioning of the maxilla to correct open
bites.
To advance maxilla in cleft palate and post traumatic
patients.
To correct open bites when combined with mandibular
procedures.
Correction of cants.
Advancement of the maxilla in class III patients.
Surgical technique:
Patient position: head end elevation by
10degree.
Reference pins should be placed when vertical
changes are planned.
Incision: Maxillary vestibular incision high in the
muco buccal fold.
Incision traverses the mucosa, muscles and the
periosteum.
LE FORT I OSTEOTOMY
Sub periosteal dissection.
Infra orbital nerve identified and preserved
Nasal mucosa dissected from nasal wall and
floor.
Dissection in buttress region kept inferiorly.
Vertical reference points placed in pyriform
aperture and buttress.

VESTIBULAR
INCISION
OSTEOTOMY
MARKINGS
Osteotomy should be kept below the pyriform
aperture region.
Initial cuts in the buttress region progressing
towards the nose.
Next the posterior cuts in the pterygo maxillary
region kept inferiorly.
Minimum of 5mm above the root apices.
The next cut in the sinus from inside out.
Same procedure for the opposite side.
POSTERIOR CUTS
SINUS CUTS
USING
RECIPROCATING
SAW
SEPTAL
OSTEOTOMY
LATERAL NASAL
OSTEOTOMY
SEPTAL CLEARANCE
Septal cartilage and the septum freed from the
maxilla.
Lateral nasal cut is then performed all the way
till perpendicular plate of palatine bone.
Final step is seperation of maxilla from pterygoid
plate.
Care should be taken to preserve the
descending palatine vessels.
PTERYGO MAXILLARY
DISJUNCTION
In case of superior repositioning of the
maxilla sufficient bone and cartilage
should be removed from the septum.
Mobilization of the maxilla is done.
Occlusal splint b/n maxilla and mandible is
then fixed.
Maxillo mandibular complex is rotated
supporting the condyles in the fossa.
CONDYLAR REPOSITIONING
Correct vertical re positioning is ensured
using reference pins.
Stabilization:
Small bone plates (1.5mm) or intra
osseous wiring applied at pyriform
aperture and buttress region.

WIRE FIXATION PLATE FIXATION
Segmenting the maxilla:
Indications:
Transverse discrepancies between the
dental arches
Vertical steps in the maxillary occlusal
plane
Space remaining in the maxillary arch.
Two para median osteotomies and one
transverse osteotomy are used.
Midline sectioning of the palate is avoided.
Osteotomised segments should never be
stripped off the nourishing mucosa.
SEGMENTING THE MAXILLA
Bone grafts:
Indicated when large defects in the walls of
maxilla are present.
Critical in buttress and lateral walls.
Advantages:
Greater stabilization
promote healing and
Consolidation of the osteotomy sites.
Autogenous bone grafts preferred
Cranial bone, iliac crest and sometimes
mandibular buccal cortex.
BONE GRAFTING
Wound closure:
Done in layers
Periosteum and muscle layer closed first
in buttress and nasal base.
Mucosa of the lip closed with a horizontal
mattress suture in v-y pattern.
This helps to maintain the height of the
exposed vermilion and lip length.

V-Y CLOSURE
NASAL STINT SUTURE
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