Maxillary Osteotomies & Associated Surgical complications

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


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.


• similar to Le Fort 1

• Oblique Para nasal skin incision

• Infraorbital rim osteotomy

• Medial canthus – osteotomy over nasal bone

• Bone grafts and fixation.


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



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.


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


Devitalized tooth :

• Osteotomies – 5mm

• Endodontic therapy

Nerve injury :

• Anatomy

• Neurosensory changes

• Careful retraction

• Reasses the patient

• Consider re-exploration


Nasolacrimal injuries:

• Epiphora

• Dacryocystorhinostomy

Oronasal and oroantral fistulas :

• Large expansion

• Intact nasal mucosa

• Decongestants, nasal sprays, antibiotics

• Oral hygiene

• Surgical closure.


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.


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.


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.


• 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

Maxillary Osteotomies & Associated Surgical complications

Education

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