Maxillary osteotomies

Dr V.RAMKUMARCONSULTANT DENTAL&FACIOMAXILLARY

SURGEONREG NO:4118-TAMILNADU-INDIA(ASIA)

Common maxillary deformities

Maxillary anteroposterior excessMaxillary anteroposterior deficiencyVertical maxillary excessVertical maxillary deficiencyAlveolar cleftsCraniosynostoses (aperts,crouzon)Binders syndromeachondroplasia

Patient evaluation and diagnosis

a. Patient concernsb. Clinical evaluation1. Facial form-frontal and profile long, short, convex, concave, flat2. Relation ship of facial thirds3. Soft tissue –dentition relations smile line, Occlusal cant, dental

midlines

Orthognathic planningTo get an optimal balance between

1.Aesthetics

2.Function

3.Stability

4.Clinical measurementsa. Vertical dimensions

b. Antero posterior dimensions

c. Transverse dimensions

d. Intra arch dimensions

Cont’d

5.Radiographic analysisa. Cephalometric

b. Orthopantomogram

6.Dental study models

7.Speech

8.Audiometry

9.Medical and psychological

Sequence of treatment planning

Dental and periodontal

Extractions

Presurgical orthodontics

Orthognathic surgery

Post surgical orthodontics

Maintenance

Others

Presurgical orthodontics

Position the teeth over their respective basal bone

Align and level the teeth

Adjust for tooth size discrepancies

Correct rotated teeth

Co-ordinate upper and lower arch widths

Types

Segmental maxillary surgery

1. Single tooth osteotomy

2. Corticotomy

3. Anterior segmental osteotomy

a.wassmund-1935

b.wunderer-1963

c. Cupar’s down fracture

Cont’d

4.Posterior segmental osteotomy

Schuchardt

Kufner

Perko & Bell

5.Horse shoe osteotomy

Wolford and epker

Total maxillary surgery

Le fort I osteotomy a. Classic down fracture b. Buttress release (surgically assisted maxillary expansion) c. Quadrangular

Le fort II osteotomy a. Anterior b. Pyramidal c. quadrangular

Cont’d

Le fort III osteotomy

Gillies

Tessier

4.Other midface osteotomies

a. Zygomatic osteotomies

b. Malar –maxillary osteotomy

Segmental maxillary osteotomies

Surgical repositioning is possible for small dento alveolar segments provided maximum mucoperiosteal attachment is maintained

Incisions planned such that maximum soft tissue pedicle is maintained

Apicoectomy of teeth should be avoided during the procedure to prevent pulpal atrophy

Single tooth osteotomies

for upper anterior teeth which are dilacerated or traumatically impacted

Incision-high vestibular cut or two vertical incisions on either side of tooth

Osteotomy- 3 mm apical to root apex and at least 2-3 mm from alveolar crest

Separation done using fine osteotomes

Fixing done to adjacent teeth using inter dental wires

Corticotomy

To permit surgically assisted retraction of upper anterior teeth in class II div I mal occlusionsVestibular incision from premolar to premolar is usedCortical bone removed labially and palatallyBone also removed from 5mm above the teeth

Posterior segmental maxillary osteotomy

Correction of anterior or posterior open bite

Correction of posterior cross bites

Closure of edentulous spaces as in cleft cases

Horse shoe osteotomy

Palate remains in original position

Dento alveolar complex alone is repositioned

Aim is to minimize the size of the reduction of the nasal cavity

Technically difficult since multiple areas of bony contacts are there

Anterior segmental maxillary osteotomy

Used when alteration of premaxilla in the vertical plane is required as in anterior open bite or deep over bite

Three techniques are usually described

Down fracture technique preferred when vertical movement is required

Cupar’s down fracture

Pre operative Post operative

technique

Incision Osteotomy cuts

Cont….

Fixation – wire osteosynthesis Closure

Wassmund technique

Incisions

vertical incisions in premolar region and along frenum

Midline sagittal section along hard palate

osteotomies

bone cuts made through tunneling approach under mucosaBuccal- right angled osteotomy with extraction of first premolarsSub labial-separation of nasal septum and lateral nasal wallPalatal-transverse cut from first premolar to first premolar10-15 mm of bone between nasal floor and tooth apices

Wunderer technique

Similar to wassmund

Palate is exposed by a transverse palatal incision with margins away from osteotomy site

Le fort I osteotomy

Classic le fort I down fracture (bell)

1.Allows full mobilization of maxilla

2.Permits bone surgery under direct vision

3.Reduced risk of relapse

incision Osteotomy cuts

Pterygoid dysjunction

Surgical technique

Vestibular incision from first molar to first molar

Osteotomy at least 5 mm above apices of the teeth

Anterior cut-4-5 mm above canine

vertical cut-zygomatic buttress region

Posterior cuts-4-5 mm above molar apices

Cont’d

Osteotomy of lateral nasal wall and septum

Separation of pterygomaxillary junction

Curved osteotomes used for pterygoid disjunction

Down fracture of maxilla using rowes disimpaction forceps

Cont’d

Complete mobilization and trimming of maxilla is done

Maxilla should be able to sit in a passive position

Stability and healing is facilitated by interpositional bone grafts

Case -1

Incision Osteotomy cuts

Cont…..

Completion of osteotomy cuts Down fracture

Cont…

Pre op Cephelogram Post op Cephelogram

Le fort II osteotomy

For correction of nasomaxillary hypoplasia

It is a pyramidal naso-orbital maxillary osteotomy

Le fort III osteotomy

Total midface osteotomy

For correction of various craniofacial syndromes like aperts crouzon etc

Post surgical orthodontics

Final tooth alignment and parallelism

Maximum inter digitations

Ideal overbite and over jet

Centric occlusion =centric relation

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