Maxillary procedures and soft tissue changes /certified fixed orthodontic courses by Indian dental academy

Maxillary procedures and soft tissue
changes
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Contents :
 History
 Anatomic considerations
 Maxillary deformities
 Midface osteotomies
 Surgical procedures
 Complications
 references


Introduction
 Orthognathic surgery
 correct both facial deformity and oral dysfunction.
 Facial beauty is difficult to define in precise terms
 subtle differences between individuals can produce marked aesthetic

contrasts.
 Different racial forms of beauty are not comparable and so ethnic

norms are required to correct the abnormality.
 skeletal abnormality is recognisable, measurable.

History


History
1859 – Von Langenbeck – nasophyrngeal angiofibroma.
1867 – David Cheever – Le fort 1 osteotomy- nasal obstruction
20th century :-dentofacial deformities
1921 – Cohn Stock – A M O
1950 – Gillies & Harrison – Le fort 111
1959 – schuchardt- post maxillary osteotomy
1969 -75 – Bell – Biologic basis
1970’s – Kufner, Henderson & jackson – L 1

History
Initial Days..


Segmental osteotomies



Complete mobilization was
avoided



High incidences of relapse


 1965- Obwegeser complete mobilization of maxilla  repositioning

could be accomplished without tension
 Until 1960-pedicle of soft tissue on buccal side
 *Bell 1969-75-as long as maxilla is pedicled to palatal mucosa ,labial

gingiva and mucosa ,down fracture of the maxilla with complete
mobilization can be accomplished with adequate vascular supply

*JOS-1969;27;249-Revascularization after lefort 1 osteotomy

Anatomic considerations :


External carotid artery :
Maxillary artery
Facial artery
Ascending pharyngeal artery



Bell et al 1975,
Quejada -1986
B/L descending
palatine artery can
be transected –if
basic principles are
followed


 Bell et al 1995-proved the

excellent collateral circulation of
the maxilla.
 Restoration of blood supply 1 week

post operatively-Dodson -1994


Mid face osteotomies
Segmental maxillary osteotomy

Total maxillary osteotomy

Single tooth
Anterior segmental
Posterior segmental
Horseshoe


Total maxillary osteotomy
Le Fort 1

SAME
Classic down fracture
Quadrangular

Le Fort 11 Le Fort 111

Anterior L F 11
Pyramidal L F 11
Quadrangular L F 11


Mid face

Zygomatic
Malar maxillary

Transverse maxillary deficiencies
 Complete and accurate evaluation - transverse dimension .
 Treated with orthodontic expansion  relapse after appliance

removal
 Orthopedic /rapid maxillary expansion
 Predictable and stable results (Angell -1860 using expansion screw )
 1960- Haas reintroduced teq, as age increases resistance to

expansion
 This led to SAME www.indiandentalacademy.com

Transverse maxillary deficiency :
 Incidence : 8%
 Etiology :Congenital,

Developmental (thumb sucking )
Traumatic
Iatrogenic (cleft palate)
 Diagnosis :

dental cross bite
skeletal cross bites (Jacobs-JAO1980)
high arched palate
paranasal hollowing and narrow alar base
P A cephalogram
frontal tomography
C T scans.

Rocky mountain analysis*
 10+/-1.5mm -TMD
 Total transverse deficiency

<5mm orthopedic expansion
>5mmsurgical expansion

Ricketts –angle orthodontics 1981;51;115-50

Transverse maxillary deficiency

 Treatment :

1. S D E (slow dento alveolar expansion )2-4months
2. O R M E (orthopedic rapid maxillary expansion) 1-4 weeks
3. S A M E(surgically assisted maxillary expansion )1-2 weeks
4. S M O (segmental maxillary osteotomy)

 * “To achieve the desired expansion and stability ,transverse maxillary

expansion should be accomplished by sutural adjustments in the
craniofacial complex not by alveolar bending and dental tipping.”

*Starnbaatch –angle orthodontics 1966

SAME
 Brown-1938- midpalatal split
 Timms – major resistance to expansion is midpalatal suture.*
 Kennedy –lateral maxillary osteotomy with midpalatal split
 *Shetty-all bony buttress contribute resistance for expansion but

midpalatal suture followed by pterygomaxillary articulations

*Bjoms 1981;9;180
*JOMS 1994-;52;742


SAME:
Indications of S A M E :
 Skeletal maxillomandibular transverse discrepancy > 5mm
 Significant TMD asstd with a narrow maxilla and wide mandible
 Failed orthodontic expansion
 Necessity for a large amount > 7mm of expansion
 Extremely thin and delicate gingival tissues with buccal gingival recession
 Significant nasal stenosis


Benefits of S A M E :


Skeletal and dental stability



Non-extraction orthodontic alignment of teeth



Esthetics by eliminating negative space



Periodontal health



Nasal respiration


SAME:

Technique of S A M E :
 Mandibular dentition should be
decompensated
 Maxillary expansion appliance
– preoperatively

Surgical technique :
1 Incision


B/L maxillary osteotomy with step at buttress

Release of nasal septum


Midline palatal osteotomy


Lateral nasal wall osteotomy (anterior 1.5mm)

B/L release of the pterygoid plates


Activation of the appliance : 3-4mm then 1-1.5 mm


 Soft tissue closure

 Alar base Cinch with non resorbable suture + v-y closure

 SAME can be used for unilateral asymmetries


SAME:
 Maxilla should remain stationary – 5 days then 0.5mm /day

 Ilzarovs principle- “healing period of 5 days allows for capillary healing

across the bony gap”

 0.5mm-1mm/day –expansion > this causes gingival recession


During expansion
 discomfort
 severe increase in pain then bony

interferences

Tightness and minor discomfort


During expansion


Clinical signs of SAME
 Immature attached gingival tissue - medial to each central incisor tooth
 Expansion exceeds the ability of the attached gingiva to remodel 

sign of success (if b/l and symmetric)
 Recession / gaping occurs then rate should be decreased
 Over correction is not required
 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.


Modifications of SAME
Age
Palatal tori
Skeletal open bite / open bite
When future Lefort 1


Palatal tori
At the time of SAME
Modifications of incisions

Tori excision
After six months
SAME


Skeletal open bite / open bite
Ramped cut
Angled cut

Vertical step
At the buttress


segmental osteotomies :
 Performed many years before total maxillary osteotomies
 Allows for improvement in occlusion but at the expense of facial

esthetics
 Past decade the versatility and reliability of total maxillary osteotomies
 AMO -

Isolated anterior open bite /bimaxillary protrusion
 PMO-

pre prosthetic surgery

Single tooth osteotomy :
Indications
tooth malposition
Dental ankylosiss
Closure of diastema
Initially some surgeons were reluctant to do this teq


Soft tissue necrosis



Tooth devitaliztion

 Pulpal necrosis

*Variety of studies & bell -5mm and above the apices – adequate to maintain the vitality
Anterior& posterior Subapical osteotomies -3mm is adequate(sheideman-joms.1985;43;408 )

*yoshida-biologic responses of the pulp to single tooth osteotomy OOOO-1996;82
Bell-revsclstion & bone healing after AMO. JOS1969;27;249,1978

Single tooth osteotomy
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 maxillary osteotomies :
1921 – Cohn Stock.
Transverse palatal incision
Wedge shaped osteotomy green stick fracture retracted the anterior
segment Relapsed within 4 weeks
Various incision designs for desired osseous movements .
*Bell- overall procedure is predictable from standpoint of dental stability
and soft tissue changes.

* Stability and soft tissue changes in anterior part of jaw surgery A J ORDNTCS;1973

Indications :
 Correction of bimaxillary protrusion.
 Marked protrusion of the maxillary teeth (normal incisor axial

inclination to alveolar bone)
 Anterior open bite
 To retract the anterior teeth when that cannot be accomplished by

conventional orthodontic treatment.(pt noncomplience)
 When orthodontic tooth movement is inadvisable.(ankylosiss, root

resorption)
 Improvement in appearance.

 *Radioactive microsphere teq used assess the blood flow in AMO

in macaque monkeys.
 Variation in flap design didn’t affect the postop blood supply to ant

maxillary segment.
 This study gives scientific credence to different incisions for AMO
 Blood supply can be maintained by-

labial-buccal & palatal tissues ,
labial –buccal tissues alone
palatal tissues alone
*Nelson –quantation of blood flow after AMO in three teq-JOS;1978;36;108

A M O Techniques :
 Wunderer
 Wassmund
 Cupar


Wunderer-AMO
 When posterior movement of A

M segment
 Transpalatal incision
 Can be combined with buccal

vertical incision in the region of
the planned extractions
/interdental osteotomies


Wunderer teq-AMO
 Advantages-direct palatal access transverse palatal osteotomy through

molar site
This teq relies on intact buccal pedicle

Modifications of Wunderer teq
-midline vertical incision +incisions at extractions sites 
horizontal osteotomy
separation of nasal septum from maxillary segment performed directly


Wassmund technique : 1935
 vertical incision – planned

extraction or interdental osteotomy.
 Preserves both buccal & palatal
soft tissues.
Anterior nasal spine
incision.
 Osteotomy : buccal horizontal
osteotomy
Transpalatal osteotomy
if required midpalatal
sagittal split
repositioning of entire
segment.

Cupar method :
Technique :
A buccal vestibular incision
is created, allowing direct
access to the anterior lateral
maxillary walls, piriform
aperture, nasal floor and
septum.
Most commonly used for AMO*

*Epker joms a modifed AMO 1977 ;5; 35

Cupar method :

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.


Posterior maxillary osteotomy :
Schudart in 1959 :
Indications :
 Posterior maxillary alveolar hyperplasia
 Total maxillary hyperplasia
 Distal repositioning(guiding the eruption of impacted teeth )
 Spacing in the dentition
 Transverse excess or deficiency
 Posterior open bite.
Surgical technique :
Incision :
buccal vestibular incision from 3-6
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(3 rd molor

extraction site or like lefort I osteotomy )

 Palatal osteotomy – curved osteotome.
 Acrylic splint
 Fixation.


Horizontal osteotomy 5 mm
above the root apices.
Vertical osteotomy through the
extraction sites.

Palatal osteotomy – curved osteotome.


Combination anterior and posterior
maxillary osteotomy :
 Horseshoe osteotomy
 Historical purpose
 Maxillary alveolar hyperplasia with or with out anterior open bite deformity
 Transverse maxillary hypoplasia.


SAME

Segmental maxillary
osteotomy

Relapse

Pogrel-11.8%(molar)
Greco-8.8%(canine)
7.7%(molar)

Stephens-30%(canine)
23%(molar)
Phillips-30% premolar
51% molar

Pattern of expansion

More at canine region
Less at molar region

Less at canine region
More at molar region

Osteotomy of articulations

Not all articulations are not
osteotomised superiorly
and inferiorly

extraction

no


yes

SAME
All direction movement Two surgical
procedures

Segmental
single

Difficult
Teq sesnsitive
Potentially more
morbid
Total theater timings

SAME+ Lefort I


Which one to select?
SAME /Segmental osteotomy


 Only in transverse SAME
 When pt requires anterior posterior and vertical movements

if >6mm SAME
if <7mmsegmental
 If two separate surgical procedures are planned then SAME should be

performed


Maxillary procedures and soft tissue changes /certified fixed orthodontic courses by Indian dental academy

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