Maxillary and Midface Osteotomies

Presented by: Dr Mohammed Haneef

ContentsIntroduction/HistoryAnatomical ConsiderationsSingle tooth/mulitple tooth osteotomyAnterior maxillary osteotomyPosterior maxillary osteotomyLefort I osteotomyLefort II osteotomyLefort III osteotomySurgically Assisted Maxillary Expansion

Introduction Earliest orthognathic surgery known as orthodontic

surgery 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.

History1859 – Von Langenbeck – nasophyrngeal polyps.

1867 – David Cheever – Le fort 1 osteotomy- nasal obstruction

20th century :-dentofacial deformities

1921 – Cohn Stock – A M O

1950 – Gillies & Harrison – Le fort III

1959 – Schuchardt- post maxillary osteotomy

1969 – Classical L I – Bell

1970’s – Kufner, Henderson & jackson – L II 1990 – Keller & Sather, Quadrangular L I

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 down fracture of the maxilla with

complete mobilization can be accomplished with adequate

vascular supply*JOS-1969;27;249-Revascularization after lefort I osteotomy

ProtocolDesign soft tissue to maintain adequate collateral

blood supply to the ostetomised segment and to avoid injury to vital structures.

Provide optimum exposure.Minimum periostel stripping.Gentle soft tissue handling.Avoid injury to neurovascular bundle.Make osteotomy cuts under constant irrigation with

normal saline.Plan interdental osteotomy cuts with out damaging

periodontal status of adjoining teeth.

Anatomical Considerations

Bell et al 1995-excellent collateral

circulation of the maxilla.

Restoration of blood supply 1 week post

operatively-Dodson -1994

1 week –increase in periosteal-endosteal

blood supply

2 weeks –vessels connecting segments

4 weeks blood circulation in segments

12 weeks

Mid face OsteotomiesSegmental maxillary osteotomy

Single tooth

Anterior segmental

Posterior segmental

Horseshoe

Total maxillary osteotomyLefort ISAME

Classic

Quadrangular

Lefort IIAnterior LF II

Pyramidal LF II

Quadrangular LF II

Lefort III

MidfaceZygomatic

Malar - Maxillary

Corticotomy/Ostetomy In 1892 , Cunningham, first defined it as a linear cutting

technique in the cortical plates surrounding the teeth to produce mobilization of the teeth for immediate movement.

Köle (1959) thoroughly described the clinical application of orthodontically moving teeth after interproximal bone segmentation as a means to expedite tooth movement. He suggested that teeth can be segmented and moved as “small boxes” through bone remodeling without involving the periodontal ligament. Technique was described as an adjunct in the correction of numerous types of malocclusions, with different treatment protocols such as nonextraction and space closure approaches. Using this method, he claimed orthodontic treatment could be accomplished in six to twelve weeks.

Regional acceleratory phenomenon(RAP). This process was described initially by Frost (1989) based on observations of bone fracture healing. In summary, he described a series of orchestrated events consisting of increased cellular activity during healing around the fracture site. These events were characterized by reduction in bone density due to the accelerated bone turnover. The cortical bone porosity appeared to be related to osteoclastic activity that may have contributed to tooth mobility. It has been suggested that the peak of such phenomenon is one or two months after the insult, with effects lasting six to 24 months.

Wilcko and colleagues (2001) reported, Patients with moderate to severe crowding to accelerate tooth movement. The surgical procedure consisted of interproximal vertical grooves on the labial and lingual cortices of all teeth. A subapical horizontal scalloped corticotomy connected the vertical grooves. In addition, numerous circular perforations were drilled on the cortical bone surfaces and a resorbable allograft was packed over the corticotomies and exposed cortical bone. They called this procedure Periodontally Accelerated Osteogenic Orthodontics (PAOO).

Surgical techniqueThe surgical technique for PAOO consists of 5 steps viz.1) Raising of flap, 2) Decortication, 3) Particulate grafting, 4) Closure and 5) Orthodontic force application.

Indicated Tooth malposition.Dental ankylosis.closure of diastema.Sever crowdingFailure of conventional orthodontic treatment

Advantages: Reduction in the treatment time. Lower incidance of relapse.

Disadvantages: Injury to teeth Periodontal compromise Devitalization of teeth.

Seminars in Orthodontics, 2012: 18(4); 286-294

Int. J. Odontostomat 2013; 7(1):79-85, Case Reports in Dentistry 2012; 694527

Anterior Segmental Osteotomy

Cohn-Stock (1920) Wassmund (1935) Wunderer (1963) Cupar (1955) Epker and wolford (1980)

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 techq 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;36:108-112

Downfracture TechniqueTechnique : 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*

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.

Complications of AMO

1. Loss of vitality of the dentition 2. Damage to tooth roots3. Persistent periodontal defects4. Osseous necrosis of the dentoosseous segments5. Communication with the maxillary sinus and nasal

cavity 6. Hemorrhage 7. Oronasal or oroantral fistulas8. Atrophic rhinitis – complete inferior turbinectomy

9. Unfavourable nasolabial esthetics - Shortening & thinning of the upper lip - widening of the alar bases - upturning of the nasal tip

10. Nasal Septal Deviation - Deviation or bucking of the nasal septum cause - inadequate bone removal from the nasal crest of the

maxilla or inadequate trimming of the cartilagenous septum

Posterior Segmental Osteotomy Schuchardt (1959) Kufner (1971) - described a single buccal incision approach. Perko – Bell technique (1967) Indications 1. 1 Post maxillary alveolar hyperplasia2. 2 Total maxillary hyperplasia (when combined with

AMO)3. 3 Distal repositioning of the post maxillary alveolar

fragment to provide space for proper eruption of an impacted canine or bicuspid tooth

4. Spacing in the dentititon that can be closed by ant repositioning of the posterior segment

5. Transverse excess or deficiency6. Posterior open bite7. Posterior cross bite

Complications

Loss of teeth vitality Periodontal defects Necrosis of segment Relapse

Advantages Decreased morbidity Can be performed as outpatient procedures

Combination Anterior & Posterior Maxillary Osteotomy

Also called Horseshoe osteotomy

A combined form of anterior and posterior subapical osteotomies "total

subapical maxillary osteotomy" were reported by Paul 1969 for

midface hypoplasia.. This technique was further described by West &

Epker 1972, Hall & Roddy 1975, Wolford & Epker 1975, West and

McNeil 1975 and Hall & West 1976. Maloney (1982) reviewed this

technique and described it as a good technique during his time.

Indication Maxillary alveolar hyperplasia with or without an anterior open bite deformity

Transverse hypolplasia without a vertical component

This procedure creates a three piece maxilla, with the central nasal portion left

undisturbed, through the use of palatal parasagittal osteotomies

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:683-92

Lefort I Osteotomy

*“Lefort I osteotomy has become the work horse of

Orthognathic surgical procedures .its ease ,its broad

application to resolve many functional and aesthetic problems

and the dependability of its results support this evolution.”

Blood supply

Nasal airway problems and sinus problems*- no adverse

consequences

*-Bell, jos1975;33;412* walker, turvey joms1988

Orthognathic surgery of the maxilla was first described in 1859 by von langenbeck for the removal of nasopharyngeal polyps.

The first American report of a maxillary osteotomy was by David Cheever in 1867 for the treatment of complete nasal obstruction secondary to recurrent epistaxis for which a right hemi maxillary down fracture was used.

Wasmund introduced his lefort I or total maxillary osteotomy technique in 1927

Axhausen used a similar technique in 1934 to correct a healed maxillary fracture. He reported complete mobilization with immediate repositioning. He also reported the use of curved osteotome for pterygomaxillary disjunction.

Separation of the pterygomaxillary junction was advocated by Schuchardt in 1942

Moore and Ward in 1949 recommended horizontal transection of the pterygoid plates for the advancement. However, this technique was abandoned due to incidence of severe bleeding in most cases

Most of these techniques simply mobilized the maxilla to one degree or another, and then placed orthopedic forces on it to achieve desired positioning- a sort of unintentional distraction osteogenesis. These methods were associated with high levels of relapse

• Hugo Obwegesser 1965 advocated complete mobilisation of maxilla so that maxilla could be repositioned without tension. This aided in stabilisation which was documented by Haller, Hogemann & Wilmar and Perko

• Bennett & Wolford (1985) described cutts Parallel FH plane to prevent ramping effect.

• The correct used of curved osteotome described by Turvey and Fonseca in 1980

• Precious et al described pterygomaxillary dysjunction without the use of osteotome (1991)

• Use of Swan neck osteotome by cheng ( 1993)• Use of Saw by cheng (1993)• Use of Shark Fin osteotome by laster (2002)• Twist technique by fredricko (2012)

In 1965, Obwegeser suggested complete mobilization of the maxilla so that repositioning could be accomplished without tension. This proved to be a major advance in stabilization, as documented by Hogemann and Willmar, De Haller, and Perko respectively

Early descriptions of the rigid fixation of maxillary osteotomies were published by Michelet and colleagues in 1973, Horster in 1980, Drommer and Luhr in 1981, and Luyk and ward-booth in 1985. Since that time, many methods have been advocated for the rigid fixation of maxillary osteotomies. These have included bone plates, metallic mesh, pins, the rigid adjustable pin (RAP) system, and resorbable fixation.

In the early 1970s, Bell and colleagues demonstrated that early osseous union with minimal osteonecrosis occurred following total maxillary osteotomy, indicating that the palatal soft tissue pedicle and the labial buccal gingival provide an adequate nutrient pedicle for single stage osteotomy.

Bell and colleagues in 1975 provided evidence through micro angiographic studies that bilateral transection of the descending palatine vessels did not adversely affect the lefort I osteotomy procedure if basic surgical principles were followed.

Studies by Dodson and co workers in 1994 measured the blood flow to the maxillary gingiva, using laser Doppler flowmetry following lefort I osteotomy with sacrifice of bilateral descending palatine arteries. Their results were similar to those of previous studies, showing transient vascular ischemia and restored blood flow in the anterior maxilla one week postoperatively.

Bell and colleagues in 1995 continued to investigate the limits of this surgical technique by performing the lefort I osteotomy using a standard circum vestibular incision, segmentalizing the maxilla, stretching the palatal vascular pedicle and transecting the descending palatine arteries. The result was uncomplicated post operative healing, with only transient vascular ischemia.

Hugo Obwegesser 1969 described a high quadrangular Le Fort I osteotomy for midface deficiency correction. This technique was later named as Quadrangular Le Fort I osteotomy by Keller & Sather 1989.

Kuffner in 1970 also described a quadrangualar lefort I osteotomy.

Indications The lefort I osteotomy can be used to correct a variety of

maxillofacial problems maxillary advancement, especially in cleft palate and post

trauma patients To correct maxillary prognathism Superior repositioning of the maxilla, to correct vertical

maxillary excess Inferior repositioning of the maxilla, to correct vertical

maxillary deficiency Widening of the maxilla, to correct transverse

discrepancies 3D repositioning of the maxilla ( segmental osteotomies ) In all instances of apertognathia, lefort I osteotomy should

be given consideration because of the stability issues.

Surgical technique

1. Positioning of the patient-10 degree head

elevation

2. Hypotension GA (90mm/Hg systolic*)

3. Infiltration of the soft tissue with a

vasoconstrictor.2% lidocaine (1;100000)*Anderson-delibrate hypotensive anesthesia for orthoganthic surgery.adult orthodontic orthognathic surgery 1986;1;133

Modifications

Technique An intraoral incision is made in the buccal vestibule of the maxilla from

the molar region of one side to the opposite one and a mucoperiosteal flap is raised exposing the anterior-lateral walls of the maxilla.

The dissection is extended laterally and superiorly towards the zygomatic buttress and the zygomatic process of the temporal bone.

The infraorbital nerve is identified and the dissection is then extended to the orbital floor with a curved periosteal elevator in order to simplify the following osteotomies and to achieve direct control of periorbital tissues.

The osteotomy is performed with a reciprocating saw or a fissure bur, starting from the lateral aspect of the piriform aperture and is extended to the medial aspect of the inferior orbital rim. The second osteotomy line starts from the lateral aspect of the inferior orbital rim and is directed towards the zygomatic buttress as far back as is possible.

This osteotomy is completed with a chisel, which is inclined backwards and laterally, in order to create an enlarged mobilized segment of the malar bone. The two osteotomies are then connected along the anterior orbital floor with curved osteotomes specially designed for this manoeuvre and for protection of periorbital tissues.

The same procedure is performed on the opposite side. The osteotomy of the nasal septum is performed according to Le Fort I routine modalities, whereas the osteotomy of the medial walls of the maxillary sinuses are carried out in a higher position.

Particular attention must be drawn to pterygomaxillary osteotomy both apically and medially in order to simplify the mobilization of the maxillo-malar complex.

Advantages of these modifications are the following: 1. The aesthetic 'epicentre' of the zygomatic buttress is included in the osteotomized segment. 2. The osteotomies along the orbital floor are performed under direct control, thus avoiding possible damage to the periorbita. 3. The larger and thicker osteotomized maxillo-malar segment reduces the risk of green-stick or undesired fractures of the thin anterior wall of the maxillary sinus. 4. The laterally inclined osteotomy of the malar bone permits the creation of an inclined plane instead of a gap following maxillo-malar advancement, thus facilitating bone grafting and the stabilization of the maxillo-malar complex with titanium miniplates along the lateral and medial osteotomies.

Complications: The post surgical complications include:

Wound infectionBone sequestrum without sepsisNeurologic deficit involving the infraorbital nerve was

considered minor and transient in all patients (in contrast to lefort II patients), as nerve handling is relatively minor with this procedure

Irregular infraorbital rim contour, because of onlay bone grafting in this area

Nasolacrimal duct dysfunction, due to passage of the transosseous medial orbital rim wires or miniplate placement.

Infraorbital emphysema, if the patient blows his or her nose

Iliac crest donor site complications, are infrequent and minor.

Segmentalization

Postsurgical management The surgical splint placed for 6 weeks. Elastics should be worn for at the time for 6 to 8 weeks. Non – exertional activity for 6 to 8 weeks. Nasal spray(oxymetazolin) Systemic decongestion

Hierarchy of stabilityMaxillary advancement, posterior and superior movements are shown to be stable whereas inferior & transverse movements are unstable.

Advantages Speed General familiarity with the osteotomy design Simplicity Facility in repositioning the maxilla superiorly & posteriorly The ease & safety of segmentation It can be combined with lateral maxillary osteotomyDisadvantages Possible telescoping of repositioned segments Difficulty for application of screw and plate in individuals

with aberrant anatomy. Difficulty in positioning corticocancellous bone grafts in the

pterygopalatine region. Potential for unpredictable changes in the vertical maxillary

position

Complications Intraoperative Postoperative

Intraoperative 1. Incision design & closure2. Unfavourable osteotomy - # at the junction of the horizontal process of the palatine bone with the palatal process of the maxilla - high horizontal # of the pyramidal process of the palatine bone - horizontal # of the pterygoid plates

3. Bleeding PSA Artery Greater palatine artery Maxillary artery Pterygoid venous plexus

Management Localized pressure packing directed at the bleeding point Cauterization with either chemical or with diathermy Ligation of the ECA Transantral ligation of maxillary artery Angiographic emoblization

4. Bradycardia Profound bradycardia & asystole occur during down fracture or mobilization of maxilla – Trigemino- cardia reflex(TCR)Seen with the procedures which result in manipulation of the central or peripheral portions of the trigeminal n TCR – bradycardia < 60b/m, hypotension with a drop in the mean arterial pressure of more than 20% coincidental with surgical manipulation or traction at or around branches of the TN.Management – manipulation of the maxilla should be stopped immediately - Administration of anticholinergic medications such as atropine or glycopyrolate

6. Improper maxilary repositioning - failure to seat one or both of the mandibular condyles

during maxillary repositioning will cause improper maxillary positioning & a malocclusion

cause - insufficient bone removal

Postoperative

Infections Sinusitis Occlusal derrangement Unaesthetic apperence Vascular compromise Haemotoma Devitalization of teeth Periodontal problems Oroantral communication

Eur Rev Med Pharmacol Sci. 2013 Feb;17(3):379-84.

Surgical Assisted Maxillary Expansion (SAME)

Brown first described SAME in 1938 - midpalatal split A LeFort I type of osteotomy with a segmental split of the

maxillaand the placement of a triangular unicortical iliac graft for correction of maxillary constriction was presented by Steinhauser in 1972.

Indications:

Skeletal maxillomandibular transverse discrepancy greater than 5mm Significant TMD associated with a narrow maxilla and wide mandible Failed 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 Widening of the arch following collapse associated with the cleft palate

deformity

Technique

Complications Those due to inadequate surgery:

PainDental tippingPeriodontal breakdownPost orthodontic relapse

Those due to expansion Lack of appliance expansionDeformation of the appliance due to processing errorsStripping or loosening of midpalatal screw

Intraoperative hemorrhage Devitalization of the teeth

Lefort II OsteotomySteinhauser 1980Anterior L F II OsteotomiesPyramidal LF II OsteotomiesQuadrangular LF III Osteotomies.

Indications:Maxillary- zygomatic deficiency with skeletal class III

malocclusion, and normal nasal projection.Nasomaxillary deficiency, a pyramidal lefort II

osteotomy Maxillary alveolar – palatal cleft deformity & normal

nasal projection

Anterior Lefort II

Described in detail by converse et al (1970)

Relating to nasomaxillary hypoplasia.Only naso-orbital osteotomy, but doesn’t

include posterior maxilla of infra-orbital rims.

Principles

The principles of these procedure are:The foreshortened nasal septal frame work must be

advanced as it will oppose nasal lengthening.A forward and downward placement of nasal and

maxillary complex is required to correct midface deficiency.

The naso lacrimal apparatus must not be disturbed.Bone grafts should be used to restore the Bone

deficiencies.Skin coverage and nasal lining must be provided to

accommodate the nasal elongation.

Procedure

The upper part of this osteotomy done, through a V shaped incision with the apex at glabella and extended bilaterally along both sides of nose to reach just above the alar base. The cartilaginous and bony part of nose is separated and the columella is pulled down.

Osteotomy begins at lower end of nasal bone directed medially to the medial wall of orbit than downward to reach the floor of orbit posterior to naso lacrimal apparatus. Then it is brought to infra orbital margin medial to the nerve and extended downwards to the alveolar bone posterior to 1st premolar. Then a posteriorly based palatal flap is raised and 5/5 are extracted the osteotomy is completed through the sockets of this dividing hard palate. Now the segment is mobilised and advanced. This can be fixed by a prefabricated acrylic splint.

This Procedure:Lengthens the noseNasal tip moved anteriorly and downwards.

Advances anterior maxillary segment.This technique was modified by Psillakis

& Co worker 1973 by taking a transverse osteotomy above the apices of anterior teeth and augmenting the nasomaxillary segment. This is not biologically sound so this technique is hardly used nowadays

Pyramidal Lefort IIHenderson and Jackson 1973

Indication Nasomaxillary hypoplasia : 4 types- Involving dentoalveolar segment- Excluding dentoalveolar segment (Binders syndrome)- Cleft palate patients- Pan facial problems

Quadrangular Lefort II

• First described by Kufner (1971), modified by Souyris et al (1973), Champy et al (1980) and by Steinhauser (1980).

• Middle osteotomy• Keller and Sather did the entire

procedure intraorally

COMPLICATIONS: A) INTRAOPERATIVE COPLICATIONS:

HaemorrhageUnfavourable osteotomy

Uncommon. – Unfavorable fracture below the orbital rim if incomplete or improperly angled bone cuts are present.

B) POSTOPERATIVE COMPLICATIONS:1) Orbital complications: diplopia, enopthalmus, chemosis, ecchymosis.

Diplopia- extra ocular muscle spasm secondary to trauma and edema from the orbital floor periosteum elevation.Enopthalmus – due to herniation of the orbital fat into the antrum. These orbital Complications are more common in the pyramidal lefort II or III osteotomy, as a significant large portion of the orbital rim and contents is surgically exposed.

2) Nasolacrimal duct dysfunction: Secondary to edema (rather than transection) from surgical manipulation.

3) Infraorbital nerve dysfunction:Experienced by all patients undergoing the various lefort II osteotomy procedures (except the pyramidal type when the orbital rim cut is medial to the nerve.

All patients experience varying degrees of dysesthesia (ex: numbness, tingling) for varying periods (3-12 months).

4) Infraorbital rim contour irregularity

5) Wound sepsis

6) Surgical advancement relapse .

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

Lefort III Osteotomy

Intraoperative Haemorrhage Unfarouble ostetomy Iatrogenic injur

PostraoperativeHaemorrhageinfectionsNasolacrimal duct damageEnoptholmosesNeurosensory defecitsRelapseMenigiocoele