Cirurgia Ortognática

Cirurgia Ortognática

Abordagem clínica e cirúrgica

Prof. Horácio Costa

Serviço de Cirurgia Plástica Reconstrutiva e Craniomaxilofacial Unidade de Microcirurgia Centro Hospitalar de Gaia

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Anatomy Concepts Craniofacial Bones



Anatomy Concepts Craniofacial Muscular insertions



Anatomy Concepts

Craniofacial - Infratemporal and Pterigoid areas



Anatomy Concepts

Craniofacial – Nasal cavity



Anatomy Concepts

Mandible – Development concepts



Mandible – Muscular insertions

Anatomy Concepts



Muscles of Mastication

Anatomy Concepts



Vascular supply

Anatomy Concepts



Nerves - Trigemium

Anatomy Concepts



Growth Modifications

1- Deficient mandibular growth

2- Excessive mandibular growth

3- Deficient maxilar gowth

4- Excessive maxilar growth

5- Assymmetric growth



Treatment Options

Orthodontic Camouflage

Surgical Camouflage

Maxillary Osteotomies

Mandibular Osteotomies

Rhinoplasty

Genioplasty

Soft tissue procedures




GOAL – Correction of the obvious aspects of

the deformity without correction of underlying

deformity itself



Class II

- Retraction of protuding maxillary incisor teeth

- Displacement of the teeth of both arches (upper

teeth back and lower teeth forward)

- Reposition of the chin and/or nose (genioplasty

and/or rhinoplasty)




Class III

- Moving the lower teeth backwards

- Displacement of the teeth of both arches (upper

teeth forward and lower teeth backwards)

- Reposition of the chin and/or nose (genioplasty

and/or rhinoplasty)

- Only grafts to the anterior maxilla




Assimetry

- Displacement of the teeth of both arches

- Only grafts (maxilla and/or mandible)

- Rhinoplasty

- Genioplasty




Surgical Camouflage

Surgical camouflage has the same goal as orthodontic camouflage

GOAL – Remove the appearence of jaw

deformity without correcting the underlying

skeletal problem



Genioplasty – Chin surgery

Augmentation:

- Bone grafts

- Cartilage grafts

- Alloplastic materials

Reduction

Advancement

Retrusion

Rotation

Surgical Camouflage



Rhinoplasty – Nose surgery

Dorsum Augmentation:

- Bone grafts

- Cartilage grafts

- Alloplastic materials

Dorsum Reduction:

alar cartilages

Tip Surgery cartilagenous septum

columella

Surgical Camouflage



Rhinoplasty – Nose types

(from Fomon and Bell (1970) – variations in normal nasal anatomy among racial and ethnic groups)

Leptorrhine:

- usually found in Whites

- a long, high, narrow nose and nostrils

Rhinoplastic Treatment:

- Elevation of the Tip

- Reduction of nasal projection

- Modification of the nasal dorsum

Surgical Camouflage





Mesorrhine:

- usually found among Asians

- lack of dorsal height and columellar support

Rhinoplastic Treatment: - Dorsum augmentation

- Tip narrowing

Surgical Camouflage





Platyrrhine:

- usually found among Blacks - a flat, broad nose and wide nostrils

Rhinoplastic Treatment:

- Dorsum narrowing

- lateral nasal osteotomies

- Dorsum augmentation

- Cartilage graft

- Alar base marrowing

- Resection

Surgical Camouflage



Soft Tissue Procedures Lip

- Reduction Cheiloplasty (rarely indicated)

- Lenghtening of short filtrum (V-Y cheiloplasty)

- Management of Aging changes:

- Lift procedure (skin excision)

- Augmentation:

• fat grafts

• collagen

• human dermis

• human fascia

• synthetic materials

Surgical Camouflage



Submental area - Lipectomy

- Liposuction

- Platysmal lift

- Rhytidectomy with SMAS plicature

Soft Tissue Procedures

Surgical Camouflage




Le Fort I Osteotomy

Le Fort II Osteotomy

Le Fort III Osteotomy

Anterior subapical osteotomy:

- Wassmund Technique

- Wunderer Technique

Posterior Subapical Osteotomy

Nasomaxillary Osteotomy




Le Fort I Osteotomy



Le Fort II Osteotomy





Le Fort III Osteotomy



Anterior subapical osteotomy - Wassmund Technique




Anterior subapical osteotomy - Wunderer Technique




Posterior Subapical Osteotomy




Nasomaxillary Osteotomy




Sagital Split Osteotomy

Intra-oral Vertical Ramus Osteotomy

Extra-oral Vertical Ramus Osteotomy

Combined Vertical Ramus and Sagittal Osteotomies

Inferior Alveolar Neurovascular Bundle Decompression

Body Osteotomy/ Ostectomy

Midline Osteotomy / Ostectomy

Inferior Border Osteotomy

Anterior Subapical Osteotomy

Total Subapical Ostectomy




Mandibular Osteotomies - History

1940














Obegeweser 1964







Extra-oral Vertical Ramus Osteotomy












Combined Vertical Ramus and Sagittal Osteotomies




Inferior Alveolar Neurovascular Bundle Decompression




Body Ostectomy




Midline Osteotomy / Ostectomy




Inferior Border Osteotomy




Anterior Subapical Osteotomy




Total Subapical Ostectomy




Fixation and Stabilization

Traditional Wire Fixation Methods

Combination of: Transosseous wire fixation

Skeletal wire fixation

Maxillomandibular Immobilization for 6 to 8 weeks



Rigid Internal Fixation

Techniques

Bicortically Fully Thread Screw

Bicortical Fully Thread Lag Screw

Small Bone Plates + Monocortical Thread Screw

Maxillomandibular Immobilization with wires:

• Intra-operative - Immediate Removal

• Post-operative - from 2 to 3 weeks

Linear pattern

Triangular pattern












Fixation and Stabilization Rigid Internal Fixation

Advantages:

→ Improved Comfort and Convenience:

Post-operative airway control

Nutrition

Speech

Oral Hygiene

→ Increased Safety in the immediate post-operative period:

Excessive hemorrhage

Vomiting

Airway suctioning




Advantages:

Increased stability

More rapid bone healing

Evaluation of Post-operative Occlusion in the Operating room

Ability to stabilize unstable bony segments (Unanticipated fractures)

Faster Reduction of Post-operative Edema

Rehabilitation of Muscles and the TM Joint




Disadvantages:

→ Technical Difficulties:

Plate contouring sometimes difficult

Improper Position of screws (Be careful with the

mandibular condyles displacement)

→ Increased Costs

→ Increased Risk of Infection (Buckley et al. 1989)

Maxillary surgery WF and RIF 2%

Mandibular Surgery WF 3% RIF 9%




Disadvantages:

→ Possible Need for Plate Removal (Buckley et al.1989)

Maxillary surgery 2%

Mandibular surgery 7%

Persistent wound infection

Metal sensitivity (stainless steel)

Bothersome presence (plate or screw palpation through

skin or mucosa)

Fixation and Stabilization Fixation and Stabilization




Disadvantages:

Neurosensory Disturbances

Tooth Devitalization

Post-operative TM Joint Symptoms

Torquing

Distraction

Rotation

Condylar segments



Wire Fixation

Healing is the result of a secondary bone healing process

in which the first step is the formation of a callus. This is followed by generation of new osteoblastic activity, deposition of bone and eventual remodeling.


Under compression, bone appears to heal primarily

without no obvious endosteal or periosteal callus. At 6 weeks post-operatively, the strength of RIF osteotomies is twice compared with WF (Reitzik and Schorl, 1983)

Fixation and Stabilization – Bone Healing



Plating and or Screw Techniques

Malposition of Bony Segments

Post Surgically

Occlusal Disharmony

Reoperation

BE

AWARE

…




Wire Fixation Rigid Internal Fixation Plates and / or Screws

Some movement in

osteosynthesis

Very little movement in

osteosynthesis

Possible spontaneous

improvement

Muscle forces

Post-operative orthodonty

No prospect of spontaneous

improvement

RE-OPERATION ? RE-OPERATION




Surgical Complications Intra-operative

- Improper positioned osteotomy

- Unanticipated fractures (variability in bone architecture and density)

- Mandibular Ramus (BSSO – 5 to 22%)

- Pterygoid Plates (Le Fort I 80%)

- Oral-Antral Fistula (Maxillary segmental surgery)

- Oral-Nasal Fistula (Maxillary segmental surgery)

- Difficult stabilization and fixation



Hemorrhage - Measures to solve this problem:

- use of vasoconstrictors

- controlled hypotensive anesthesia

- careful surgical technique

- visualization of the problem area:

- Rapid completion of an osteotomy to allow application of direct pressure, vascular clips or electrocautery

- Arteriography with selective embolization

- External carotid ligation

Unanticipated hemorrhage can be a problem!

Surgical Complications



Nerve Transection Infraorbital Nerve

Lingual Nerve

Inferior Alveolar Nerve

Mental Nerve

Nerve lesion can be caused by:

- stretch - retraction

- surgical transection

Be careful with

anatomic

variations!




Post-Operative Moderate to Severe Edema

Echimosis / Bruising

Temporary limitation of mandibular range of motion

(decrease of motion – SSRO 29%; IVRO 10%)

Temporary neurosensory alteration

(lips, cheeks, gingival tissue, tongue and teeth)

Difficulties with speech, hygiene and nutrition

Nausea and vomiting

Infection

Minor deviations in occlusion and segment position

Removal of rigid internal fixation




Post-Operative Devitalization or loss of teeth and periodontal problems

Development or worsening of TMD

(8,5% and 5% respectively Upton et al., 1984)

Malocclusion requiring secondary surgery:

- Malunion or Nonunion:

- poor reduction

- failure of reduction and/or fixation

- chronic infection

- metabolic bone disorders

- Condylar Resorption

- Condylar Avascular necrosis

- Delayed Hemorrhage (7 to 21 days)




Post-Operative Major Vascular Complications (more related to fracture of the pterygoid plates)

Aneurysm

Arteriovenous fistula

Embolism




Prof. Horácio Costa Serviço de Cirurgia Plástica Reconstrutiva e Craniomaxilofacial

Unidade de Microcirurgia Centro Hospitalar de Gaia


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Cirurgia Ortognática