Anterior maxillary osteotomy and posterior displacement

The maxillary pre-bone osteotomy is used for surgical correction of maxillary deformity. If the maxillary deformity occurs only in part of the maxilla, a partial or segmental osteotomy of the maxilla can be performed to correct the deformity. This type of surgery is a commonly used type. Treatment of diseases: maxillary protrusion Indication The posterior maxillary osteotomy is applied to the anterior humerus of the maxilla, and the rest of the maxilla is normal, and the posterior teeth have a good relationship. Contraindications The entire maxillary lordosis, including the posterior teeth and alveolar process, also moved forward and presented the mandibular distally. Preoperative preparation There are many types of dental malformations, and the situation is different. The deformity may be simple or complicated. Patients often have a variety of mental and psychological states. Therefore, there are many factors to consider before surgery, and various preparations should be made according to the specific situation. 1. As with general surgery, detailed medical history enquiries, records, and comprehensive physical examinations are required before orthognathic surgery, including: general and partial examinations. The whole body examination focuses on the situation of important organs. Local examinations include facial examinations, oral and dental model examinations, and X-ray examinations (cephalometric measurements, full-mouth curved torsions, and dental fragments). Based on the above results, a definitive diagnosis is made and a question table is listed as a basis for developing a treatment plan. The final treatment plan should be able to solve all or most of the problems listed in the table. 2. Determining the preoperative prediction of the therapeutic effect before performing orthognathic surgery. The most common methods are: photo cutting and pairing, cephalometric X-ray film tracing, cutting and cutting (paper-cut surgery) and dental model surgery. The latter two are more important. Through the preoperative prediction, comprehensively judge the effect of the design surgery, and if necessary, make corrections. In recent years, scholars have used computers, graphic digitizers, cameras, scanners, etc. to acquire and input images, and perform fixed-point, measurement, analysis, and surgical simulations to predict postoperative morphology of the patient's side. Recently, computer-aided three-dimensional surgical design simulation systems and computer-aided three-dimensional skull models have been established to create more precise conditions for the design and prediction of orthognathic surgery. (1) Cephalometric Prediction Tracing with Cutting and Piecing together: cephalometric measurement, cutting, or cutting. It is an important means of preoperative prediction of orthognathic surgery. The specific method is as follows. 1 Place the cephalometric X-ray film on the viewing box (or the viewing light) and draw the two trajectories in the transparent tracing paper. 2 Take a well-drawn trajectory map and cut the bone segment ready for osteotomy and movement. For example, this example is intended to be a maxillary LeFortI osteotomy and upward movement. 3 Place the cut piece of paper (such as the maxilla in this case) on another complete trajectory map so that it is in the desired position of movement (as in this case, up). 4 Place the remaining part of the jaw of the first trajectory (such as the remaining mandible in this case) on the complete trajectory to fit the piece of paper that moves the bone. This is the expected general position of the jaw after orthognathic surgery. 5 Then draw a soft tissue outline on the outer circumference of the bone to obtain a general outline of the postoperative shape. This is one of the main references for predicting the outcome of surgery. (2) Model Surgery: referred to as model surgery. On the tooth model (usually on the shelf), simulate the design of the operation, saw the model, and move the block in the desired position, fixed with sticky wax. Observe and measure the changes of the model to judge and predict the effect of the operation. It is a three-dimensional template, and the paper-cutting surgery is a three-dimensional simulation. One of the commonly used preoperative prediction methods. 1 First take the mold, pour out the tooth model, and transfer the to the shelf through the facial arch to obtain the relationship between the mouth and fix it. And draw a horizontal and vertical reference baseline on the model. 2 If necessary, draw a longitudinal baseline in the medial side of the temporal side; between the canines to the canines, between the first molars and the first molars, cross the ankles as a baseline. 3 Remove the single jaw model, and use the model saw to saw the tooth model according to the surgical design and divide it into several pieces (such as the maxillary segmental osteotomy in this case). 4 On the mandible model on the rack, place the cut tooth model blocks in the desired position. 5 After each model is in place, the model blocks are connected by sticky wax and fixed on the frame, which is the postoperative condition. Observe the original baseline position on the model, measure and calculate the distance after the movement, which can be used as a reference for surgical design. 3. For patients with major orthodontic surgery requiring orthognathic surgery, it is often necessary to combine preoperative and postoperative orthodontic treatment to achieve the desired results. The main contents of preoperative orthodontic treatment are: correcting a few dislocated teeth, removing Interfere with or block, align the dentition, adjust the shape or width of the dental arch, and coordinate the upper and lower dental arches so that the upper and lower dentition can obtain a wide occlusal contact relationship during surgery; and it is important to remove the compensation and adjustment of the teeth. The inclination of the tooth to move the bone segment to the desired position after the surgical osteotomy. 4. When the surgical plan is determined, a occlusal guide (ply plate) should be made on the model that has completed the model surgery. If you are preparing for the simultaneous osteotomy of the upper and lower jaws, it is often necessary to make two occlusal guides. One is a transitional (intermediate) occlusal guide; the other is a maintenance occlusal guide (final guide), that is, the guide is finally worn during the operation to maintain the ideal position of the upper and lower jaws, and then fixed between the jaws. 5. Prepare the fixation device for the bone segment several days before surgery (such as dental arch splint, adhesive bracket or external fixation device). 6. Do oral care, treat dental disease, and cure if necessary. 7. Prepare for general anesthesia and prepare for general anesthesia. It is estimated that blood transfusion is required, and blood is reserved. 8. Finally, there is an important point in preparing the patient's mind and conducting the necessary psychological counseling. All the designs and the results obtained at the end should be told to the patient in detail, and their opinions should be solicited so that the doctor and the patient can find the unity of both the subjective and the objective. In this way, it is possible to obtain the patient's postoperative cooperation and achieve the desired effect, and finally obtain a satisfactory postoperative effect. Otherwise, subjective and objective inconsistency, although the expected surgical results have been achieved, still can not meet the patient's excessively high non-conformity requirements, backfired. Surgical procedure Tooth extraction It is often necessary to remove one premolar on each side, usually the first premolar. According to the conventional method of tooth extraction. 2. Incision Make an incision on the labial side. At the maxillary vestibular groove, a transverse incision was made from the first premolar on one side to the first premolar on the contralateral side. 3. Separation and exposure The periosteum was cut through the periosteum and the periosteal separator was used for subperiosteal separation. The front part of the nose and the lower edge of the plow hole are exposed. Be careful to avoid excessive separation (downward direction of the gums), so as to preserve the soft tissue and ensure blood supply. 4. Osteotomy The horizontal osteotomy is performed immediately after the outer edge of the plow hole. Cut the bone with a split drill, taking care not to accidentally damage the root tip of the maxillary canine. Then, in the vertical osteotomy site, the subperiosteal detachment is performed from the small periosteum separator, and the sputum tissue is gently pulled up with a small hook. This vertical osteotomy site is generally at the premolar of the extraction. After the hook is exposed, the split drill is inserted into the vertical osteotomy and connected to the horizontal osteotomy line made from the outer edge of the plow hole. When osteotomy, the bone plate on the temporal side should be cut off at the same time. It is often possible to extend the left hand finger or the middle finger to the temporal mucosa on the temporal side to sense the osteotomy and prevent the perforation and damage to the temporal soft tissue. If necessary, a small periosteal separator can be inserted from the temporal submucosa of the extraction area to push the soft tissue of the temporal side and protect the aorta. When osteotomy is performed, it is necessary to design the bone mass to be removed according to the preoperative examination and measurement results, and to make two corresponding osteotomy lines to remove part of the bone. The same method is used for contralateral osteotomy. If necessary, insert a bone knife between the distal and near middle bone osteotomy lines and gently dig into the bone that has not been completely cut off. 5. Fold the front part of the maxilla and trim it to remove the bone After completing the horizontal and bilateral vertical osteotomy, the right thumb and finger are used to hold the upper part of the maxilla gently to the lower part, so that the anterior part of the maxilla is broken and lowered. The nasal side of the maxillary part of the maxilla can be revealed. According to the preoperative design, the bone of the posterior margin of the anterior segment of the maxillary bone was removed and trimmed. If you need to move the anterior part of the maxilla upwards, you need to remove some of the bone in the midline and even have a groove shape, so as to avoid bending deformation of the nasal septum when the maxilla is moved up. For the above bone removal and dressing, it can be carried out with a grinding head. If necessary, a partial nasal septum can be removed under the periosteum of the lower septum. 6. Move the bone segment, seat it, fix it After removing enough bone and trimming, move the broken front part of the maxilla back (and upwards if necessary) to the desired position. You can wear a bite guide to position it first. Fix with a dental splint. At the same time, the jaw is fixed at the same time to ensure the ideal bite relationship, and the osteotomy segment is fixed with a titanium plate. 7. Stitching The soft tissue incision of the labial region was used for intermittent suture. complication See the main complications of orthognathic surgery. Orthognathic surgery may have complications during and after surgery. The surgeon should perform the operation in a serious and responsible spirit, abide by the surgical requirements, operate correctly, carefully and carefully, observe the condition closely after the operation, and timely handle the abnormal situation to prevent various complications. Airway obstruction Acute obstruction of the respiratory tract and even suffocation are the most serious complications. During general anesthesia, due to vomiting aspiration, secretion obstruction, improper position, tongue fall, tracheal edema after tracheal intubation, and subsequent local tissue edema, plus intermaxillary fixation and other factors may cause respiratory obstruction. Measures should be taken to prevent it from happening. Close observation of the condition and elimination of factors that may cause acute obstruction of the respiratory tract. If signs of dyspnea appear (such as nasal agitation, three concave signs, etc.), it should be treated in time to prevent the occurrence of asphyxiating complications. 2. Bleeding Intraoperative injury to larger blood vessels can cause more serious bleeding, such as the maxillary LeFortI osteotomy when the internal maxillary artery or the aorta is injured, and the mandibular ascending branch is used to damage the inferior alveolar artery. Therefore, in the LeFortI type osteotomy, the osteotome can not be placed too high during the process of breaking off the distal end of the maxilla and the wing, and the direction of the incision cannot be upward to prevent damage to the internal artery of the jaw. When cutting the inner wall of the maxillary sinus, care should be taken to avoid damage to the aorta near the posterior end. It is often possible to use a bone knife to cut the bone and not to reach the trailing edge while retaining part of the bone to avoid accidental injury to the aorta. After the maxilla is broken down by the technique and the instrument, the posterior bone is trimmed. When the mandibular ascending branch is sagittal and osteotomy, the osteotome should not be too deep to avoid damage to the inferior alveolar artery. After the ascending branch is opened by the "cracking" method, the bone piece is opened and the bone piece is opened. Deeply repair the bone under direct vision. When the mandibular ascending longitudinal osteotomy (vertical or oblique osteotomy) is performed, the osteotomy line should remain behind the mandibular hole to prevent damage to the inferior alveolar artery. 3. Nerve damage For example, the mandibular nerve may be accidentally injured in the sagittal split osteotomy of the mandibular ascending branch. Precautions during osteotomy are the same as prevention of damage to the inferior alveolar artery. When the osteotomy and the moving bone segment are completed for fixation, care should be taken to avoid the occurrence of postoperative nerve injury symptoms caused by the compression of the inferior alveolar nerve by the bone segment. 4. Segmental necrosis The reason is mostly caused by excessive peeling of soft tissue or damage to the supply of blood vessels. Therefore, the separation and exposure of the bone surface should not be too large, especially in the distal heart segment (the bone segment near the gingival direction), the surface soft tissue should not be excessively separated, but the soft tissue should be kept as much as possible to maintain blood circulation and ensure bone. Healing. 5. Damaged root tip and pulp necrosis The root is simultaneously cut off because the transverse osteotomy line is too low (too close to the cutting edge or face). Therefore, the possible position of the root tip should be judged. The method includes: preoperative photographing of the X-ray film to detect the position and length of the root, and referring to the data of the normal normal root length, the intraoperative observation shows that the alveolar bone surrounded by the root has a slight elevation. After estimating the root length and the position of the root tip, a transverse osteotomy line is designed in the telecentric direction of the root tip of 4 to 5 mm (the maxilla is above the apex of the maxillary root and the mandible is below the root tip of the mandible). 6. Unconnected bone or poor bone healing Mainly due to poor fixation, insufficient contact of the bone segment, and poor blood supply. Therefore, the bone must be well fixed during and after surgery. Generally, inter-bone fixation (ligation fixation or micro-plate strong internal fixation) is used, supplemented by intermaxillary fixation, suspension fixation, and external stent fixation. In addition, the osteotomy design should consider maximizing the contact wounds when the bone segments (blocks) are connected, and prevent excessive peeling of the soft tissue and the like during the operation.