LeFort I osteotomy and maxillary advancement

LeFort I osteotomy and maxillary advancement for surgical correction of maxillary deformities. The maxillary LeFort I osteotomy is the basic procedure for the treatment of maxillary deformity. On the basis of this procedure, appropriate changes or supplements with other procedures can be used to correct most of the upper jaw deformities. For example: LeFort I osteotomy, advancement and bone grafting to correct maxillary retraction deformity, LeFort I osteotomy, downshift and bone grafting to correct maxillary vertical dysplasia, for LeFortI osteotomy, upshift The technique is used to correct the vertical development of the maxilla, the maxillary osteotomy and the posterior movement to correct the maxillary prominence, and the LeFort I osteotomy for the segmental osteotomy to correct the posterior teeth dislocation and anterior teeth retraction. The back teeth are too long and twisted and deformed. Treatment of diseases: infants and maxillary osteomyelitis Indication The LeFort I osteotomy for maxillary advancement is suitable for maxillary retraction deformity. Contraindications 1. Patients with poor general condition and general anesthesia and major surgery. 2. Patients with pseudo-maxillary retraction due to mandibular lordosis. 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 trajectory map on the transparent tracing paper. A total of two images are drawn. 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 include: correcting a few misplaced teeth, removing interference or blocking, aligning the dentition, adjusting the shape or width of the dental arch, and coordinating the upper and lower dental arches so that the upper and lower dentition can obtain a wide occlusion during the operation. Contact relationship; it is also important to remove the compensation of the teeth and adjust the inclination of the teeth so that the bone segments can be moved to the desired position after the 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 General anesthesia, nasal cannula. Take the supine position and raise your head slightly. Local mucosal incisions can be injected with normal saline or procaine containing low concentrations of epinephrine to reduce bleeding. Incision A transverse incision is made in the maxillary vestibular groove. Incision was made in the upper jaw from the second molar to the contralateral second molar in the vestibular groove. Cut through the periosteum to the bone surface. 2. Reveal the maxilla The periosteal separator was used to perform subperiosteal separation on the bone surface, and the outer wall of the maxilla and the root of the humerus were exposed, and the posterior stalk was separated to the upper maxillary suture. However, do not separate too much from the bottom (near the gums) to maintain soft tissue and ensure blood supply to the maxilla and maxillary teeth. After fully removing the lateral wall of the maxilla, the puncture hole and the nasal septum, the nasal floor and the nasal outer wall were separated along the nasal floor by a small periosteal separator. 3. Cut off the lateral wall and inner wall of the maxilla According to the X-ray examination, intraoperative observation of the bone surface (visible swelling of the bone surrounding the root of the tooth), and reference to the parameters of the general root length, the position of the root tip of each upper jaw is estimated. The osteotomy line is designed above the 4 to 5 mm from the apex of the tooth and can often be drilled for marking. A small periosteal separator is placed under the periosteum of the lateral wall of the nasal cavity for protection. The outer wall of the maxilla can be cut by a drill bit or a saw. The lateral part of the maxillary can be removed from the lateral part of the anterior self-plough hole, the cusp of the cusp, and the lower jaw of the gingival sulcus (Fig. 10.8.1.3-8). Osteotomy can also be performed from the back to the front. Under the protection of the separator placed under the periosteum of the outer wall of the nasal cavity, the inner wall of the maxillary sinus is cut with a thin bone knife or a bone saw, and the aorta is prevented from being damaged when the rear is behind. The other side of the maxilla was cut by the same method. A small gauze can be used to fill the osteotomy line during the osteotomy to reduce bleeding. 4. Cut off the base of the nasal septum At the base of the nose, a septum or a humeral chisel is placed over the anterior nasal sinus and at the base of the septum. The direction is parallel to the hard palate and the chisel is gently inserted into the posterior margin of the septum to separate the septum from the maxilla. When cutting in, pay attention to the direction and do not tilt upwards to avoid damage to the nasal mucosa. 5. Break off the posterior edge of the maxilla Finally, at the maxillary suture, between the posterior maxillary nodule and the lower end of the wing, the arcuate sharp bone knife is inserted inwardly to separate the maxilla from the wing, often near the trailing edge of the hard palate. Place the left hand finger or middle finger at the ankle mucosa to feel the osteotomy. When cutting bone, special attention should be paid: the bone knife should be placed in the lower part of the maxillary joint of the wing. The direction of the chisel should be inward and try to move forward. Avoid cutting the bone knife in the upward direction to avoid damage to the upper jaw. Blood vessels within the sulcus (such as the internal jaw artery). 6. Fold the upper jaw down After completing each osteotomy step, the thumb is gradually applied downward in the anterior portion of the maxilla to break the entire maxilla downward. The hand is broken by the hand-cranked maxilla to make it fully active. At this point, the LeFort I osteotomy has been basically completed. 7. Move the maxilla, position and bone graft Pre-formed and sterilized bite guides are worn on the lower jaw. The maxilla is advanced to achieve the desired ideal position for the occlusal relationship of the occlusal guide. Temporary intermaxillary fixation is performed using a pre-ligated arch cleat (or a bonded hook) to maintain the desired position of the maxilla. If the maxillary bone moves forward and the gap created behind it is large (>0.5cm), the bone can be implanted to eliminate the gap and prevent recurrence. The bone can often be self-plucked, trimmed into a wedge shape, and implanted in the gap to maintain the position of the maxillary advancement. 8. Fix the maxillary bone block Generally, the wire inter-bone ligation or the titanium micro-bone plate is firmly fixed to maintain the position of the maxillary bone and ensure bone healing. It can be drilled and drilled on both sides of the osteotomy line at the edge of the thicker plow hole and the maxillary iliac crest, and the wire is used for ligation between the bones. A miniature titanium plate can also be used for inter-bone fixation. In addition, it is often necessary to assist the fixation. Generally can be used as a sling bow suspension. That is, the guide needle is pierced into the oral cavity in the cheek, and the wire is retracted, and the wire is taken out only to the skin without exiting the skin. Under the skin, it is bypassed over the zygomatic arch and re-enters the cavity through the deep side of the zygomatic arch, so that the wire is bypassed. The zygomatic arch, the wire at both ends of the mouth is ligated with the dental arch splint to suspend. It can also be suspended under the armpit. That is, it is exposed upwards to the inferior border of the infraorbital area (be careful not to damage the infraorbital nerve vascular bundle), and is separated inwardly along the sacral floor by about 1 cm. Under the protection of the periosteal separator, drilling, wearing a wire, and a dental arch splint Ligation, at present, strong internal fixation has been widely used, and the above-mentioned auxiliary fixation has been gradually eliminated. 9. Suture incision Mucosal wounds are used for intermittent sutures. complication 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.