Cirurgia Ortognática
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Transcript of 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
Anatomy Concepts Craniofacial Bones
Prof. Horácio Costa
Anatomy Concepts Craniofacial Muscular insertions
Prof. Horácio Costa
Anatomy Concepts
Craniofacial - Infratemporal and Pterigoid areas
Prof. Horácio Costa
Anatomy Concepts
Craniofacial – Nasal cavity
Prof. Horácio Costa
Anatomy Concepts
Mandible – Development concepts
Prof. Horácio Costa
Mandible – Muscular insertions
Anatomy Concepts
Prof. Horácio Costa
Muscles of Mastication
Anatomy Concepts
Prof. Horácio Costa
Vascular supply
Anatomy Concepts
Prof. Horácio Costa
Nerves - Trigemium
Anatomy Concepts
Prof. Horácio Costa
Growth Modifications
1- Deficient mandibular growth
2- Excessive mandibular growth
3- Deficient maxilar gowth
4- Excessive maxilar growth
5- Assymmetric growth
Prof. Horácio Costa
Treatment Options
Orthodontic Camouflage
Surgical Camouflage
Maxillary Osteotomies
Mandibular Osteotomies
Rhinoplasty
Genioplasty
Soft tissue procedures
Prof. Horácio Costa
Orthodontic Camouflage
GOAL – Correction of the obvious aspects of
the deformity without correction of underlying
deformity itself
Prof. Horácio Costa
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)
Orthodontic Camouflage
Prof. Horácio Costa
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
Orthodontic Camouflage
Prof. Horácio Costa
Assimetry
- Displacement of the teeth of both arches
- Only grafts (maxilla and/or mandible)
- Rhinoplasty
- Genioplasty
Orthodontic Camouflage
Prof. Horácio Costa
Surgical Camouflage
Surgical camouflage has the same goal as orthodontic camouflage
GOAL – Remove the appearence of jaw
deformity without correcting the underlying
skeletal problem
Prof. Horácio Costa
Genioplasty – Chin surgery
Augmentation:
- Bone grafts
- Cartilage grafts
- Alloplastic materials
Reduction
Advancement
Retrusion
Rotation
Surgical Camouflage
Prof. Horácio Costa
Rhinoplasty – Nose surgery
Dorsum Augmentation:
- Bone grafts
- Cartilage grafts
- Alloplastic materials
Dorsum Reduction:
alar cartilages
Tip Surgery cartilagenous septum
columella
Surgical Camouflage
Prof. Horácio Costa
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
Prof. Horácio Costa
Rhinoplasty – Nose types
(from Fomon and Bell (1970) – variations in normal nasal anatomy among racial and ethnic groups)
Mesorrhine:
- usually found among Asians
- lack of dorsal height and columellar support
Rhinoplastic Treatment: - Dorsum augmentation
- Tip narrowing
Surgical Camouflage
Prof. Horácio Costa
Rhinoplasty – Nose types
(from Fomon and Bell (1970) – variations in normal nasal anatomy among racial and ethnic groups)
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
Prof. Horácio Costa
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
Prof. Horácio Costa
Submental area - Lipectomy
- Liposuction
- Platysmal lift
- Rhytidectomy with SMAS plicature
Soft Tissue Procedures
Surgical Camouflage
Prof. Horácio Costa
Maxillary Osteotomies
Le Fort I Osteotomy
Le Fort II Osteotomy
Le Fort III Osteotomy
Anterior subapical osteotomy:
- Wassmund Technique
- Wunderer Technique
Posterior Subapical Osteotomy
Nasomaxillary Osteotomy
Prof. Horácio Costa
Maxillary Osteotomies
Le Fort I Osteotomy
Prof. Horácio Costa
Le Fort II Osteotomy
Maxillary Osteotomies
Prof. Horácio Costa
Maxillary Osteotomies
Le Fort III Osteotomy
Prof. Horácio Costa
Anterior subapical osteotomy - Wassmund Technique
Maxillary Osteotomies
Prof. Horácio Costa
Anterior subapical osteotomy - Wunderer Technique
Maxillary Osteotomies
Prof. Horácio Costa
Posterior Subapical Osteotomy
Maxillary Osteotomies
Prof. Horácio Costa
Nasomaxillary Osteotomy
Maxillary Osteotomies
Prof. Horácio Costa
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
Prof. Horácio Costa
Mandibular Osteotomies - History
1940
Prof. Horácio Costa
Mandibular Osteotomies - History
Prof. Horácio Costa
Mandibular Osteotomies - History
Prof. Horácio Costa
Mandibular Osteotomies - History
Prof. Horácio Costa
Sagital Split Osteotomy
Mandibular Osteotomies
Obegeweser 1964
Prof. Horácio Costa
Sagital Split Osteotomy
Mandibular Osteotomies
Prof. Horácio Costa
Extra-oral Vertical Ramus Osteotomy
Mandibular Osteotomies
Prof. Horácio Costa
Intra-oral Vertical Ramus Osteotomy
Mandibular Osteotomies
Prof. Horácio Costa
Intra-oral Vertical Ramus Osteotomy
Mandibular Osteotomies
Prof. Horácio Costa
Combined Vertical Ramus and Sagittal Osteotomies
Mandibular Osteotomies
Prof. Horácio Costa
Inferior Alveolar Neurovascular Bundle Decompression
Mandibular Osteotomies
Prof. Horácio Costa
Body Ostectomy
Mandibular Osteotomies
Prof. Horácio Costa
Midline Osteotomy / Ostectomy
Mandibular Osteotomies
Prof. Horácio Costa
Inferior Border Osteotomy
Mandibular Osteotomies
Prof. Horácio Costa
Anterior Subapical Osteotomy
Mandibular Osteotomies
Prof. Horácio Costa
Total Subapical Ostectomy
Mandibular Osteotomies
Prof. Horácio Costa
Fixation and Stabilization
Traditional Wire Fixation Methods
Combination of: Transosseous wire fixation
Skeletal wire fixation
Maxillomandibular Immobilization for 6 to 8 weeks
Prof. Horácio Costa
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
Prof. Horácio Costa
Prof. Horácio Costa
Prof. Horácio Costa
Prof. Horácio Costa
Prof. Horácio Costa
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
Prof. Horácio Costa
Fixation and Stabilization Rigid Internal Fixation
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
Prof. Horácio Costa
Fixation and Stabilization Rigid Internal Fixation
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%
Prof. Horácio Costa
Rigid Internal Fixation
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
Prof. Horácio Costa
Fixation and Stabilization Rigid Internal Fixation
Disadvantages:
Neurosensory Disturbances
Tooth Devitalization
Post-operative TM Joint Symptoms
Torquing
Distraction
Rotation
Condylar segments
Prof. Horácio Costa
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.
Rigid Internal Fixation
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
Prof. Horácio Costa
Plating and or Screw Techniques
Malposition of Bony Segments
Post Surgically
Occlusal Disharmony
Reoperation
BE
AWARE
…
Fixation and Stabilization
Prof. Horácio Costa
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
Fixation and Stabilization
Prof. Horácio Costa
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
Prof. Horácio Costa
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
Prof. Horácio Costa
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!
Surgical Complications
Prof. Horácio Costa
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
Surgical Complications
Prof. Horácio Costa
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)
Surgical Complications
Prof. Horácio Costa
Post-Operative Major Vascular Complications (more related to fracture of the pterygoid plates)
Aneurysm
Arteriovenous fistula
Embolism
Surgical Complications
Prof. Horácio Costa
Prof. Horácio Costa Serviço de Cirurgia Plástica Reconstrutiva e Craniomaxilofacial
Unidade de Microcirurgia Centro Hospitalar de Gaia