B. N.

Epker: A Modified Anterior Maxillary Ostectomy 35

Ginwalla, M. S.: Bilateral benign hypertrophy of mas- Martensson, G.: Hypertrophy of the masseter muscles.
sorer muscle. J. Oral Surg. 19 (1961) 482 Aeta oto-laryng. (Sto&h.) 50 (1959) 526
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chirurgicale de l'hypertrophie du masseter. Ann. masseter muscles. Ann. Otol. 60 (1951) 538
chir. Plast. 4 (1959) 787 Obwegeser, H.: Personal Communication (1974)
Guggenheim, P., L. B. Cohen: The nature of masseteric
hypertrophy. Arch. Otolaryng. 73 (1961) 15 Oppenheim, H., M. Wing: Benign hypertrophy of mas-
Gurney, C. E.: Chronic bilateral benign hypertrophy of seter muscle. Arch. Otolaryng. 70 (1959) 207
the masseter muscles. Amer. J. Surg. 73 (1947) 137 Perho, M.: Hipertrofija masetera. Chir. max.-fac. Plast.
IIersh, ]. H.: Hypertrophy of the masseter muscle. Arch. 4, Fasc. 1 1963
Otolaryng. 43 (1946) 593 Tempest, M. N.: Simple unilateral hypertrophy of the
tIonee, P. L., ]. ]. Bloem: On the differential diagnosis masseter muscle. Brit. J. plast. Surg. 4 (1951) 136
of masseter muscle hypertrophy (Case Report). J. Thoma, H.: Disea.ses of muscles of the face. In: Oral
max.-fac. Surg. 2 (1974) 246 Pathology, Ed. 3. Mosby, St. Louis 1950
Kern, A. B.: Masseter muscle hypertrophy. Arch. Derm.
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following submandibular absecces. Brit. J. Oral
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J. max.-fac. Surg. 5 (1977) 35-38

© Georg Thieme Verlag, Stuttgart

A Modified Anterior Maxillary Ostectorny

Bruce N. Epker

Center for Correction of Dentofacial Deformities (Director: B. N. Ephor, D.D.S., Ph.D.),

John Peter Smith Hospital, Fort Worth, Texas, U.S.A.

Summary a m o d i f i e d technique for anterior m a x i l l a r y

Two basic operative approaches for anterior maxil- ostectomy. The soft tissue incision used in this
lary ostectomy have been used by most surgeons; technique is similar to that described by Cupar
~he Wassmund (1935) and Wunderer (1962) techniques. (1954). The sequence of bony cuts and the "down-
Both have been clinically and experimentally tested fracturing" of the anterior m a x i l l a with com-
and found to be sound procedures (Bell 1969, Jensen
etal. 1976, Sokoloski etal. 1976). The author has de- pletion of the ostectomies is new. This technique
veloped and used for the last five years a modified offers some a d v a n t a g e s over the more commonly
surgical procedure for anterior maxillary ostectomy used W a s s m u n d (1935) and Wunderer (1962)
which has some technical advantages. The pur- techniques for a n t e r i o r m a x i l l a r y ostectomy.
pose of this paper is to describe this technique. No
These technical advantages are: 1. it is techni-
significant complications have occurred with this pro-
cedure in over eighty cases. cally simple, 2. provides direct access to the nasal
septal structures and thereby allows one to deal
Key-Words: Maxillary ostectomy; Orthodontic sur- with these structures directly and prevent bu&ling
gery. of the cartilaginous nasal septum, ,I. permits ex-
cellent access to the a n t e r i o r - s u p e r i o r m a x i l l a so
Introduction that when it is moved superiorly it can be r e a d i l y
Anterior m a x i l l a r y ostectomy is perhaps the ostectomized without compromise of the nasal
most commonly e m p l o y e d operative p r o c e d u r e airway, 4. permits r e m o v a l of the p a l a t a l bone
utilized for the correction of d e n t o f a c i a l deform- under direct visualization and 5. provides an ex-
ities. The purpose of this p a p e r is to discuss cellent vascular pedicle.
36 B. N. Epker

Fig. 1A-F
Schematic illustration of individual
with maxillary prognathism.

A) Proposed cuts for anteriour

maxillary ostectomy.
B) Soft tissue incision high in the
culcus.
C) Crestal tissue undermined and
retraced with skim hook while
completing interdental ostectomy.
D) Nasal mucosa reflected and
transpalatal osteotomy being
completed with osteotome.
E) Anterior maxilla down fractur-
ed, exposing superior maxillary
surface and palatal cut so that it
can be completely ostectomized.
F) Anterior maxilla repositioned
and suspended in the splint.

Operative Technique adequate amount of maxilla to carry out the

A schematic illustration of the proposed surgical indicated bony cuts (Fig. 1B). In the regions
procedure on a patient with maxillary prog- where the teeth are removed and the interdental
nathism is seen in Fig. I. ostectomies are to be done, the mucoperiosteum is
undermined to the crestal bone (Fig. 1C). Ante-
With the patient under general naso-tracheal riorly, the cartilagenous nasal septum is elevated
inhalation anesthesia, local analgesic with from the vomerian groove with a periosteal
1:200,000 epinephrine is injected into the buccal elevator and the nasal mucoperiosteum elevated
sulcus from the zygomatic-alveolar crest (lst mo- from the floor of the anterior nasal cavity
lar area) on one side to that on the other. This is (Fig. 1 D). If tearing of the nasal mucoperiosteum
done prior to prepping the patients face to allow is avoided, little bleeding is encountered in this
the epinephrine to obtain its maximum effec- area.
tiveness. Next, the indicated osteotomies and ostectomies
With an electric cutting knife a horizontal in- are completed under direct visualization. No
cision is made in the depth of the buccal sulcus, palatal incisions or mucosal undermining is done.
just above the level of the teeth apices, from the First the subapical cuts are made from the piri-
area of the tooth to be extracted on one side to form aperture of the nose posteriorly. Next, the
the same area on the opposite side. Superiorly, the alveolar ostectomies are completed bilaterally
mucoperiosteum is undermined exposing an without attempting to complete the entire trans-
 A Modified Anterior Maxillary Ostectomy 37

Fig. 2A-D
Operative technique.
A) Incision with electric cutting
knife,
B) Down-fractured maxilla after
completion of the osteotomies
and removal of the necessary
transplantal bone and nasal
crest of the maxilla.
Fig. 2A Fig. 2 B

C) The freely mobile down-

fractured anterior maxilla with
all ostectomies completed.
D) The anterior maxilla properly
repositioned via all occlusal
acrylic splint wired to the
maxillary dentition without inter-
maxillary fixation.
Fig. 2 C Fig. 2 D

Fig. 3 A + B
Considerations in planning.

A) An individual with excessive

interlabial distance, lip in-
competence and excessive ex-
posure of anterior maxillary
teeth.
B) Profile would be worsened
by setting back the anterior
maxilla and thereby accentuat-
ing the nose and making the
naso-labial angle more obtuse.
Fig. 3 A Fig. 3 B

palatal ostectomy. A palpating finger is placed sible, with little technical difficulty, to perform
on the palatal mucosa and the transpalatal this operation posteriorly through the first or
ostectomy is completed with the osteotome and second molar tooth areas. If no teeth are to be
the anterior maxilla "down-fractured" (Fig. 1D). removed the entire alveolar and palatal cut can
The transpalatal ostectomy is completed after the be made in the same manner with thin osteo-
anterior maxilla is "down-fractured" (Fig. 1E). tomes.
This provides excellent direct access to the nasal Following removal of the nasal crest of the
crest of the maxilla and the midpalatal bone for maxilla, to prevent septal deviation, the indicated
removal of the indicated bone in these areas. midpalatal bone is similarly removed under
Utilizing this down-fracture technique it is pos- direct visualization (Fig. I E).
38 B . N . Epker: A Modified Anterior Maxillary Ostectomy

After completion of the ostectomies the teeth are lary excess and significant Iip incompetence
placed into a preformed acrylic occlusal splint (Fig. 3), and 2. in individuals with a Class II
and the splint wired to the maxillary dentition face, who possess an obtuse naso-labial angle. In
so that intermaxillary fixation is unnecessary. the former instance, a superior repositioning of
A n orthodontic arch wire can also be used to the entire maxilla is indicated whereas in the
avoid the use of intermaxillary fixation (Fig. 1F). latter a mandibular advancement affords the
The incision is closed with 3-0 chromic suture. optimum result.
The excessive palatal mucosa is left untouched Utilizing this procedure almost exclusively during
and shrinks to a normal configuration within the past five years, we have had no m a j o r com-
10 days. plications associated with loss of teeth, bone or
The basic steps in the operation on a patient are soft tissues. The access one achieves with this
illustrated in Fig. 2. technique allows the surgeon readily to reposition
the anterior maxilla in the various directions:
Discussion superiorly, posteriorly and inferiorly. Even when
During the last five years, we have performed the transpalatal ostectomy is to be through the
over one hundred anterior maxillary ostectomies molar region this procedure can be utilized.
at our institution; most of them in conjunction
with other procedures such as mandibular ad- Conclusion
vancement, horizontal osteotomy of the man- W e have employed this technique with good
dible, anterior mandibular subapical ostectomy, success for several years without devitalization
and posterior maxillary ostectomy. Despite its of segments or loss of teeth. Recently, the blood
common usage, and because of its technical flow in this technique has been studied and
simplicity, care must be exercised not to utilize found to be as sufficient, or perhaps better than
this procedure injudiciously when others would that in the more commonly employed Wassmund
afford the patient a superior aesthetic and func- and Wunderer procedures (Olson et al. 1976). The
tional result (West and Epher 1972, Epker and technical ease, direct access to all areas to be
Wolford 1975, Wolford and Epker 1975). Two ostectomized, and biological soundness of this
common instances in which we have observed its operative approach make it worthy of considera-
misuse are: 1. in individuals with vertical maxil- tion.

References

Bell, W. H.: Revascularization and Bone Healing after Osteotomy: Wassmund Procedure, IADR Abstract
Anterior Maxillary Ost.ectomy. J. oral Surg. 27 No. 943 (1976)
(1969) 249 Wassmund, M.: Lehrbuch der praktischen Chirurgie
Cupar, I.: Die chirurgische Behandlung der Form- und 6es Mundes und der Ki.efer, Bd. I. Meusser, Leip-
Stellungsverfinderungen des Oberkiefers. ~st. Z. zig 1935
Stomat 51 (1954) 565; Bull Soc. Cons. Acad. R.P.F. West, R. A., B. N. Epker: The Posterior Maxillary
Jougosl. 2 (1955) 60 Ostectomy, Its Place in the Treatment of Dento-
Epker, B. N., L. M. Wolford: Middle Third Face Osteo- facial Deformities. J. oral Surg. 30 (1972) 562
tomies: Their Use in the Correction of Develop- Wolford, L. M., B. N. Epker: The Combined Anterior
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Jemen, G., R. Nelson, M. Pata, M. Meyer: Quantita- Wwnderer, S.: Die Prognathieoperation mittels fron-
tion of Blood Flow Following Anterior Maxillary tal gestieltem Maxillafragment. Ost. Z. Stomat. 59
Osteotomy: Wunderer Procedure, IADR Abstract (1962) 9S
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Director of Oral and Maxillo-Facial-Surgery
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