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PRESENTED BY –DR. SHEETAL KAPSE
INCLUSIONS - INTRODUCTION FEATURES OF MAXILLA DEVELOPMENT SURGICAL ANATOMY CONCLUSION RESOURCES
INTRODUCTION 2nd largest bone of face 2 maxillae forms whole of upper jaw Each maxilla contributes in formation of –1. ...
FEATURES OF MAXILLA Each maxilla has –1. A body2. 4 processes – frontalzygomaticalveolarpalatine
BODY OF MAXILLA Shape – pyramidal It has –1. Base – directed medially at nasal surface2. Apex - directed laterally at zy...
ANTERIOR / FACIAL SURFACE Directs laterally Incisive fossa -depressor septi Incisivus – alveolar margin Nasalis – supe...
 Canine fossa – levator anguli oris Infraorbital foramen levator labii superioris Medially – the nasal notch- anterior...
POSTERIOR / INFRATEMPORAL SURFACE Concave Directed – backward & laterally Forms – anterior wall of infratemporalfossa ...
SUPERIOR / ORBITAL SURFACE Smooth, triangular & slightly concave Forms – Greater Part Of Floor Of Orbit Anterior border...
Posterior border – smooth & rounded Forms most anterior margin ofinferior orbital fissure In middle – infraorbital groo...
The superior surface presents – Infraorbital groove & canal Canalis sinosus Inferior oblique muscles
THE MEDIAL /NASAL SURFACE Part of lateral wall of nose Posterosuperiorly – maxillary hiatus Above the hiatus – air sinu...
THE MEDIAL /NASAL SURFACE Infront of the hiatus – nasolacrymal groove articulates withdescending process of lacrymal bone...
THE MEDIAL /NASAL SURFACE More anteriorly – conchal creast for articulation with inferiornasal concha. Above the conchal...
PROCESSESOFMAXILLA1. FRONTAL2. ZYGOMATIC3. ALVEOLAR4. PALATINE
FRONTAL PROCESS Projects upward & backwards to articulateabove – nasal margin of frontal boneinfront – nasal bonebehind –...
FRONTAL PROCESS Medial surface – forms lateral wall of nosefrom above downwards –1. Uppermost roughened area for articula...
 Pyramidal lateral projection Anterior, posterior & superior surfaces converge here Superiorly – rough, to articulate w...
 Forms half of alveolar arch Bears socket for maxillary teeth In adults = 8 sockets Buccinator arises from posterior p...
 Thick horizontal plate Projecting medially Forms largest part of roof & floor Inferior surface – concave & forms ante...
 Various foramina & pits Posterolaterally –greater & lesserpalatine foremen Superior surface –concavefrom side to side ...
Medial border – Thicker anteriorly Groove betweennasal crest of 2 maxilla receives lower border vomerAnterior part of ri...
ARTICULATIONS OF MAXILLA Superiorly – 3 bones1. Frontal2. Nasal3. Lacrymal Laterally – 1 bone1. Zygomatic bone
ARTICULATIONS OF MAXILLAMedially – 5 bones1. Ethmoid2. Inferior nasal concha3. Vomer4. Palatine5. Opposite maxilla
AGE CHANGES IN MAXILLA AT BIRTH –1. Transverse & anterioposterior diameter > vertical diameter2. Well marked frontal proc...
DEVELOPMENT OF MAXILLA MAXILLA develops from ossification in mesenchyme of maxillary processof 1st arch. No arch cartila...
 From this trough a downward extension of bone forms the lateral alveolarplate. Medial alveolar plate – from junction of...
According to B.D. Chaurassia’s human anatomy 4th edition vol. 3 TheHead & Neck MAXILLA ossifies from 3 centers in the mem...
SURGICALANATOMYOFMAXILLA
Normal AnatomyFace (midface) is the region from supraorbital rimsto maxillary alveolar process
Major structuresare labeled in thepicture.Nasofrontal sutureZygomaticofrontalsutureZygomaticotemporalsutureSOF = Superior ...
Nasofrontal sutureZygomaticofrontal sutureZygomaticotemporal suture3D CTLeft Lateral View
Axial viewKey structuresA = Frontal sinus, anterior wallB = Frontal sinus, posterior wall*Note: The right frontal sinus is...
• Do not confuse the suture between nasal bone andfrontal process of maxilla for a fracture• Look for a piece of fracture ...
Clear maxillary sinuses can almostrules out certain fractures such asZMC, LeFort, blowout fracturesKey structuresF = Groov...
Key structuresH = Maxillary sinus,anterior wallI = Maxillary sinus,medial wallJ = Medial pterygoidplateK = Lateral pterygo...
Lucency in midline of the maxilla is anormal finding seen occasionallyKey structuresJ = Medial pterygoid plateK = Lateral ...
Coronalsection• Remind yourself that CT can miss subtletooth fracture, although with the coronaland sagittal reformation. ...
Key structuresD = Orbit, medial wallM = Nasal septum5 = Maxilla, frontal process15 = Maxilla bone/ hard palate16 = Frontal...
Key structuresM = Nasal septumN = Ethmoid bone,perpendicular plateO = Orbit, roofP = Orbit, floorQ = Maxillary sinus,poste...
Key structuresJ = Medial pterygoidplateK = Lateral pterygoidplateN = Ethmoid,perpendicular plate3 = Sphenoid sinus10 = Zyg...
Key structuresP = Orbit, floor7 = Pterygoid bone9 = Maxillary sinus15 = Maxilla bone /hardPalate• Orbital blowout fracture...
Key structures3 = Sphenoid sinus4 = Nasal bone15 = Maxilla bone/ hard palateMid saggital section
WATER’S VIEWThe most comprehensive singleprojection display Excellent view ofMaxillaMaxillary sinusesZygomaZygomatic arche...
WATER’S VIEWRule:smooth, nondisrupted,same contour on both sidesKey structures1 = Frontal sinus2 = Maxillary sinus3 = Fron...
Line ABegins at inner surface ofZygomaticofrontal suture, followsorbital surface ofzygoma, maxilla, frontalprocess of maxi...
Line CBeginsat lateral andinferior margins of maxilla,extends along lateral wall ofmaxillary sinus and inferiorsurface of ...
Mc Grigor’s /Campbell’s line
Caldwell’s ViewExcellent view ofEntire rim of orbit, esp.superomedial rimEthmoid sinusFloor of orbit may be wellseen in pe...
Key structures1 = Ethmoid sinuses2 = OrbitLine A, B, C, D = superior,lateral, inferior and medialwalls of the orbit,respec...
Lateral cephalogramExcellent view of1. Frontal sinus: anterior wall2. Maxillary sinus: anterior and posteriorwall3. Spheno...
Key structures1 = Frontal sinus2 = Maxillary sinus3 = Sphenoid sinus4 = Hard palate5 = Anterior wall of temporal fossaBetw...
TOWN’S VIEWKey structures1 = Zygomatic archLine A = Posterolateral wall of maxillarysinusRule:Smooth, nondisrupted lineExc...
Hot Sites
Maxillary Fractures Types of maxillary fractures - Maxillary sagittal fracture (maxillary sinus fracture) Palate fractu...
Maxillary sagittal fracture Maxillary sinus fracture Fracture of a maxilla in sagittal plane, involving anterior-lateral...
68-year-old man was founddown.There is a sagittal planefracture of the left maxillarysinus (red arrow) withhemosinus (H)
Isolated alveolar processfracture Fracture of any portion of the alveolar process Clinically evident by malalignment and...
Middle age women fell onto her mouth.Red arrows show the comminuted fractures of the maxillary alveolar processon the righ...
LeFort Fractures Among the most severe fractures seen in face and associated withhigh-energy trauma Named after René LeF...
LeFort I fracture Definition: transmaxillary fracture Transverse (horizontal) fracture of inferior maxillae, involving m...
48-year-old man was kicked by a horse.LeFort I fracture line along bilateral maxillary sinuses (red arrows). Pterygoid pla...
LeFort II fracture Pyramid-shaped maxillary fracture, involving maxillarysinuses (anterior-lateral walls), inferior orbit...
Middle age man in motor vehicle accident.Fracture lines are demonstrated in red arrows.Fracture of pterygoid plates are pr...
LeFort III fracture Craniofacial disjunction This fracture separates calvaria (skull) from the facialbones. Most severe ...
32-year-old man, unrestraineddriver in a motor vehicleaccident.Blue arrows define LeFort II fracture.Red arrows define the...
malar fractures-Trauma to infraorbital margin may cause sensoryloss of infraorbital skin.Sometimes injury to nasolacrymal ...
Imaging Approach - Plain Film Friendly line (anterolateralantral wall of maxillary sinus) Both intact NO ZMC or LeFort ...
 Clear sinus sign (= all sinuses and mastoid are clear of fluid), there arethree possible facial fractures: Nasal bone f...
TRAJECTORIES OF MAXILLAAccording to Bennignhoff – Vertical trajectories1. Frontonassal buttress2. Malarzgomatic buttress3...
 Maxilla is spongy bone & houses paranasal sinuses- absorbs the energy of blunt trauma Articulation with frontal process...
SINUS LIFT PROCEDURE
ECTOPIC INFRAORBITAL NERVEIN A MAXILLARY SINUS SEPTUM:ANOTHER POTENTIALLYDANGEROUS VARIANT FORSINUS SURGERYP. Mailleux1, O...
POSITION OF INFRAORBITALFORAMENSárka Bejdová a,*, Václav Krajícek b, MiroslavPeterka a,c, Pavel Trefný a,d, Jana Velemínsk...
Majority – Oval in male skull (54.7%) & on left side (52.8%) Round on right side (34) & oval in left side (23) Directed...
Variability in palatal shape and size inpatients with bilateral complete cleft lipand palateSárka Bejdová a,*, Václav Kraj...
 Flatter & narrower in bilateral cleft lip & palate cases. Most notable size difference is in area in between maxilla & ...
Anatomical variation and morphology in theposition of the palatine foramina in adultMaria Piagkou , Theodore Xanthos , Sop...
 The study was conducted on 71, Greek dry, adult humanskulls of the twentieth century available in the AnatomicalMuseum o...
 High tuberosity block – for maxillary anesthesia. Control hemorrhage in cases of repair of nasal septum(septorhinoplast...
Mean distance of greater & lesser palatine foramina frommidsagittal suturegreater palatine foramina = 1.53 cmlesser palati...
Mean distance of greater palatine foramina from posterior border ofmaxillaRt side = 0.46 ± 0.10 cm Lt side = 0.47 ± 0.11 cm
Mean distance of greater & lesser palatine foramina from alveolarridgeRt side = 0.31 ± 0.17 cm Lt side = 0.29 ± 0.16 cmAva...
 Average anteroposterior diameter = Average transverse diameter = 76.2% cases = between proximal distal surface of maxi...
53.45 % cases = 131% cases = 2 (bilaterally)2.1 % cases = 5 (rare)
CONGENITAL DEFECTSMacrostomia Microstomia
Oblique cleft lipBilateral cleft lipcleft lip & cleftpalate
SYNDROMEASSOCIATED
ROMBERG / PARRY ROMBERG SYNDROME– progressive hemifacial atrophy
CROUZON SYNDROME/ CRANIFACIALDYSOSTEOSIS – midface hypoplasia,underdeveloped maxilla
APERT SYNDROME/ACROCEPHALOSYNDUCTYLY –middle third of face is markedly retruded
Marfan syndrome
DYCROCYSTORHINOSTOMY
Some important structures related toposterior wall of maxilla
MAXILLOFACIALTRAUMA
MECHANISM OF INJURY Middle third of face is a complex of bones & cartilages organized in a systemof buttresses. In adults...
 STANLEY & NOWARK (1985) did cephalometric study about thecadaver facial impacts where they stresses on importance of ang...
2. Horizontal impacts along the Frankfort plane = Le Fort II fracturepyramidal fracture
3. Direct horizontal or angular blow at the level of upper teeth but below theanterior nasal spine = Le Fort I or horizont...
 Riu et al 1960 Blanton & Biggs 1969 proposed that –when force is transmitted frombelow the honeycomb (Blanton &Biggs) p...
GEOMATRIC CONCEPTOFTHE CRANIOFACIAL SKELETON These models represents simplified interpretations of thecomplex anatomy of ...
 Rowe & Killey (1955) emphasized the mechanical strength of 3 pairedgirders in transmission of force evenly to the skull ...
 In a functional analysis of the facial skeleton Sicher & Du Brul 1975considered that the facial structures are anchored ...
 Sturla et al 1980performed cadaverimpaction studies &proposed a latticeshaped structure offacial skeleton.They emphasize...
 Manson et al 1983 and Gruss & Mackinnon 1986advised that anterior vertical buttress are reconstituted topreserve the fac...
 Gentry et al 1983 studied the thin axial section CT scan of cadaver &identified 3 horizontal sturts1. Superior2. Middle...
 3 sagittal sturts –1. Median / septal2. Parasagittal3. Lateral
 2 paired posterior coronal sturts –1. Posterior maxillary2. pterygoid
IMPORTANCE OF OHNGREN’S PLANE
MAXILLARYOSTEOTOMYHistory - 1859 Langenbeck1921 Cohn Stock
Osteotomy Segmental maxillary osteotomies1. Single tooth osteotomy2. Corticitomies3. Anterior segmental osteotomy4. Poste...
 Total maxillary osteotomies1. Le Fort I osteotomy2. Le Fort II osteotomy3. Le Fort III osteotomy
Le Fort I osteotomy
Vascular structures
 Seibert (1997) – palatal contribution to blood supply ofmobilized Le Fort I segment , which is mainly by –1. Ascending p...
Le Fort II osteotomy
Le Fort III osteotomy
Segmental maxillary osteotomy
Anterior segmentalosteotomy
Posterior segmentalosteotomy
SAME (surgically assisted maxillaryexpansion)
External SinusSurgeryAndrew H. Murr, MDJOURNAL OFAMERICAN RHINOLOGY SOCIETYRevised 6/2011care.american-rhinologic.org/exte...
Caldwell-Luc ApproachGeorge Caldwell (1893); New York & Henri Luc (1897); Paris
PNEUMATIZATION OF MAXILLARY SINUS Increase pneumatization –thinning of walls Mattila & Westerholm 1968-continuation ofwi...
RESOURCESTEXT BOOK –1. B.D. Chaurassia’s human anatomy 4th edition vol. 3 The Head & Neck.2. Gray’s Anatomy 39th edition.3...
RESOURCESOTHER SOURCES -1. Reoperative midface trauma.Yang RS, Salama AR, Caccamese JF. Oral Maxillofac Surg Clin North Am...
ANY QUESTION…..KINDLY CONTACTSheetal.kapse@yahoo.com
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
Maxilla  anatomy, development & surgical anatomy
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Maxilla anatomy, development & surgical anatomy

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Maxilla anatomy, development & surgical anatomy

  1. 1. PRESENTED BY –DR. SHEETAL KAPSE
  2. 2. INCLUSIONS - INTRODUCTION FEATURES OF MAXILLA DEVELOPMENT SURGICAL ANATOMY CONCLUSION RESOURCES
  3. 3. INTRODUCTION 2nd largest bone of face 2 maxillae forms whole of upper jaw Each maxilla contributes in formation of –1. Face2. Nose3. Mouth4. Orbit5. Infratemporal fossa6. Pterygopalatine fossa
  4. 4. FEATURES OF MAXILLA Each maxilla has –1. A body2. 4 processes – frontalzygomaticalveolarpalatine
  5. 5. BODY OF MAXILLA Shape – pyramidal It has –1. Base – directed medially at nasal surface2. Apex - directed laterally at zygomatic process3. 4 surfaces – anterior / facialposterior / infratemporalmedial / nasalsuperior / orbitalEncloses a cavity – maxillary sinus
  6. 6. ANTERIOR / FACIAL SURFACE Directs laterally Incisive fossa -depressor septi Incisivus – alveolar margin Nasalis – superiolateral, along nasal notch
  7. 7.  Canine fossa – levator anguli oris Infraorbital foramen levator labii superioris Medially – the nasal notch- anterior nasal spine
  8. 8. POSTERIOR / INFRATEMPORAL SURFACE Concave Directed – backward & laterally Forms – anterior wall of infratemporalfossa Separated from anterior surface 2-3 alveolar canals for – posterior superioralveolar nerve Posteroinferiorly – maxillary tuberosity &superficial head of medial pterygoidmuscle Above maxillary tuberosity -anterior wallof infratemporal fossa, grooved bymaxillary nerve
  9. 9. SUPERIOR / ORBITAL SURFACE Smooth, triangular & slightly concave Forms – Greater Part Of Floor Of Orbit Anterior border forms – part of inferior orbital margincontinues with lacrymal crest of frontal process
  10. 10. Posterior border – smooth & rounded Forms most anterior margin ofinferior orbital fissure In middle – infraorbital grooveMedial border – Anteriorly lacrymal notch, converted into nasolacrymal canal Behind the notch, articulation with -LacrymalLabrynth of ethmoidOrbital process of palatine bone
  11. 11. The superior surface presents – Infraorbital groove & canal Canalis sinosus Inferior oblique muscles
  12. 12. THE MEDIAL /NASAL SURFACE Part of lateral wall of nose Posterosuperiorly – maxillary hiatus Above the hiatus – air sinuses Below the hiatus – anterior part of inferior meatus Behind the hiatus –articulates withperpendicular plate ofpalatine bone&encloses greater& lesser palatine canals
  13. 13. THE MEDIAL /NASAL SURFACE Infront of the hiatus – nasolacrymal groove articulates withdescending process of lacrymal bone & lacrymal process ofinferior nasal concha to forms nasolacrymal canal
  14. 14. THE MEDIAL /NASAL SURFACE More anteriorly – conchal creast for articulation with inferiornasal concha. Above the conchal crest – atrium of middle meatus.
  15. 15. PROCESSESOFMAXILLA1. FRONTAL2. ZYGOMATIC3. ALVEOLAR4. PALATINE
  16. 16. FRONTAL PROCESS Projects upward & backwards to articulateabove – nasal margin of frontal boneinfront – nasal bonebehind – lacrymal bone Lateral surface – divided by anterior lacrymal crest intoanterior smooth & posterior grooved anterior lacrymal crestgives attachment tolacrymal fascia &medial palpebral ligament
  17. 17. FRONTAL PROCESS Medial surface – forms lateral wall of nosefrom above downwards –1. Uppermost roughened area for articulation with ethmoid2. Ethmoidal crest – a horizontal ridge, articulates with middle nasalconcha3. Below the ethmoidal crest– atrium of middle meatusconchal crestinferior meatus
  18. 18.  Pyramidal lateral projection Anterior, posterior & superior surfaces converge here Superiorly – rough, to articulate with zygomatic boneZYGOMATIC PROCESS
  19. 19.  Forms half of alveolar arch Bears socket for maxillary teeth In adults = 8 sockets Buccinator arises from posterior part of its outer surface upto1st molar tooth. Maxillay torus (occasionally)ALVEOLAR PROCESS
  20. 20.  Thick horizontal plate Projecting medially Forms largest part of roof & floor Inferior surface – concave & forms anterior 3/4th of bony hardpalate.PALATINE PROCESS
  21. 21.  Various foramina & pits Posterolaterally –greater & lesserpalatine foremen Superior surface –concavefrom side to side & formsfloor of nasal cavity.
  22. 22. Medial border – Thicker anteriorly Groove betweennasal crest of 2 maxilla receives lower border vomerAnterior part of ridge – incisal crest & anterior nasal spine, Incisive canalPosterior border articulates with horizontal plate of palatine boneLateral border is continuous with alvolar process
  23. 23. ARTICULATIONS OF MAXILLA Superiorly – 3 bones1. Frontal2. Nasal3. Lacrymal Laterally – 1 bone1. Zygomatic bone
  24. 24. ARTICULATIONS OF MAXILLAMedially – 5 bones1. Ethmoid2. Inferior nasal concha3. Vomer4. Palatine5. Opposite maxilla
  25. 25. AGE CHANGES IN MAXILLA AT BIRTH –1. Transverse & anterioposterior diameter > vertical diameter2. Well marked frontal process3. Body consists of little more than alveolar process4. Tooth sockets – close to orbit5. Maxillary sinus is a mere furrow on the lateral wall of nose IN ADULTS –Vertical Diameter Is More due to –1. Developed alveolar process2. Increased size of maxillary sinus IN OLD –1. Infantile condition2. Resorption of alveolar bone
  26. 26. DEVELOPMENT OF MAXILLA MAXILLA develops from ossification in mesenchyme of maxillary processof 1st arch. No arch cartilage / primary cartilage Center of ossification – close to the cartilage of nasal capsule Center of ossification – in angle between division of infraorbital nerve From this center the bone formation spreads – Bony trough for infraorbital canal is formed .Posteriorly – below the orbit toward the developing maxillaAnteriorly – toward the future incisor regionSuperiorly – to form frontal processMedially – to form palate
  27. 27.  From this trough a downward extension of bone forms the lateral alveolarplate. Medial alveolar plate – from junction of palatal process & main body offorming maxilla. These plates forms a trough of bone around the maxillary tooth germ. There is contribution of secondary cartilage. Zygomatic / malar cartilage adds in development of maxilla.
  28. 28. According to B.D. Chaurassia’s human anatomy 4th edition vol. 3 TheHead & Neck MAXILLA ossifies from 3 centers in the membrane –1. 1 center for maxilla proper – 6th week of IUL, above the canine fossa2. 2 centers for premaxillaOf 2 premaxillary centers-o Main center above the incisive fossa - 7th week of IULo Second center – ventral margin of nasal septum - 10th week of IULsoon fuses with palatal process of maxilla.Premaxilla begin to fuse with alveolar process almost immediately after theossification begins.
  29. 29. SURGICALANATOMYOFMAXILLA
  30. 30. Normal AnatomyFace (midface) is the region from supraorbital rimsto maxillary alveolar process
  31. 31. Major structuresare labeled in thepicture.Nasofrontal sutureZygomaticofrontalsutureZygomaticotemporalsutureSOF = Superior orbital fissureIOF = Inferior orbital fissureOrbital ‘rim’3D CTAnterior View
  32. 32. Nasofrontal sutureZygomaticofrontal sutureZygomaticotemporal suture3D CTLeft Lateral View
  33. 33. Axial viewKey structuresA = Frontal sinus, anterior wallB = Frontal sinus, posterior wall*Note: The right frontal sinus is notpneumatized in this case.Posterior wall of frontal sinus fracture may coexistwith brain injury
  34. 34. • Do not confuse the suture between nasal bone andfrontal process of maxilla for a fracture• Look for a piece of fracture in the optic foramen, it isthe true emergency of facial fractureKey structuresD = Orbit, medial wallE = Orbit, lateral wallF = Suture betweensphenoid andzygomatic bones= Nasomaxillarysuture1 = Globe2 = Ethmoid sinus3 = Sphenoid sinus4 = Nasal bone5 = Maxilla, frontalprocess6 = Orbit, lateral rim7 = Sphenoid bone8 = Optic foramenAxial view
  35. 35. Clear maxillary sinuses can almostrules out certain fractures such asZMC, LeFort, blowout fracturesKey structuresF = Groove forinfraorbital nerveG = Maxillary sinus,posterolateral wall5 = Maxilla, frontal process9 = Maxillary sinus10 = Zygomatic arch11 = Pterygoid bone12 = Nasolacrimal duct13 = Mandible, condyleAxial view
  36. 36. Key structuresH = Maxillary sinus,anterior wallI = Maxillary sinus,medial wallJ = Medial pterygoidplateK = Lateral pterygoidplate9 = Maxillary sinus14 = Mandible, ramusFracture of the pterygoid plates may representLeFort fractureAxial view
  37. 37. Lucency in midline of the maxilla is anormal finding seen occasionallyKey structuresJ = Medial pterygoid plateK = Lateral pterygoid plateL = Maxilla, spine14 = Mandible, ramus15 = Maxilla bone/ hard palateAxial view
  38. 38. Coronalsection• Remind yourself that CT can miss subtletooth fracture, although with the coronaland sagittal reformation. Obtainorthopanthogram or dedicated tooth filmwhen in doubtKey structuresL = Maxilla, spine* = Nasomaxillary suture4 = Nasal bone5 = Maxilla, frontal process
  39. 39. Key structuresD = Orbit, medial wallM = Nasal septum5 = Maxilla, frontal process15 = Maxilla bone/ hard palate16 = Frontal sinus17 = Mandible, bodyCoronal section
  40. 40. Key structuresM = Nasal septumN = Ethmoid bone,perpendicular plateO = Orbit, roofP = Orbit, floorQ = Maxillary sinus,posterolateral wall**= Zygomaticofrontalsuture1 = Globe2 = Ethmoid sinus6 = Orbit, lateral rimCoronal section
  41. 41. Key structuresJ = Medial pterygoidplateK = Lateral pterygoidplateN = Ethmoid,perpendicular plate3 = Sphenoid sinus10 = Zygomatic arch14 = Mandible, ramus18 = Mandible, angleCoronal section
  42. 42. Key structuresP = Orbit, floor7 = Pterygoid bone9 = Maxillary sinus15 = Maxilla bone /hardPalate• Orbital blowout fractureis best seen in sagittaland coronal images• Facial CT is notcompleted without imagereconstructionSagittal section
  43. 43. Key structures3 = Sphenoid sinus4 = Nasal bone15 = Maxilla bone/ hard palateMid saggital section
  44. 44. WATER’S VIEWThe most comprehensive singleprojection display Excellent view ofMaxillaMaxillary sinusesZygomaZygomatic archesRims of orbits,esp. floorNasal bones
  45. 45. WATER’S VIEWRule:smooth, nondisrupted,same contour on both sidesKey structures1 = Frontal sinus2 = Maxillary sinus3 = Frontal process ofZygoma4 = Body of Zygoma (malareminence)5 = Temporal process ofZygomaDotted line = zygomaticofrontalsutureDolan’s lines of referenceLine A, B, C
  46. 46. Line ABegins at inner surface ofZygomaticofrontal suture, followsorbital surface ofzygoma, maxilla, frontalprocess of maxilla and archof nasal boneIf drawn to both sides, theline is similar to lazy ‘W’ orhalf frame of readingglassesLine BBegins at lateral andinferior margin of maxillaand extends along lateralwall of maxillary sinus andinferior surface of zygomaticArch Ends at glenoid fossa
  47. 47. Line CBeginsat lateral andinferior margins of maxilla,extends along lateral wall ofmaxillary sinus and inferiorsurface of zygomatic archEnds at glenoid fossa“Friendly Line”Medial half of Line C is theanterolateral wall of themaxillary sinus.If it is disrupted, thepossibilities of fracture include1) Isolated maxillaryantrum2) Zygomaticomaxillarycomplex (ZMC)3) LeFort
  48. 48. Mc Grigor’s /Campbell’s line
  49. 49. Caldwell’s ViewExcellent view ofEntire rim of orbit, esp.superomedial rimEthmoid sinusFloor of orbit may be wellseen in petrous bones areprojected below the inferiororbital rim (not in thisexample)
  50. 50. Key structures1 = Ethmoid sinuses2 = OrbitLine A, B, C, D = superior,lateral, inferior and medialwalls of the orbit,respectivelyLine E = midline nasalseptum and vomerRule:Ethmoidsinuses densityshould be equal, darkerthan orbitSmoothnondisruptedorbital walls2
  51. 51. Lateral cephalogramExcellent view of1. Frontal sinus: anterior wall2. Maxillary sinus: anterior and posteriorwall3. Sphenoid sinus4. Pterygoid plate, hard palate5. Floor of anterior cranial fossa,
  52. 52. Key structures1 = Frontal sinus2 = Maxillary sinus3 = Sphenoid sinus4 = Hard palate5 = Anterior wall of temporal fossaBetween green arrows =Pterygoid plateLine A = Anterior wall offrontal sinusLine B = Anterior cranialfossaLine C = Anterior wall ofmaxillary sinusLine D = Posterior wall ofmaxillary sinus
  53. 53. TOWN’S VIEWKey structures1 = Zygomatic archLine A = Posterolateral wall of maxillarysinusRule:Smooth, nondisrupted lineExcellent view of Maxillary sinus:posterolateral wall Zygomatic arch
  54. 54. Hot Sites
  55. 55. Maxillary Fractures Types of maxillary fractures - Maxillary sagittal fracture (maxillary sinus fracture) Palate fracture Alveolar process fracture LeFort fractures LeFort I fracture LeFort II fracture LeFort III fracture Combination (bilateral, hemi-)
  56. 56. Maxillary sagittal fracture Maxillary sinus fracture Fracture of a maxilla in sagittal plane, involving anterior-lateral wallof a maxillary sinus (LeFort fractures represent bilateral maxillaryfractures) Due to direct blow to either right or left midface Plain film shows opacified maxillary sinus, however it is usuallyinadequate for diagnosis
  57. 57. 68-year-old man was founddown.There is a sagittal planefracture of the left maxillarysinus (red arrow) withhemosinus (H)
  58. 58. Isolated alveolar processfracture Fracture of any portion of the alveolar process Clinically evident by malalignment and displacement of teethcontained within fractured segment Even on CT, fracture may be subtle and easily overlooked Further imaging may be needed when the diagnosis is madeX-ray of the teeth or a panoramic view (look for dental injuries)Chest radiograph (look for aspirated teeth)
  59. 59. Middle age women fell onto her mouth.Red arrows show the comminuted fractures of the maxillary alveolar processon the right side. These fractures are considered ‘open’ as they are connectedto the oral cavity.
  60. 60. LeFort Fractures Among the most severe fractures seen in face and associated withhigh-energy trauma Named after René LeFort, a French physician, who studied facialfractures in cadavers. Result was published in 1901 Key facts - In each type, there is a partial or complete separation of maxilla from theremainder of the facial skeleton All LeFort fractures must extend through posterior face, transects thepterygoid processes Any combination of LeFort I, II, and III patterns can occur
  61. 61. LeFort I fracture Definition: transmaxillary fracture Transverse (horizontal) fracture of inferior maxillae, involving maxillarysinuses (all except superior walls), lateral margin of nasal fossa, nasalseptum and pterygoid plates Clinical: free floating and movable hard palate with maxillary teeth Imaging findings Opacified bilateral maxillary sinuses Transverse fracture through the inferior maxillae above hard palate Best shown and confirmed by coronal and sagittal reformatted CT images
  62. 62. 48-year-old man was kicked by a horse.LeFort I fracture line along bilateral maxillary sinuses (red arrows). Pterygoid platefractures are not shownH = Hemosinus, Blue arrow = Mandibular fracture
  63. 63. LeFort II fracture Pyramid-shaped maxillary fracture, involving maxillarysinuses (anterior-lateral walls), inferior orbital rim, orbitalfloor and nasofrontal sutureClinical: free floating, movable midface includingmaxillary teeth, hard palate and nose Imaging findings: Opacified bilateral maxillary sinuses and orbital emphysema Fractures of anterior/lateral walls of maxillary sinuses, inferior orbitalrims/floors and disruption of nasofrontal suture Best seen and confirmed by coronal reformatted CT images
  64. 64. Middle age man in motor vehicle accident.Fracture lines are demonstrated in red arrows.Fracture of pterygoid plates are present in alltype of LeFort fractures.H = Hemosinus
  65. 65. LeFort III fracture Craniofacial disjunction This fracture separates calvaria (skull) from the facialbones. Most severe of all LeFort fractures Definition: separation of facial bones from the skull Zygomas separated from sphenoid at zygomatico-sphenoid sutures Nasal bones and medial orbital walls separated from frontal bone at nasofrontal sutures Best seen in coronal imagesClinical: movement of face relative to the skull Imaging findings: Plain film will underestimate degree of injuryto severe soft tissue swellingobscuring the bony details. CT is recommended due
  66. 66. 32-year-old man, unrestraineddriver in a motor vehicleaccident.Blue arrows define LeFort II fracture.Red arrows define the LeFort III fracture.
  67. 67. malar fractures-Trauma to infraorbital margin may cause sensoryloss of infraorbital skin.Sometimes injury to nasolacrymal duct – epiphora.
  68. 68. Imaging Approach - Plain Film Friendly line (anterolateralantral wall of maxillary sinus) Both intact NO ZMC or LeFort fractures Blowout fracture Isolated fractures of lateral orbitalwall, zygomatic arch One disrupted ZMC fractures Maxillary sagittal fracture (isolated sinusfracture) Both disrupted LeFort fractures
  69. 69.  Clear sinus sign (= all sinuses and mastoid are clear of fluid), there arethree possible facial fractures: Nasal bone fractures Isolated zygomatic arch fractures Mandible fractures Bloody sinuses Pterygoid plate fracture present - probable LeFort fracture Maxillary wall fractures Orbital floors, NOE region fractures ZMC fractures With fracture of lateral margin of nasal fossa= LeFort I With fracture of inferior orbital rim = LeFort II With fracture of zygomatic arch = LeFort III
  70. 70. TRAJECTORIES OF MAXILLAAccording to Bennignhoff – Vertical trajectories1. Frontonassal buttress2. Malarzgomatic buttress3. Pterygoid buttress horizontal trajectories1. Hard palate2. Orbital margin3. Zygomatic arches4. Palatal bone5. Lesser wing of sphenoid
  71. 71.  Maxilla is spongy bone & houses paranasal sinuses- absorbs the energy of blunt trauma Articulation with frontal process & zygoma – stability. Porous – ample blood supply – prevents spread ofinfection. Boney defect > 5 mm = grafting.
  72. 72. SINUS LIFT PROCEDURE
  73. 73. ECTOPIC INFRAORBITAL NERVEIN A MAXILLARY SINUS SEPTUM:ANOTHER POTENTIALLYDANGEROUS VARIANT FORSINUS SURGERYP. Mailleux1, O. Desgain2, M.I. Ingabire1Evidence in Health and Social Care(Online journal)www.rbrs.org/dbfiles/journalarticle_0814.pdfWorld Neurosurg. 2011 Sep-Oct;7 2010, 93:308-309 ; discussion 266-7
  74. 74. POSITION OF INFRAORBITALFORAMENSárka Bejdová a,*, Václav Krajícek b, MiroslavPeterka a,c, Pavel Trefný a,d, Jana Velemínskáa Variability in palatal shape and size inpatients with bilateral complete cleft lip andpalate assessed using dense surface modelconstruction and 3D geometricMorphometrics, Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 201e208100Skulls196 sides
  75. 75. Majority – Oval in male skull (54.7%) & on left side (52.8%) Round on right side (34) & oval in left side (23) Directed inferomedially – 65.8 % in males- 67.8 % in females Present in vertical line with 1st premolar = 70/196 sidesno gender predilection Mean distance between infraorbital margine & infraorbital foramen =7.39 1.63 mm 4/ 100 skulls – accessory foramina1 accessory foramina – 2 male & 1 female2 accessory foramina – 1 male skullmostly on left side & oval in shape.
  76. 76. Variability in palatal shape and size inpatients with bilateral complete cleft lipand palateSárka Bejdová a,*, Václav Krajícek , Miroslav Peterka , Pavel Trefný ,JanaVelemínská ; Variability in palatal shape and size in patients with bilateralcomplete cleft lip and palate assessed using dense surface modelconstruction and 3D geometric morphometrics; Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 201e208.
  77. 77.  Flatter & narrower in bilateral cleft lip & palate cases. Most notable size difference is in area in between maxilla & maxilla, evenpremaxilla can remain separate from rest of the palate. Mean Palatal configuration of premaxilla & adjacent palatal area in lateralprojection is –concave in normal individualsclefted in bilateral cleft lip & palate cases Palate of clefted patient is more conical anteriorly than posteriorly.
  78. 78. Anatomical variation and morphology in theposition of the palatine foramina in adultMaria Piagkou , Theodore Xanthos , Sophia Anagnostopoulou, Theano Demesticha , Evangelos Kotsiomitis, GiannoulisPiagkos, Vassilis Protogerou , Dimitrios Lappas , PanayiotisSkandalakis , Elizabeth O. Johnson ; Anatomical variation andmorphology in the position of the palatine foramina in adulthuman skulls from Greece; Journal of Cranio-Maxillo-FacialSurgery 40 (2012) e206ee210
  79. 79.  The study was conducted on 71, Greek dry, adult humanskulls of the twentieth century available in the AnatomicalMuseum of the Department of Anatomy, Faculty ofMedicine, Athenian University. The investigated normal skulls with fully erupted 3rdmaxillary molars were evaluated to describe the intraorallandmarks of the GPF and related structures.
  80. 80.  High tuberosity block – for maxillary anesthesia. Control hemorrhage in cases of repair of nasal septum(septorhinoplasty). Greater palatine artery can damage in fracture of –1. Medial wall of maxillary sinus2. Lateral wall of maxillary sinus3. Pterygomaxillary dysjunction4. Downfracturing of maxilla Greater palatine foramen is also important in closure oforoantral communication with palatal flap.
  81. 81. Mean distance of greater & lesser palatine foramina frommidsagittal suturegreater palatine foramina = 1.53 cmlesser palatine foramina = 1.46 ± 0.22 cm (rt),1.47 ± 0.17 cm (lt)
  82. 82. Mean distance of greater palatine foramina from posterior border ofmaxillaRt side = 0.46 ± 0.10 cm Lt side = 0.47 ± 0.11 cm
  83. 83. Mean distance of greater & lesser palatine foramina from alveolarridgeRt side = 0.31 ± 0.17 cm Lt side = 0.29 ± 0.16 cmAvarage = 0.3 cmRt side = 0.41 ± 0.19 cmLt side = 0.38 ± 0.02 cm
  84. 84.  Average anteroposterior diameter = Average transverse diameter = 76.2% cases = between proximal distal surface of maxillary 3rd molars 71.9 % cases = at the junction of palatine bone & inner lamella of pterygoidplateRt side = 0.53 ± 0.09 cm Lt side = 0.54 ± 0.09 cmLt side = 0.27 ± 0.05 cmRt side = 0.26 ± 0.06 cm
  85. 85. 53.45 % cases = 131% cases = 2 (bilaterally)2.1 % cases = 5 (rare)
  86. 86. CONGENITAL DEFECTSMacrostomia Microstomia
  87. 87. Oblique cleft lipBilateral cleft lipcleft lip & cleftpalate
  88. 88. SYNDROMEASSOCIATED
  89. 89. ROMBERG / PARRY ROMBERG SYNDROME– progressive hemifacial atrophy
  90. 90. CROUZON SYNDROME/ CRANIFACIALDYSOSTEOSIS – midface hypoplasia,underdeveloped maxilla
  91. 91. APERT SYNDROME/ACROCEPHALOSYNDUCTYLY –middle third of face is markedly retruded
  92. 92. Marfan syndrome
  93. 93. DYCROCYSTORHINOSTOMY
  94. 94. Some important structures related toposterior wall of maxilla
  95. 95. MAXILLOFACIALTRAUMA
  96. 96. MECHANISM OF INJURY Middle third of face is a complex of bones & cartilages organized in a systemof buttresses. In adults it is extensively pneumatized. The maxilla a box like bone has been harder to assess as an entity;NAHUM (1975) tested the thin anterior wall of maxilla & found that thisshattered at quite low force loadings in the range 150-300 lbs (0.67-1.34kN).208- 475 lb for zygoma> 75 lb for nasal bone
  97. 97.  STANLEY & NOWARK (1985) did cephalometric study about thecadaver facial impacts where they stresses on importance of angle of impactin relation to the horizontal buttress of the facial skeleton.Impact on the nasion at 30-60oabove the horizontal = Le Fort IIIfracture (craniofacial disjunction)
  98. 98. 2. Horizontal impacts along the Frankfort plane = Le Fort II fracturepyramidal fracture
  99. 99. 3. Direct horizontal or angular blow at the level of upper teeth but below theanterior nasal spine = Le Fort I or horizontal maxillary fracture.
  100. 100.  Riu et al 1960 Blanton & Biggs 1969 proposed that –when force is transmitted frombelow the honeycomb (Blanton &Biggs) pyramidal (Riu et al)configuration of paranasal sinuses ,with maxillary sinus forming thebase & sphenoid sinus forming theapex, forms an architecturalstructure that is particularly wellsuited to a protective energyabsorbing role.
  101. 101. GEOMATRIC CONCEPTOFTHE CRANIOFACIAL SKELETON These models represents simplified interpretations of thecomplex anatomy of the bony structural pillars thattransmits the forces of mastication, devised to furtherunderstanding of fracture patterns .
  102. 102.  Rowe & Killey (1955) emphasized the mechanical strength of 3 pairedgirders in transmission of force evenly to the skull base –1. Alveoli & transpalatal arch2. Palatine-pterygoid buttress posteriorly3. Zygomaic complex laterallyAdditionl support in the central buttress ofvomer & ethmoid vertical plateThe arched palate & infraorbital rim join theanterior & lateral girders.
  103. 103.  In a functional analysis of the facial skeleton Sicher & Du Brul 1975considered that the facial structures are anchored to the skull base by 3 pairsof curved vertical pillars –1. Canine pillar2. Zygomatic pillar3. Pterygoid pillarThese authors gave greater importance to thehorizontal pillars connecting the curved verticalpillars, specially the supraorbital bar.
  104. 104.  Sturla et al 1980performed cadaverimpaction studies &proposed a latticeshaped structure offacial skeleton.They emphasized on theimportance of vertical pillars &transverse plateforms – the hardpalate below & frontal sphenoidbone above.
  105. 105.  Manson et al 1983 and Gruss & Mackinnon 1986advised that anterior vertical buttress are reconstituted topreserve the facial height, in case of trauma.
  106. 106.  Gentry et al 1983 studied the thin axial section CT scan of cadaver &identified 3 horizontal sturts1. Superior2. Middle / orbital3. Inferior / palatal
  107. 107.  3 sagittal sturts –1. Median / septal2. Parasagittal3. Lateral
  108. 108.  2 paired posterior coronal sturts –1. Posterior maxillary2. pterygoid
  109. 109. IMPORTANCE OF OHNGREN’S PLANE
  110. 110. MAXILLARYOSTEOTOMYHistory - 1859 Langenbeck1921 Cohn Stock
  111. 111. Osteotomy Segmental maxillary osteotomies1. Single tooth osteotomy2. Corticitomies3. Anterior segmental osteotomy4. Posterior segmental osteotomy5. Horse shoe osteotomy
  112. 112.  Total maxillary osteotomies1. Le Fort I osteotomy2. Le Fort II osteotomy3. Le Fort III osteotomy
  113. 113. Le Fort I osteotomy
  114. 114. Vascular structures
  115. 115.  Seibert (1997) – palatal contribution to blood supply ofmobilized Le Fort I segment , which is mainly by –1. Ascending palatinebranch of facial artery2. Ascending pharyngealbranch of externalcarotid artery.
  116. 116. Le Fort II osteotomy
  117. 117. Le Fort III osteotomy
  118. 118. Segmental maxillary osteotomy
  119. 119. Anterior segmentalosteotomy
  120. 120. Posterior segmentalosteotomy
  121. 121. SAME (surgically assisted maxillaryexpansion)
  122. 122. External SinusSurgeryAndrew H. Murr, MDJOURNAL OFAMERICAN RHINOLOGY SOCIETYRevised 6/2011care.american-rhinologic.org/external_sinus_surgery
  123. 123. Caldwell-Luc ApproachGeorge Caldwell (1893); New York & Henri Luc (1897); Paris
  124. 124. PNEUMATIZATION OF MAXILLARY SINUS Increase pneumatization –thinning of walls Mattila & Westerholm 1968-continuation ofwidening of sinus after dentalextraction. Young v/s adult maxillary sinus Killey & Kay 1972 –9/362 oroantralcommunication in 0-15 years of agegroup.
  125. 125. RESOURCESTEXT BOOK –1. B.D. Chaurassia’s human anatomy 4th edition vol. 3 The Head & Neck.2. Gray’s Anatomy 39th edition.3. Ten Cate’s Oral Histology, 6th edition.4. The Head & Neck by- Hennry Hollinshed5. Killey’s fracture of middle third of facial skeleton6. Orthognathic Surgery By – George Dimitroulis, M. Franklin Dolwick, Joseph E. VanSickels.7. Craniomaxillofacial trauma by – D.J. David, D.A. Simpson.8. Oral & maxillofacial surgery fonseca vol. 2 by – Betts & Turvey.9. The Maxillary Sinus & Its Dental Implications by – Killey & Kay.
  126. 126. RESOURCESOTHER SOURCES -1. Reoperative midface trauma.Yang RS, Salama AR, Caccamese JF. Oral Maxillofac Surg Clin North Am. 2011Feb;23(1):31-45, v. Epub 2010 Dec 3.2. Gruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid fixation and immediate bone graftreconstruction. Clin Plast Surg. 1989 Jan;16(1):93-1043. Evidence in Health and Social Care,4. World Neurosurg. 2011 Sep-Oct;7 2010, 93: 308-309 ; discussion 266-75. P. Mailleux, O. Desgain, M.I. Ingabire;Ectopic infraorbital nerve in a maxillary sinus septum:anotherpotentially dangerous variant for sinus surgery6. Maria Piagkou , Theodore Xanthos , Sophia Anagnostopoulou , Theano Demesticha , EvangelosKotsiomitis, Giannoulis Piagkos, Vassilis Protogerou , Dimitrios Lappas , Panayiotis Skandalakis , ElizabethO. Johnson ; Anatomical variation and morphology in the position of the palatine foramina in adult humanskulls from Greece; Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e206ee2107. Sárka Bejdová a,*, Václav Krajícek , Miroslav Peterka , Pavel Trefný ,Jana Velemínská ; Variability in palatalshape and size in patients with bilateral complete cleft lip and palate assessed using dense surface modelconstruction and 3D geometric morphometrics; Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 201e208.
  127. 127. ANY QUESTION…..KINDLY CONTACTSheetal.kapse@yahoo.com

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