Maxxilla seminar ih

2. PRESENTER : Dr. ITRAT HUSSAIN
MODERATOR : Dr. RAKSHAK ANAND

3.  Introduction
 Embryology, Growth and Development
 Age Changes
 Anatomy
 Muscle Attachments
 Surgical Anatomy

4. • Paired bone
• Irregular, pneumatic bone
• 2ND Largest bone of face
• Each assists in forming
the boundaries of three
cavities :mouth, nose, orbit
•

5. EMBRYOLOGY
GROWTH AND
DEVELOPMENT

6.  PRENATAL
 POST NATAL
 The period of the ovum { from fertilization to the end of the
14th day
 The period of the embryo { from 14th day to about the 56th
day
 The period of the foetus { from 56th day until the 280th day –
birth }

7.  The most typical
feature in
development of face
is formed by the
pharyngeal or
branchial arches.
 These arches
contribute to the
characteristic external
appearance of
embryo.

8. Maxilla is formed from 1st
pharyngeal arch.
1st pharyngeal arch lying lateral
to the stomodeum divides in 2
processes.
Dorsal process – Maxillary
process.
Ventral process –
Mandibular process.

9.  At about 21 DAYS
after fertilization.
 Developing brain &
the pericardium form
2 prominent bulges on
the ventral aspect of
the embryo.

10.  These bulges are
separated by the
stomodeum .
 The floor of the
stomodeum - formed
by the -
BUCCOPHARYNGEL
MEMBRANE
(separates it from the
foregut)

11.  The mesoderm
covering the
developing forebrain
proliferates & forms a
downward projection
that overlaps the
upper part of the
stomodeum known as
FRONTONASAL
PROCESS

12. Between the 3RD & 8TH WEEKS
Each mandibular arch forms the lateral wall
of the stomodeum, which gives of a bud
from its dorsal end called the MAXILLARY
PROCESSES
At this stage the stomodeum is overlapped
from above by the frontal process, below
by the mandibular process & on either side
by the maxillary process

13.  During the 4th week,
the ectoderm overlying
the frontonasal process
shows bilateral
thickenings, known as
NASAL PLACODES
 These placodes sink
below the surface to
form nasal pits

14.  The palate is formed by the
contributions of the :
• Maxillary process
• Palatal shelves
• Frontonasal process
The frontonasal process gives rise to
the premaxillary region
the palatal shelves form the rest of
the palate
Development of palate

16.  The line of fusion of lateral palatal
shelves is traced by midpalatal
suture, which is ‘Y’ shape in
infancy and ‘T’ shape in childhood.
Growth at midpalatal suture
ceases at 1-2 YEARS of age.
Clinical correlates
 Defective fusion of the various
components of the palate gives
rise to clefts in the palate.
Hard palate :
intra membranous ossification of
mesoderm of palate.
Soft palate:
ossification does not extends to
posterior most part.

17. occurs from the 8th week of intra-uterine life
 intramembranous type of ossification
 Palate ossifies from a single centre derived from
the maxilla
 The most posterior part of the palate does not
ossify & forms the soft palate
 The mid-palatal suture ossifies by 12-14 YEARS

18.  The maxillary complex is attached to the cranial
base,
 Hence it influences the development of this
region

19.  The growth of the nasomaxillary complex is produced by
the following mechanisms
• DISPLACEMENT
• GROWTH AT SUTURES
• SURFACE REMODELING

20. • Growth of the cranial base leads to a passive or secondry
displacement of the nasomaxillary complex in a downward &
forward direction.

21. • The maxilla is connected
to the cranium & cranial
base by a number of
sutures which include :
 The fronto-nasal suture
 The fronto-maxillary
suture
 The zygomatico-
temporal suture
 The zygomatico-
maxillary sututre
 The pterygo-palatine
suture

22. • These sutures are all oblique &
more or less parallel to each
other which allows the
downward & forward
repositioning of the maxilla as
the growth occurs at these
sutures – Weinmann & Sicher
• This leads to opening up of space
at the sutural attachments
• New bone is formed on either
side of the suture. Hence, a
tension related bone formation
occurs at the sutures

23. • Massive surface remodeling
by bone deposition &
resorption brings about,
increase in size; change in
shape of bone; & change in
functional relationship

24. • Bone deposition occurs along
the posterior margin of the
maxillary tuberosity leading to
lengthening of the dental arch &
enlargement of the antero-
posterior dimension of the
entire maxillary body - helps to
accommodate the developing
molars

25. • Bone resorption on the floor
of the nasal cavity is
compensated deposition on
the palatal side, resulting in a
downward shift leading to an
increase in the maxillary
height

26. • As teeth start erupting, bone
deposition occurs at the
alveolar margins. This
increases the maxillary
height & depth of the palate :
the expanding “V” principle-
Enlow .

27.  Second largest bone of the
face.
 Pair of irregular pneumatic
bones
 Made up of medullary bone
 Maxilla houses the largest of
the paranasal sinuses, the
maxillary sinus.

28. Two maxillae articulate
to form
1. Whole upper
jaw.
2. Roof of oral
cavity.
3. Greater part
of floor and lateral
wall of nasal cavity
and part of nasal
bridge.
4. Greater part
of floor of each
orbit.

30. 1. BODY- Large and pyramidal in shape.
2. FOUR PROCESSES Frontal
Zygomatic
Alveolar
Palatine

31.  Three sided pyramid
 Base -facing the nasal
cavity
 Apex being elongated
into the zygomatic
process
 Hollowed out by the
maxillary sinus
 Presents 4 surfaces-
anterior, posterior
(infratemporal), orbital
and nasal.

32. Faces anterolaterally
Forms the anterior part of
cheek. - called mallar
surface.
Boundaries
• Posteriorly- zygomaticoalveolar crest or
jugal crest
• Medially – extends at the edge of the
border of pyriform aperture
• Laterally- canine fossa, infraorbital
foramen

33.  Two or three alveolar canals
present . Transmit PSA nerve
and vessels.
 Posteroinferior is maxillary
tuberosity.- roughened
superomedially where it
meets the pyramidal process
of palatine bone.
Fibres of medial pterygoid are
attached here.
 Anterior boundary of the
pterygopalatine fossa and is
grooved by maxillary nerve.

34.  Triangular
 forms most of the floor of
orbit.
 Anteriorly - medial border
bears a lacrimal notch .
 Behind which it articulates
with the lacrimal bone, the
orbital plate of the ethmoid
and posteriorly with the
orbital process of the
palatine bone.
 Posteriorly - forms most of
the anterior edge of the
inferior orbital fissure.

35. •The infraorbital groove lies
centrally - transmits infraorbital
nerve and vessels.
•Near its midpoint, the infraorbital
canal has a small lateral branch,
the canalis sinuosus ( anterior
superior alveolar nerve )

36. •The site of the attachment of inferior oblique may be
indicated by a small depression in the bone at the
anteromedial corner of the orbital surface, lateral to
the lacrimal groove.

37. •Displays posteriosuperiorly the large
irregular maxillary hiatus leading into
the maxillary sinus.
• Posteriorly, surface is roughened
where it meets the perpendicular plate
of the palatine bone.
• traversed by pterygopalatine groove -
descends forwards from the
midposterior border, - converted into a
greater palatine canal by the
perpendicular plate.

38. Anterior to the hiatus-the
nasolacrimal groove is present
makes up about two-thirds of
the circumference of the
nasolacrimal canal.
 rest is contributed by the
descending part of the lacrimal
bone and the lacrimal process of
the inferior nasal concha.
More anterior is an oblique
conchal crest which articulates
with the inferior nasal concha.

39. Anterior, infratemporal and orbital surfaces
converge at a pyramidal projection, the zygomatic
process.
 Anterior surface: extension of anterolateral surface
of maxillary body,
 Posteriorly, it is concave and continuous with
infratemporal surface.
 Superiorly, it is roughly serrated for articulation
with zygomatic bone.
 Inferiorly, a bony arched ridge, the
zygomaticoalveolar ridge or jugal crest, separates
the facial (anterior) and infratemporal surfaces.

40.  Projects posterosuperiorly
between the nasal and
lacrimal bones.
 lateral surface is divided
by the anterior lacrimal
crest which gives
attachment to the medial
palpebral ligament .
 The smooth area anterior
to the lacrimal crest gives
attachment to the
orbicularis oculi and
levator labii superioris
alaeque nasi .

41. •The medial surface is part of the lateral wall of nose. A rough
subapical area articulates with the ethmoid and closes anterior
ethmoidal air cells.
•Below it is the ethmoidal crest , forms the upper limit of the
atrium of the middle meatus.
•The frontal process articulates above with the nasal part of the
frontal bone.
•Its anterior border articulates with the nasal bone and its
posterior border articulates with the lacrimal bone.

42.  The alveolar process is thick and
arched, wide behind, and
socketed for the roots of the
upper teeth.
 The eight sockets on each side
vary according to the tooth type.
 The socket for the canine is
deepest, the sockets for molars
are widest and subdivided into
three by septa.
 Those for incisors and second
premolar are single and that for
the first premolar usually double.

43.  thick and horizontal, projects medially from the
lowest part of the medial aspect of the maxilla.
 forms a large part of the nasal floor and hard palate
and is much thicker in front.
 The palatine process displays numerous vascular
foramina and depressions for palatine glands and,
posterolaterally, two grooves that transmit the
greater palatine vessels and nerves.

44. •The incisive fossa is placed between
the two maxillae behind the incisor
teeth.
•Two lateral incisive canals, each
ascending into its half of the nasal
cavity, open in the incisive fossa &
they transmit the terminations of the
sphenopalatine artery and
nasopalatine nerve.
•Two additional median openings, anterior and
posterior incisive foramina, are occasionally
present. they transmit the nasopalatine nerves.

46.  Sometimes, root apices are
in closer proximity to the
sinus floor mainly due to
- Large sinuses
- Floor of sinus descending
below roots of teeth
- Unerupted or partially
erupted teeth
 Low incidence in children
 Fractures of bony floor
 Acute or chronic abscess of
upper teeth

48. MAXILLARY ARTERY
1st (mandibular) part: deep to the condyle of mandible
2nd (pterygoid) part: neighbourhood of lateral pterygoid muscle
3rd (pterygopalatine) part: into the pterygopalatine fossa

49. Branches of the 1st part:
1) Deep auricular (to external acoustic meatus)
2) Anterior tympanic artery (to the tympanic membrane)
3) Middle meningeal (to dura mater and calvaria)
4) Accessory meningeal aa. (to the cranial cavity)
5) Inferior alveolar artery (to the mandibular gingiva and teeth)

50. Branches of the 2nd part:
1) Deep temporal artery (to the temporal muscle)
2) Pterygoid artery(to the pterygoid muscles)
3) Masseteric artery (to the masseter muscle)
4) Buccal artery (to the buccinator muscle)
o deep auricular (da)
o anterior tympanic (at)
o middle meningeal (mm)
o accessory middle meningeal (amm)
o inferior alveolar (ia)
o buccal (b)
o deep temporal (dt)
o posterior superior alveolar (psa)
o descending palatine (dp)
o infraorbital (io)
o sphenopalatine (sp)

51.  In most of technique used in
closure of cleft palate the platal
flap are based on greater palatine
artery surgeon must take care of
that he doesn’t damage it , which
lead to necrosis of flap and oro-
nasal fistula.
 The greater palatine artery need to
be mobilized
 The surgeon has to detached all
the connective tissue of greater
palatine artery for mobilization of
flap for closure of fistula
 In von langenback technique the
palatal flap are based on both
greater palatine and naso palatine,
therefore it gives dual supply to the
flap

52. Osteomyelitis of the maxilla is much less
frequent than that of mandible .
Maxillary blood supply is more extensive
Thin cortical plates and a relative paucity
of medullary tissues in maxilla preclude
confinement of infections within bone and
permit the edema and pus into soft tissues
and paranasal sinuses

53. CAVERNOUS SINUS
THROMBOSIS

57.  At birth the transverse & sagittal maxillary
dimensions are greater than the vertical.
 The frontal process is prominent but the body is little
more than an alveolar process, since the alveoli
reach almost to the orbital floor.
 In adults the vertical dimension is greatest,reflecting
the development of the alveolar process &
enlargement of the sinus.

58.  The suture between the
premaxilla and the
maxilla in the fetus
and infant extends just
lateral to the lateral
incisor tooth, and
therefore the part of
the alveolar arch
bearing the incisor
teeth is often referred
to as the premaxilla.

59.  When teeth are lost, the
bone reverts towards its
infantile shape. Thus its
height diminishes, the
alveolar process is
absorbed & the lower
parts of bone contract &
become reduced in
thickness at the
expense of the labial
wall.

61. Resist occlusal
load

65.  The bulk of the strength lies in the facial surface of the
skeleton
 Interconnected laminae provide an excellent cross
braced type of structure which transmits occlusal stress
through the alveolar process to the skull base around the
nasal cavity and orbital contents
 As it is clothed over large areas of their surfaces, all
fractures are open to nasal or oral cavity thus increasing
risk of infection
 For the same reason, inspite of gross comminution, all
fragments of bone retain a periosteal blood supply

67. Pitfalls:
a) # caused by loc penetrating missile injuries & gun
shot wounds not included.
b) Only meant for bilateral # occuring at same level
c) mid palatine split along palatal suture not described
d) Inaccurate prediction of reduction techniques.

68. Fracture not involving the occlusion
Central region
Nasal bone/ septum (lateral, anterior injuries)
Frontal process of the maxilla
Nasoethmoid
Fronto-orbito-nasal dislocation
Lateral region (zygomatic bone, arch and maxilla )
Fracture involving the occlusion
Dento alveolar
Subzygomatic:
Le Fort (I, II)
Supra zygomatic:
Le Fort III

69. ∏ Assault
∏ RTA
∏ Gunshot wounds
∏ Sports
∏ Falls
∏ Industrial accidents

70. Prevalence of mid-
face fractures
Fracture Type Prevalence
Zygomaticomaxillary complex (tripod fracture) 40 %
LeFort
I 15 %
II 10 %
III 10 %
Zygomatic arch 10 %
Alveolar process of maxilla 5 %
Smash fractures 5 %
Other 5 %

71.  Horizontal fracture line
above the level of the
floor of the nose
involving the lower third
of the septum, and the
mobile fragment consists
of the palate, the
maxillary alveolar
process and the lower
thirds of pterygoid plates
and associated portions
of the bones

72. A). Le fort I/ Floating fracture/ Guerin fracture/ Low level fracture/
Subzygomatic fracture
1. Mobility of maxillary alveolar segment (floating fracture)
2. Pain and tenderness while speaking or clenching
3. Ecchymosis or laceration in labial or buccal vestibule
4. Ecchymosis at Greater Palatine foramen (Guerin sign)
5. Swelling and oedema of upper lip
6. Distubance in occlusion
7. Bilateral epistaxis
8. Brusing of palatal tissues (15-20% of cases)
9. Percussion of teeth – cracked pot sound
Clinical Features

74. B). Le fort II/ Pyramidal fracture/ Mid level fracture/ Subzygomatic
fracture
1. Oedema mid third of face (Moon face)
2. Paresthesia of cheek
3. Bilateral circumorbital ecchymosis
4. Bilateral subconjunctival haemorrhage
5. Dish face deformity
6. Depressed nose
7. Epistaxis
8. CSF rhinorrhea
9. Limited ocular movement (Diplopia)
10. Mal occlusion
11. Inability to open mouth
12. Step deformity at IO margins
13. Mobility of fractured fragment at nasal bridge and IO margin.

76. C). Le fort III/ Craniofacial dysfunction/ High level fracture/
Suprazygomatic fracture
1. Oedema of face (Panda facies)
2. Bilateral periorbital edema
3. Bilateral circumorbital ecchymosis (Racoon eyes)
4. Bilateral subconjunctival haemorrhage
5. Dish face deformity
6. Depressed nose, flattening of nose
7. Epistaxis
8. CSF rhinorrhea
9. Limited ocular movement (Diplopia, Enophthalmos)
10. Hooding of eyes
11. CSF otorrhoea
12. Mal occlusion – posterior gagging of occlusion
13. Inability to open mouth
14. Mobility of fractured fragment at FZ sutures
15. Tenderness over zygomatic bone, arch and FZ suture
16. Ecchymosis at mastoid process (Battle’s sign)

77. 1. Emergency care and stabilization
2. Initial assessment
3. Definitive treatment
4. Continuing care

78. ∆ Airway immediately evaluated for obstruction
∆Control of oral or nasal bleeding
Possibility of C – spine fracture – endotracheal incubation
should not be attempted
Cervical collar in case of suspected spine fractures
∆Circulation

79. 1. History
2. Palpation of entire facial skeleton
3. I/O Examination
4. Ophthalmologic exam / consultation
5. Radiographic examination

80. Palpation of facial skeleton
Bowstring
test

81. ∆ Aims of treatment
1. Relieve pain
2. Precise anatomical reduction of the # fragment
3. Stable fixation of the reduced fragment
4. Restore function
5. Restore the dental occlusion

82. Preoperative planning:
∆ Need for surgical airway
∆ Open/closed method of reduction
∆ Necessity for and type if IMF to be employed in case
for closed reduction
∆ Type of osteosynthesis in case of open method
∆ Need for internal suspension in case of communited
#
∆ Timing of surgery

83. Open reduction Closed reduction
Displaced # Non displaced #
Multiple # of facial bones Grossly communited #
Edentulous maxillary # - with severe
displacement
Fractures associated with significant
loss of soft tissues
Edentulous maxillary # - opposite to
Edentulous mandibular #
Edentulous maxillary #
Delay of treatment In children with developing dentition
Inter position of soft tissues between
non contacting displaced # segment

84. Removal of Maxillary
jaw bone , roof of mouth ,
along with exraction of
upper teeth
Types
 Partial Maxillectomy .
 Medial Maxillectomy .
 Total Maxillectomy .

86. Its is thus, very important to
understand the anatomy of maxilla
in detail with all its related aspects
to help us in planning the surgical
procedure with all the success.

87. Gray’s Anatomy 39th edition
Sicher and DuBrul’s Oral Anatomy
Textbook of Human Osteology : Inderbir Singh
Human Osteology : B D Chaurasi
Killey’s Fractures of the Middle Third of the Facial Skeleton
Oral and Maxillofacial Infectons. Topazian