Professional Documents
Culture Documents
_____________________________________________
* Resident in Oral and Maxillofacial Surgery of the Hospital Association of Bauru - Base Hospital
and Brazilian College of Oral and maxillofacial Surgery.
** Professors of Oral and Maxillofacial Surgery in Hospital Association of Bauru - Base Hospital and
Brazilian College of Oral and Maxillofacial Surgery.
*** Resident in Oral and Maxillofacial Surgery of the Hospital Association of Bauru - Base Hospital
and Brazilian College of Oral and maxillofacial Surgery.
**** Professor Doctor in Oral and Maxillofacial Surgery of the Pontific Catholic University – Rio
Grande do Sul.
765
PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
ABSTRACT
RESUMO
INTRODUCTION
recurrent epistaxis in a patient with nasal polyps, maxillary osteotomy was necessary
to stop the bleeding (CHEEVER, 1867). To correct dentofacial deformities,
anteroposterior maxillary deficiency, were performed only in the following
(WASSMUND, 1927).
The delineation of the bone cut associated with the mobilization of the
maxilla was, and remains, the most promising method to overcome the resistance of
the soft tissues of the face. Furthermore, it provides the maxillary repositioning in
the desired position by surgeon. However, the biological bases and the main aspects
related to the particularities of surgical technique have been established through
studies of revascularization by angiographic and microscopic analysis. These
observations have given ground to state that the palate mucosa associated with
vestibular gingiva showed an adequate nutrient pedicle for the osteotomized and
mobilized maxilla (BELL; FONSECA; KENNEDY, 1975). Increasing the
confidence and safety of the professionals in indicate this procedure.
Since that, the Le Fort I osteotomy has been performed routinely in
the movements of the maxilla. However, some complications, especially trans-
operative are reported with regard to lesions of vascular and nervous structures of the
pterygomaxillary region. The presence of several vessels and nerves in this region
(maxillary artery, maxillary vein, pterygoid plexus and pterygopalatine ganglion)
aware that surgeon must be very careful in respect to surgical technique, especially in
the osteotomy with chisels in posterior wall of maxilla, as well as in the separation of
the pterygoid process of sphenoid bone of the maxillary tuberosity (O `REGAN;
BHARADWAJ, 2005).
A few studies have been conducted to investigate the anatomical
relationships around pterygomaxillary suture (TURVEY; FONSECA; HILL, 1980;
NAVARRO; ZORZETTO; TOLEDO-FILHO, 1982 and APINHASMIT;
CHOMPOOPONG; METHATHRATHIP et al., 2005). Consequently, there is a
lack of credible information concerning the measurements of these anatomical
landmarks, especially about the correct positioning of chisels in relation to the
relevant structures.
Therefore, the idealization of this research by describing the
relationship of the main anatomic marks in pterygomaxillary region through a study
that measured skulls, are justified. The proposal was to guide the oral and
maxillofacial surgeons to develop a technique that respects the limits imposed by the
vascular and nervous structures during the osteotomy in this region with chisels and
to prevent complications during the surgery and postoperatively.
LITERATURE REVIEW
The pterygomaxillary disjunction is one of the most important step of
the Le Fort I. The surgeon must know the anatomy of the region and the main
complications of this peculiar step of orthognathic surgery that associated with
down-fracture of the maxilla are the moments of greatest potential for accidents and
complications.
Aware of this, in order to make reading more enjoyable, the literature
review was divided into topics. The first one will review anatomical structures in the
region, and the second the main papers on anatomical measurements and finally, the
available techniques for pterygomaxillary disjunction and complications associated
with them.
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PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
ANATOMICAL STRUCTURE OF
PTERYGOMAXILLARY REGION
Maxila
The maxilla is the second largest bone of the face, and connect to the
other maxilla to form the entire upper arch, most of the oral cavity roof, nasal cavity
floor and wall orbital floors, part of infratemporal and pterygopalatine fosse. It also
contains the inferior orbital fissure and pterigomaxilar fissure (GRAY, 1995). The
maxilla has four processes, the frontal, zygomatic, alveolar and palatine. The body
of the maxilla is hollow and communicates with the nasal cavity via the maxillary
ostium in the middle nasal meatus. The bone has reinforced areas, known as pillars
when vertical (pterygomaxillary, zygomatic and nasomaxillary) and arches when
they are horizontal (supraorbital, infraorbital, maxillary and zygomatic) (FREITAS,
2006).
Sphenoid
The sphenoid bone is located at the base of the skull, anterior to the
temporal and occipital bone. It consists of a central portion or body, two greater
wings and two lesser wings, and two pterygoid plates that are directed inferiorly
from the body and wings (GRAY, 1973). In the greater wing are founded round,
oval and spinosum foramen, and spine of the sphenoid ridge and the Eustachian tube.
The lesser wing is crossed by the optical channel and contains the anterior clinoid
process (SPALTEHOLZ, 1988). The pterygoid processes of sphenoid bone has two
plates: lateral and medial. The first is short and wide (for the lateral pterygoid
muscle) and the other is long and narrow. Both are united, above, to form the
pterygopalatine groove, and then diverge to form the deep pterygoid fosse (for the
medial pterygoid muscle). A notch between the two plates is filled by the pyramidal
process of palatine bone. The medial plate of pterygoid runs inferiorly to the
pterygoid hamulus, whose lateral face is carved in the shape of the groove, the
groove of pterygoid hamulus (for the tendon of the tensor veli palatini)
(SPALTEHOLZ, 1988). The superior orbital fissure is enclosed by greater and
lesser sphenoid wing and contains the following structures: superior ophthalmic vein,
oculomotor nerve, trochlear nerve, abducens nerve, frontal nerve, lacrimal nerve,
nasociliary nerve (GRAY, 1995).
Palatine
The palatine bones are located posterior to maxilla and anterior to the
processes of the sphenoid bone. Participate in dividing of oral, nasal and orbital
cavity. Its horizontal blade shows nasal surface smooth and slightly excavated and
palatine face creased. Forms transverse palatine suture with the palatine process of
the maxilla, and with the contralateral palatine bone forms midpalatal suture
(SPALTEHOLZ, 1988). From the posterior margin of the angle formed by two
blades, horizontal and perpendicular, protrudes the pyramidal process, which
articulates with pterygoid processes. In the perpendicular plate, should be mentioned
the following structures and anatomical marks sphenopalatine notch, greater palatine
768
PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
groove, lesser palatine canals, nasal concha ridge, orbital process and sphenoid
process (SPALTEHOLZ, 1988).
Pterygopalatine fosse
The pterygopalatine fosse is a small pyramidal space below the apex
orbit, it communicates with the infratemporal fosse through the fissure
pterygomaxillary with the nasal cavity by the sphenopalatine foramen and with the
orbit by the inferior orbital fissure. The round foramen has its opening in the
posterior wall of the same being crossed by the maxillary nerve, which follows a
anterolateral course (GRAY, 1973).
Maxillary Artery
The maxillary artery is the larger of the terminal branches of the
external carotid artery, arising in the parotid gland behind medially the neck of the
mandible. There is a varying relation between the artery and lateral pterygoid
muscle. In more than 50% of persons, the artery is lateral to the muscle, passing
between the mandible and sphenomandibular ligament. In the remaining, the artery
passes medial to the lateral pterygoid muscle. It has many branches: deep auricular
artery, anterior tympanic artery, middle meningeal artery, inferior alveolar artery,
anterior and posterior deep temporal artery, masseteric artery, internal and external
pterygoid artery, buccal artery; posterior superior alveolar artery, infraorbital artery,
descending palatine artery, pterygoid canal artery, sphenopalatine artery
(FONSECA; WALKER, 1991).
In resume, the maxillary artery, the main branch of the external
carotid, distributes branches to maxilla, mandible, muscles of mastication, palate,
nasal cavity walls and part of the dura mater (SPALTEHOLZ, 1988).
Pterygoid Plexus
Pterygopalatine Ganglion
The pterygopalatine ganglion was usually described with the
maxillary nerve to be in the path of this nerve, however, it is a parasympathetic nerve
ganglion intermediate process in which the synapses of neurons pre-and post-
ganglionic visceral efferent pathways general. For this reason it is described in the
intermediate nerve (SPALTEHOLZ, 1988). The motor fibers of facial-intermediate
(V2) has different real origins, all of which are nuclei of the bridge: 1. Nucleus of the
facial nerve to the muscle mimic, stylohyoid muscle and posterior belly of digastrics
muscle. 2. Nucleus tears, to the tear nasal and palatine glands. 3. Salivary rostral
nucleus, are distributed to the submandibular and sublingual glands.
Anatomical Measurements
Figure 2 –Swan neck osteotome to pterygomaxillary separation. The curved handle accommodates
the cheek.
Source - Figure taken from the article: CHENG, H. H. ROBINSON, P. Evaluation of a swan's neck
osteotome for pterygomaxillary dysjunction in the Le Fort I osteotomy. Brit. J. oral Surg.,
v. 31, p. 52-3, 1993.
the chisel was used trough the soft tissues of the maxillary tuberosity, before the
other osteotomies of Le Fort I osteotomy (LANIGAN; GUEST, 1993). More
recently with the development of ultrasonic curettes, the pterygomaxillary suture
separation proved, according to the authors, to be efficient, with greater safety for the
descending palatine artery showing highly predictable results (UEKI;
NAKAGAWA; MARUKAWA, 2004).
DYSFUNCTION OF
EUSTACHIAN TUBE
OPHTHALMIC
COMPLICATIONS
cranial nerves, injury to internal carotid artery and blindness (CRUZ, SANTOS,
2006).
INTRAOPERATIVE OR
POSTOPERATIVE HEMORRHAGE
ARTERIOVENOUS
FISTULA
During orthognathic surgery, when occur the lesion of an artery near a
venous plexus, with spontaneous anastomosis is called arteriovenous fistula. The
most revealing sign of this complication is buzzing and permanent pulsation in face
in the postoperative period. Despite the low incidence in the literature, it is essential
that the surgeon diagnose that condition. The treatment consists of selective
embolization of the vessels near the fistula (HABAL, 1986 and LANIGAN; HEY,
WEST, 1991).
Figure 5 - Classification scheme of types of separation of the region pterigomaxilar. The black dot
shows the greater palatine canal.
Source: Image taken from the article: UEKI, K.; HASHIBA, Y.; MARUKAWA, K. et al.,
Assessment of pterigomaxilar separation in Le Fort I osteotomy in class III patients. J. oral
Maxillofac. Surg., v. 67, p. 833-9, 2009.
MATERIAL AND METHODS
This research project was referred to the Ethics committee in
research with human subjects at the Faculty of Dentistry of Santa Fé do Sul -
FUNEC, which obtained authorization for its execution by means nº. 0000028.
Were objects of these study 30 dry, dentated skulls, from the
Department of Anatomy, Faculty of Dentistry of Bauru, São Paulo University -
USP. The pterygomaxillary suture was measured bilaterally.
Therefore, a chart was created for the purpose of recording the data
obtained by measuring between points named by means of letters of the alphabet in
order to elucidate the main anatomical landmarks to be carefully observed in
orthognathic surgery (Table 1).
These measurements were taken by a researcher trained for this
urpose, being held on two occasions with an interval of fifteen days, to compare data
and check if there was an error noteworthy. For the measurements realization, we
used a 150 mm digital caliper (Starret ®) and a needle point compass at the defined
points by the distances to be analyzed, crashed to the bar and the digital caliper
obtained in the desired measures. The studied points correspond to the following
distances (Figures 6, 7, 8, 9 e 10).
776
PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
SKULLS Nº 30
SKULL SIDE(R) A–B A–C A-B A-E A-F
RIGHT
(L)LEFT
01 R
L
02 R
L
03 R
L
04 R
L
05 R
L
06 R
L
07 R
L
08 R
L
09 R
L
10 R
L
11 R
L
12 R
L
13 R
L
14 R
L
15 R
L
16 R
L
17 R
L
18 R
L
19 R
L
20 R
L
21 R
L
22 R
L
23 R
L
24 R
L
25 R
L
26 R
L
27 R
L
28 R
L
29 R
L
30 R
L
Source - Data gathered from Service of the Oral and Maxillofacial Surgery.
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PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
Figure 6 - A-B - The lowest point of the suture (A) to the most superior point pterygomaxillary suture
(B).
Source - Photo taken from the gallery skulls of the Department of anatomy of FOB-USP.
Figure 7 – A-C - The lowest point of the pterygomaxillary suture (A) and contralateral side of the
palate (C).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP.
Figure 8 – D AB (distance from the outermost point of the zygomatic pillar (D) the pterygomaxillary
suture (A-B).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP.
778
PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
Figure 9 - A-E (from the lowest point of the pterygomaxillary suture (A) to the orbital apex (E).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP
Figure 10 – A-F (from the lowest point of pterygomaxillary suture to skull base (F).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP.
RESULTS
Table 2 - Data obtained from measures in the pterygomaxillary suture and their anatomical relations.
Source - Results taken from Service of the Oral and Maxillofacial Surgery.
780
PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
Table 3 – Mean values, standard deviation, minimum and maximum value of the measures evaluated.
Source: Results taken from Service of the Oral and Maxillofacial Surgery.
Distância (mm)
45
40
35
30
25
20
15
10
0
A-B A-C Perp. A-B A-E A-F
Source: Results taken from Service of the Oral and Maxillofacial
Medidas Surgery.
781
PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
Comparing the left and right sides of the skulls, only in the
measurements A-E and A-F there was a statistically significant difference, p<0.05.
Table 4 - Comparison between the right and left sides by paired t test.
Right Left
Measure t P
Mean dp Mean dp
DISCUSSION
The literature is limited in studies that correlates surgical techniques
and anatomical basis of pterygomaxillary region in orthognathic surgery. The
knowledge of this anatomic region for correct disjunction of pterygomaxillary suture
is essential. The vascular and nervous structures (maxillary artery, maxillary vein,
pterygoid plexus and ganglion pterigoplalatine) at this region are important
parameters for placement of the instruments used for pterygomaxillary disjunction
(GRAY, 1973; SPALTEHOLZ, 1988; FONSECA; WALKER, 1991 and GRAY,
1995). There is consensus among the authors, including of the present paper that this
statement is true, which justifies studies designed to measures specific anatomic
landmarks of this region to increase the knowledge of this region.
The height of the pterygomaxillary suture (A-B) observed in the skulls
measured in this study, was in average 11.55 mm, without statistically significant
differences between the right and left sides of the skulls. In contrast, other studies
showed that the height of the pterygomaxillary suture was in average 14.6 mm
(TURVEY; FONSECA, HILL, 1980), 15.22 mm (CHOI, PARK, 2003) or 15.14
mm (APINHASMIT; CHOMPOOPONG; METHATHRATHIP et al., 2005).
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PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
same. This technique is certainly the most used and older, which suggests that the
number of complications in front of the universe of all operated patients is small.
What justifies further studies with the other techniques, to obtain data with greater
reliability, in terms of statistical significance.
CONCLUSIONS
Considering the results obtained from this research and literature
review, we can conclude that:
1. The anatomical knowledge of the pterygomaxillary region is of
fundamental importance in pterygomaxillary disjunction.
2. Most complications during the Le Fort I osteotomy is related to the
pterygomaxillary disjunction.
3. The craniometric measurements used help the professional in the
execution of the maxillary osteotomy.
4. The safety of disjunction with the use of curved chisel is directly
proportional to the domain of this technic.
5. The chisels used to pterygomaxillary disjunction may have a width
from 8 to 10 mm,
6. Surgeons must not introduce the curved osteotome more than
10mm in pterygomaxillary separation.
REFERENCES *
APINHASMIT, W.; CHOMPOOPONG, S.; METHATHRATHIP, D. et al., Clinical
anatomy of the posterior maxilla pertaining to Le Fort I osteotomy in Thais. Clin.
Anat., v. 18, n. 5, p. 323-9, 2005.
ARAUJO, A. Cirurgia ortognática . São Paulo: Ed. Santos, 1999.
BELL, W. H.; FONSECA, R. J.; KENNEDY, J. W. Bone healing and
revascularization after total maxillary osteotomy. J. oral Surg., v. 33, n. 4, p. 253-60,
1975.
BELL, C. S.; THRASH, W.J.; ZYSSET, M.K. Incidence of maxillary sinusits
following Le Fort I maxillary osteotomy. J. oral Maxillofac. Surg., v. 44, p. 100-6,
1986.
CHEEVER, D. W Naso-pharyngeal polypus attached to the basilar process of
occipital and body of the sphenoid bone success fully removal by a section,
displacement and subsequent replacement and reunion of the superior maxillary
bone. Boston Med. Surg. J., v. 8, p. 162, 1867.
CHENG, H. H; ROBINSON, P. P. Evaluation of a swan's neck osteotome for
pterygomaxillary disjunctions in the Le Fort I osteotomy. Brit. J. oral Surg., v. 31, p.
52-3, 1993.
CHOI, J.; PARK, H. S The clinical anatomy of the maxillary artery in the
pterygopalatine fosse. J. oral Maxillofac. Surg., v. 61, p. 72-8, 2003.
CRUZ, A. A. V.; SANTOS, A. C. Blindness after Le Fort I osteotomy: A possible
complication associated with pterygomaxillary separation. J. Craniomaxillofac.
Surg., v. 34, p. 210-6, 2006.
DAVID, C. M. Medicina intensiva. Rio de Janeiro: Ed. Revinter, 2004.
________________________________
* According to ABNT norms.
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PTERYGOMAXILLARY REGION IN SKULLS –
ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY
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