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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 5  |  Page : 32-35

Palatal tear: A complication during anterior maxillary osteotomy using cupar technique


Department of Oral and Maxillofacial Surgery, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Saurbh Sharma
No. 330/3, Near Modern School, Rly Road, Shiv Colony, Palwal - 121 102, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_47_17

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  Abstract 

This is case report of 20-year-old female who was surgically treated with anterior maxillary osteotomy (AMO) in maxilla and anterior sub apical osteotomy in mandible. AMO was done with Cupar technique in which a palatal tear occurred intraoperatively. The palatal tear was managed conservatively maintaining the blood supply to osteotomized segment by Coe pack application & later on splint fabrication and antiobiotics and decongestants. Other choices like a buccal fat pad or a tongue flap can be used if fistula or tear is large.

Keywords: Anterior maxillary osteotomy, Cupar technique, palatal tear


How to cite this article:
Sharma S, Gupta A, Sharma R, Rathee I. Palatal tear: A complication during anterior maxillary osteotomy using cupar technique. Indian J Dent Sci 2017;9, Suppl S1:32-5

How to cite this URL:
Sharma S, Gupta A, Sharma R, Rathee I. Palatal tear: A complication during anterior maxillary osteotomy using cupar technique. Indian J Dent Sci [serial online] 2017 [cited 2020 Sep 22];9, Suppl S1:32-5. Available from: http://www.ijds.in/text.asp?2017/9/5/32/214931


  Introduction Top


Anterior maxillary osteotomy (AMO) is a versatile procedure in the management of a variety of deformities of the anterior maxillary dentoalveolar component. AMO was first described by Cohn-Stock in 1921. Evolution of this procedure has taken place and is currently practiced in three popular variations: the Wassmund, Wunderer, and down-fracture techniques described by Cupar and later modified by Bell and Epker.

The Wassmund procedure involves only subperiosteal tunneling and no flaps and maintains both the palatal and labial vasculature. The Wunderer method involves a palatal flap elevation with preservation of the labial pedicle and is an out-fracture technique. The down-fracture (Cupar method) uses a circumvestibular incision for labial osteotomies and tunneling for the palatal osteotomy. Cupar, 1955, modified two-stage procedure of AMO into single-stage down-fracturing technique. This technique is mainly indicated if superior positioning is the dominant.

Objective

Epker described some advantages of this down-fracture technique as follows:

  1. It is technically simple
  2. Provides direct access to nasal crest of maxilla and associated nasal septal structures
  3. Permit removal of palatal bone under direct vision
  4. Gives excellent vascular pedicle.


Although both the Cupar and Wunderer techniques are versatile in their function, the down-fracture method is recommended when superior or combined superior and posterior repositioning is required, whereas the Wunderer techniques are useful for anteroposterior repositioning.

The Wassmund modification ensures the best vascularity.

Indications for AMO in our study included:

  1. Anterior open bite
  2. Bimaxillary dentoalveolar protrusion
  3. Excessive vertical or anteroposterior development of the maxillary dentoalveolar process in patients where relationships between the posterior teeth are acceptable
  4. Excessive inclination of anterior teeth
  5. Duration of treatment, a relative indication in the Asian Indians.



  Case Report Top


A 20-year-old female patient was referred from Department of Orthodontics to the Department of Oral and Maxillofacial Surgery, Sudha Rustagi College Of Dental Science and Research, Faridabad, with a complaint of forwardly placed teeth. After complete examination and clinical studies, AMO was decided in both jaws.

Following are the extraoral [Figure 1],[Figure 2],[Figure 3] and intraoral [Figure 4] photographs of the patient.
Figure 1: Pre operative frontal view

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Figure 2: Left lateral view and right lateral view

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Figure 3: Right oblique view and left oblique view

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Figure 4: Intraoral photograph

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The patient was diagnosed with Class II skeletal jaw base relation on account of normally placed maxilla and backwardly placed small-sized mandible, with vertical growth pattern, dentoalveolar Angle's Class I malocclusion with proclined maxillary and mandibular incisors.

Moreover, the patient was advised for anterior maxillary and mandibular osteotomy with Cupar technique followed by orthodontic treatment. Following are the postoperative photographs of the patient [Figure 5] and [Figure 6] and palatal tear [Figure 7].
Figure 5: Post-operative frontal view

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Figure 6: Left lateral view and right lateral view

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Figure 7: Palatal tear

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Surgical method

Oronasal lacerations and fistula Oronasal fistula are uncommon but may occur, particularly after segmental maxillary osteotomies. Palatal expansion >6–8 mm increases the risk of soft tissue breakdown.

Care should be taken to avoid tears in the palatal mucosa, and any lacerations should be repaired in a tension-free manner whenever possible.

If primary repair is not possible because it would require the elevation of palatal flaps impacting the blood supply to the maxilla, then repair should be delayed and performed as a separate surgical procedure once the maxilla is healed.

Many smaller lacerations typically close spontaneously. Tears can be best avoided by attention to detail when sectioning the hard palate. Hydrostatic elevation of the palatal mucosa along the osteotomy line just before sectioning helps. When significant widening is needed, multiple parasagittal palatal osteotomies should be made to distribute the distance of the expansion required.

A buccal vestibular incision is created, allowing direct access to the anterior lateral maxillary walls, pyriform aperture, and nasal floor, and septum. The sequence of osteotomies is operator dependent, but the general procedure involves completion of the vertical buccal and horizontal osteotomies under direct visualization. The nasal mucosa is elevated from the superior surface of the maxilla. It is easy to complete the osteotomies if the nasal septum is first released from the maxillary crest. The horizontal osteotomy is completed, and the vertical osteotomy is then performed bilaterally between the teeth. Through this vertical cut, the transpalatal osteotomy is completed with either a reciprocating saw or an osteotome, but no effort is made to perform the ostectomy at this time. Similar to the Wassmund technique, a finger is placed on the palatal mucosa to palpate the osteotome in an attempt to prevent any tissue trauma as the osteotome is advanced. The transpalatal ostectomy is then completed under direct visualization from above, allowing excellent access to the nasal crest of the maxilla and midpalatal bone for osseous recontouring. This procedure may be performed through a molar extraction site if indicated by the treatment plan.

Latest photograph of the palatal tear is shown in [Figure 8].
Figure 8: Latest photograph of palate

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  Discussion Top


Multiple factors come into play when treating the individual with a dentofacial deformity to provide the most esthetic and functional result.

Due to the precise planning required and complexity of the surgery, a multitude of levels exists from which errors can occur. For even the most experienced surgeon, unforeseen complications may arise. Obstacles that may lead to complications can be divided as:

  • Preoperative
  • Intraoperative
  • Postoperative.


In this article, the most common complication is discussed, i.e., palatal tear – a complication during anterior maxillary osteotomy using Cupar technique.

According to Rajan Gunaseelan et al. in 2009 did a study on 103 patients, in which palatal mucosal tear was the most frequently encountered complication and was evident in 11 patients. All these patients had small, palatal lacerations in their free gingival margin because of excess mucoperiosteal tunneling in the palatal aspect. One patient had a buttonhole tear in the midpalatal region.

However, the healing of the osteotomized segment was uneventful. The importance of the integrity of the palatal mucoperiosteum in the down-fracture technique and of its attachment to the underlying osteotomized segment is well documented and must be maintained with great care.

In 2014, Megan T. Robl et al. also did a study on 1000 patients and concluded that, despite proper site selection and careful surgery, violation of palatal mucosa may occur.

In most cases, small tears do not need treatment and heal uneventfully. If a larger opening is present, it can be managed by placing a very small amount of collagen membrane layer in the tear the area is dried and then sealed with Dermabond. AMO is a reliable, simple procedure in the management of deformities of the dentoalveolar region. However, the literature offers very little information about this procedure. The necessity of AMO has declined because of recent advancements in orthodontic-orthognathic treatment. In this particular case, conservative treatment was done. We treated the palatal tear by placing perio Coe-Pak for 3 days. Moreover, a palatal splint was given for 7 days. Antibiotics and nasal decongestant were prescribed for a week. After 10 days, we regularly induced the bleeding by probing along the margins of palatal tear. A regular follow-up was done for 4 months. Gradually, the denuded area healed by granulation. Till that time, orthodontic treatment was discontinued. After almost 4 months, orthodontic treatment was started again.


  Conclusion Top


Postoperative fistulas in the oronasal and oroantral regions generally result from soft tissue injury at the time of surgery. Fistulas have been reported with isolated segmental as well as total maxillary osteotomies.

This may occur as a result of rotary instruments, saws, or osteotomies that perforate the palatal mucosa at the time the segmental osteotomies are completed. Impingement of soft tissue in the segmental osteotomy site during segment repositioning and fixation may also result in tissue necrosis and fistula formation. Tearing of palatal mucosa at the time of attempted tissue stretching may also result in nonhealing defects. This is most common when a bony osteotomy is made in the midline of the maxilla while attempting to stretch the midpalatal tissue careful soft tissue manipulation at the time of surgery in an attempt to prevent tissue perforation is the best method for prevention of fistula formation.

When expansion is needed, the palatal mucosa can be incised with two parallel incisions just medial to the greater palatine foramen; bony separation then occurs in the midpalatal area. The tissue can stretch and expand in an area well away from the bony separation. An alternative technique involves making parasagittal cuts in the nasal floor immediately adjacent to the lateral nasal wall. The osteotomy can thus be made over tissue that is thicker and somewhat more elastic. If a small tear is noted following a bony cut, care should be taken to release the palatal tissue from above before expansion of segments.

When a fistula is noted postoperatively, several measures can be pursued that may allow the fistula to close spontaneously.

Preventing sinus or nasal infections is essential. This includes antibiotic therapy, decongestants, and nasal drainage. Construction of an appliance that will obdurate the fistula without placing pressure on the overlying tissue will generally help in closure by reducing food contamination.

Careful attention must be given to the construction of any appliance used to obdurate a fistula in the immediate postoperative period. Excess pressure on the palatal mucosa may result in decreased vascularity, resulting in further loss of soft tissue and associated bone. If local measures, appropriate medical therapy, and fistula obturation have been unsuccessful, surgical closure of the fistula will be required.

When considering closure of a fistula, it is important to ensure that at least 6 months have elapsed to allow for revascularization of the maxillary segment. Carefully managed fistulas will continue to close for 8–12 weeks. If this therapy is not successful, a soft tissue flap should be raised from an area farthest from segments with the least potential for decreased vascularity.

Timing varies, but the maxilla should be revascularized by 6 months. If a large segment of the maxilla was involved in the initial hypovascular state, distant flaps should be considered. Choices include a buccal fat pad or a tongue flap, among others.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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