Biologic Basis for Maxillary Osteotomies

WILLIAM H. BELL
Division of Oral Surgery, University of Texas Southwestern
Medical School, Dallas, Texas 75235

ABSTRACT Adult Rhesus monkeys were used as experimental models to in-

vestigate revascularization and bone healing in different single-stage anterior,
posterior and total maxillary osteotomy techniques.
Microangiographic and histologic studies demonstrated that intraosseous and
intrapulpal circulation to the mobilized maxillary segments were maintained by
the experimental flap designs which maintained intact soft tissue; the frag-
ments healed by osseous union within six weeks without immobilization of the
mandible.
The treatment of many severe dental-facial deformities is difficult and chal-
lenging. Functional and stable occlusions with facial balance and harmony have
been attained in many adult patients by maxillary osteotomy techniques.
The Rhesus monkey serves as an excellent experimental model to develop new
biologically sound maxillary surgical orthodontic techniques.

A large proportion of the adult popula-
tion with dental-facial deformities due to
severe malocclusion may never receive the
benefits of orthodontic treatment. Many
adults object to wearing orthodontic ap-
pliances for the prolonged period of time
necessary to properly treat their maloc-
clusion. Professional careers preclude
many patients from wearing fixed appli-
ances. The condition of the periodontium
and missing posterior teeth which would
usually serve a s anchorage teeth, may con-
traindicate treatment by orthodontics
alone.
The goal of surgical-orthodontic treat-
ment of dental-facial deformities is to pro-
vide a functional occlusion with facial bal-
ance and harmony. Multiple operations
may be necessary to attain these objectives
as the clinical manifestations of such de-
formities often defy correction by a single
surgical procedure. Unit recent years,
surgical correction was focused on the
mandible and frequently failed. However,
with the introduction of anterior (Cohn-
Stock, '21; Wassmund, '35) and posterior
maxillary osteotomies (Schuchardt, '61 )
and total maxillotomy (Axhausen, '34;
Wassmund, '35), techniques which were
pioneered by European surgeons, restora-
tion of occlusal balance and facial har-
AM. J. PHYS.ANTHROP., 38: 279-290.
mony was attainable in practically all
cases.
When maxillary surgical procedures
were introduced to the United States (Kole,
'59; Murphey and Walker, '63; Mohnac,
'65; Obwegeser, '66), the rationale for
using the various surgical techniques for
correcting dental-facial deformities was
empirical. Basic questions concerned with
the healing of the surgical wounds pro-
duced by maxillary osteotomies had not
been investigated. Many surgeons felt that
the maxilla healed by fibrous union. Devi-
talization of teeth and bone in the mobil-
ized segments had been reported. Varying
degrees of relapse subsequent to posterior
maxillary osteotomy (Schuchardt, '61 ) and
total maxillary osteotomy were reported.
The blood vessels necessary to maintain
circulation to the mobilized bony segments
and teeth had not been studied. Conse-
quently both one-stage and two stage
procedures were devised to prevent impair-
ment of the vascular supply to the mobil-
ized dental-alveolar segments (Schuchardt,
'54).
In 1965, a n animal investigation was
designed to delineate the biology of maxil-
lary osteotomy wound healing. Since then
adult Rhesus monkeys have been used a s
experimental models to investigate the re-
279
280 WILLIAM H. BELL

Fig. 1 * Perfusion technique (modified after Rhinelander a n d Baragry). AV, air vent; CC,
cannulated common carotid artery; FA, cannulated femoral artery; Hg, mercury; HP, house
air pressure; M, “U” tube manometer; and P, perfusant.

vascularization and bone healing associ-
ated with various maxillary techniques
(Bell, ’69; Bell and Levy, ’70, ’71). The
Rhesus monkey, Macaca mulatta, was
selected as the experimental animal be-
cause of anatomic, physiologic, and dental
similarities to the human.
Since maxillary osteotomies are usually
performed in adults, large, male Rhesus
monkeys, 8 to 14 years of age, weighing
a n average of 9 kg, were chosen for study.
Acrylic splints were made from stone study
models of each monkey’s dentition. Various
one-stage anterior maxillary, posterior
maxillary (fig. 3 ) and total maxillary
osteotomies were performed by various flap
designs. The mobilized maxillary segments
were fixed with acrylic splints ligated to
the anterior and posterior teeth with inter-
dental wires. Because the mandible was
not immobilized, the animals were fed a
normal diet.’ Unoperated monkeys served
as controls.
The animals were killed 1, 3, 6 and 24
weeks after surgery. Before death each
animal was premedicated and anesthetized.
The right and left common carotid
arteries were exposed, cannulated, hepa-
rinized and perfused with barium sulfate *
under a constant pressure of 120 mm Hg
(Rhinelander and Baragry, ’62; Bell, ’69)
(fig. 1) . The heads were disarticulated and
fixed in formalin. Microangiographic and
histologic study was carried out after
1 Zu/Preem Science Diet, Theracon Laboratories,
Topeka, Kansas.
2 Micropaque.
Illustrations in figures 1-6 were included in the
article, “Revascularization and bone healing after an-
terior maxillary osteotomy,” by W. H. Bell and B. L.
Levy, in Journal of Oral Surgery April 1969. Illustra-
tions in figure 7 were included i i the article, “Correc-
tion of skeletal type of anterior open bite,” by W. H.
B,ell, in Journal of Oral Surgery, October 1971. Copy-
right by the American Dental Association. Reprinted
by permission.
 BIOLOGIC BASIS FOR MAXILLARY OSTEOTOMIES 281

Fig. 2 Microangiograms of 1 mm transverse tissue slices from premolar (A) and

molar region ( B ) of control animal: buccal (B), palatal (Pa), maxillary sinus (MS) and
nasal cavity ( N ) blood vessels penetrating bone and anastomosing with intramedullary
blood vessels ( I ) and periodontal vascular plexus (Pe); P, premolar tooth; M, molar tooth;
T, turbinate.

each maxilla was decalcified, dehydrated,
cleared, and embedded in paraffin and
beeswax. Serial 1 mm transverse, sagittal
and horizontal tissue slices were cut from
the specimens for microangiographic
study. Each 1 mm tissue slice was then
cut at 7 for histologic study.
RESULTS
Control animals. The injection medium
was distributed through most of the can-
cellous intraosseous, intrapulpal and soft
tissue blood vessels (fig. 2). The maxilla
was vascularized by a highly complex
interconnected network of vessels that
terminated in the gingiva and mucosa as
capillary loops of variable length (Bell and
Levy, '71). All dental osseous components
received blood from a multiplicity of
sources. Gingival, buccal, labial, palatal,
nasal, and maxillary sinus vessels pene-
trated and traversed the cortical bone and
anastomosed with the periodontal plexus
encircling the teeth. Dental pulps were
vascularized by interosseous dental alveo-
lar vessels and branches from the peri-
odontal plexus. Submucosal palatal vessels
anastomosed near the midline of the palate
with vessels from the opposite side. Buccal
and gingival tissues received blood from
buccal soft tissues and from intraalveolar
vessels. Soft tissue and intraosseous vessels
282 WILLIAM H . BELL
supplied blood to the reticulated vascular
plexus making up the periosteum. Vessels
of the gingiva, periodontal plexus, lingual
mucosa and labial alveolar mucosa were
interconnected by vascular anastomoses.
The nasal cavity was lined with a vascular
net work of variable thickness; the turbi-
nates by a relatively thick vascular plexus
that was surrounded by a thin reticulated
vascular plexus. The avascular nasal
septum was covered by a reticulated vascu-
lar plexus.
Experimental animals. The surgical
soft tissue wounds produced by various flap
designs healed by primary intention, with-
out detectable postoperative infection. The
dental alveolar segments were freely mov-
able one week after surgery and slightly
movable after three weeks. After six weeks
there was clinical union of the osteotomized
segments. The individual teeth in the mo-
bilized bone segments remained stable.
There was generalized distribution of
the micropaque throughout the intraos-
seous and intrapulpal tissues of all mobil-
ized osseous segments (figs. 4, 5). The pulp
 BIOLOGIC BASIS FOR MAXILLARY OSTEOTOMIES
e periosteal blood vessels penetrating the
Fig. 3 Schematic drawing of soft tissue and
bone incisions used for posterior maxillary oste-
otomy in experimental animals.
canals of several teeth adjacent to the ver-
tical interdental bone cuts were not vascu-
larized because their apical blood supply
was severed by labial and buccal bone cuts
through the teeth apices. The pulp canals
of all other teeth, however, were viable
and vascularized despite the fact that ver-
tical interdental osteotomies were made
between closely spaced teeth and subapical
bone cuts just above the apices of teeth,
Microangiographic study of the one week
283
specimens revealed focal areas of intra-
osseous ischemia in the margins of the sec-
tioned alveolar bone segments that were
separated by a n avascular zone (fig. 4).
Within three weeks the circulation between
all of the sectioned bone fragments had
been reconstituted. The raised buccal and
labial soft tissue flaps were reattached to
the underlying bone as shown by the many
buccal and palatal cribriform plates and
anastomosing with intraosseous blood ves-
sels and the periodontal vascular plexus
(fig. 5 A ) . Histologically, there was a n in-
tense osteoblastic proliferation within the
marrow spaces and around many of the
spicules of the spongiosa (fig. 5B). Mini-
mal osteonecrosis was found throughout
the mobilized maxillary bone segments.
Some empty lacunas were present in the
proximal and distal margins of the bone
incisions.
Six weeks after the osteotomies there
was no detectable intraosseous or intra-
pulpal ischemia. The reparative response
in the endosteal vascular bed appeared
more intense than it did in the periosteal
vascular bed. Histologically, the proximal
and distal bony segments were united with
cancellous bone.
Twenty-four weeks after maxillary
osteotomies, the periosteal and endosteal
circulatory beds had been virtually recon-
stituted to their normal vascular architec-
ture. The endosteal-periosteal anastomosis
through cortical bone had been restored.
Histological examination of the osteotomy
wounds revealed healing of the cortical
bone and remodeling of the spongiosa.
DISCUSSION
The results of these clinically analogous
animal studies indicated that single-stage
anterior, posterior, and total maxillarv
osteotomies were biologically sound surgi-
cal procedures. Preservation of the integ-
rity of the incisive canal or greater pala-
tine arteries was not essential to maintain
circulation to the anterior or posterior
maxillary dental alveolar segments. The
intraosseous and soft tissue collateral cir-
culation and the freely anastomosing
gingival, palatal, floor of the nose, maxil-
lary sinus, and periodontal plexuses, per-
284 WILLIAM H . BELL

Fig. 4 Microangiogram of 1 mm sagittal tissue slice one week after posterior maxillary
osteotomy shows generalized intraosseous and intrapulpal distribution of injection medium;
avascular zone (arrows) between margins of vertical bone cut between premolar teeth; MS,
maxillary sinus; C, canine tooth; T, tuberosity.

mitted many technical variations of maxil-
lary osteotomies, without jeopardizing the
blood supply to the maxillary dental alveo-
lar segments (fig. 6). Intraosseous and
intrapulpal circulation was not signifi-
cantly altered by interdental and subapical
alveolar osteotomies when the bone cuts
were made away from the apices of the
teeth; maximal attachment of the muco-
periosteum on the lingual or buccolabial
surface of the mobilized osseous or dental-
osseous segments was preserved. When
carefully pedicled flaps were used to main-
tain these attachments, the segments could
be mobilized and transposed safely in any
direction.
The encouraging results attained in the
animal wound healing studies generated
much enthusiasm and confidence in clini-
cal maxillary osteotomies. Adult dental-
facial deformities which previously could
not be treated by either mandibular surgery
or orthodontics without severely compro-
mising the result, could now be treated in
a practical period of time. Treatment of
such a case (skeletal type of anterior open
bite) is shown in figure 7. Multiple maxil-
lary osteotomies, genioplasty and ortho-
dontics effected a stable and functional
occlusion with facial balance in 14 months.
Since 1967, 20 skeletal Class I1 maloc-
clusions have been treated by anterior
maxillary osteotomy, genioplasty and ortho-
dontics (12 patients had no orthodontics;
8 patients had orthodontics). The average
treatment time was approximately nine
 BIOLOGIC BASIS FOR MAXILLARY OSTEOTOMIES 285

Fig. 5A Microangiogram of 1 mm transverse tissue slice from first molar region three
weeks after posterior maxillary osteotomy shows proliferation of endosteal ( E ) and periosteal
( P ) circulatory beds; reattachment of buccal and palatal mucoperiosteal flaps to underlying
bone; vascularization of pulp canal from periodontal vascular plexus and accessory root
canal (arch); Buccal ( B ) ; and palatal osteotomy sites ( P a ) ; nasal cavity ( N C ) ; first
molar tooth ( T ) .

months. Five patients with retromaxillism dontic techniques in a n average of 8.5

associated with mandibular prognathism
were treated by surgically advancing the
entire maxilla (total maxillary osteotomy).
Seventeen patients with bimaxillary dental
protrusion were treated by surgical ortho-
months.
Long-term clinical and radiographic
studies of the patients who have had maxil-
lary alveolar surgery showed no periodontal
problems and minimal crestal alveolar
 Fig. 5B Photomicrograph of buccal bone. Periosteum is thickened by fibrous connective
tissue. Osteophytes are seen beneath periosteum. Osteoid and new bone bridge fragments.
Endosteal osteoid appears limited to proximal fragment ( H & E, original magnification X 8).

Fig. 6 Schematic composite illustration of blood supply to anterior maxillary region

showing freely anastornosing gingival plexus, palatal plexus, periodontal plexus, labial
artery, intraalveolar vessels, apical vessels, and pulp vessels. This vascular architecture per-
mits anterior maxillary osteotomies without compromising circulation to the anterior
maxillary segment and teeth.
 BIOLOGIC BASIS FOR MAXILLARY OSTEOTOMIES 287

Fig. 7A Facial profile before treatment Fig. 7B Facial profile after treatment.
Fig. 7 Case Report. Skeletal type of anterior open bite with Class I1 malocclusion treated in 14
months by surgical-orthodontic techniques. Maxillary canine teeth were extracted to facilitate pos-
terior maxillary osteotomies and retraction of procumbent maxillary incisors. Lower first premolar
teeth were extracted to allow orthodontic correction of crowded mandibular dental arch.

Fig. 7C Occlusion before treatment.

288 WILLIAM H. BELL
Fig. 7D Occlusion after 14 months of surgical-orthodontic treatment.
Fig. 7E Posterior maxillary osteotomy to level
maxillary occlusal plane; vertical facial dimen-
sion is reduced and chin contour restored by
anterior sliding genioplasty.
bone loss in the interdental osteotomy
sites (between 1 and 2 m m ) . (Bell and
Dann, in press). All teeth in the alveolar
segments, except one (subsequently re-
tained by endodontic therapy), tested vital
within eight months after surgery. There
was no radiographic evidence of root re-
sorption. Long-term cephalometric studies
of treated cases demonstrated remarkable
stability of dental-skeletal changes effected
by maxillary osteotomies. They also
showed minimal resorption of the trans-
posed mental symphysis bone segments.
ACKNOWLEDGMENTS
The author wishes to thank Miss
Rebecca Sprowls, Miss Judy Peterson, and
Mrs. Dorothy Gilbert for technical assist-
ance in preparing this paper.
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1971 Revascularization and bone heal-
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Surg., 29: 313-320.
 BIOLOGIC BASIS FOR MAXILLARY OSTEOTOMIES
Fig. 7F Schematic diagram showing bucco-
labial mucoperiosteal flap design for anterior
maxillary osteotomy; horizontal subapical osteo-
tomy is directed palatally to and through palatal
cortical plate; digital pressure on palatal mucosa
indicates when lingual cortices are sectioned; ver-
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'Lr
Fig. 7G Cephalometric tracings before (solid
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