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National Journal of Maxillofacial Surgery
 
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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 4  |  Page : 191-193  

Modified Cupar's method for immediate diastema closure


Department of Oral and Maxillofacial Surgery, Saveetha University, Chennai, Tamil Nadu, India

Date of Submission15-Jul-2020
Date of Acceptance18-May-2021
Date of Web Publication20-Aug-2022

Correspondence Address:
Dr. Ashutosh Avinash Deshpande
Saveetha Dental College and Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.NJMS_148_20

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   Abstract 


Anterior maxillary osteotomy or ostectomy (AMO) is a safe, reliable, and easily adaptable procedure routinely performed in orthognathic surgery for the management of the dentoalveolar segment of the anterior maxilla. The anterior segmental maxillary osteotomy was first performed in 1921 by Cohn–Stock. Several modifications were done regarding approaches for AMO; however, Cupar's method is the most preferred approach by the surgeons and in practice since several decades. A novel midline split osteotomy is performed in combination with Cupar's method for superior and posterior repositioning of anterior maxillary segment in combination with immediate closure of diastema in this case report.

Keywords: Anterior maxillary osteotomy, midline split, modified Cupar's method


How to cite this article:
Deshpande AA, Muthusekhar M R, Hemavathy O R, Murali S. Modified Cupar's method for immediate diastema closure. Natl J Maxillofac Surg 2022;13, Suppl S1:191-3

How to cite this URL:
Deshpande AA, Muthusekhar M R, Hemavathy O R, Murali S. Modified Cupar's method for immediate diastema closure. Natl J Maxillofac Surg [serial online] 2022 [cited 2022 Oct 5];13, Suppl S1:191-3. Available from: https://www.njms.in/text.asp?2022/13/4/191/353929




   Introduction Top


Anterior maxillary osteotomy or ostectomy (AMO) is an orthognathic procedure, which allows mobilization and repositioning of anterior maxillary segment in an upward, downward, or rotational manner (by osteotomy alone) or in posterior direction (if an ostectomy is performed). Rarely, the segment can be advanced and the gap in between can be grafted with the bone. It was first introduced in 1921 by Cohn–Stock.[1] Several modifications were done regarding approaches for AMO over many years. These modifications were given by Wassmund in 1927, Wundere in 1963, and Cupar in 1954.[2] Cupar's method is the most preferred approach by the surgeons. In this case report, we have performed a midline split in combination with anterior maxillary ostectomy for posterior and superior repositioning of the anterior maxillary segment along with immediate diastema closure.


   Case Report Top


A 28 years old female patient reported with a chief complaint of forwardly placed upper front teeth since childhood and complained of inability to close her lips. Extraoral examination revealed convex profile, incompetent lips, acute nasolabial angle, gummy smile, and flared and protruding teeth [Figure 1]a and [Figure 1]c. Intraoral and radiographic examinations revealed increased overjet and increased overbite. Increased incisal show was also noted. The patient wanted immediate results for personal reasons.
Figure 1: (a) Preoperative photograph showing forwardly placed anterior teeth, midline diastema, incompetent lips. (b) Postoperative photograph (after 3 months). (c) Preoperative photograph of bite of the patient. (d) Postoperative photograph (after 3 months) showing corrected midline diastema

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Diagnosis and treatment planning

Radiographs revealed that the overjet was 10 mm and the overbite was 8 mm. The patient had an incisal view of 8 mm at rest. Final diagnosis made was skeletal class two malocclusion. After all the clinical, radiographic investigations, mock surgery and blood investigations superior (by 6 mm) and posterior (by 7 mm) repositioning of anterior maxilla was planned under general anesthesia.

Surgical procedure

Labial incision was placed according to the Cupar's method, extending from the mesial aspect of right maxillary first molar till the mesial aspect of left maxillary first molar. The area was infiltrated with local anesthetic solution for hemostasis and clean surgical field. Maxillary first premolars were extracted on both the sides. Labial incision was placed according to the Cupar's method, extending from the mesial aspect of right maxillary first molar till the mesial aspect of left maxillary first molar. Subperiosteal dissection was done. Piriform apertures were identified and nasal mucosa was protected by placing periosteal elevators. Horizontal osteotomy was performed labially (to allow 6 mm of superior repositioning) 5 mm above the apices of the teeth to avoid damage to the teeth. Vertical osteotomy was performed through the sockets of maxillary premolars to facilitate the posterior reposition of the anterior maxillary segment by 7 mm. The downfracture of the segment was performed with the help of an osteotome. Midline split was done [Figure 2]a. The diastema was closed by simple interdental wiring between the two maxillary central incisors [Figure 2]b. The anterior maxillary segment was fixed in the desired position (according to the prefabricated splint) with the help of two “L-” shaped titanium plates. Furthermore, interdental wiring was placed in between the maxillary canine and the second premolar to increase stability of the segment posteriorly. Alar cinch sutures were placed. The incision was closed with 3-0 polyglactin sutures. The patient was discharged within 2 days postoperatively.
Figure 2: (a) Intraoperative photo showing anterior maxillary segment with midline split. (b) Midline split secured with interdental wiring

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Follow-up

The patient was advised for follow-up at 1st and 6th weeks and the next follow-up was scheduled after 3 months postoperatively. All interdental wirings were removed after 6 weeks. The patient showed excellent profile changes after the surgical procedure [Figure 1]b. The patient was advised to undergo postoperative orthodontics for the correction of minor occlusal discrepancies.


   Discussion Top


Anterior maxillary osteotomy or ostectomy (AMO) with midpalatine split is a safe, reliable, and easily adaptable procedure routinely performed in orthognathic surgery for the management of the dentoalveolar segment of the anterior maxilla.[3] It provides a different approach for segmentalization of the maxilla and exposure of the labial aspect of the maxillary bone by a vestibular circumferential cut and labial flap to facilitate the labial osteotomy under direct vision. A palatal osteotomy is performed through the vertical tunnel. Furthermore, the midpalatine split is made after the downfracture of the segment under direct vision. Vascularity of the segment is maintained by greater palatine pedicle.

Indications for AMO with midpalatine split includes bimaxillary dentoalveolar protrusion, anterior open bite, excessive inclination of anterior teeth, and anteroposterior and vertical maxillary excess where the patient has a stable occlusion posteriorly and patients with the chief complaint of immediate cosmetic corrections along with the presence of wide midline diastema.[4] Although AMO with midpalatine split is a simple and versatile procedure, very little information is available in the literature about this procedure. Furthermore, use of this procedure is decreasing due to the recent advancements in the orthodontic–orthognathic treatments. However, it still a very effective and quick treatment options for immediate correction of anterior maxillary discrepancies and midline diastema closure.

The complications encountered during this procedure are similar to that observed in Le Fort I osteotomies.[5] It can be present from minor problems such as hypersensitivity of the teeth to loss of the osteotomized segment due to avascular necrosis. Some complications are specific to AMOs and are different than those which are encountered during Le Fort I osteotomy. The most commonly encountered complication is palatal tear due to aggressive instrumentation. It can be observed at marginal mucosa extending toward the center or can be observed as a buttonhole defect in the palatal vault. Another possible complication observed in this procedure is delayed union of the maxillary segments and can be associated with the poor bony contact, improper fixation, or stabilization of the bony segments. However, all the complications can be avoided with proper technique and proper instrumentation. None of the mentioned complications were observed in the presented case.

In the presented case, the patient had skeletal Class II malocclusion with acceptable occlusion posteriorly. Furthermore, the patient wanted immediate correction of her appearance. Furthermore, with the proper surgical technique, the expected complications and need for the extensive surgery can be minimized. A combination of AMO (by Cupar's method) along with the midline split was performed, which provided the desired correction of lip incompetency and protruding teeth. Furthermore, the correction of midline diastema was achieved. The patient showed desirable results after 3 months postoperatively and was satisfied with the surgery.


   Conclusion and Clinical Applications Top


This technique can be employed where correction of bimaxillary dentoalveolar protrusion, anterior open bite, excessive inclination of anterior teeth, anteroposterior and vertical maxillary excess, and the immediate change in the profile is desired. The advantages of this techniques are simple, quick, easily adaptable, immediate, and desired results. Furthermore, with the proper surgical technique, the expected complications and need for the extensive surgery can be minimized.

Acknowledgment

The authors would like to express the heartfelt gratitude to the Chancellor, Director of Academics, the Principal and the Vice Chancellor, HOD and their professors, readers, lecturers, and their fellow postgraduates, Department of Oral and Maxillofacial Surgery of Saveetha Dental College and support from their families.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bell WH. Correction of maxillary excess by anterior maxillary osteotomy. A review of three basic procedures. Oral Surg Oral Med Oral Pathol 1977;43:323-32.  Back to cited text no. 1
    
2.
Kannan VS, Narayanan GR, Ahamed AS, Velaven K, Elavarasi E, Danavel C. Anterior maxillary osteotomy: A technical note for superior repositioning: A bird wing segment. J Pharm Bioallied Sci 2014;6:S107-9.  Back to cited text no. 2
    
3.
Ahmed MM. Long-term stability of anterior segmental maxillary osteotomy. Int J Adult Orthodon Orthognath Surg 1999;14:297-303.  Back to cited text no. 3
    
4.
Gunaseelan R, Anantanarayanan P, Veerabahu M, Vikraman B, Sripal R. Intraoperative and perioperative complications in anterior maxillary osteotomy: A retrospective evaluation of 103 patients. J Oral Maxillofac Surg 2009;67:1269-73.  Back to cited text no. 4
    
5.
Kramer FJ, Baethge C, Swennen G, Teltzrow T, Schulze A, Berten J, et al. Intra- and perioperative complications of the LeFort I osteotomy: A prospective evaluation of 1000 patients. J Craniofac Surg 2004;15:971-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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