3. Introduction
Earliest orthognathic surgery known as orthodontic
surgery
Dentofacial deformities affect 20% of the population.
Orthognathic surgery is a team work.
This team must
Correctly diagnose existing deformities
Establish an appropriate treatment plan
Execute recommended treatment.
Function
Aesthetics
Stability
Minimizing the treatment time.
Basic theraputic goals
4. History
1859 – Von Langenbeck – nasophyrngeal polyps.
1867 – David Cheever – Le fort 1 osteotomy- nasal
obstruction
20th century :-dentofacial deformities
1921 – Cohn Stock – A M O
1950 – Gillies & Harrison – Le fort III
1959 – Schuchardt- post maxillary osteotomy
1969 – Classical L I – Bell
1970’s – Kufner, Henderson & jackson – L II
1990 – Keller & Sather, Quadrangular L I
5. Initial Days..
Segmental osteotomies
Complete mobilization was avoided
High incidences of relapse
1965- Obwegeser complete mobilization of maxilla
repositioning could be accomplished without tension
Until 1960-pedicle of soft tissue on buccal side
*Bell 1969-75-as long as maxilla is pedicled to palatal
mucosa ,labial gingiva down fracture of the maxilla with
complete mobilization can be accomplished with adequate
vascular supply
*JOS-1969;27;249-Revascularization after lefort I osteotomy
6. Protocol
Design soft tissue to maintain adequate collateral
blood supply to the ostetomised segment and to
avoid injury to vital structures.
Provide optimum exposure.
Minimum periostel stripping.
Gentle soft tissue handling.
Avoid injury to neurovascular bundle.
Make osteotomy cuts under constant irrigation
with normal saline.
Plan interdental osteotomy cuts with out
damaging periodontal status of adjoining teeth.
12. Bell et al 1995-excellent collateral
circulation of the maxilla.
Restoration of blood supply 1 week post
operatively-Dodson -1994
1 week –increase in periosteal-endosteal blood
supply
2 weeks –vessels connecting segments
4 weeks blood circulation in segments
12 weeks
14. Corticotomy/Ostetomy
In 1892 , Cunningham, first defined it as a linear cutting
technique in the cortical plates surrounding the teeth
to produce mobilization of the teeth for immediate
movement.
Köle (1959) thoroughly described the clinical
application of orthodontically moving teeth after
interproximal bone segmentation as a means to expedite
tooth movement. He suggested that teeth can be
segmented and moved as “small boxes” through bone
remodeling without involving the periodontal ligament.
Technique was described as an adjunct in the correction
of numerous types of malocclusions, with different
treatment protocols such as nonextraction and space
closure approaches. Using this method, he claimed
orthodontic treatment could be accomplished in six to
twelve weeks.
15. Regional acceleratory phenomenon(RAP). This process was
described initially by Frost (1989) based on observations of bone
fracture healing. In summary, he described a series of
orchestrated events consisting of increased cellular activity
during healing around the fracture site. These events were
characterized by reduction in bone density due to the accelerated
bone turnover. The cortical bone porosity appeared to be related to
osteoclastic activity that may have contributed to tooth mobility.
It has been suggested that the peak of such phenomenon is one or
two months after the insult, with effects lasting six to 24 months.
Wilcko and colleagues (2001) reported, Patients with moderate to
severe crowding to accelerate tooth movement. The surgical
procedure consisted of interproximal vertical grooves on the labial
and lingual cortices of all teeth. A subapical horizontal scalloped
corticotomy connected the vertical grooves. In addition,
numerous circular perforations were drilled on the cortical bone
surfaces and a resorbable allograft was packed over the
corticotomies and exposed cortical bone. They called this
procedure Periodontally Accelerated Osteogenic Orthodontics
(PAOO).
16. Surgical technique
The surgical technique for PAOO consists of 5
steps viz.
1) Raising of flap, 2) Decortication,
3) Particulate grafting, 4) Closure and
5) Orthodontic force application.
Indicated
Tooth malposition.
Dental ankylosis.
closure of diastema.
Sever crowding
Failure of conventional orthodontic treatment
Advantages:
Reduction in the treatment time.
Lower incidance of relapse.
Disadvantages:
Injury to teeth
Periodontal compromise
Devitalization of teeth.
20. 1921 – Cohn Stock.
Transverse palatal incision
Wedge shaped osteotomy green stick fracture retracted
the anterior segment Relapsed within 4 weeks
Various incision designs for desired osseous movements .
*Bell- overall procedure is predictable from standpoint of
dental stability and soft tissue changes.
* Stability and soft tissue changes in anterior part of jaw surgery A J ORDNTCS;1973
21. Indications :
Correction of bimaxillary protrusion.
Marked protrusion of the maxillary teeth (normal
incisor axial inclination to alveolar bone)
Anterior open bite
To retract the anterior teeth when that cannot be
accomplished by conventional orthodontic
treatment.(pt noncomplience)
When orthodontic tooth movement is
inadvisable.(ankylosiss, root resorption)
Improvement in appearance.
22. *Radioactive microsphere techq used assess the blood flow in
AMO in macaque monkeys.
Variation in flap design didn’t affect the postop blood supply to ant
maxillary segment.
This study gives scientific credence to different incisions for AMO
Blood supply can be maintained by
labial-buccal & palatal tissues ,
labial –buccal tissues alone
palatal tissues alone
*Nelson –quantation of blood flow after AMO in three teq- JOS, 1978;36:108-112
23.
24.
25. Downfracture Technique
Technique :
A buccal vestibular incision is created, allowing
direct access to the anterior lateral maxillary walls,
piriform aperture, nasal floor and septum.
Most commonly used for AMO*
Advantages :
Direct access to the nasal structures
Unhampered access – bone grafting
Ability to remove bone under direct visualization
Preservation of blood supply
Ease of placement of rigid internal fixation.
26.
27. Complications of AMO
1.
2.
3.
4.
5.
6.
7.
8.
Loss of vitality of the dentition
Damage to tooth roots
Persistent periodontal defects
Osseous necrosis of the dentoosseous segments
Communication with the maxillary sinus and nasal
cavity
Hemorrhage
Oronasal or oroantral fistulas
Atrophic rhinitis – complete inferior turbinectomy
28. 9. Unfavourable nasolabial esthetics
- Shortening & thinning of the upper lip
- widening of the alar bases
- upturning of the nasal tip
10. Nasal Septal Deviation
- Deviation or bucking of the nasal septum
cause
- inadequate bone removal from the nasal crest of the
maxilla or inadequate trimming of the cartilagenous
septum
29. Posterior Segmental Osteotomy
Schuchardt (1959)
Kufner (1971) - described a single buccal incision approach.
Perko – Bell technique (1967)
Indications
1. 1 Post maxillary alveolar hyperplasia
2. 2 Total maxillary hyperplasia (when combined with AMO)
3. 3 Distal repositioning of the post maxillary alveolar fragment
to provide space for proper eruption of an impacted canine or
bicuspid tooth
4. Spacing in the dentititon that can be closed by ant
repositioning of the posterior segment
5. Transverse excess or deficiency
6. Posterior open bite
7. Posterior cross bite
30.
31. Complications
Loss of teeth vitality
Periodontal defects
Necrosis of segment
Relapse
Advantages
Decreased morbidity
Can be performed as outpatient procedures
32. Combination Anterior & Posterior Maxillary
Osteotomy
Also called Horseshoe osteotomy
A combined form of anterior and posterior subapical osteotomies "total
subapical maxillary osteotomy" were reported by Paul 1969 for
midface hypoplasia.. This technique was further described by West &
Epker 1972, Hall & Roddy 1975, Wolford & Epker 1975, West and
McNeil 1975 and Hall & West 1976. Maloney (1982) reviewed this
technique and described it as a good technique during his time.
Indication
Maxillary alveolar hyperplasia with or without an anterior open bite deformity
Transverse hypolplasia without a vertical component
This procedure creates a three piece maxilla, with the central nasal portion left
undisturbed, through the use of palatal parasagittal osteotomies
35. Lefort I Osteotomy
*“Lefort I osteotomy has become the work horse of
Orthognathic surgical procedures .its ease ,its broad
application to resolve many functional and aesthetic
problems and the dependability of its results support this
evolution.”
Blood supply
Nasal airway problems and sinus problems*- no adverse
consequences
*-Bell, jos1975;33;412
* walker, turvey joms1988
36. Orthognathic surgery of the maxilla was first described in 1859 by von
langenbeck for the removal of nasopharyngeal polyps.
The first American report of a maxillary osteotomy was by David
Cheever in 1867 for the treatment of complete nasal obstruction
secondary to recurrent epistaxis for which a right hemi maxillary down
fracture was used.
Wasmund introduced his lefort I or total maxillary osteotomy
technique in 1927
Axhausen used a similar technique in 1934 to correct a healed
maxillary fracture. He reported complete mobilization with immediate
repositioning. He also reported the use of curved osteotome for
pterygomaxillary disjunction.
Separation of the pterygomaxillary junction was advocated by
Schuchardt in 1942
Moore and Ward in 1949 recommended horizontal transection of the
pterygoid plates for the advancement. However, this technique was
abandoned due to incidence of severe bleeding in most cases
Most of these techniques simply mobilized the maxilla to one degree or
another, and then placed orthopedic forces on it to achieve desired
positioning- a sort of unintentional distraction osteogenesis. These
methods were associated with high levels of relapse
37. • Hugo Obwegesser 1965 advocated complete
mobilisation of maxilla so that maxilla could be
repositioned without tension. This aided in
stabilisation which was documented by Haller,
Hogemann & Wilmar and Perko
• Bennett & Wolford (1985) described cutts
Parallel FH plane to prevent ramping effect.
• The correct used of curved osteotome described
by Turvey and Fonseca in 1980
• Precious et al described pterygomaxillary
dysjunction without the use of osteotome (1991)
• Use of Swan neck osteotome by cheng ( 1993)
• Use of Saw by cheng (1993)
• Use of Shark Fin osteotome by laster (2002)
• Twist technique by fredricko (2012)
38. In 1965, Obwegeser suggested complete
mobilization of the maxilla so that repositioning
could be accomplished without tension. This
proved to be a major advance in stabilization, as
documented by Hogemann and Willmar, De
Haller, and Perko respectively
Early descriptions of the rigid fixation of
maxillary osteotomies were published by
Michelet and colleagues in 1973, Horster in
1980, Drommer and Luhr in 1981, and Luyk and
ward-booth in 1985. Since that time, many
methods have been advocated for the rigid
fixation of maxillary osteotomies. These have
included bone plates, metallic mesh, pins, the
rigid adjustable pin (RAP) system, and
resorbable fixation.
39. In the early 1970s, Bell and colleagues demonstrated that early
osseous union with minimal osteonecrosis occurred following
total maxillary osteotomy, indicating that the palatal soft tissue
pedicle and the labial buccal gingival provide an adequate
nutrient pedicle for single stage osteotomy.
Bell and colleagues in 1975 provided evidence through micro
angiographic studies that bilateral transection of the
descending palatine vessels did not adversely affect the lefort I
osteotomy procedure if basic surgical principles were followed.
Studies by Dodson and co workers in 1994 measured the blood
flow to the maxillary gingiva, using laser Doppler flowmetry
following lefort I osteotomy with sacrifice of bilateral
descending palatine arteries. Their results were similar to
those of previous studies, showing transient vascular ischemia
and restored blood flow in the anterior maxilla one week
postoperatively.
Bell and colleagues in 1995 continued to investigate the limits
of this surgical technique by performing the lefort I osteotomy
using a standard circum vestibular incision, segmentalizing the
maxilla, stretching the palatal vascular pedicle and transecting
the descending palatine arteries. The result was uncomplicated
post operative healing, with only transient vascular ischemia.
40. Hugo Obwegesser 1969 described a high quadrangular
Le Fort I osteotomy for midface deficiency correction.
This technique was later named as Quadrangular Le
Fort I osteotomy by Keller & Sather 1989.
Kuffner in 1970 also described a quadrangualar lefort I
osteotomy.
41. Indications
The lefort I osteotomy can be used to correct a variety
of maxillofacial problems
maxillary advancement, especially in cleft palate and
post trauma patients
To correct maxillary prognathism
Superior repositioning of the maxilla, to correct
vertical maxillary excess
Inferior repositioning of the maxilla, to correct vertical
maxillary deficiency
Widening of the maxilla, to correct transverse
discrepancies
3D repositioning of the maxilla ( segmental
osteotomies )
In all instances of apertognathia, lefort I osteotomy
should be given consideration because of the stability
issues.
42. Surgical technique
1. Positioning of the patient-10 degree head
elevation
2. Hypotension GA (90mm/Hg systolic*)
3. Infiltration of the soft tissue with a
vasoconstrictor.2% lidocaine (1;100000)
*Anderson-delibrate hypotensive anesthesia for orthoganthic surgery.adult orthodontic orthognathic surgery 1986;1;133
45. Technique
An intraoral incision is made in the buccal vestibule of the maxilla
from the molar region of one side to the opposite one and a
mucoperiosteal flap is raised exposing the anterior-lateral walls of
the maxilla.
The dissection is extended laterally and superiorly towards the
zygomatic buttress and the zygomatic process of the temporal bone.
The infraorbital nerve is identified and the dissection is then
extended to the orbital floor with a curved periosteal elevator in
order to simplify the following osteotomies and to achieve direct
control of periorbital tissues.
The osteotomy is performed with a reciprocating saw or a fissure
bur, starting from the lateral aspect of the piriform aperture and is
extended to the medial aspect of the inferior orbital rim. The second
osteotomy line starts from the lateral aspect of the inferior orbital
rim and is directed towards the zygomatic buttress as far back as is
possible.
This osteotomy is completed with a chisel, which is inclined
backwards and laterally, in order to create an enlarged mobilized
segment of the malar bone. The two osteotomies are then connected
along the anterior orbital floor with curved osteotomes specially
designed for this manoeuvre and for protection of periorbital tissues.
46. The same procedure is performed on the opposite side. The
osteotomy of the nasal septum is performed according to Le
Fort I routine modalities, whereas the osteotomy of the
medial walls of the maxillary sinuses are carried out in a
higher position.
Particular attention must be drawn to pterygomaxillary
osteotomy both apically and medially in order to simplify
the mobilization of the maxillo-malar complex.
Advantages of these modifications are the following:
1. The aesthetic 'epicentre' of the zygomatic buttress is included
in the osteotomized segment.
2. The osteotomies along the orbital floor are performed under
direct control, thus avoiding possible damage to the periorbita.
3. The larger and thicker osteotomized maxillo-malar segment
reduces the risk of green-stick or undesired fractures of the thin
anterior wall of the maxillary sinus.
4. The laterally inclined osteotomy of the malar bone permits the
creation of an inclined plane instead of a gap following maxillomalar advancement, thus facilitating bone grafting and the
stabilization of the maxillo-malar complex with titanium
miniplates along the lateral and medial osteotomies.
47. Complications:
The post surgical complications include:
Wound infection
Bone sequestrum without sepsis
Neurologic deficit involving the infraorbital nerve was
considered minor and transient in all patients (in contrast to
lefort II patients), as nerve handling is relatively minor with
this procedure
Irregular infraorbital rim contour, because of onlay bone
grafting in this area
Nasolacrimal duct dysfunction, due to passage of the
transosseous medial orbital rim wires or miniplate
placement.
Infraorbital emphysema, if the patient blows his or her nose
Iliac crest donor site complications, are infrequent and
minor.
50. Postsurgical management
The surgical splint placed for 6 weeks.
Elastics should be worn for at the time for 6 to 8 weeks.
Non – exertional activity for 6 to 8 weeks.
Nasal spray(oxymetazolin)
Systemic decongestion
Hierarchy of stability
Maxillary advancement, posterior and superior movements
are shown to be stable whereas inferior & transverse
movements are unstable.
51. Advantages
Speed
General familiarity with the osteotomy design
Simplicity
Facility in repositioning the maxilla superiorly & posteriorly
The ease & safety of segmentation
It can be combined with lateral maxillary osteotomy
Disadvantages
Possible telescoping of repositioned segments
Difficulty for application of screw and plate in individuals with
aberrant anatomy.
Difficulty in positioning corticocancellous bone grafts in the
pterygopalatine region.
Potential for unpredictable changes in the vertical maxillary
position
52. Complications
Intraoperative
Postoperative
Intraoperative
1. Incision design & closure
2. Unfavourable osteotomy
- # at the junction of the horizontal process of the
palatine bone with the palatal process of the maxilla
- high horizontal # of the pyramidal process of the
palatine bone
- horizontal # of the pterygoid plates
53. 3. Bleeding
PSA Artery
Greater palatine artery
Maxillary artery
Pterygoid venous plexus
Management
Localized pressure packing directed at the bleeding point
Cauterization with either chemical or with diathermy
Ligation of the ECA
Transantral ligation of maxillary artery
Angiographic emoblization
54. 4. Bradycardia
Profound bradycardia & asystole occur during down fracture
or mobilization of maxilla – Trigemino- cardia reflex(TCR)
Seen with the procedures which result in manipulation of the
central or peripheral portions of the trigeminal n
TCR – bradycardia < 60b/m, hypotension with a drop in the
mean arterial pressure of more than 20% coincidental with
surgical manipulation or traction at or around branches of the
TN.
Management – manipulation of the maxilla should be stopped
immediately
- Administration of anticholinergic medications such as
atropine or glycopyrolate
55. 6. Improper maxilary repositioning
- failure to seat one or both of the mandibular condyles
during maxillary repositioning will cause improper
maxillary positioning & a malocclusion
cause
- insufficient bone removal
57. Surgical Assisted Maxillary
Expansion (SAME)
Brown first described SAME in 1938 - midpalatal split
A LeFort I type of osteotomy with a segmental split of the
maxillaand the placement of a triangular unicortical iliac graft for
correction of maxillary constriction was presented by Steinhauser
in 1972.
Indications:
Skeletal maxillomandibular transverse discrepancy greater than
5mm
Significant TMD associated with a narrow maxilla and wide mandible
Failed orthodontic expansion
Necessity for a large amount more than 7mm of expansion
Extremely thin and delicate gingival tissues with buccal gingival
recession
Significant nasal stenosis
Widening of the arch following collapse associated with the cleft
palate deformity
59. Complications
Those due to inadequate surgery:
Pain
Dental tipping
Periodontal breakdown
Post orthodontic relapse
Those due to expansion
Lack of appliance expansion
Deformation of the appliance due to processing errors
Stripping or loosening of midpalatal screw
Intraoperative hemorrhage
Devitalization of the teeth
60. Lefort II Osteotomy
Steinhauser 1980
Anterior L F II Osteotomies
Pyramidal LF II Osteotomies
Quadrangular LF III Osteotomies.
Indications:
Maxillary- zygomatic deficiency with skeletal
class III malocclusion, and normal nasal
projection.
Nasomaxillary deficiency, a pyramidal lefort II
osteotomy
Maxillary alveolar – palatal cleft deformity &
normal nasal projection
61. Anterior Lefort II
Described in detail by converse et al
(1970)
Relating to nasomaxillary hypoplasia.
Only naso-orbital osteotomy, but doesn’t
include posterior maxilla of infra-orbital
rims.
62. Principles
The principles of these procedure are:
The foreshortened nasal septal frame work must be
advanced as it will oppose nasal lengthening.
A forward and downward placement of nasal and
maxillary complex is required to correct midface
deficiency.
The naso lacrimal apparatus must not be disturbed.
Bone grafts should be used to restore the Bone
deficiencies.
Skin coverage and nasal lining must be provided to
accommodate the nasal elongation.
63. Procedure
The upper part of this osteotomy done, through a V shaped
incision with the apex at glabella and extended bilaterally
along both sides of nose to reach just above the alar base.
The cartilaginous and bony part of nose is separated and the
columella is pulled down.
Osteotomy begins at lower end of nasal bone directed
medially to the medial wall of orbit than downward to reach
the floor of orbit posterior to naso lacrimal apparatus. Then
it is brought to infra orbital margin medial to the nerve and
extended downwards to the alveolar bone posterior to 1st
premolar. Then a posteriorly based palatal flap is raised
and 5/5 are extracted the osteotomy is completed through
the sockets of this dividing hard palate. Now the segment is
mobilised and advanced. This can be fixed by a
prefabricated acrylic splint.
64. This Procedure:
Lengthens the nose
Nasal tip moved anteriorly and downwards.
Advances anterior maxillary segment.
This technique was modified by Psillakis
& Co worker 1973 by taking a transverse
osteotomy above the apices of anterior
teeth and augmenting the nasomaxillary
segment. This is not biologically sound so
this technique is hardly used nowadays
65. Pyramidal Lefort II
Henderson and Jackson 1973
Indication
Nasomaxillary hypoplasia : 4 types
- Involving dentoalveolar segment
- Excluding dentoalveolar segment (Binders
syndrome)
- Cleft palate patients
- Pan facial problems
66.
67. Quadrangular Lefort II
• First described by Kufner (1971),
modified by Souyris et al (1973), Champy
et al (1980) and by Steinhauser (1980).
• Middle osteotomy
• Keller and Sather did the entire
procedure intraorally
68. COMPLICATIONS:
A) INTRAOPERATIVE COPLICATIONS:
Haemorrhage
Unfavourable osteotomy
Uncommon. – Unfavorable fracture below the orbital rim if incomplete
or improperly angled bone cuts are present.
B) POSTOPERATIVE COMPLICATIONS:
1) Orbital complications: diplopia, enopthalmus, chemosis, ecchymosis.
Diplopia- extra ocular muscle spasm secondary to trauma and edema
from the orbital floor periosteum elevation.
Enopthalmus – due to herniation of the orbital fat into the antrum.
These orbital Complications are more common in the pyramidal lefort II
or III osteotomy, as a significant large portion of the orbital rim and
contents is surgically exposed.
69. 2) Nasolacrimal duct dysfunction:
Secondary to edema (rather than transection) from surgical
manipulation.
3) Infraorbital nerve dysfunction:
Experienced by all patients undergoing the various lefort II osteotomy
procedures (except the pyramidal type when the orbital rim cut is
medial to the nerve.
All patients experience varying degrees of dysesthesia (ex:
numbness, tingling) for varying periods (3-12 months).
4) Infraorbital rim contour irregularity
5) Wound sepsis
6) Surgical advancement relapse .
70. Lefort III Osteotomy
Sir Harold Gillies – 1942
Tessier
High level midface osteotomy surgery
Midface anteriorly or inferiorly or both
Indications :
Total midface hypoplasia primarily in anterioposterior and
vertical dimension.
Syndromic patients (aperts, crouzens syndrome
