SlideShare a Scribd company logo
1 of 73
Download to read offline
Maxillary and Midface Osteotomies

Presented by: Dr Mohammed Haneef
Contents
Introduction/History
Anatomical Considerations
Single tooth/mulitple tooth osteotomy
Anterior maxillary osteotomy
Posterior maxillary osteotomy
Lefort I osteotomy
Lefort II osteotomy
Lefort III osteotomy
Surgically Assisted Maxillary Expansion
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
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
 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
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.
Anatomical Considerations
Maxillary Orthognathic surgery
Maxillary Orthognathic surgery
Maxillary Orthognathic surgery
Maxillary Orthognathic surgery
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
Single tooth
Segmental
maxillary
osteotomy

Anterior segmental
Posterior segmental

Mid face
Osteotomies

Horseshoe
SAME
Lefort I

Classic
Quadrangular

Total
maxillary
osteotomy

Anterior LF II
Lefort II

Pyramidal LF II

Lefort III

Quadrangular LF II

Midface

Zygomatic
Malar - Maxillary
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.
 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).
 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.
Seminars in Orthodontics, 2012: 18(4); 286-294
Int. J. Odontostomat 2013; 7(1):79-85, Case Reports in Dentistry 2012; 694527
Anterior Segmental Osteotomy
Cohn-Stock (1920)
Wassmund (1935)
 Wunderer (1963)
 Cupar (1955)
 Epker and wolford (1980)
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
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.
 *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
Maxillary Orthognathic surgery
Maxillary Orthognathic surgery
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.
Maxillary Orthognathic surgery
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
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
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
Maxillary Orthognathic surgery
Complications
 Loss of teeth vitality
 Periodontal defects
 Necrosis of segment
 Relapse

Advantages
 Decreased morbidity
 Can be performed as outpatient procedures
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
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:683-92
Maxillary Orthognathic surgery
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
 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
• 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)
 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.
 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.
 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.
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.
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
Maxillary Orthognathic surgery
Modifications
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.
 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.
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.
Maxillary Orthognathic surgery
Segmentalization
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.
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
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
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
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
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
Postoperative
 Infections
 Sinusitis
 Occlusal derrangement
 Unaesthetic apperence
 Vascular compromise
 Haemotoma
 Devitalization of teeth
 Periodontal problems
 Oroantral communication

Eur Rev Med Pharmacol Sci. 2013 Feb;17(3):379-84.
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
Technique
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
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
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.
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.
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.
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
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
Maxillary Orthognathic surgery
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
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.
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 .
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
Maxillary Orthognathic surgery
Maxillary Orthognathic surgery
Intraoperative
 Haemorrhage
 Unfarouble ostetomy
 Iatrogenic injur

Postraoperative
Haemorrhage
infections
Nasolacrimal duct damage
Enoptholmoses
Neurosensory defecits
Relapse
Menigiocoele

More Related Content

What's hot

Orthognathic Surgery: diagnosis
Orthognathic Surgery: diagnosis Orthognathic Surgery: diagnosis
Orthognathic Surgery: diagnosis mrinalini123456789
 
Condylar fractures
Condylar fracturesCondylar fractures
Condylar fracturesZeeshan Arif
 
Secondary alveolar bone grafting
Secondary alveolar bone graftingSecondary alveolar bone grafting
Secondary alveolar bone graftingTejaswini Pss
 
Maxillary orthognathic surgery
Maxillary orthognathic surgeryMaxillary orthognathic surgery
Maxillary orthognathic surgerydrmohitmangla
 
Mandibular Condylar fractures & its Management
Mandibular Condylar fractures & its ManagementMandibular Condylar fractures & its Management
Mandibular Condylar fractures & its ManagementMehul Hirani
 
Surgical approaches to tmj
Surgical approaches to tmjSurgical approaches to tmj
Surgical approaches to tmjAditi Rajvanshi
 
Mandibular osteotomies
Mandibular osteotomiesMandibular osteotomies
Mandibular osteotomiesRam Yadav
 
Conylar hyperplasia
Conylar hyperplasia Conylar hyperplasia
Conylar hyperplasia Weam Faroun
 
Apertognathia and its surgical management
Apertognathia and its surgical managementApertognathia and its surgical management
Apertognathia and its surgical managementHimanshu Soni
 
Surgery first orthognathic approach
Surgery first orthognathic approach Surgery first orthognathic approach
Surgery first orthognathic approach Dr.Lekshmi Vijayan
 
diagnosis and treatment planning for orthognathic surgery
diagnosis and treatment planning for orthognathic surgerydiagnosis and treatment planning for orthognathic surgery
diagnosis and treatment planning for orthognathic surgeryZeeshan Arif
 

What's hot (20)

Distraction Osteogenesis
Distraction OsteogenesisDistraction Osteogenesis
Distraction Osteogenesis
 
Ramus osteotomy
Ramus osteotomy Ramus osteotomy
Ramus osteotomy
 
Le fort i maxillary osteotomy
Le fort i maxillary osteotomyLe fort i maxillary osteotomy
Le fort i maxillary osteotomy
 
Orthognathic Surgery: diagnosis
Orthognathic Surgery: diagnosis Orthognathic Surgery: diagnosis
Orthognathic Surgery: diagnosis
 
Genioplasty
GenioplastyGenioplasty
Genioplasty
 
Condylar fractures
Condylar fracturesCondylar fractures
Condylar fractures
 
Secondary alveolar bone grafting
Secondary alveolar bone graftingSecondary alveolar bone grafting
Secondary alveolar bone grafting
 
Maxillary orthognathic surgery
Maxillary orthognathic surgeryMaxillary orthognathic surgery
Maxillary orthognathic surgery
 
Mandibular Condylar fractures & its Management
Mandibular Condylar fractures & its ManagementMandibular Condylar fractures & its Management
Mandibular Condylar fractures & its Management
 
Surgical approaches to tmj
Surgical approaches to tmjSurgical approaches to tmj
Surgical approaches to tmj
 
Genioplasty
 Genioplasty Genioplasty
Genioplasty
 
Orthognathic surgery
Orthognathic surgeryOrthognathic surgery
Orthognathic surgery
 
Condylar fractures
Condylar fracturesCondylar fractures
Condylar fractures
 
Mandibular osteotomies
Mandibular osteotomiesMandibular osteotomies
Mandibular osteotomies
 
Bone grafts in oral surgery
Bone grafts in oral surgeryBone grafts in oral surgery
Bone grafts in oral surgery
 
Condylar #
Condylar #Condylar #
Condylar #
 
Conylar hyperplasia
Conylar hyperplasia Conylar hyperplasia
Conylar hyperplasia
 
Apertognathia and its surgical management
Apertognathia and its surgical managementApertognathia and its surgical management
Apertognathia and its surgical management
 
Surgery first orthognathic approach
Surgery first orthognathic approach Surgery first orthognathic approach
Surgery first orthognathic approach
 
diagnosis and treatment planning for orthognathic surgery
diagnosis and treatment planning for orthognathic surgerydiagnosis and treatment planning for orthognathic surgery
diagnosis and treatment planning for orthognathic surgery
 

Viewers also liked

orthognathic surgery/ fixed orthodontics courses
orthognathic surgery/ fixed orthodontics coursesorthognathic surgery/ fixed orthodontics courses
orthognathic surgery/ fixed orthodontics coursesIndian dental academy
 
Orthognathic surgery new microsoft power point presentation
Orthognathic surgery new microsoft power point presentationOrthognathic surgery new microsoft power point presentation
Orthognathic surgery new microsoft power point presentationmemoalawad
 
Distraction osteogenesis versus bsso for advancement of the retrognathic mand...
Distraction osteogenesis versus bsso for advancement of the retrognathic mand...Distraction osteogenesis versus bsso for advancement of the retrognathic mand...
Distraction osteogenesis versus bsso for advancement of the retrognathic mand...Indian dental academy
 
4.orthognathic surgery
4.orthognathic surgery4.orthognathic surgery
4.orthognathic surgeryZhi Yen
 
Orthognathic surgery and treatment
Orthognathic surgery and treatmentOrthognathic surgery and treatment
Orthognathic surgery and treatmentluthar martin
 
Orthognathic surgery
Orthognathic surgeryOrthognathic surgery
Orthognathic surgeryAhmed Adawy
 
Orthognathic complications
Orthognathic complicationsOrthognathic complications
Orthognathic complicationsArjun Shenoy
 

Viewers also liked (11)

surgical proedures in orthodontics
surgical proedures in orthodonticssurgical proedures in orthodontics
surgical proedures in orthodontics
 
orthognathic surgery/ fixed orthodontics courses
orthognathic surgery/ fixed orthodontics coursesorthognathic surgery/ fixed orthodontics courses
orthognathic surgery/ fixed orthodontics courses
 
Orthognathic surgery new microsoft power point presentation
Orthognathic surgery new microsoft power point presentationOrthognathic surgery new microsoft power point presentation
Orthognathic surgery new microsoft power point presentation
 
Orthognathic surgery
Orthognathic surgery Orthognathic surgery
Orthognathic surgery
 
Orthognathic Surgery
Orthognathic SurgeryOrthognathic Surgery
Orthognathic Surgery
 
Distraction osteogenesis versus bsso for advancement of the retrognathic mand...
Distraction osteogenesis versus bsso for advancement of the retrognathic mand...Distraction osteogenesis versus bsso for advancement of the retrognathic mand...
Distraction osteogenesis versus bsso for advancement of the retrognathic mand...
 
4.orthognathic surgery
4.orthognathic surgery4.orthognathic surgery
4.orthognathic surgery
 
Orthognathic surgery and treatment
Orthognathic surgery and treatmentOrthognathic surgery and treatment
Orthognathic surgery and treatment
 
Orthognathic surgery
Orthognathic surgeryOrthognathic surgery
Orthognathic surgery
 
Orthognathic complications
Orthognathic complicationsOrthognathic complications
Orthognathic complications
 
Orthognathic surgery
Orthognathic surgeryOrthognathic surgery
Orthognathic surgery
 

Similar to Maxillary Orthognathic surgery

MAXILLRY OSTEOTOMY.pptx
MAXILLRY OSTEOTOMY.pptxMAXILLRY OSTEOTOMY.pptx
MAXILLRY OSTEOTOMY.pptxDentalYoutube
 
Maxillary Orthognathic Surgery
Maxillary Orthognathic SurgeryMaxillary Orthognathic Surgery
Maxillary Orthognathic SurgeryDr Rayan Malick
 
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...Indian dental academy
 
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...Indian dental academy
 
Corticotomy for Rapid Acceleration
Corticotomy for Rapid AccelerationCorticotomy for Rapid Acceleration
Corticotomy for Rapid AccelerationRohan Bhagat
 
Orthognathic surgery-Mid face procedures
Orthognathic surgery-Mid face proceduresOrthognathic surgery-Mid face procedures
Orthognathic surgery-Mid face proceduresIndian dental academy
 
Maxillary procedures and soft tissue changes
Maxillary procedures and soft tissue changesMaxillary procedures and soft tissue changes
Maxillary procedures and soft tissue changesShibani Sarangi
 
Endodontic surgeries /orthodontics courses
Endodontic surgeries /orthodontics coursesEndodontic surgeries /orthodontics courses
Endodontic surgeries /orthodontics coursesIndian dental academy
 
Corticotomy in the Modern Orthodontics
Corticotomy in the Modern OrthodonticsCorticotomy in the Modern Orthodontics
Corticotomy in the Modern Orthodonticsiosrjce
 
Corticotomy in the Modern Orthodontics
Corticotomy in the Modern OrthodonticsCorticotomy in the Modern Orthodontics
Corticotomy in the Modern OrthodonticsAbu-Hussein Muhamad
 
distraction osteogenesis
 distraction  osteogenesis  distraction  osteogenesis
distraction osteogenesis MIKYJOLY
 
Catatan tutor scenario 2 inggris
Catatan tutor scenario 2 inggrisCatatan tutor scenario 2 inggris
Catatan tutor scenario 2 inggriscameliasenada
 
acclerated orthodontics.pptx
acclerated orthodontics.pptxacclerated orthodontics.pptx
acclerated orthodontics.pptxMonicaRajput12
 
Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...
 Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery... Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...
Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...Abu-Hussein Muhamad
 
Mandibular orthognathic procedures 1- ih
Mandibular orthognathic procedures 1- ihMandibular orthognathic procedures 1- ih
Mandibular orthognathic procedures 1- ihitrat hussain
 
PREPROSTHETIC SURGERY 2.pptx
PREPROSTHETIC SURGERY 2.pptxPREPROSTHETIC SURGERY 2.pptx
PREPROSTHETIC SURGERY 2.pptxMalaM67
 
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...Abu-Hussein Muhamad
 
ORTHOGNATHIC SURGERY.pptx
ORTHOGNATHIC SURGERY.pptxORTHOGNATHIC SURGERY.pptx
ORTHOGNATHIC SURGERY.pptxDerrickOM
 
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...
 Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma... Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...Abu-Hussein Muhamad
 
Preprosthetic surgery.ppt
Preprosthetic surgery.pptPreprosthetic surgery.ppt
Preprosthetic surgery.pptomfsanids
 

Similar to Maxillary Orthognathic surgery (20)

MAXILLRY OSTEOTOMY.pptx
MAXILLRY OSTEOTOMY.pptxMAXILLRY OSTEOTOMY.pptx
MAXILLRY OSTEOTOMY.pptx
 
Maxillary Orthognathic Surgery
Maxillary Orthognathic SurgeryMaxillary Orthognathic Surgery
Maxillary Orthognathic Surgery
 
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
 
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
Maxillary procedures and soft tissue changes /certified fixed orthodontic cou...
 
Corticotomy for Rapid Acceleration
Corticotomy for Rapid AccelerationCorticotomy for Rapid Acceleration
Corticotomy for Rapid Acceleration
 
Orthognathic surgery-Mid face procedures
Orthognathic surgery-Mid face proceduresOrthognathic surgery-Mid face procedures
Orthognathic surgery-Mid face procedures
 
Maxillary procedures and soft tissue changes
Maxillary procedures and soft tissue changesMaxillary procedures and soft tissue changes
Maxillary procedures and soft tissue changes
 
Endodontic surgeries /orthodontics courses
Endodontic surgeries /orthodontics coursesEndodontic surgeries /orthodontics courses
Endodontic surgeries /orthodontics courses
 
Corticotomy in the Modern Orthodontics
Corticotomy in the Modern OrthodonticsCorticotomy in the Modern Orthodontics
Corticotomy in the Modern Orthodontics
 
Corticotomy in the Modern Orthodontics
Corticotomy in the Modern OrthodonticsCorticotomy in the Modern Orthodontics
Corticotomy in the Modern Orthodontics
 
distraction osteogenesis
 distraction  osteogenesis  distraction  osteogenesis
distraction osteogenesis
 
Catatan tutor scenario 2 inggris
Catatan tutor scenario 2 inggrisCatatan tutor scenario 2 inggris
Catatan tutor scenario 2 inggris
 
acclerated orthodontics.pptx
acclerated orthodontics.pptxacclerated orthodontics.pptx
acclerated orthodontics.pptx
 
Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...
 Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery... Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...
Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...
 
Mandibular orthognathic procedures 1- ih
Mandibular orthognathic procedures 1- ihMandibular orthognathic procedures 1- ih
Mandibular orthognathic procedures 1- ih
 
PREPROSTHETIC SURGERY 2.pptx
PREPROSTHETIC SURGERY 2.pptxPREPROSTHETIC SURGERY 2.pptx
PREPROSTHETIC SURGERY 2.pptx
 
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Max...
 
ORTHOGNATHIC SURGERY.pptx
ORTHOGNATHIC SURGERY.pptxORTHOGNATHIC SURGERY.pptx
ORTHOGNATHIC SURGERY.pptx
 
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...
 Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma... Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...
Titanium Button With Chain by Watted For Orthodontic Traction of Impacted Ma...
 
Preprosthetic surgery.ppt
Preprosthetic surgery.pptPreprosthetic surgery.ppt
Preprosthetic surgery.ppt
 

More from Mohammed Haneef Farooq (15)

Primary care in trauma
Primary care in traumaPrimary care in trauma
Primary care in trauma
 
Genioplasty in Brief
Genioplasty in BriefGenioplasty in Brief
Genioplasty in Brief
 
Head and Neck Infections
Head and Neck InfectionsHead and Neck Infections
Head and Neck Infections
 
Antibiotics in Oral and Maxillofacial Surgery
Antibiotics in Oral and Maxillofacial SurgeryAntibiotics in Oral and Maxillofacial Surgery
Antibiotics in Oral and Maxillofacial Surgery
 
Skin
Skin Skin
Skin
 
Osteoradionecrosis
OsteoradionecrosisOsteoradionecrosis
Osteoradionecrosis
 
Metabolic response to trauma
Metabolic response to traumaMetabolic response to trauma
Metabolic response to trauma
 
Mandibular trauma
Mandibular traumaMandibular trauma
Mandibular trauma
 
Local anaesthesia
Local anaesthesia Local anaesthesia
Local anaesthesia
 
Infections of head and neck
Infections of head and neckInfections of head and neck
Infections of head and neck
 
Head injuries
Head injuriesHead injuries
Head injuries
 
Fluid and electrolytes
Fluid and electrolytes Fluid and electrolytes
Fluid and electrolytes
 
Development of face
Development of faceDevelopment of face
Development of face
 
Chronic infections of jaws
Chronic infections of jaws  Chronic infections of jaws
Chronic infections of jaws
 
Primary care in trauma dr haneef
Primary care in trauma   dr haneefPrimary care in trauma   dr haneef
Primary care in trauma dr haneef
 

Recently uploaded

blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Transport across cell membrane (passive, active, vesicular)
Transport across cell membrane (passive, active, vesicular)Transport across cell membrane (passive, active, vesicular)
Transport across cell membrane (passive, active, vesicular)MedicoseAcademics
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Understanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well essUnderstanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well essAbhishekKumar524514
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 

Recently uploaded (20)

blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Transport across cell membrane (passive, active, vesicular)
Transport across cell membrane (passive, active, vesicular)Transport across cell membrane (passive, active, vesicular)
Transport across cell membrane (passive, active, vesicular)
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Understanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well essUnderstanding AIDS:a roadmap to well ess
Understanding AIDS:a roadmap to well ess
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 

Maxillary Orthognathic surgery

  • 1. Maxillary and Midface Osteotomies Presented by: Dr Mohammed Haneef
  • 2. Contents Introduction/History Anatomical Considerations Single tooth/mulitple tooth osteotomy Anterior maxillary osteotomy Posterior maxillary osteotomy Lefort I osteotomy Lefort II osteotomy Lefort III osteotomy Surgically Assisted Maxillary Expansion
  • 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
  • 13. Single tooth Segmental maxillary osteotomy Anterior segmental Posterior segmental Mid face Osteotomies Horseshoe SAME Lefort I Classic Quadrangular Total maxillary osteotomy Anterior LF II Lefort II Pyramidal LF II Lefort III Quadrangular LF II Midface Zygomatic Malar - Maxillary
  • 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.
  • 17. Seminars in Orthodontics, 2012: 18(4); 286-294
  • 18. Int. J. Odontostomat 2013; 7(1):79-85, Case Reports in Dentistry 2012; 694527
  • 19. Anterior Segmental Osteotomy Cohn-Stock (1920) Wassmund (1935)  Wunderer (1963)  Cupar (1955)  Epker and wolford (1980)
  • 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
  • 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.
  • 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
  • 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
  • 33. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:683-92
  • 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
  • 56. Postoperative  Infections  Sinusitis  Occlusal derrangement  Unaesthetic apperence  Vascular compromise  Haemotoma  Devitalization of teeth  Periodontal problems  Oroantral communication Eur Rev Med Pharmacol Sci. 2013 Feb;17(3):379-84.
  • 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
  • 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
  • 73. Intraoperative  Haemorrhage  Unfarouble ostetomy  Iatrogenic injur Postraoperative Haemorrhage infections Nasolacrimal duct damage Enoptholmoses Neurosensory defecits Relapse Menigiocoele