The document presents an overview of maxillary orthognathic procedures, discussing the history, anatomical considerations, various surgical techniques (like segmental and LeFort osteotomies), and soft tissue changes associated with these surgeries. It highlights the importance of addressing dentofacial deformities, which affect a significant portion of the population and can lead to functional and aesthetic issues. Complications, patient expectations, and surgical considerations are also underscored, emphasizing the need for expertise in managing such complex interventions.

1. PRESENTED BY- DR. SAHANA M.S
MAXILLARY ORTHOGNATHIC
PROCEDURES AND SOFT
TISSUE CHANGES

2. CONTENTS
 INTRODUCTION
 AIMS & OBJECTIVES
 HISTORY
 ANATOMICAL CONSIDERATIONS
 ANTERIOR AND POSTERIOR MAXILLARY SEGMENTAL
OSTEOTOMY
 SARME
 LEFORT -I OSTEOTOMY
 MAXILLARY QUADRANGULAR LEFORT I AND QUADRANGULAR
LEFORT II OSTEOTOMY
 HIGH LEVEL MIDFACE OSTEOTOMY
 CLEFT OSTEOTOMIES
 COMPLICATIONS
 CONCLUSION
 REFERENCES

3. INTRODUCTION
 Dentofacial deformities affect 20%of the population.
 The incidence of Transverse Maxillary Deficiency is estimated to be
between 8% & 18%
 Patients with dentofacial deformities may demonstrate various degrees
of functional and aesthetic compromise.
 Such deformities may be limited to either one jaw or both the jaws.
 Tremendous advancement in field of orthognathic surgery have been
made since 1970s.

4. AIMS & OBJECTIVES
1
• Prioritize the problem list of the patient.
2
• Review of the risk-benefit considerations.
3
• Consideration of the patient’s expectations
& values.
Fonseca vol 2- Orthognathic surgery

5. HISTORY
 1859: Von-Langenback did the first orthognathic
procedure.
 1921:Cohn-Stock introduced the anterior maxillary
osteotomy.
 1927:Wassmund reported the first total maxillary
osteotomy.
 Bells research- biologic basis for orthognathic surgery.

6. GOALS
Correct Masticatory / Swallowing
abnormalities
Establish Functional occlusion
Correct inability to open and close the
jaws
Correct TMJ dysfunction, pathosis /
pain & Myofacial pain
Correct Structural abnormalities and
speech problems

7. ANATOMICAL CONSIDERATIONS

8. ANATOMICAL CONSIDERATIONS
 VASCULAR ANATOMY:
All the vessels are branches of
the ECA.
Anastomosed ascending
palatine and ascending
pharyngeal artery joins the
lesser palatine artery.
Sphenopalatine, posterior
superior alveolar and
infraorbital arteries are the
others

9. ORTHOGNATHIC PROCEDURES IN
MAXILLA
SEGMENTAL
MAXILLARY
OSTEOTOMY
Anterior segmental
osteotomy
Posterior segmental
osteotomy
Combined procedure
TOTAL
MAXILLARY
OSTEOTOMY
Lefort I osteotomy
Quadrangular lefort I
osteotomy
Lefort II osteotomy
Quadrangular Lefort II
osteotomy
Lefort III osteotomy/ High
mid-face osteotomy

10. ANTERIOR SEGMENTAL OSTEOTOMY
 INDICATIONS
Excess vertical or
antero-posterior
dimension of maxillary
alveolar process
To close an anterior
open bite
To retract anterior
maxillary teeth
When orthodontic teeth
movement cannot be
done
To correct marked
protrusion of maxillary
teeth with normal
incisor inclination
between teeth and bone

11. ANTERIOR SEGMENTAL OSTEOTOMY
 TECHNIQUES:
WUNDERER TECHNIQUE
WASSMUND TECHNIQUE
CUPAR TECHNIQUE

12.  WUNDERER TECHNIQUE:
ANTERIOR SEGMENTAL OSTEOTOMY

13.  WASSMUND TECHNIQUE:
ANTERIOR SEGMENTAL OSTEOTOMY

14.  CUPAR TECHNIQUE:
ANTERIOR SEGMENTAL OSTEOTOMY
Cupar technique is the most
commonly used technique for AMO.
 A buccal vestibular incision is
created.
 Direct access to the anterior
lateral maxillary walls.
Nasal mucosa is elevated from the
maxilla.
Horizontal osteotomy is completed
followed by vertical osteotomy
between teeth.

15. ADVANTAGES
Direct
access to
the nasal
structures
Ease of
placement of
rigid internal
fixation.
Ability to remove
bone under direct
visualization
Unhampered
access to superior
maxilla
Preservation of
blood supply
through
excellent
palatal pedicle
ANTERIOR SEGMENTAL OSTEOTOMY

16. POSTERIOR MAXILLARY OSTEOTOMY
 INDICATIONS
Posterior
maxillary
alveolar
hyperplasia
Total
maxillary
hyperplasia
Distal
repositioning
to guide the
eruption of
impacted
canine and
bicuspids
Spacing in
the dentition
Transverse
excess or
deficiency
Posterior
open bite

17. POSTERIOR MAXILLARY OSTEOTOMY
CONTRAINDICATIONS:
Damage to the vital structures.
When repositioning of the entire
maxilla is recommended.

18. COMBINED ANTERIOR AND POSTERIOR
MAXILLARY OSTEOTOMY
Also called as
Horse shoe
osteotomy
Used for patient
with maxillary
alveolar
hyperplasia
with or without
anterior open
bite deformity
Transverse
hypoplasia
without vertical
component
Abandoned
procedure

19. SURGICALLY ASSISTED MAXILLARY
EXPANSION
 Brown-1938- midpalatal split
 Timms – major resistance to expansion is midpalatal suture.
 Kennedy –lateral maxillary osteotomy with midpalatal split
 Shetty-all bony buttress contribute resistance for expansion but
midpalatal suture followed by pterygomaxillary
articulations were the primary areas of resistance.

20. SURGICALLY ASSISTED MAXILLARY
EXPANSION
 INDICATIONS
Skeletal maxillomandibular transverse
discrepancy >5mm
Significant transverse maxillary deficiency
associated with wide mandible
Failed orthodontic expansion
To avoid segmental osteotomies
Significant nasal stenosis

21. SURGICALLY ASSISTED MAXILLARY
EXPANSION

22. SURGICALLY ASSISTED MAXILLARY
EXPANSION
 TECHNIQUE

23.  TECHNIQUE
SURGICALLY ASSISTED MAXILLARY
EXPANSION
Maxilla should remain stationary – 5 days then 0.5mm /day
0.5mm-1mm/day –Expansion > this causes gingival recession

24. LEFORT I OSTEOTOMY
 INDICATIONS
• Deficient
vertical
maxilla
• Convex
profile (class
II~ horizontal
excess)
• Vertical
maxillary
excess (
gummy
smile)
• Post trauma
• Cleft lip & palate
• Nasomaxillary
hypoplasia
• Severe mandibular
prognathism (class
III)
Anterior Superior
Inferior
Posterior

25. LEFORT I OSTEOTOMY

26. LEFORT I OSTEOTOMY

27. LEFORT I OSTEOTOMY
 DESIGN OF OSTEOTOMY
A. Low level osteotomy
B. Osteotomy approaching
Infraorbital rims
C. Osteotomy including Cheek
prominence
D. Low level horizontal
osteotomy

28. LEFORT I OSTEOTOMY
 SURGICAL TECHNIQUE:

29. LEFORT I OSTEOTOMY

30. LEFORT I OSTEOTOMY

31. LEFORT I OSTEOTOMY

32. LEFORT I OSTEOTOMY

33. LEFORT I OSTEOTOMY

34. LEFORT I OSTEOTOMY
To
Summarize.......

37. SURGICAL COMPLICATIONS OF SEGMENTAL LEFORT I
OSTEOTOMY
M.W.Ho, M.A.Boyle, J.C.Cooper, M.D.Dodd, D.Richardson
CONCLUSION:
The overall complication rate was 27%. There was no segmental loss of
bone or teeth.
Our results show that complications in this cohort were relatively low, and
that segmental maxillary surgery is safe as an adjunct in carefully selected
cases.
British Journal Of Oral & Maxillofacial Surgery, 23 Sep 2010

38. QUADRANGULAR LEFORT-I OSTEOTOMY
 INDICATIONS
1) Maxillary –
zygomatic
horizontal
deficiency
2) Class 111
skeletal
malocclusion
3) Maxillary
vertical excess or
deficiency
4) Maxillary
transverse
deficiency

39. QUADRANGULAR LEFORT-I OSTEOTOMY

41. QUADRANGULAR LEFORT-II OSTEOTOMY
INDICATIONS
1)Maxillary – zygomatic
horizontal deficiency
2)Class 111 skeletal
malocclusion
3)Maxillary vertical excess
or deficiency
4)Maxillary transverse
deficiency
CONTRAINDICATIONS
1)Vertical excess or
deficiency of more
tham 5mm
2)Patients with
retruded nasal
projection
3)Patients with
anterior open bite

42. QUADRANGULAR LEFORT-II OSTEOTOMY
 TECHNIQUE:

43. LEFORT II OSTEOTOMY
Nasomaxillary
hyoplasia
Involving
dentoalveolar
segment
Excluding
dentoalveolar
segment
Cleft palate
patients
INDICATIONS

44. LEFORT II OSTEOTOMY
 1)General anesthesia
 2)Intraoral and oblique
paranasal skin incisions
 3)Osteotomy in infraorbital rim
 4)Connected with intraoral
osteotomy cuts
 5)Nasal bridge osteotomy
 6)Mobilisation of maxilla
 7)Splint fixation
 8)Intermaxillary fixation
 9)Grafts placement
 10)Mini plate fixation
SURGICAL STEPS:

45. LEFORT III OSTEOTOMY
 INDICATIONS:
1)Total midface
hypoplasia
primarily in AP &
vertical dimension
2)Syndromic
synostosis
(Aperts,
Crouzons
syndrome)
3) Post
traumatic
deformity
4)Non
syndromic
midface
retrusion

46. LEFORT III OSTEOTOMY

48. ORTHOGNATHIC SURGERY IN CLEFT
PATIENTS
 Most patients with cleft express some amount of mid face
deficiency.
 Problems due to cleft:-
 Nasal breathing
 Speech, hearing and olfaction.
 Sometimes exorbitism and eyelid in adequacy.

49. IN CLEFT PATIENTS
 Maxillofacial growth in children
Retruded maxillae and mandible.
Steeper mandibular plane angle.
Maxillary protrusion in an operated
bilateral cleft lip and palate.
Transverse deficiency in operated
palate patients.
Generally decreased vertical and
horizontal growth of maxilla.

50. ORTHOGNATHIC IN CLEFTS
OSTEOTOMY CUTS
INCISIONS

51. ORTHOGNATHIC IN CLEFTS
LATERAL VIEW

52. ORTHOGNATHIC IN CLEFTS
DOWNFRACTURING THE MAXILLA
CLOSURE

53. ORTHOGNATHIC IN CLEFTS
BONE GRAFTING

54. SOFT TISSUE CHANGES
 Most important aspect at end of the surgery –achievement
of an aesthetically pleasing facial soft tissue envelope .
 With the refinement of surgical procedures and the advent
of rigid fixation techniques the surgeon can predict the final
outcome of osseous and soft tissue changes .

55. SOFT TISSUE CHANGES
 NASAL CHANGES
Affects lower aspect of
nasal dorsum
Widening of alar base
Shortening of columellar
height, Alar height and
Nasal tip projection.
Changes in Nasolabial
angle.

56. SOFT TISSUE CHANGES
Direction
Maxillary
Movement
Alar Bases Nasal Tip Nasolabial
Angle
Superior Increase Increase Decrease
Anterior Increase Increase Decrease
Inferior Inferior Decrease Increase
Posterior None Decrease Increase

57. SOFT TISSUE CHANGES
 LABIAL CHANGES
ANTERIOR SEGMENTAL
REPOSITIONING- SETBACK
ANTERIOR SEGMENTAL
REPOSITIONING- ADVANCEMENT
Increase in nasolabial angle Decrease in nasolabial angle
Lengthning of upper lip Slight shortening and thinning of
lip(2mm)
Decrease in interlabial gap Alar base widening
Uncurling and retraction of lower lip Advancement of upper lip,subnasale and
nose

58. SOFT TISSUE CHANGES
SUPERIOR REPOSITIONING INFERIOR REPOSITIONING
Elevation of nasal tip Loss of nasal tip support  polybeak
deformity
Widening of alar base (2-4mm) Downward repositioning of the columella
and alar base
Decrease in Nasolabial angle Increase in Nasolabial angle
No change in the angulation of the upper
lip.
Thinning of lip

59. COMPLICATIONS
COMPLICATIONS
Vascular
Neural
Infections
Relapses
Periodontal
defects
following
lefort 1
segmental
osteotomy
Joint
dysfunction

60. COMPLICATIONS
 VASCULAR COMPROMISE:
 Incidence is low
 To look for - Cyanosis and Ischaemia
 Venous congestion
TREATMENT:
•Removal of maxillomandibular fixation
•Removal of splints
•Angiographs to detect site of spasm or occlusion
Administration of Anticoagulants, Beta blockers, Vasodilators,
Hyperbaric oxygen therapy
After irreversible damage debridement of necrotic tissue is undertaken
followed by intraoral free graft

61. COMPLICATIONS
 HAEMORRHAGE:
 During intraop period-Internal maxillary artery,Posterior superior
alveolar artery, Greater palatine artery.
 Postop period- Nasopalatineartery,nasoseptal,sphenopalatine artery.
TREATMENT-
Nasal packing, decongested with a LA with a vasoconstrictor.
LA in the nose and around the greater palatine foramen.
Therapeutic transcatheter arterial embolization .

63. COMPLICATIONS
 NEURAL:-
 Injury to the nerve is more common in mandibular procedures
after BSSO than in cases of total down fracture of maxilla
 Study conducted by Kari Panula et al states that incidence of
infraorbital nerve injuries is about 6% on 12 months follow up
when tested objectively.
 During Le Fort osteotomy it is recognized that the nasopalatine
and posterior, middle, and anterior superior alveolar nerves are
completely severed as an intrinsic part of the surgical procedure.
 Despite ligation and division of the neurovascular bundle,
sensory recovery does occur and is most likely to represent
collateral axonal sprouting from adjacent nerves.

64. COMPLICATIONS
 INFECTIONS:-
 Overall, the incidence of infection is reported to be between
0% and 18% with either a perioperative or a combined
perioperative and postoperative antibiotic course.
 Rates of infection between 0% and 53% have been reported
without antibiotics.
Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242 231

65. COMPLICATIONS
 RELAPSE:-
 Relapse is usually three dimensional, with vertical, horizontal,
and sagittal components that may occur concurrently.
 On comparison mandibular procedures>maxillary procedures
 Relapse tends to be proportionately greater with greater
advancements.
 Bone grafting large advancements (>8 mm) may help to
reduce relapse.

66. COMPLICATIONS
 TEMPOROMANDIBULAR DISORDERS:-
 Researchers believe that malocclusion plays some role in TMD.
 Numerous studies support the notion that orthognathic
surgery decreases the overall prevalence of TMD signs and symptoms.
 With respect to orthognathic surgery patients with preexisting TMD,
subjective improvement ranges from 0% to 75%, with a mean of 18%
 Objective improvement ranges from 7% to 72%, with a mean of 48%.
 R.A. Bays, G.F. Bouloux / Oral Maxillofacial Surg Clin N Am 15 (2003) 229–242

67. COMPLICATIONS- RARE
 Permanent Blindness
 Nasolacrimal obstruction or injury
 Orbital compartment syndrome
 Avascular necrosis (most of which were segmental)
 False aneurysm of sphenopalatine artery
 False aneurysm of maxillary artery
 Carotid-cavernous sinus fistula
 Vomerosphenoidal dysarticulation
 Cranial nerve III palsy
 Keratitis

68. SEQUENCING
 MANDIBLE FIRST:-
Timothy Turvey journal of oral and maxillofacial surgery 2011 august 69(8):2217-2224
Downgrafting the maxilla
If uncertain about the interocclusal
registration accuracy
When intraoperative MMF wires are to
be used
When fixation of the maxilla may not
be rigid
When performing concomitant TMJ
surgery

69. CONCLUSION
 Esthetic appearance is critical and of utmost importance in our
society
 Dentofacial and craniofacial deformities not only have a significant
psychological effect on individuals but also on general health status
of same.
 Correction of these deformities cannot be done always by same
protocol and requires indepth knowledge of the subject and can
involve other specialities also.

70. REFERENCES
1. Oral & maxillofacial surgery-Fonseca vol 2
2. Oral & maxillofacial trauma-Rowe & Williams vol 2
3. Principles of Oral & maxillofacial surgery-Peterson vol 2
4. Killeys- 5th Edition
5. Maxillofacial trauma & facial reconstruction-Peter Ward Booth
vol 1
6. Essentials of Orthognathic surgery- Reyneke