HISTORY ,CLASSIFICATION,TYPES, MODIFICATIONS ,COMPLICATIONS AND RECENT ADVANCEMENT OF MAXILLARY OSTEOTOMY PROCEDURE IN ORTHOGNATHIC SURGERY

1. ORTHOGNATHIC SURGERY
(MAXILLARY OSTEOTOMIES PROCEDURES)
PRESENTED BY
DR PREETI SHARMA
(DEPT. OF OMFS)
1

2. CONTENTS
• INTRODUCTION
• HISTORY
• SURGICAL ANATOMY
• TYPES OF MAXILLARY OSTEOTOMY
• COMPLICATIONS
• REFERENCES
2

3. INTRODUCTION
• Osteotomy- the surgical cutting or dividing of bone, usually to correct a deformity
• Maxilla can be mobilized and repositioned and the healing continues as long as the
mobilizes maxilla is pedicled on broad soft tissue base (soft palate, lateral
pharyngeal wall, buccal mucosa).
• Indicated in correction of malocclusion ,dentofacial deformities , craniofacial
abnormalities etc.
• Le Fort I osteotomy is a commonly performed maxillary procedure for the
correction of dentofacial deformity.
3

4. HISTORY
• Von Langenbeck (1859) - For the removal of nasopharyngeal polyps.
• Cheever (1867) - For the treatment of complete nasal obstruction secondary to recurrent
epistaxis for which a right hemi maxillary down fracture was used.
• Wassmund (1927) - LeFort I osteotomy for the correction of the mid facial deformities
and used orthopedic force post surgically
• Axhausen (1934) - Described total mobilization of the maxilla with immediate
repositioning for an open bite case
• Schuchardt (1942) - First advocated the pterygomaxillary dysjunction.
• Moore and Ward (1949) - Horizontal transaction of the pterygoid plates for advancement
• Obwegeser (1965) - Complete mobilization of the maxilla so that repositioning could be
accomplished without tension.
4

5. SURGICAL ANATOMY
5

6. 6

7. VASCULAR SUPPLY
7

8. Midface
Osteotomies
Segmental
maxillary
osteotomy
Single tooth
Anterior segmental
Posterior segmental
Horseshoe
Total
maxillary
osteotomy
LEFORT I
SAME
Classic
Quadrangular
LEFORT II
Anterior LF II
Pyramidal LF II
Quadrangular LF II
LEFORT III
MIDFACE Zygomatic
8

9. SINGLE TOOTH OSTEOTOMY
Indication:
• Tooth mal position
• Dental ankylosis
• Closure of diastema
Advantage:
• Reduction in the treatment time.
• Lower incidence of relapse
Disadvantages:
• Injury to teeth
• Periodontal compromise
• Devitalization of teeth
9

10. Procedure:
*5mm and above the apices – adequate to maintain the vitality
Anterior& posterior Subapical osteotomies -3mm is adequate(sheideman-
joms.1985;43;408 ) *Yoshida-biologic responses of the pulp to single tooth osteotomy OOOO-1996;82 bell-revsclstion & bone healing after
AMO. Jos1969;27;249,1978
10

11. ANTERIOR SEGMENTAL OSTEOTOMY
Indications :
• Correction of bi maxillary protrusion.
• Marked protrusion of the maxillary teeth:
• Anterior open bite where there is no vertical maxillary excess
• To retract the anterior teeth when orthodontic treatment is not feaseable
• When orthodontic tooth movement is inadvisable.( tooth ankylosis , root resorption)
• To improve facial appearance in prognathic maxilla with incompetent lips
11

12. Wassmund 1927:
• Both the labial and palatal blood supply are
maintained.
Indicated :
• Closure of multiple interdental spaces and for
anteroposterior repositioning of the premaxilla.
• Maintain the best vascularity in comparison to all
other ASMO methods.
12

13. Wunderer 1963
• Maintenance of the labial blood supply.
• main advantage : Direct access for the palatal
osteotomy , especially if posterior segments of the
premaxilla must be removed
• Indicated:
-for setback of the anterior part of the maxilla
-Blood flow studies have demonstrated that the
transpalatal approach causes the greatest decrease in
blood supply to the anterior maxilla
13

14. Cupar (1954)
• Approach for down-fracture of the anterior
maxilla
• Commonly used technique
• Minor version of total maxillary osteotomy
• Indicated:
for superior repositioning of the anterior
maxilla in cases of vertical maxillary excess
14

15. Epker 1977
• Modified the Cupar technique for down-fracture of the anterior maxilla
• Used only labial flaps and vertical tunnels labial to the teeth to be extracted, which
were usually premolars on both sides
• repositioning of the anterior maxilla superiorly, posteriorly and inferiorly
Advantages :
• preservation of the palatal pedicle,
• ease of placement of internal fixation,
• provide access to the nasal septal structures
• a direct approach for removal of palatal bone.
15

16. 16
Vertical osteotomy
Horizontal osteotomy
Transpalatal osteotomy

17. 17
Midpalatal
sagittal incison
Tunneling
WASSMUND METHOD

18. 18
WUNDERER METHOD

19. (a) Down-fracture anterior segment of maxilla and maintaining palatal
mucosa. (b) Midline or paramidline osteotomy for horizontal movement
19
CUPER METHOD

20. 20

21. (a) Alar cinch placement to control alar base, (b) V-Y closure of mucosa to maintain upper lip length
21

22. POSTERIOR SEGMENTAL OSTEOTOMY
• Introduced by Schuchardt in 1954 as a two-staged procedure used in the surgical
correction of open-bite deformity
• Kufner (1971) - described a single buccal incision approach.
• Perko (1967) - Bell technique
22

23. • Indications
1. Post maxillary alveolar hyperplasia
2. Total maxillary hyperplasia (when combined with AMO)
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 dentition that can be closed by ant repositioning of the posterior
segment
5. Transverse excess or deficiency
6. Posterior open bite
7. Posterior cross bite
23

24. Schuchardt technique for posterior maxillary segmental
osteotomies.
(a) Limited buccal incision with combined horizontal and
anterior vertical osteotomies
(b) coronal sectional view indicating bone cuts
(c) limited palatal incision located medial to planned
lateral palatal osteotomy
(d) coronal view of subnasal palatal alveolar and lateral
sinus wall osteotomies
24

25. 25
Kufner technique for posterior maxillary segmental
osteotomies.
(a) Coronal sectional view of trans antral palatal
osteotomy via chisel following lateral sinus wall
osteotomy
(b) Coronal view of trans antral palatal osteotomy
trimming of bone segment

26. Perko–Bell technique for posterior maxillary osteotomies.
(a) Limited buccal incision with combined horizontal and vertical osteotomies
(b) limited palatal incision located medial to planned lateral palatal osteotomy
(c) coronal sectional view indicating bone cuts with transantral medial nasal wall osteotomy
26

27. 27
Pterygomaxillary
disjunction with a
curved osteotome
Down fracturing using
digital pressure Fixation

28. Combination Anterior & Posterior Maxillary Osteotomy
(Horseshoe osteotomy)
• A combined form of anterior and posterior subapical osteotomies
• Paul 1969 "total subapical maxillary osteotomy" were reported 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
28

29. 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
The method has more or less been
replaced by the traditional
Le Fort I osteotomy
29

30. LEFORT 1 OSTEOTOMY
Indications
• To correct maxillary prognathism
• Midface hypoplasia
• Severe mandibular prognathism:reduce amount of mandibular setback
• 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
• Apertognathia, lefort I osteotomy should be given consideration because of the
stability issues.
• Often needed along with mandibular osteotomy to correct dentofacial
asymmetries,asymmetric mandibular growth,condylar hyperplasia and hemifacial
microsomia
30

31. SURGICAL TECHNIQUE
• Step 1: Infiltration of the soft tissue with
a vasoconstrictor
• Step 2: Mucosal incision
• Step 3: Completing the soft tissue incision
through the periosteum
• Leave at least 5 mm of nonkeratinized epithelium
inferior to the incision
• Incision should be increased posteriorly to
approximately 10 mm at the buttress area.
• A V-shaped incision at the labial frenum helps
with alignment in later suturing
The incision is angled superiorly so more soft tissue is left
inferiorly for later ease of suturing and for sufficient blood
supply support to the downfractued maxilla
31

32. • Step 4: Subperiosteal dissection • Step 5: Placement of reference marks
• The subperiosteal dissection is carried
superiorly and posteriorly to identify the
piriform rim, infraorbital nerve, zygomatic
buttress, and posterior maxilla
• Vertical and horizontal reference marks are scored on
the bone and the distances between them measured
32

33. • EXTERNAL REFRENCE MARKER
33

34. • Step 6: Anterior buccal osteotomy • Step 7: Posterior buccal osteotomy
• A reciprocating saw is used to
perform the osteotomy.
• The osteotomy should be kept
parallel to the occlusal plane.
• The osteotomies can be kept parallel to the occlusal
plane by placing a vertical step at the buttress area.
• The maxilla can now be advanced parallel to the occlusal
plane without any vertical changes.
34

35. • Step 8: Connecting the anterior and
posterior osteotomies
• Step 9: Placement of holes for interosseous
wires
• Connect the two horizontal
osteotomies with a vertical osteotomy
at the buttress using a 701 bur.
• The holes should be placed in thick bone at the buttress
areas and positioned in such a way that the vector of the
positioning wire will support the repositioning of the
maxilla
35

36. • Step 10: Separation of the tuberosity from
the pterygoid plates
• Step 11: Completion of the posterior
osteotomy
• The contents of the pterygoid maxillary fissure and
soft palate are protected by placing the index
finger at the hamulus palatally to feel the
osteotome as it separates the tuberosity and the
pterygoid plates.
• The osteotome is directed medially and downward.
• The osteotomy is completed using a small osteotome
while the pterygoid osteotome is still in position,
protecting the soft tissue behind the maxilla.
36

37. • Step 12: Osteotomy of the lateral nasal wall • Step 13: Repeating the procedure on the
opposite side
• Step 14: Completing the nasal spine
subperiosteal dissection
• The lateral nasal wall is separated. Note that the
wall deviates posteriorly; therefore, care should be
taken not to damage the descending palatine
neurovascular bundle at the posterior end of the
wall.
• A small, wet sponge is placed on the completed side.
• The osteotomies should be placed at the same level and
angle on both sides according to the surgical treatment
plan
• Place a ramus retractor subperiosteally in the midline
over the anterior nasal spine
• (ANS). Dissect the rest of the periosteum from the ANS.
37

38. • Step 15: Completing the nasal mucosa
dissection
• Step 16: Osteotomy of the septal cartilage
and vomer
• Separate the septal cartilage from the ANS.
Complete the dissection of the nasal mucosa from
the nasal septum and floor.
• The nasal mucosa is dissected from the ANS, nasal
septum, and piriform rim.
• The nasal cartilage and vomer are separated from the
maxillary bone using a nasal septal osteotome.
• Angle the osteotome toward the nasal floor to prevent
tearing of the nasal mucosa.
38

39. • Step 17: Maxillary downfracture • Step 18: Redefining osteotomies when
maxillary downfracture fails
• The maxilla is downfractured with downward
pressure on the anterior maxilla.
• The maxilla should downfracture easily; if it does
not, all the osteotomies, especially at the junction
between the tuberosity and the pterygoid plates
should be revised.
• The maxilla should downfracture with ease. If it does
not, following are the most probable reasons for the
failure:
-The pterygoid plates and tuberosity are not sufficiently
separated.
-The lateral nasal wall osteotomy is incomplete
(too short).
-Occasionally, the bone of the maxilla is very thick,
making downfracture difficult. In such cases, tap the lateral
nasal wall osteotomes into position (bilaterally), and
carefully push down on the osteotomes to assist in the
downfracture.
39

40. • Step 19: Mobilization of the maxilla
• The right side of the maxilla is mobilized by pushing the maxilla anteriorly using a mobilizer (or pterygoid osteotome).
• (r) The left side of the maxilla is mobilized; use a finger as a fulcrum, and protect the soft tissue at all times.
40

41. • Step 20: Reduction of the palatal aspect of
the nasal septum
• Step 21: Contouring the piriform rim
• (y) The nasal septum and remaining part of the vomer is
trimmed from the nasal floor with a bone nibbler.
• (z) Adequate trimming of the vomer and even creation of a
trough in the nasal floor is essential to accommodate the
nasal septum after maxillary repositioning. This is
especially important when the maxilla will be superiorly
repositioned.
• (aa) The piriform rim should be contoured with a vulcanite
bur to accommodate the soft tissue of the base of the nose
after maxillary repositioning.
• (bb) A hole is drilled horizontally through the ANS. This hole
will be used later for the placement of a cinch suture and for
securing the nasal septum.
41

42. • Step 22: Reversing the hypotensive
anesthesia and checking for hemorrhage
• Step 23:Feeding the wire thru butress
• Before final repositioning and fixation of the maxilla, it
advised to reverse the hypotensive anesthesia.
• While the patient is normotensive, undetected arterial
hemorrhage can be discovered and addressed, which will
help prevent postoperative hemorrhage.
• 0.018-inch interosseous wires placed at the buttress area
bilaterally.
• When more rigidity is required (eg, maxillary expansion,
maxillary downgrafting, multipiece Le Fort I procedures,
and large movements [greater than 6 mm]), more plates are
recommended.
42

43. • Step 24: Maxillomandibular wire fixation • Step 25: Maxillary repositioning
• The first maxillomandibular wire around the four central
incisors to achieve the planned interincisal relationship.
• Place the wires around the orthodontic brackets
• With the help of it the teeth could easily be “pulled into
occlusion” or into the acrylic splint
• Once the wires are removed, the teeth will return to their
original position. • With maxillomandibular fixation in position,
the maxillomandibular complex is rotated to
achieve bone contact.
• The vector of force on the condyle should be
superior and slightly anterior.There should be
no bony interferences during the rotation.
43

44. • Step 26: Turbinectomy • Step 27: Suturing the nasal mucosa
• The hypertrophied turbinate is grasped with
a tissue clamp and then removed using a
diathermy knife.
• Any tears in the nasal mucosa is identified, and repair them
with a 4-0 chromic suture.
44

45. • Step 28: Checking the position of the
nasal septum
• Step 29: Tightening the buttress wires
• The maxillomandibular complex closed to achieve the
predetermined maxillary position is rotated.
• The condyles are seated in the glenoid fossa is
ensured, and the position of the nasal septum is also
checked
• The septum should lie freely, without any interference
in the trough created in the nasal floor.
• The nasal septum may be secured in position by
placing a suture through it and through the
horizontal hole in the base of the nasal spine after
maxillary fixation.
• Copious lavage of the maxillary sinuses and nasal floor with
saline solution should be carried out before tightening the
buttress wires because small bone fragments remaining in the
sinus or nasal cavities will lead to postoperative infection.
• The maxillomandibular complex then rotated superiorly to
achieve bone apposition, and the interosseous buttress
holding wires is tighten
• Overtightening the wires is avoided in an attempt to achieve
better bone apposition because the tension it would place on
the bone would result in displacement and occlusal
discrepancy once maxillomandibular fixation is removed.
45

46. • Step 30: Checking maxillary position
using a caliper
• Step 31: Replacing the maxillomandibular
fixation
• If there is any doubt about the condylar position at
this stage, the maxillomandibular fixation should be
removed and the occlusion checked by referring to
intraoral bony reference marks or to an extraoral
reference point (eg, a Kirschner wire in the frontal
bone).
• If the maxillary position and occlusion are satisfactory,
replace the maxillomandibular fixation.
46

47. • Step 32: Placement of bone plates
maxillomandibular fixation.
• Semirigid fixation, which consists of bilateral
titanium (1.5-mm) bone plates or resorbable (2.0-
mm) plates placed anteriorly in the thick bone at the
piriform areas and two interosseous (0.018-inch)
wires placed at the zygomatic buttresses.
• The plates should be adapted to fit passively.
• Two screws should be placed on either side of the
osteotomy, and care should be taken not to place
screws into the roots of teeth, too close to the edge of
the bone, or in thin bone.
• If thin bone must be used, self-drilling screws are
recommended.
47
Non – rigid
Trans-osseous wiring
IMF – 4-6 months
Rigid/semi rigid
Metal Plates
Resorbable plates
Mesh
IMF- 4-6 weeks
• For superior movement of the maxilla : two plates at the piriform
rim with six screws per plate can be sufficient.
• The most widely used are 2.0- and 1.5-mm screws with L plates or
arched plates.
• Usually for all osteotomies where bone contact buttressing is
incomplete, additional plates are subsequently placed at the
zygomatic buttress .
• For downward movement of the maxilla interpositional grafts can
be wedged beneath the miniplates

48. 48
Step 33: Removing the maxillomandibular fixation and checking the
occlusion
• Before the occlusion is checked, the mandible should be gently
opened and closed as well as translated forward and from side to
side to ensure that the articulating disc was not displaced while
teeth were in maxillomandibular fixation.
• Wait a few minutes after removing the maxillomandibular
fixation before checking the occlusion.
• Then, with slight pressure on the chin, close the mandible until
the teeth occlude. If the planned occlusion has not been
achieved, remove the rigid fixation and identify and correct the
reason for failure.

49. • Step 34: Placement of nasal septum and cinch sutures
• Secure the septum in the trough created in the nasal floor by a suture through the septum and the
hole in the base of the ANS.
(ii)The lateral alar soft tissue is grasped with a toothed forceps.
(jj) The cinch suture is placed in a figure-eight fashion through the hole in the ANS.
49

50. 50
A, Classic alar cinch suture: Rauso et al. (2010)-
involved anchoring the fibroareolar tissues directly under both alar and passing suture through the nasal spine.
B, Classic alar cinch suture :Ritto et al. (2011)-
involved anchoring the fibroareolar tissue intraorally under both alae separately.
C, Classic alar cinch suture :Nirvikalpa et al. (2013)-
involved using hypodermic needles under both alae to accurately identify the nasofacial skin fold; a thick suture bite was
taken at this point.
D, Modified alar cinch suture:Rauso (2010)-
involved a reinsertion method by using hypodermic needles under both alae and passing the suture through the nasal spine.
E, Modified alar cinch suture :Ritto et al. (2011)-
involved a reinsertion method by using curved needles to anchor the fibroareolar tissue under both alae separately.
F, Modified alar cinch suture Nirvikalpa et al. (2013)-
involved using hypodermic needles under both alae to accurately identify the nasofacial skin fold; a thick suture bite was
taken at this point, then the suture was passed through the nasal septum.
Three studies with 146 participants undergoing LeFort I maxillary osteotomy
were included in this review. The results showed that, compared with the classic
method, both modified transseptal alar base suture and modified reinsertion
sutures significantly decreased postoperative alar and alar base widening
Vol. 117 No. 1 January 2014
Modified versus classic alar base sutures after LeFort I osteotomy: a systematic review
Xianwen Liu, DDS, " Songsong Zhu, DDS, PhD, and Jing Hu, DDS, PhD° ab West China Hospital of
Stomatology. Sichuan University. Chengdu, China: Harvard School of Dental Medicne, Boston, MA, USA

51. 51
Step 35: Submucosal suturing
• The soft tissue incision is closed in layers—first the submucosal
tissue and then the mucosa.
• Starting posteriorly, and ending at the piriform rim on both sides
by pulling the superior tissues slightly forward.

52. • Step 36: Mucosal suturing
• Step 37: Placement of elastics or
maxillomandibular fixation
• Step 38: Applying a pressure dressing
• a V-Y closure is performed and reapproximated the
mucosal midline using 4-0 chromic sutures.
• Two interrupted sutures is placed on both sides of the
midline to reapproximate it
• The mucosal suturing is done using a continuous suture,
starting posteriorly and pulling the superior tissue
slightly forward.
• When lip lengthening is indicated, more horizontal
sutures (or even bilateral V-Y suturing) may be used.
• The period of maxillomandibular fixation may vary from a
few days to 3 weeks.
• Alternatively, for most patients, two to four inter occlusally
placed elastics are sufficient to guide the teeth into the new
occlusion.
• The direction of the elastics should support the repositioning.
• Long elastics should be avoided.
• A pressure dressing is applied to help control swelling
and/or prevent hematoma formation.
52

53. Quadrilateral (Quadrangular) Osteotomy
• High-level osteotomy is a variant of the Le fort I osteotomy
• extends up to the lower part of the zygoma, to a point just below the infraorbital nerve
bilaterally
Indications:
• midface retrusion
• excessive scleral exposure
53

54. Advantage:
• improves the appearance of midfacial retrusion and flattening
• improves zygomatic prominence and support for the lower eyelid.
• This osteotomy has minimal surgical morbidity and has acceptable outcomes.
• This may therefore be considered,especially in Asian patients, as a viable
treatment alternative for midfacial advancement without augmentation of the
malar region
Lee H-J, Park H-S, Kyung H-M, Kwon T-G. Soft tissue changes and skeletal stability after modified quadrangular Le Fort I osteotomy.
Int J Oral Maxillofac Surg. 2015;44:356–61.
54

55. • If the cuts are made from high to low, a significant inferior movement of the maxilla
can be achieved which reduces the necessity for an interpositional bone graft and
alloplastic onlay grafts for the zygomatic regions.
• It is more stable than conventional inferior positioning of the maxilla as it produces
less rotation of the nasal tip than the conventional Le Fort I osteotomy.
55

56. • The surgical technique is the same as for the conventional Le Fort I osteotomy,
• but a significant sharp dissection of the masseter muscle from the zygoma is
required to expose the prominence of the zygomatic bone.
• The cuts are made just below the infraorbital nerves.
• The bony cuts directed downward to the normal pterygomaxillary disjunction
level.
• The other steps :same as LeFort I
• Fixation is with miniplates.
(care must be taken to ensure the plates are not palpable
in the infraorbital regions.)
56

57. 57
Only minor skeletal relapse (mean: 0.4 mm) was
observed in the follow-up period (mean 14.2 months).
Conclusion: The procedure should be considered
whenever vertical maxilla relapse is of concern after
anterocaudal displacement

58. F
Osteotomy lines for variations of the Le Fort I osteotomy.
(A) Conventional Le Fort I osteotomy (Axhausen 1934).
(B) Modified quadrangular Le Fort I osteotomy
(C) Quadrangular Le Fort I osteotomy (Keller and Sather, 1990).
(D) Modified Le Fort I (maxillary–zygomatic) osteotomy (Abubaker and Sotereanos, 1991)
. (E) Extended Le Fort I osteotomy (Nørholt et al., 1996).
MODIFICATIONS
58

59. Laster ‘shark-fin’ osteotome was placed, with
the fin within the cut, on the lateral wall of the
maxillary sinus and slightly inclined down
toward the occlusal plane
The Laster ‘shark-fin’ osteotome with the double perpendicular
cutting-edge.
59
Year 2002
complete or almost complete separation was obtained, whereas the use of
the Obwegeser osteotome resulted in five sites with fractures of the maxillary
tuberosity and three with high-level fractures of the pterygoid plates

60. The osteotome is driven from the nasal crest of the maxilla
toward the pterygomaxillary junction. A narrow periosteal
elevator (left) is used to protect the nasal mucosa
Immediate downfracture of the maxilla is achieved
by inwardly rotating the osteotome (arrow)
Compared with classic pterygomaxillary dysjunction, the twist technique uses a frontal
approach and a straight osteotome. This technical modification requires a substantially
smaller incision, achieves an immediate effective separation of the maxilla, and enables
adequate visualization
J Oral Maxillofac Surg 71:389-392, 2013
60

61. 61

62. 62

63. SURGICAL ASSISTED MAXILLARY EXPANSION
(SAME)
• Brown first described SAME in 1938 - mid palatal split
• A LeFort I type of osteotomy with a segmental split of the maxilla and the placement of
a triangular unicortical iliac graft for correction of maxillary constriction was presented
by Steinhauser in 1972.
63

64. Indications:
• Increasing the maxillary arch perimeter so as to correct unilateral or bilateral posterior
cross bite, with or without additional surgical procedures for other discrepancies.
• Increasing the maxillary transverse width, especially when the transverse discrepancy
is greater than 5 mm.
• Alleviating dental crowding when bicuspid extractions are not indicated.
• Reducing excessively prominent and visible buccal corridors when smiling.
• When orthodontic maxillary expansion has failed.
64

65. Technique:
• First the mandibular dentition should be decompensated
• Expansion appliance should be placed preoperatively
65
HASS HYRAX

66. Steps:
66
Step 1: Incision Step 2: Buccal Osteotomy Step 3: Palatal incision
A midpalatal incision (red line)
with mucoperiosteal dissection
(shaded areas)
buccal osteotomy is made from
the pterygomaxillary junction
to the piriform rim anteriorly,
using a reciprocating saw

67. 67
Step 4: Palatal Osteotomy Step 5: Midline Osteotomy

68. 68
Postoperative schedule :
• After 5 days appliance is activated for first time.
•1 week later the space that is being created between two front teeth is checked
and the bite also is checked.
•After another week the separation of teeth and the bite are checked one more time
and activation is stopped.
•Refered to the orthodontist for a check.
•The appliance remains in place for 3 months without further activation.
•Orthodontic treatment is then resumed

69. Modified SAME
• Unilateral or asymmetric deformities
• Osteotomy done on one side
• On Non operated site buccal bone bending and dental tipping
• Relapse occure non operated site
• Mid palatal healing:6 months
69

70. Complications:
a)Those due to inadequate surgery:
• pain
• dental tipping
• periodontal breakdown
• post orthodontic relapse
b)Those due to expansion
• lack of appliance expansion
• deformation of the appliance due to processing errors
• stripping or loosening of mid palatal screw
70

71. Segmented Le Fort I osteotomy
• Required when open bite or a transversal expansion is required in the maxilla, a
Le Fort I osteotomy approach can be combined with a multiple‐piece osteotomy to
correct an unfavourable curve of Spee or a transverse discrepancy
• maxilla can be sectioned into 2, 3, 4, 5, or 6 segments depending on the
indications
Segmentation of maxilla into 4 pieces. Segmentation of maxilla into 6 pieces
71

72. Hierarchy of predictability and stability for orthognathic surgical procedures.
STABILITY OF LEFORT 1
Stability and predictability of orthognathic surgery
Am J Orthod Dentofacial Orthop 2004;126:273-7 72

73. Soft tissue changes
• Initially, swelling and bone irregularities contribute to the soft tissue changes
observed: Approx. 1 year to dissipate.
Soft tissue changes include:
• forward movement of the base of the columella
• nasal tip elevation,
• flattening and shortening of the upper lip,
• an increased nasolabial angle.
• Alar cartilage width increases
• the nares become more exposed.
( All soft tissue changes stabilize over time, except the increase in alar cartilage width, which remains
close to immediate postoperative values)
73

74. Factors responsible for soft tissue changes:
• preoperative soft tissue thickness
• time lapsed since surgery
• postoperative wound healing
• surgical techniques
74

75. LEFORT II osteotomy
• First presented by Henderson and Jackson in 1973.
Indication
• Relatively rare
• Apert Syndrome(most common)
• Address nose and maxilla
• need for the correction of nasomaxillary hypoplasia
75

76. Variations:
• Anterior Le fort II (Converse in 1971)
• Pyramidal Le fort II(Henderson and Jackson in 1973)
• Quadrangular Le fort II (Kufner in 1971)
76

77. INCISON:
• Nasal root and medial orbital : coronal incision or paranasal incision
• infraorbital rim and orbital floor: Conjunctival or sub ciliary incision
• canine fossa and posterior maxilla: routine buccal vestibular incision
77

78. OSTEOTOMIES:
78
Horizontal cut
Vertical cut
Infraorbital foramen

79. • Repositioning of maxilla Fixation Closure
79
bone grafts: preferably with fragments of autogenous, cancellous iliac bone.

80. Anterior "Le Fort II osteotomy”
the osteotomy must be completed by cutting across the palate in the region of
the first bicuspid
80

81. Rare
Indication:
-with nasomaxillary hypoplasia complicating other facial disharmonies
Drawbacks:
-strong tendency to relapse
-retruded infraorbital rim can only be corrected in its medial portion
81
Pyramidal Le Fort II osteotomy

82. Quadrangular Le Fort II osteotomy
• Defines the technique as "major maxillary osteotomy", which is a combination of
the Le Fort I and Le Fort II classifications.
• The main difference from the other Le Fort II type osteotomies is that there is no
involvement of the nasal skeleton.
• On the other hand the total infraorbital margin can be advanced by this approach.
82

83. • Medially the bone cut reaches the
lacrimal fossa without changing the
position of the lacrimal system.
• Laterally the osteotomy goes across
the zygomatic bone and continues from
there to the pterygoid fossa and the
pterygomaxillary junction.
• With the separation from the nasal
septum and the lateral nasal walls the
mobilization of the mid facial segment
is completed
83

84. • Advantage:
-Lacrimal system is not within the operating field
• Precaution:
-damage the infraorbital nerve (recommend the use of small sharp chisels for the
dissection of the orbital floor)
-defects in the floor : filled with cancellous bone pieces
• Disadvantage:
-Relapse(MINOR DISADV. –overcorrection to be done)
-Visible scar(to prevent –trans conjunctival incison - access limited./recommend a small
incision in the lateral commissure of the eyelids (Lindorfand Steinhauser (1977).
84

85. LEFORT III Osteotomy
• Sir Harold Gillies and colleagues : first time in 1951
• 1957, Longacre used autogenous rib grafts for improvement of total mid-face deficiency
• 1967, Paul Tessier reported that mobilization and expansion of the entire midface by
means of a sub-cranial le fort lll osteotomy was possible
85

86. Indication:
• Underdevelopment of entire mid-face
• Flat/sunken appearance of mid-face
• Short nasal structure
• Deficient nasal bridge
• Exaggerated flatness of nasofrontal region
• Reduced size of orbit
• Exophthalmos
• Retro position of zygoma
86

87. • Technique:
Incision:
Bicoronal incision
Inferior eye lid incision
Buccal vestibular incision
87

88. • Osteotomy
88

89. MIDFACE Osteotomy
ZYGOMATIC/MALAR OSTEOTOMY
Schematic representation of the malar osteotomy
89

90. 90
• Surgical technique

91. COMPLICATIONS IN MAXILLARY OSTEOTOMIES
• Preoperative
• Intraoperative
• Postoperative
Dimitroulis 1998 J Adult Orthod Orthognath Surg
91

92. PREOPERATIVE
• Lack of pre-treatment objectives:
-Failure to recognize underlying skeletal abnormality
-Unexpected adverse growth
-Lack of patient co-operation
• Orthodontics:
-Insufficient decompensation
-Inadequate transverse coordination
-Uncorrected tooth size problems
-Inadequate preoperative root divergence in segmental surgery
-Improper Orthodontic appliances
92

93. • Preoperative planning error
-In traditional treatment planning, the workup
involves reproduction of the occlusal
discrepancy on a semi-adjustable articulator
through facebow transfer.
-On this relation, desired mock surgical
planning is done and splints are prepared
-Errors and inaccuracies in this model surgery
can contribute to compounding errors that are
ultimately transferred to the operating room
and patient
-use of virtual surgical planning eliminates
many of the uncertainties that go into preparing
a case
Virtual Surgical Planning in Orthognathic Surgery Farrell, Brian
B. et al. Oral and Maxillofacial Surgery Clinics, Volume 26,
Issue 4, 459 - 473
93

94. INTRA-OPERATIVE
1.VASCULAR
• Serious intra operative bleeds are rare in orthognathic surgeries
• Few reports from secondary haemorrhage has been reported
• Intraoperative complications may occur secondary to maxillary or mandibular
osteotomies
• Kramer and colleagues found extensive bleeding in 1.1% of a prospective study of
1000 patients
• Injury to the descending palatine artery during LeFort I osteotomy can be
minimized by limiting the osteotomy to 30 mm posterior to the piriform rim in
females and to 35 mm in males
Kramer FJ, Baethage C, Swennen G, et al. Intra- and perioperative complications of the LeFort I osteotomy: A prospective evaluation of 1000 patients. J Craniofacial Surg
2004;15:971
Li, K.K., J.G. Meara, and A. Alexander, Jr., Location of the descending palatine artery in relation to the Le Fort I osteotomy. Journal of Oral and Maxillofacial Surgery,
1996.54(7): p. 822–825; discussion 826–827.
94

95. • Turvey and Fonseca reported that the main trunk of the maxillary artery was most
vulnerable to the damage within the pterygopalatine fossa in the lateral position
and they recommended angling the posterior lateral maxillary osteotomy
downward to avoid damaging the artery
• Osteotome used during pterygomaxillary dysjunction: 10-15mm(mean height of
pterygomaxillary suture: 14.6mm)
Turvey, T., and R. Fonseca, The anatomy of the internal maxillary artery in the pterygopalatine fossa: its relationship to maxillary surgery. Journal of Oral Surgery
(American Dental Association: 1965), 1980. 38(2): p. 92.
95

96. • Greater palatine artery :
-if reciprocating saw go deep within the posteromedial aspect of maxillary sinus
-osteotome beyond 34mm to piriform rim along the lateral nasal wall
-mobilization of maxilla without removing bony specules
• Pterygoid venous plexus:
-Maxillary venous bleeding most commonly involves the pterygoid venous plexus
96

97. Management of heamorrhage
• Packing is suggested as the first attempt to tamponade
the hemorrhage.
• In delayed bleeding after LeFort I osteotomy, the
surgeon should reopen surgical site and move the
maxilla downward to find the bleeding source.
• direct visualization of the bleeding source and
cauterization of injured vessels stops the hemorrhage.
• ligation of the external carotid artery and angiographic
embolization.
Felice O'Rayan, A.S., Complications with Orthognathic Surgery, in Oral and maxillofacial surgery, M. Fonseca, Turvey, Editor. 2009, Saunders Elsevier. p. 419–489
97

98. 2 NEURAL
• The infraorbital nerve may be compressed, retracted or transected inadvertently during
subperiosteal dissection.
• resulted from incorrect separation during disimpaction of maxilla
• 2.2% of individuals reported long term deficit to the upper lip and 9% to the teeth, palate,
and gingiva
• Usually temporary and recovery 2-8 weeks
Robl et al . Complications in Orthognathic Surgery : Oral Maxillofacial Surg Clin N Am 26 (2014) 599–609
98

99. • TRIGEMINOCARDIAC REFLEX
Surgery performed near the cranial nerves, especially the trigeminal nerve and its
branches – greater palatine and posterior superior alveolar nerve may induce
bradycardia by stimulation of the vagus nerve and finally activation of the
parasympathetic system resulting in various types of dysrhythmia.
• bradycardia < 60b/m, hypotension with a drop in the
Management –
• manipulation of the maxilla should be stopped immediately
• Administration of anticholinergic medications such as atropine or glycopyrolate
99

100. 3.UNFAVOURABLE FRACTURE
• MANDIBLE>MAXILLA
• In maxilla unfavorable fractures may consist of pterygoid plate, sphenoid bone,
and middle cranial fossa fractures.
• Lanigan and Guest demonstrated pterygomaxillary dysjunction could cause
disruption of the pterygopalatine fossa which could extend to the skull base.
Lanigan, D.T., and P. Guest, Alternative approaches to pterygomaxillary separation. International Journal of Oral Maxillofacial Surgery, 1993. 22(3): p. 131–138.
Undesirable split
1. fragmentation
2. comminution
3. higher fracture at the pterigoid level
Renekye et al. reported the incidence of pterygoid plate fracture was 58% following
LeFort I osteotomy using postoperative CT scans
100

101. 4 OROANTRAL COMMUNICATION
• Palatal Bone is thickest in the midline where tissue is the thinnest.
• Osteotomies in the midline are more likely to result in palatal tears and these may be
less likely to heal than when a tear occurs laterally, in thicker tissues
Management
• <3 mm generally close spontaneous
• >3 mm consider obturation
• if >4-6 mm soft tissue flap
Perciaccante V, Bays R. Maxillary orthognathic surgery.In: Miloro M, editor. Peterson’s principles of oral and maxillofacial surgery. 2nd
edition. London: BC Decker; 2004. p. 1179–204
101

102. Neurologic complications
• Brainstem infarct after Le Fort I osteotomy
• CSF leak
• AV fistula
-The maxillary artery is at risk in midfacial advancement procedures
because of its close proximity to the pterygomaxillary junction in the
pterygopalatine fossa.
-Transarterial embolisation is an effective treatment of the fistula when
a surgical ligature cannot be done
British Journal of Oral and Maxillofacial Surgery 55 (2017) 641–643
Int. J. Oral Maxillofac. Surg. 2010; 39: 292–307
Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 251e254
POST OPERATIVE COMPLICATION
102

103. Nasal Abnormalities
1.Septal deviation :compression or displacement from inadequate bone
removal of the nasal crest of the maxilla or inadequate trimming of the
cartilagenous septum
2. Alar base widening: An alar base cinch suture is placed at the end of the
procedure to control width, because soft tissue reflection leads to widening of
the nose.
3. Tip over-rotation :Reduction of ANS prevents excessive rotation of the nasal
tip
4. Dorsal deformities :A twisting dorsum and tip deviation may be related to
inadequate septum reduction
Felice O'Rayan, A.S., Complications with Orthognathic Surgery, in Oral and maxillofacial surgery, M. Fonseca, Turvey, Editor.
2009, Saunders Elsevier. p. 419–489
103

104. Aesthetic complications
• common problem in superior repositioning is the bunching of the
buccal tissues leading to “chubby cheeks”
• 6 months time its settle down.
104

105. Loss of vascularity : aseptic necrosis
• Anterior maxillary osteotomy
• Transversal maxillary segmentations
Cause:
-Transection/kinking of vascular pedicle
-Major anatomical irregularities
-Poor flap design, Tearing of flaps
• Consequences :
-Loss of entire maxilla or segment,
-Flattening of papilla,
-Non vital teeth
105
• Prevention
-Fewer Segmentation: avoid small
segments
-Avoid damage to pedicle

106. Nonunion/delayed union
• Relatively high prior to the rigid fixation.
• With rigid fixation most common cause is traumatic occlusion.
• Traumatic occlusion causes unbalanced force on the maxilla, and if the bony healing has
not progressed to the strength of resisting this forces , maxillary mobility occurs
Management
In cases of mobile maxilla
• soft diet
• discontinuation or decreased strength of elastic traction,
• modified splint to balance occlusion,
• local and systemic management of infection
• elimination of parafunctional habits and
• close observation.
106

107. Surgical management in a malunion or nonunion of the maxilla involves:
• Recreation of the osteotomy with aggressive mobilization
• Removal of all fibrous tissue
• Passive repositioning of segments
• Rigid fixation to resist segment displacement (consider auxiliary fixation, transpalatal
support)
• Grafting for continuity
107

108. Malocclusion
•Immediate anterior open bite
1. Inadequate removal of posterior interferences with displacement of the condyles
from the fossa during fixation
•Late open bite development
1. Collapse of transverse expansion
a. Lack of intraoperative methods to maintain expansion (grafting, splint placement)
b. Lack of postoperative efforts by the orthodontist to maintain expansion (trans
palatal arch)
2. Orthodontic relapse
108

109. • Relapse
• Depends on :
- Degree of surgical advancement
- Degree of inferior repositioning of anterior maxilla
- Use of bone grafts in large advancements
• Other Causes :
- Increased soft tissue stretching : results in drift of the screws during bone healing
- Reduced area of bone contact at the lateral aspects of the maxilla - compromised
union
• Prevention:
- Advance the maxilla at least 2mm more than the ideal overjet to compensate for
relapse
-Provision of a period of MMF (3—4 weeks) in addition to rigid fixation in large
advancements Van Sickels BJOMS 1996;34:279—85.
109

110. Ophthalmic complications
• Loss of function of the lacrimal gland - Damage to greater petrosal or vidian
nerves interrupting parasympathetic supply to lacrimal gland
• Oculomotor and abducens palsy – Ptosis & ophthalmoplegia – Superior orbital
fissure fracture
• Blindness -Blindness after orthognathic surgery is usually not from a direct
injury to the optic nerve itself, but more commonly is the result of an ischaemic
injury to the blood supply to the optic nerve, either directly from a fracture
extending through the orbit to the optic canal or foramen, or indirectly from
swelling and edema around the nerve in the optic canal disrupting its blood
supply.
• Can occur during pterygomaxillary dysjunction or maxillary downfracture
•J. Oral Maxillofac. Surg. 2018; 47: 79–82
110

111. Loss of function of lacrimal gland
111

112. REFERENCES
112

113. 113