Maxillary osteotomies are commonly performed to correct dentofacial deformities. The Le Fort I osteotomy involves making cuts in the maxilla to mobilize it for repositioning. It has a high success rate due to the broad soft tissue attachments maintaining the blood supply to the mobilized maxilla. Precise osteotomy cuts, identification of anatomical structures, and accurate repositioning and stabilization are required. Modifications include anterior and posterior subapical osteotomies and quadrangulated osteotomies. Rigid fixation provides stability but requires precise adaptation, while non-rigid fixation offers postoperative flexibility.

1. Maxillary osteotomies
Presented by-
Dr. Maroti Wadewale
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY, GDCH, MUMBAI

2. CONTENTS :-
Introduction
History
Applied Anatomy
Biological basis
Le fort I
Modifications
Anterior sub-apical osteotomy
Posterior sub-apical osteotomy
Le fort ll
Le fort lll
Conclusion
References

3. INTRODUCTION
o Osteotomy- the surgical cutting or dividing of bone,
usually to correct a deformity
o Dentofacial deformities affect 20% of the population.
o 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).
o Le Fort I osteotomy is a commonly performed
maxillary procedure for the correction of dentofacial
deformity.

5. Hullihen SP. Case of elongation of the under jaw and distortion of the face and neck, caused by a burn, successfully treated. The American journal of dental science. 1849 Jan;9(2):157.
HISTORY

6. Von Langenback B: Beitrage zur Osteoplastik- Die Osteoplastiche Resektion des Oberkiefers, Dtsch Klin Berl 48:471, 1859.
Cheever DW: Naso-pharyngeal polyps attached to the basilar process of occipital and body of sphenoid bone successfully removed by section, displacement, and subse- quent replacement and
reunion of the supe- rior maxillary bone, Boston Med Surg J 8:161, 1867.
Wassamund M: Fracturen and luxiationen des Gesichsschadells, Berlin, 1927
Von Lagenbeck 1859 – procedure for nasopharyngeal polyps. He
did not realize it, but he performed 1st orthognathic surgery
Cheever 1867 performed a bilateral hemimaxillary down-fracture
known as the “double operation,” which resembled a Le Fort I
osteotomy, to remove nasopharyngeal pathology.
Wassmund 1927 reported his initial attempt to perform maxillary
osteotomy for correction of the open-bite deformity.
Obwegeser 1965 started to perform maxillary surgery and
described a large series of LeFort I osteotomies in 1969.

7. SURGICAL ANATOMY
• Osseous structures
• Vascular structures

8. infraorbital foramen is located between 8 and
20 mm from the nasal floor
During osteotomy of the lateral nasal wall, care
is taken to extend the osteotomy no farther
than 25 to 30 mm posteriorly from the
piriform rim. The mean length of the medial
sinus wall from the piriform rim to the
descending palatine canal is approximately 34
mm.

9. Nasolacrimal duct:-
 Located within the bony wall between maxillary sinus
& nasal cavity
 Terminates below the inferior turbinate in the
inferior meatus
 meatus of the nasolacrimal duct is unlikely to be
injured if the osteotomy is made just beneath the
infraorbital foramen and into the piriform rim at the
level of the inferior turbinate.
 Location:
10-14mm behind piriform rim
10-21 mm above nasal floor
Bell WH: Modern practice in orthognathic and reconstructive surgery , Philadelphia, 1992, WB Saunders.

11. VASCULAR ANATOMY
Blood supply of the maxilla. (A) Nasopalatine artery, (B)
Descending palatine artery, (C) Greater palatine artery,
(D) Lesser palatine artery, (E) Maxillary artery, (F)
Ascending pharyngeal artery, (G) Ascending palatine
artery, (H) Facial artery, (I) External carotid artery, (J) Le
Fort I downfracture.
Teemul TA, Perfettini J, Morris DO, Russell JL. Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery. Journal of surgical case reports. 2017 Jan

12. The internal maxillary artery enters the pterygopalatine fossa approximately 16 mm above the nasal floor.
A large descending palatine artery, which is the major vessel encountered most commonly during maxillary osteotomies,
descends through the hard palate as greater and lesser palatine arteries. Distance of descending palatine artery from tuberosity:
10mm
The average distance from the most inferior point of the pterygomaxillary junction to the posterior superior alveolar artery is
15 mm, to the infraorbital artery is 32 mm, and to the descending palatine artery is 25 mm.
Bell WH: Modern practice in orthognathic and reconstructive surgery , Philadelphia, 1992, WB Saunders.

13. BIOLOGICAL BASIS FOR ORTHOGNATHIC SURGERY
Within three weeks the circulation between all of the
sectioned bone fragments had been reconstituted.
The pulp canals of several teeth adjacent to the ver-
tical interdental bone cuts were not vascu- larized
because their apical blood supply was severed.
The dental alveolar segments were freely mov- able
one week after surgery and slightly movable after
three weeks.

14. When the descending palatine artery are
severed during maxillary osteotomy the blood
supply of maxilla is preserved via Ascending
Pharyngeal, Ascending Palatine & Soft Palate
Vessels
Preservation of the integrity of the incisive
canal or greater palatine arteries was not
essential to maintain circulation to the anterior
or posterior maxillary dental alveolar segments
Twenty-four weeks after maxillary osteotomies,
the periosteal and endosteal circulatory beds
had been virtually reconstituted to their
normal vascular architecture.

16. LE FORT 1
OSTEOTOMY

17. INDICATIONS OF LE FORT I OSTEOTOMY
Vertical maxillary excess
Vertical maxillary deficiency
A-P maxillary deficiency(maxillary hypoplasia)
Post trauma patient

19. STEPS IN LE FORT 1 OSTEOTOMY
o Preoperative preparation
o Mucosal incision & subperiosteal dissection
o Placement of reference marks
o Anterior buccal osteotomy
o Posterior buccal osteotomy
o Separation of nasal septum from septal crest of maxilla
o Pterygomaxillary separation
o Down fracture of maxilla
o Mobilization of maxilla
o Reduction of the palatal aspect of nasal septum
o Turbinectomy
o Stabilization of the repositioned maxilla
o Closure

20. PRE –OPERATIVE
Patient position
 Head elevated at 10-15 degree/reverse
trendelenberg position.
Modified hypotensive anaesthesia MAP
by increasing the amount
of inhaled anesthetics such as
sevoflurane, isoflurane, and
desflurane.
(systolic BP 100)
Kademani D, Tiwana P. Atlas of oral and maxillofacial surgery. Elsevier Health Sciences; 2015 Apr 9.

21. EXTERNAL REFERENCE MARK
Kirschner wire
• Kirschner wire at nasal bridge
• external reference markers have been shown to be more accurate
• Screw In Nasion
• The medial palpebral fissure also can be used as a reference
point instead of a metallic marker.
• Kahnberg et al found no statistically significant difference between the
two methods.
Bell WH: Modern practice in orthognathic and reconstructive surgery , Philadelphia, 1992, WB Saunders.

23. INFILTRATION OF LA AND INCISION
• LA with vasoconstrictor is injected into upper labial/
buccal sulcus
• 1:100000
• Palatal injection are unnecessary.
• 5 mm above mucogingival junction, Electrocautery
discouraged-

24. Anterior:-
-Septopremaxillary ligament from ANS
-The nasal mucosa is reflected from the
floor posteriorly upto 15 – 20 mm from
aperture and from the lateral nasal wall
Superio-lateral- zygomatic body
Posterior:-
-Tunneled to preserve mucosal pedicle
-Care is taken to maintain the integrity of
periosteum and prevent herniation of BFP
in surgical field

25. PLACEMENT OF INTERNAL REFERENCE MARKS
• Osteotomy line is demarcated by drilling holes in lateral
maxillary walls 5-6 mm above the apices of maxillary
canine and 1st molar

26. ANTERIOR BUCCAL OSTEOTOMY
•Zygomaticomaxillary buttress along the lateral
wall of maxilla and till piriform aperture.
•It terminates below inferior turbinate. To
avoid damage to nasolacrimal duct
•Parallel to occlusal plane
•With saw / rotary burs / piezo

27. IN DEPTH
• Should not be extend beyond 25-30mm from the
piriform rim posteriorly to avoid the injury to
Descending Palatine Artery
• Finally saw is reversed to make a cut in sinus
from inside out in posterior wall of maxilla
• In superior repositioning The Maxilla:-
Drill holes are made superior to the first osteotomy
line at a distance measured by small caliper. Finally
saw is used to connect these points.

28. POSTERIOR BUCCAL OSTEOTOMY
• From the ZM buttress to the tuberosity .It is
sectioned under the mucosal tunnel with
direct visualization
• 3mm lower than anterior osteotomy .Directed
inferiorly to prevent the injury to maxillary
artery or its branches.
• 5mm superior to the 2nd molar

29. 3RD MOLAR IN POSTERIOR OSTEOTOMY….
Presence of 3rd molars should not alter the
osteotomy designs.
Extraction indicated :-
Exposed during osteotomy
Interfere with repositioning

30. REPEAT THE PROCEDURE ON
OPPOSITE SIDE

31. Osteotomy of lateral nasal wall
Guarded Osteotome is placed at piriform rim and
directed posteriorly and inferiorly along the lateral nasal
wall towards the perpendicular plate of palatine bone.
Until audible change in malleting/ resistance is indicative
of perpendicuar plate of palatine bone

32. NASAL SEPTUM OSTEOTOMY
• Nasal septal osteotome is
directed posteriorly & inferiorly,
starting above the anterior nasal
spine upto 25-30mm.
• It frees the cartilagenous & bony
septum and vomer from the
superior surface of maxilla.

33. Complete sectioning of palatine bone should be accomplished,
even if it results in damaging the descending palatine artery .
 Incomplete section can result in inadvertent fractures which may
extend into orbit

34. • Techniques for pterygomaxillary
seperation:
• Obwegeser osteotome
• Swan neck & shark fin modification of
osteotomes
• pterygoid chisel
• Tessier spreaders ( by Precious et al)
• J mobilizers
PTERYGOMAXILLARY DYSJUNCTION
Obwegeser
osteotome
Tessier spreader

35.  Curved osteotome directed medially and
anteriorly at the lowest part of pterygomaxillary
junction.
 Excessive anterior angulation may increase the risk
of injuring the descending palatine artery.
 Do not direct the tip of osteotome cranially
 Maxillary artery lies approx. 25mm above the base
of the pterygomaxillary fissure
 Ostetome should be ranged in width 10-15mm
 Transmission of forces by the sphenoid bone to the
base of skull may lead to loss of vision.

37. DOWN FRACTURE OF MAXILLA
• Digital pressure is applied over the anterior maxilla.
• If resistance is encountered, revise osteotomy cuts.
• Do not use excessive force during downfracture
• Probable reasons for failure of down-fracture:
1. The pterygoid plates & tuberosity are not sufficiently
separated.
2. Lateral nasal wall osteotomy is incomplete.

38. OBILIZATION OF MAXILLA
• Place the maxillary mobilizer
bilaterally behind tuberosity & pull the maxilla forward &
downward using cricoid hook/ J stripper place in the
incisive canal.
• DPA is visualised and bone must be removed carefully
preserved/ ligated

39. Septoplasty and theReduction of theInferior Turbinates

40. BonyInterferences
• All bony interferences and premature
contacts must be adjusted.
• Most likely the area of interference is the
maxillary tuberosity and posterior maxillary
wall.

41. section of the maxilla to demonstrate the bony
cuts.

42. MAXILLOMANDIBULAR WIRE FIXATION
• The mobilized maxilla is seated in prefabricated occlusal splint and IMF is applied.
• Check the reference marks for accurate maxillary positioning

43. • Planned vertical relationship is established.
• Position of condyle in glenoid fossa should
be checked. Digital pressure anterior to
mandibular angle in upward and anterior
direction
• Make sure there are no bony interference
during the rotation
Positioning of the condyle in glenoid fossa

44. INTRAOPERATIVE DIAGNOSIS OF CONDYLAR SAG

45. STABILIZATION OF THE REPOSITIONED
MAXILLA
Non – rigid
Trans-osseous wiring
IMF – 4-6 months
Rigid/semi rigid
Metal Plates
Resorbable plates
Position screws
Mesh
IMF- 4-6 weeks

46. RIGID V/S NON-RIGID FIXATION
• Rigid Iinternal Fixation improves stability of maxillary osteotomy.
• Surgeon employing rigid fixation technique must be exacting as this techinque is
less forgiving for postoperative adjustments.
• Plate and screw lacks flexibility and skeletal adjustments and all the occulsal
changes required postoperatively are accomplished solely through dental
movements.
• Surgeon must ensure that the plates are precisely adapted to contour the
maxillay bony walls because forcing non-contoured plates against the bone may
result in displacement of bony segments as the screws are tightened.

47. • Skeletal suspension described by Epker and Fish -- great postoperative
flexibility with regard to skeletal adjustments.
• Multidimensional movements can be accomplished by selective tightening or
loosening of skeletal suspension wire
Maxillary advancements upto 5mm have shown to be stable regardless of type of
fixation used to stablise the maxilla.

51. BONE GRAFTING
Le Fort 1 osteotomies
using rigid fixation and
interpositional PBHA
grafting during
bimaxillary surgery is a
stable procedure with
good predictability in
cleft and non-cleft
patients, regardless of
the direction of vertical
maxillary movement.

52. Graft Functions
-Osteotomy stablisation
-Horizontal augmentation of infraorbital region and zygoma.
Transosseous orbital rim-pirifrom rim suspension wire
o Iliac crest graft
o Graft notched superiorly to accommodate ION
o Corticocancellous block fits as an onlay interpositional block on the
infraorbital rim and body of zygoma
o Transossoue wire is tightened.
Ti miniplates and screws are placed between the graft and advanced maxilla
Body of zygoma
Piriform rim

53. CLOSURE
• Alar base cinch
• A slowly resorbing suture (e.g., 2-
0 polyglycolic acid)
Nasalis muscle are grasped and
suture is passed through each
muscle in the superior aspect of
flap & sutured to the muscles in
the inferior limb of incision.

54. If the tissue bulk in the inferior part of flap is
inadequate to support the suture, a hole can be
drilled through the ANS & a cinch suture can be
placed

56. V-Y CLOSURE
• Helps in maintaining the height of exposed vermilion & lip length
• A skin hook is placed in the midline to create an “inverted T” closure of approximately 1 cm length.
• When mucosa is closed suture should grasp the thinnest layer of tissue

57. MODIFICATION IN LE FORT-I OSTEOTOMY

59. MAXILLARY QUADRANGULAR LE FORT I OSTEOTOMY
Historical review
1st described by Obwegeser as a LeFort-I
osteotomy in which osteotomy was
placed “as high as possible,from the
tuberosity area arround the whole
maxilla, staying just beneath the
infraorbital foramen.”

60. SURGICAL INDICATIONS
Pts with maxillary-zygomatic deficiency ,class III skeletal
malocclusion with normal nasal projection.
Pts with normal nasal projection with infraorbital and
zygoma deficiency
(desiring reduced surgical morbidity).

61. • Osteotomy :-
Horizontal osteotomy begins from piriform rim at
level of infraorbital nerve extending laterally just
inferior to the IOF to zygoma body.
At this point it makes a right angle and proceeds
inferiorly through the maxillary buttress and
through the lateral antral wall to PtM fissure.
Posteriorly osteotomy is completed at vertical wing
of palatine bone just anterior to pterygoid plate
with osteotome.

64. 1 weeks – increased
periosteal-endosteal
vascular supply ,
granulation tissue
composed fibroblasts
and capillaries.
2 weeks –
osteophytic bone
from periosteum
and bony edges,
blood vessels
arising from
endosteum,
reattachment of
soft tissue of
underlying bone.
4 weeks – bony callus
– maintains vitality of
maxilla, active
osteoblastic activity
6 weeks – soft tissue
flaps completely
reattached to
underlying bone ,
callus shows mature
bone.
12 weeks – osseous
bridging between
fragments appeared
complete
REVASCULARISATION AND HEALING IN ORTHOGNATHIC SURGERY

65. Complication OF Le Fort-I osteotomy

67. Source of bleeding:
I. Lateral & medial pterygoid muscles
II. Posterior superior alveolar artery
III. Greater palatine artery
IV. Terminal branches of maxillary artery
V. Pterygoid venous plexus
VI. Internal carotid artery
HEMORRHAGE

69. Protocol for the Management of Postoperative Hemorrhage
Rapid
release of
maxillo-
mandibular
fixation
allows for
clearing of
intraoral and
pharyngeal
clots.
If brisk ac- tive
hemorrhage is
occurring
when the
patient is first
seen, large
Foley catheters
should be
placed
bilaterally to
serve as
temporary
posterior nasal
packs
A
tracheost
omy
should be
considere
d
patient's
general
status
should be
quickly as-
sessed, vital
signs
monitored,
and
intravenous
fluids started
approxim
ate
assessme
nt of
blood
loss
Coagulatio
n studies
should be
done
nasal area
should
then be
examined
with a
good light
source,
Embolization
of the
internal
maxillary
artery and
its distal
branches
should be
considered if
recurrent
hemorrhage
occurs
Ligation of the
external carotid
or internal
maxillary
arteries is
another
possibility for
the
management of
recur- rent
arterial bleeding
if therapeutic
embolization
cannot be
performed

70. CONSIDERATION TO PREVENT BLEEDING IN LF-I OSTEOTOMY
• Knowledge of the anatomy, especially that of the posterior maxilla &
pterygopalatine fossa.
• Careful and gentle surgical technique.
• Proper completion of osteotomies before attempt an downfracturing of maxilla.
• Avoiding application of excessive forces.

71. UNFAVOURABLE OSTEOTOMY
• LeFort-I osteotomy requires separation of maxillary tuberosity from Pterygoid plate
and pyramidal process of palatine bone as well as nasal septum.
• Osteotomy at pterygo-palatine area is largely blind because the area can not be
visualised before downfracture.
Most Common type of unfavorably osteotomies
• Fracture at the junction of horizontal process of palatine bone with the palatal
process of maxilla.
• High horizontal fracture of the pyramidal process of palatine bone
• Horizontal fracture of pterygoid plates,both with or without separation from the
tuberosity.

72. Trigemino-Cardiac Reflex
• Sudden decrease in pulse rate (PR) and mean arterial blood (MABP) pressure that may consequently
develop asystole and even cardiac arrest .
• 1.6% during maxillofacial, temporomandibular,orthognathic surgeries.
C/F :-
Bradycardia less than 60 beats /min
Hypotension.
Theories:-
1. Anxiety
2. Anesthetic Agent(hypocapnia, hypoxemia)
3. Stimulation of lingual and palatal branches of TG nerve as the triggering factor.
Sensory branches of TGN send signals from gasserian ganglion to sensory nucleus TGN. Which are then transferred to
vagus motor nucleus through short nerves and directed to myocardium through cardiac branches of vagus nerve .

73. TRIGEMINO-CARDIAC REFLEX IN LE FORT-I OSTEOTOMY
Management :
Manipulation of
maxilla should be
stopped
immediately
Administration of
anticholinergic
drugs

74. Avascular necrosis
The spectrum of vascular compromise ranges from loss of bony segment ,loss of teeth to loss of attach gingiva.
Early sign:
Blanching
Cyanosis of attach gingiva and mucosa
Etiology
o Vascular insult to maxilla
o Excessive manipulation of segments.
o Hypoperfusion from prolong hypotensive anesthesia
o The preservation of the integrity of the descending palatine arteries was not found to be essential to maintain circulation
to the down-fractured maxilla.
Management:
• Returning the maxilla back to its original or intermediate position & checking for improved tissue colour & blood flow
• Oral hygiene maintenance and systemic antibiotics to prevent secondary infection
• Surgical debridement of necrotic tissue with the use of hyperbaric oxygen.

76. FACTORS RESPONSIBLE FOR SUCH COMPLICATIONS
• Improper design of soft tissue incision
• Excessive stretching of palatal soft tissue pedicle
• Segementalization of maxilla
• Extensive hypotension
• Severance of descending palatine vessels

77. NON-UNION/DELAYED UNION
Causes:
• scarring due to previous surgery
• Poor surgical planning
• Para-functional habits
• Posterior and superiorly positioned maxilla with poor bone contact
• Systemic-diabetes, smoking
• Prevention-
• when unstable maxilla anticipated-boneplates+auxillary fixation
• IMF:1-6weeks, skeletal wires
• Use of bone grafts for large defects

78. treated with additional forms of fixation and/or immobilization. Currently, we use
bone plates combined with suspension wires and 6 weeks of immobilization in
many of these cases.
Grafting has been advocated in the pterygomaxillary area; however, graft material
also should be placed in large defects in the anterior and lateral maxillary wall
areas.

79. RELAPSE
Postoperative movement either towards the preoperative position or farther
away from it.
Proffit et al coined the phrase “Hierarchy of stability” in which they quantified
relapse according to different types of procedure

80. STABLE MAXILLARY MOVEMENTS
Superior
movement
Maxillary
advancement
Posterior movement

81. UN STABLE MAXILLARY MOVEMENTS
Transverse movement
Inferior movement

82. • Maxillary superior repositioning
-Mean relapse rate 11% to 3% from anterior and posterior maxilla,respectively,at mean follow
up of 14 months.
• Maxillary advancement:-
-Relapse of 5-19% at average follow up of 15 months with RIF
-It is proportional to amount of advancement. Bone grafting in advancement>8mm reduces
relapse.
• Maxillary inferior repositioning
-28% and 70% relapse rate at anterior and posterior maxilla,at follow up of 14 months.
• Maxillary transverse widening
• Least stable – prolonged retention

83. NERVE INJURYInfra Orbital Nerve injury:-
Injured due to traction and compression
6% Neurosensory deficient at 12 months when tested objectively
all patients reported satisfaction with the surgical results, and would recommend the procedure
to others.
Descending/Greater Palatine Nerve injury
-Nasopalatine,
-Posterior, Middle, Anterior superior alveolar nerve are completely severed.
-Despite ligation and division of neurovascular bundle, sensory recovery does occur and
represent collateral axonal sprouting from adjacent nerve.

84. Post operative vision loss
• Rare complication(0.25%)*
Etiology
1. Postoperative intraorbital bleeding
2. Intraoperative Hypotension & hypoperfusion of
the optic nerve: retina & optic nerve are
sensitive to hypoperfusion or ischemia, it can
only tolerate ischemia for 60-90 min.

85. MISCELLANEOUS
abducens palsy, three cases of oculomotor palsy

89. incidence of 4.76% of maxillary sinusitis

91. ANTERIOR MAXILLARY
SUB-APICAL
OSTEOTOMY
first anterior
segmental maxillary
osteotomy (ASMO)
was reported at the
beginning of the
twentieth century.
Günther Cohn-Stock

92.  Indications
• Bimaxillary protrusion with mandibular subapical osteotomy
• Maxillary Prorusion
• Ant open bite provided VME is not present
• Orthodontic treatment is not feasible
• Esthetic consideration
 Biologic basis
BS anterior maxilla maintained by labial-buccal and palatal tissues
Types
(1) WASSMUND METHOD
(2) WUNDERER METHOD (OUT #)
(3) CUPAR METHOD (Down #)

93. WASSMUND METHOD
Preserves both buccal and palatal soft tissue pedicles.
Procedure
1) Vertical mucosal incision b/w 3 & 4 (gingival margin to
level of anterior nasal floor.)
(superior to the root apex of maxillary
canine.)
2) Mucoperiosteum reflected to apical 3rd of max canine
3) Tunnel subperiostelly expose nasal piriform aperture
4) Extraction or presurgical space of 3 – 5 mm.

94. 5) Palatal mucosa reflected to just past the midline
6)Osteotomy – bony cuts done leaving 2mm over the adjacent teeth
7)Bone in midpalatine region is thick, sometimes a midpalatal
incision may be required.

95. • Repeated on opposite side
• Dentoalveolar segment disarticulated from nasal
septum
• Anterior midline mucoperiosteal incision
reflected ….nasal septal osteotome malleted
above nasal spine to free the segment from the
septum.
• After mobilising placed into occlusal splint.
• Palatal soft tissue pedicle checked for any folds,
compromising the blood supply

96. WUNDERER METHOD
Facial soft tissue incisions similar to wassmund’s method#
Mucoperiosteal incision transversely across palate (anterior
to the planned osteotomy site)
Palatal mucosa posterior to the incision elevated
Pre planned extraction performed ….
Osteotomy upto the anterior nasal aperture done
Note : Facial portion osteotomy is done first and adequacy of
perfusion of facial soft tissue pedicle confirmed first , then
proceed with palatal osteotomy else as a second stage
procedure

97. • If superior repositioning required, access to junction of ANS and nasal septum poor.
• A vertical incision can be made over the anterior nasal spine, (but Labial flap represents total
blood supply to the anterior maxilla, it is not recommended.
Advantages
• Direct palatal access - ability to create transverse osteotomy through a molar site
• Relies on intact buccal pedicle for blood supply.
• Separation of nasal septum performed easily.
• Modified to include midline vertical incision to achieve access to horizontal osteotomy through a sub-periosteal
tunnel connected with the vertical incisions at extraction site

98. CUPAR METHOD
• Commonly used technique
• Minor version of total maxillary osteotomy
• Buccal vestibular incision is created allowing direct
access –
anterior lateral maxilla
piriform aperture
nasal floor and sepum

99. ADVANTAGES OF CUPAR’S TECHNIQUE
1. Direct access to nasal structures
2. Unhampered access to superior maxilla –
reduction of vertical maxillary excess /
Bone grafting in downward cases.
3. Ability to remove palatal bone under
direct visualization.
4. Preservation of blood supply  palatal
pedicle
5. Ease of placement of RIF.

100. POSTERIOR SUB-
APICAL OSTEOTOMY

101. Schuchardt , 1959
Indications
• Posterior maxillary alveolar hyperplasia
• Total maxillary hyperplasia
• Distal repositioning of posterior segment
• Anterior repositioning of posterior segment
• Transverse excess or deficiency
• Posterior open bite

102. INCISION DESIGN
1) Horizontal vestibular incision from canine to 2M
below zygomatic buttress with tunneling access
2) Mucoperiosteum reflected superiorly
leaving inferior intact
3) Horizontal osteotomy followed with vertical
osteotom

103. TRANSANTRAL OSTEOTOMY
High palatal vault permits palatal osteotomy transantrally beneath the nasal floor.
A, Transantral osteotomy is made at the junction of the horizontal palate and vertical alveolar process.
B, Approach for deep vaulted palates. - the transantral cut is completed along the entire anteroposterior extent of the
planned palatal osteotomy
except in the area of the descending palatal neurovascular bundle.
C, Approach for flat shallow palates. Patients with low flat palatal vaults are
more easily osteotomized through the nasal floor

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

105. • orthodontic stabilizing arch wire can be inserted into buccaI
headgear tubes to further stabilize the posterior dento-alveolar
segment
• Rigid fixation is applied
• When the patient has multiple missing teeth or when lateral
expansion of more than 5 to 7 mm of the maxillary segment has
occurred transpalatal orthodontic stabilization should be considered
• Closure of soft tissue incisions is done
• When lateral expansion does not leave enough palatal
tissue for closure, additional mucoperiosteal incisions on
the contralateral palate may be required to mobilize
palatal tissue so that mucosa can be closed over the
palatal osteotomy site.

106. SURGICALLY ASSISTED MAXILLARY EXPANSION
• Assists to correct deformities in transverse dimension.
• First described by Angell in 1860
• This procedure is in essence combination of distraction
osteogenisis and controlled soft tissue expansion.
Diagnosis and clinical evaluation:
• Para nasal hallowing
• Narrowed alar base
• Deepening of nasolabial folds
• Zygomatic deficiency
ngell, E. H.: Treatment of irregularities of the permanent or adult teeth, Dent. Cosmos 1: 540-544, 1860.

107. Treatment options
based on skeletal maturity
• Slow dentoalveolar expansion
• Orthopedic rapid maxillary expansion
• SAME
• Segmental maxillary osteotomy
Advantages of SAME
• improved stability
• non extraction alignment of dentition
• elimination of negative space
• improved periodontal health and nasal respiration

108. Indications:
• skeletal discrepancy greater than 5mm associated with wide mandible
• failed orthodontic expansion
• extremely thin, delicate gingival tissue
• significant nasal stenosis.
• More than 7 mm of expansion
Technique:
• First the mandibular dentition should be decompensated
• Expansion appliance should be placed preoperatively

109. Step 2: Buccal
Osteotomy
Step 2: Buccal Osteotomy
Step 1: Incision
Step 4: Palatal Osteotomy
Step 4: Palatal Osteotomy
Step 5: Midline Osteotomy

110. • Maxilla should remain stationary for 5 days
postoperatively.
• Pt should feel discomfort while activation.
• Expansion at a rate of 0.5 mm/day
• Over correction is not recommended.
• Retention:
6 to 12 months after expansion

111. SINGLE TOOTH OSTEOTOMY
 Indications
 Tooth malposition
 Dental ankylosis
 Closure of a diastema
 Biologic basis
 Collateral circulation within maxilla
surrounding soft tissue envelope
are adequate.
 Freely anastomosing vessels
gingiva
palate
floor of nose
periodontal plexus network allows
maintenance of blood supply
One or more teeth and their supporting
bone can be moved as a segment.

112. LE FORT II
OSTEOTOMY

113. HISTORY
• 1970, Converse and associates described a pyramidal nasoorbital maxillary
osteotomy that approached le fort ll osteotomy in concept
• 1973, Psillakis and associates gave the modified pyramidal naso-orbital maxillary
osteotomy
• 1973, Henderson and Jackson , described the le fort ll osteotomy closely
following the fracture pattern.

114. Surgical access to nasoorbital component:
Two oblique incisions on either side of the
nose over the frontal process of maxilla/
dorsal nasal incision
Alternatively , bicoronal flap combined with
infraorbital or conjuctival approach
SURGICAL TECHNIQUE

115. • Sub-periosteal dissection carried out to expose nasal
bridge and medial orbital walls until the anterior and
posterior lacrimal crest
• Medial canthal ligament should not be disturbed
• Periosteum from medial orbital floor raised to meet
the medial wall dissection behind the lacrimal sac
• Sac and duct raised from their bony attachments

116. • Transverse cut made through nasal bone
below the known position of cribriform
plate(crista galli)
• Cut extended into medial wall of orbit
just below the medial canthal
attachment across upper part of
lacrimal groove and just through
posterior lacrimal crest
• Second cut made along orbital floor
between lacrimal duct medially and
infra-orbital canal laterally
• The two cuts connected by a small chisel
behind the lacrimal groove

117. • The osteotomy is continued down the
anterior aspect of maxilla well past the infra-
orbital nerve
• From this point, posterior and lateral parts of
the osteotomy are completed as for le fort l
through intra-oral incision
• Separating the maxilla from the pterygoid
plates as in le fort 1 procedure

118. • Maxilla is disimpacted using Rowe’s
disimpaction forceps for initial separation and
mobilized freely using a Tessier’s maxillary
mobilizers
• It is then advanced according to pre-
operative plan
• Fixed using miniplate osteosynthesis

120. Henderson, D., I. T. Jackson:
Nasomaxillaryhypoplasia-
theLeFortIIosteotomy.Brit.J.oralSur
g.11(1973)77◊◊

121. LE FORT- III
OSTEOTOMY

122. HISTORY
• 1950, Gillies published an account of the first high maxillary osteotomy
to correct middle face deficiency secondary to craniostenosis
• 1957, Longacre used onlaid 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

123. INDICATIONS
• 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
• Syndromic patients: Crouzon, Apert etc

124. • Exposure of the middle face:
• Bilateral maxillary vestibular incisions,
bilateral inferior eye-lid incisions and either
a bicoronal flap or incisions over dorsum of
the nose
• Periorbita is dissected approx 10mm deep
into both orbits, lacrimal apparatus
identified and protected.(no tearing of
orbital fat)
SURGICAL TECHNIQUE
Kademani D, Tiwana P. Atlas of oral and maxillofacial surgery. Elsevier Health Sciences; 2SEBASTIANI AM, REBELATTO NL, KLÜPPEL LE, COSTA DJ, ANTONINI F, MORAES RS. Le Fort III osteotomy for

125. • Nasofrontal osteotomy carried out below the level of cribriform plate and above the
horizontal orbital axis to minimize intra-cranial involvement
• Osteotomy proceeds in the medial orbital wall above the lacrimal apparatus and attachment
of medial canthal tendon extending 1cm into the orbit

126. • Osteotomy of lateral orbital rim begins with direct visualisation of orbital and temporal sides of
lateral orbital rim and wall
• Osteotomy proceeds posteriorly and inferiorly from anterior extent of FZ suture to zygomatic
buttress.
• Within the orbit, osteotomy is carried inferiorly and posteriorly into inferior orbital fissure.
• Osteotomy carried across the orbital floor joining the osteotomy of the medial wall and that of
lateral wall in the inferior orbital fissure carefully preserving the infra-orbital nerve

127. • Next, pterygoid plates freed from the maxilla via intra-oral vestibular approach
• Final osteotomy is separation of perpendicular plate of ethmoid and vomer from the cranial
base
• Osteotome angled posteriorly and inferiorly along the slope of cranial base to avoid fracture
of cribriform plate and intra-cranial involvement
• Patency of all cuts tested and rowe’s disimpaction forceps used to mobilize the mid-face

128. • Mid-face skeleton must rest passively in the forward position in the pre-
formed occlusal splint
• Accurately pre-pared grafts are placed along zygomatic buttress defects,
lateral orbital rim and wall defects, nasofrontal defects, pterygomaxillary
regions.
• Fixation is carried out and operated site thoroughly irrigated and closed

129. CONCLUSION
• The experiments of Rene Le Fort in 1901 contributed largely not only to the
understanding of maxillofacial fractures but also laid the foundation of osteotomy lines
used today for maxillofacial deformities.
• The works of William Bell largely established the biologic basis of maxillary osteotomy
and subsequently today with le fort ll and lll osteotomies a vast spectrum of craniofacial
deformities can be corrected
• The basic principles of surgery and our understanding of vascular anatomy continue to be
the cornerstone while performing these osteotomies
• Any violations of these basic principles will frequently lead to undesirable
complications
• Proper diagnosis and careful treatment planning will always provide efficient results to
our patients

130. REFERENCES
• Oral and maxillofacial surgery: .Fonseca: vol-2
• Peterson: vol-2
• Essentials of orthognathic surgery: Reyneke.
• Maxillofacial surgery:Ward Booth: vol-2
• Atlas of Oral and Maxillofacial Surgery.
• Contemporary Treatment of DENTOFACIAL DEFORMITY.
• Orthognathic Surgery - Principles and Practice - Jeffrey C. Posnick