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GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
Oral & Maxillofacial Surgery
SEMINAR
On
Orthognathic Surgery Midface procedures
Presented By:
Dr. Satyajit Sahu
III MDS
Orthognathic Surgery Midface procedures
Introduction
Orthognathic surgery has evolved over many years to correct both
facial deformity and oral dysfunction. Facial beauty is difficult to define in
precise terms because subtle differences between individuals can produce
marked aesthetic contrasts. Furthermore, different racial forms of beauty are
not comparable and so ethnic norms are required to correct the abnormality.
Despite this skeletal abnormality is recognisable, measurable, and usually
correctable by orthognathic surgery.
Orthognathic surgery started as "Orthodontic surgery as an aid to
orthodontics, later graduated to orthognathic surgery as a remedial measure to
orthodontic limitations.
Orthognathic surgery is mainly directed at the correction of basal bone
defects. he aim is to attain aesthetic, psychological and functional
rehabilitation of the patient. !owever fine tooth movements for the optimum
results are difficult to obtain with orthognathic surgery alone. "uch finer
ad#ustments can be achieved by orthodontics. Orthognathic surgery along
with rhinoplasty and orthodontics can rehabilitate patients with facial
deformities and oral dysfunction.
Historical events
!ullihen was the first person to correct #aw deformity surgically in
$%&', when he corrected an anterior open bite by mandibular subapical
osteotomy. Orthognathic surgery of the ma(illa was first described in $%)'
by *on +angenbeck for the removal of nasopharyngeal polyps. ,heever $%-.
reported a ma(illary osteotomy for complete nasal obstruction secondary to
epista(is, he used a right hemima(illary down fracture. +ater many ma(illary
osteotomy techniques were described for the treatment of pathological
process.
/lair in the early $'00s was the first to classify #aw deformity into
five classes as 1 2andibular prognathism, 2andibular retrognathism,
3lveolar mandibular protrusion, 3lveolar ma(illary protrusion and open bite.
4n $'0$, +e Fort published his classic description of the natural planes
of ma(illary fracture. ,ohn5stock $'6$ described segmental osteotomy of
ma(illa which was modified by 7assmund 8$'6-9 by a labial approach.
,upar $')&, :ole $')' and 7underer $'-; reported a direct surgical access
to these procedures which improved mobilisation and maintained blood
supply. 7assmund 8$'6.9 described a total hori<ontal ma(illary osteotomy to
close a posterior open bite and this constitute earliest work of +e fort 4
surgery. 3(hausen 8$';&9 performed the first total mobilisation of the
ma(illa.
=osterior segmentali<ation of the ma(illa was first used by "chuchardt
$')' for correction of open bite. his had limited stability owing to its
incomplete mobilisation. :ufner $'.0 improved on this technique by
completely mobilising the osteotomi<ed segment prior to repositioning.
=aceno 8$'669 published some basic principles of roentgenographic
cephalometry which was later modified and popularised by /roadbent and
!olfrath 8$';)9. Down 8$'&)9 put forward some standard measurements
which helped the diagnosis of deformities of midface. /urstone et al $'.% >
$'%0 gave an analysis for the assessment of dentofacial deformity using
cephalometric radiographs " he cephalometric analysis for Orthognathic
surgery" 8,O?"9.
@se of bone grafts in midface surgical advancement were reported by
Aowe 8$')&9, ,ernea and associates 8$'))9, +erinac 8$')%9.
"eparation of the pterygoma(illary #unction was first advocated by
"chuchardt in $'&6. 2oore and 7ard $'&' recommended hori<ontal
transection of the pterygoid plates for advancement. his technique was
associated with severe bleeding so 7ilmar advocated the pterygoma(illary
dis#unction technique for +e fort 4 osteotomy.
3 combined form of anterior and posterior subapical osteotomies "total
subapical ma(illary osteotomy" were reported by =aul $'-' for midface
hypoplasia.. his technique was further described by 7est > Bpker $'.6,
!all > Aoddy $'.), 7olford > Bpker $'.), 7est and 2cCeil $'.) and !all
> 7est $'.-. 2aloney 8$'%69 reviewed this technique and described it as a
good technique during his time. his technique is hardly in use now.
!ugo Obwegesser $'-) advocated complete mobilisation of ma(illa so
that ma(illa could be repositioned without tension. his aided in stabilisation
which was documented by !aller, !ogemann > 7ilmar and =erko.
!ugo Obwegesser $'-' described a high quadrangular +e Fort 4
osteotomy for midface deficiency correction. his technique was later named
as Duadrangular +e Fort 4 osteotomy by :eller > "ather $'%'.
,onverse > ,olleagues in $'.0 described an osteotomy at +e Fort 44
level but this had several biologic and anatomical flaws so this technique did
not have appreciation later. !enderson > Eackson $'.; described a classic +e
Fort 44 osteotomy for correction of midface deficiency.
:ufner $'.$ described an osteotomy procedure for midface deficiency
correction, which was named as quadrangular +e fort 44 osteotomy by
"teinhFuser $'%0. his technique was modified by "toleinga > /rown in
$''- which prevents damage to infra orbital nerve.
*ascular supply of lower ma(illa and alveolar portion was e(tensively
studied by /ell and +evi 8$'.$9 and /ell et al 8$'.'9. hey concluded that
the vitality of segment will not be affected if either palatal or buccal flaps
were retained undisturbed.
Bpker and 7oodford $'%0 gave a detailed down fracture technique for
+e fort 4 ma(illary osteotomy based on palatal flap. hey advocated the use
of same for anterior ma(illary segment 0steotomy.
"ir !arold ?illies > !arrison $')0 performed +e Fort 444 osteotomy
for midface deficiency.
=aul essier $'-. described various techniques for correction of
orbito5craniofacial deformities.
he first use of bone plating was carried out by "oerensen in $'$. for
fracture mandible. /ernd "piessl $'.& was the first to use rigid fi(ation after
sagittal split osteotomy. @se of rigid fi(ation to stabilise osteotomised
segment was reported by ,hampy > associates $'.-, 2ischelet, +eyoness >
Desus $'.;, Dromer and +uhr $'%$, "teinhFuser $'%- etc. 2iniaturised
plates were used by +uhr $'%$, "teinhFuser $'%- etc. 2iniaturised plates by
+uhr, $'%' solved the problem of e(cessive bulk of miniplates for use in
midface.
he latest developments in orthognathic surgery is the use of ad#utant
plastic surgical procedures like blepharoplasty, rhinoplasty, rhitidectomy,
liposuction , lip correction and the use of the principle of distraction
osteogenesis for correction of #aw deformities.
Anatomy of midface
he skeleton of midface is made up of intricate attachment of various
bones, these include two ma(illa, two nasal bones, two palatine bones, two
<ygoma and their temporal process, two inferior nasal conchae, the vomer,
the ethmoid and the pterygoid process of the sphenoid bones. he articulation
of these bones give the pro#ection to midface. 3ny e(cess or deficiency in
this region produces an unaesthetic deformity.
he midface is in relation to important aesthetic and functional
landmarks such as the orbit, nasal cavity, ma(illary sinus and the oral cavity.
he ma(illa is a paired bone of the upper #aw, fused to form one
central focus of the midface. 4t acts as a base for containing the teeth, support
for nasal cartilages, gives attachments to muscles and forms the ma#or bony
plate for palate and orbit. Bach hemima(illa contain a large pyramidal shaped
body, the ma(illary sinus and four prominent process G the frontal, alveolar,
<ygomatic and palatine process. he body of ma(illa is hollow and contains
the ma(illary sinus. he infero lateral walls of the ma(illa are thinner and are
directed in a angular fashion with narrower bottom and gradually increasing
in si<e superiorly. "o an osteotomy cut in this area would result in
telescoping of the inferior segment into the antrum and resulting in
instability. he frontal process arises from the anteromedial corner of the
body of ma(illa and it articulates with nasal bone, frontal bones to form the
medial wall of the orbit. he <ygomatic process of the ma(illa arises from the
anterolateral corner of the ma(illa and articulates with <ygoma laterally. hey
together form the floor and lateral wall of the orbit. he highly vascular nasal
mucosa is loosely attached to the rim of the pyriform ring of the ma(illa. his
can be easily raised from the palatine process of the ma(illa. he infraorbital
nerve and vessels pass through the infraorbital foramen which lies at the
anterior surface of the ma(illa below the infraorbital rim. 3 damage to this
nerve is most likely in +e fort 44 and 444 procedures and this would produce
profound paresthesia H anaesthesia of the upper lip and part of nose.
he <ygoma is a paired bone and makes up the essence of the cheek
prominence. 4t is diamond shaped bone. 4ts deficiency along with infraorbital
deficiency would result in increased visibility of sclera. his has four process
by which it attaches to frontal bone, ma(illa and temporal bone.
Casal bones are rectangular and articulate with frontal bone and
process of frontal and ma(illa. his gives the anatomic pro#ection to the nasal
bridge.
=alatine bones are paired bones which connect the ma(illa with the
sphenoid bone through pterygoid plates. 4t has a body and two process the
hori<ontal and vertical. he greater and lesser palatine nerves and vessels
pass through this bone. =osteriorly this bone articulates with pterygoid plates.
his articulation is dis#uncted during total ma(illary osteotomies when
ma(illa is to be advanced or impacted superiorly.
he inferior nasal concha is a paired bone that form the bony support
of the inferior turbinates bilaterally. 4n some instances this might be enlarged
which makes superior impaction of ma(illa difficult.
Biological basis for maxillary osteotomies.
he delivery of an adequate amount of blood to the tissue capillaries
for normal function of the organ is the primary purpose of the vascular
system. "uccessful transportation of the ma(illary dento5osseous segments by
+e fort 4 osteotomy depends on preserving the vitality of the segment by
proper design of the soft tissue and bone cuts.
B(tensive studies on the blood supply of ma(illa by /ell > +evy $'-' and
others have shown an e(tensive anastomosis between the terminal branches
of the ma(illary vessels. his allows a wide range of buccal and palatal flaps
to be raised. Formerly tunnelling procedures have been used to maintain a
dual supply from the tissues of the cheek and palatal vessels. "tudies by /ell
> +evy $'-' have shown that interruption of these, for e(ample the palatine
vessels, will not lead to necrosis of bony segments, provided adequate
buccolabial periosteal flaps retained.
2a(illa receives its blood supply from branches of ma(illary artery G
the palatine artery and superior alveolar arteries. 4t also receives collateral
supply from the branches of facial artery. he collateral circulation within the
ma(illa and its evolving soft tissues and the many vascular anastomosis in the
ma(illa, permit numerous technical modifications of the +e fort 4 osteotomy.
Iou et al $''$ studied the vasculature of the ma(illa. !e stated that
$. normal blood supply of the ma(illa originates centrifugally from the
alveolar medullary arterial system.
6. he mucoperiosteal arterial system also gives off many branches
that penetrate the cortical bone and supply the ma(illa.
;. he vascular connections between the ma(illa and the surrounding
soft tissues consist of not only the capillaries but also arteries and
veins.
hese multiple source of blood supply to the ma(illa and abundant
vascular communications between the hard and soft tissues constitute the
biological foundation for maintaining dento5osseous viability despite
transection of the medullary blood supply after ma(illary osteotomies.
"o for anterior ma(illary osteotomy when a labial mucoperiosteal flap
is reflected , the collateral circulation is from the palatal vessels, care has to
be taken not to damage the palatal vessels. 7hen a palatal mucoperiosteal
flap is raised for osteotomy then the labial vessels has to be preserved.
/ell $'-', /ell > levy $'.$ have demonstrated the viability of large or
small segments of the ma(illa when vascular pedicles from the palatal, facial
or both mucosal surfaces were not detached from the osteotomised segments.
hey also observed that ligation of the greater palatine arteries bilaterally did
not adversely affect the outcome of the surgery when adequate palatal
mucosa and labiobuccal gingival pedicles were maintained.
3<a< > "hteyer $'.. and 7estwood > ilson $'.) observed that the
most common complication in surgery with multiple segments is the loss or
devitali<ation of an occasional tooth ad#acent to the interradicular osteotomy
site.
"tudies by Eustin et al 600$ has shown that there is a hyper5vascularity
in the pulpal and gingival tissue during healing 8 6
nd
G;
rd
week9 after
ma(illary osteotomies.
Timing of surgery
3s a rule of thumb it is better to wait till the skeletal growth is
completed before doing orthognathic surgery. here has been report in
literature to support the corrective surgical measure even during the growth
period, specially if there is compelling psychological need for such
intervention in the patient.
2a(illary growth usually ceases 6 years before mandibular growth
completion but there is a difference of - years in late maturers. =ost
menarche growth of ma(illa is negligible. Aadius epiphyseal fusion is a
definite indicator of completion of ma(illary growth.
"urgical correction for ma(illary e(cess is not contraindicated during
growth period as reduction in growth of ma(illa helps in the surgical measure
for the patient.
Surgical approach to Midface.
"urgical treatment of dentofacial deformity was not undertaken until
the beginning of the twentieth century due to difficulties in access to facial
bones and the problems of anaesthesia.
Barly surgeries were directed towards mandible mainly through the
e(tra oral approach which had the disadvantage of visible scar. he ma(illary
procedures were initially linked to the management of cleft problems.
7asmund $';), 3(hausen $';. > $';' and "chuchardt $'&6 developed
approaches initially to anterior ma(illa and later to posterior and whole
ma(illa.
Requirements of approach to facial bones.
here are number of prerequisites for approach to facial bones, these include.
$. his must be a safe approach which allows a clear view for placement of
bone cuts and gives a good access for instruments.
6. 7hile placing incisions thought must be given to possible problems such
as pro(imity to vital structures, scarring and infection.
he important structures include large vessels and nerves like facial nerve
and vessels, infra orbital nerves and mental nerve, nasolacrimal duct, canthal
ligaments, e(ternal auditory canal etc.
he access to the facial bones can be broadly classified into two
categories 1 transcutaneous and intraoral.
he best access is through skin but this leaves a visible scar. he skin
incisions should be placed in such a way that it is hidden or follow natural
skin creases.
he intraoral approach avoids scarring but it provides relatively poor
visibility and access difficulties. Often special instruments are required with
this technique.
Extra oral approaches to midface.
+e fort 4 osteotomy is approached entirely through the intraoral
approach, while +e fort 44 and +e fort 444 might require incisions around the
orbit. hese incisions are to be placed in such a way that it minimises
scarring and also does not effect functional limitations. 3 variety of incision
have been used for accessing midface. hese include.
$. rans con#unctival incision.
6. 2edial canthal incision.
;. 4nfra orbital incision.
&. /lepharoplasty incision.
). B(tended eyebrow incision.
-. /icoronal incision.
.. 4ncisions to approach naso5orbit area.
Trans conjunctival incision
his incision is used when access to the infra orbital region is needed
during +e fort 44 and 444 osteotomies.
!ere the incision is placed in the inferior forni(. ,are is taken to avoid
damage to lower lid tarsal plate and also to cornea. ,ornea is protected by
suturing the upper edge of con#unctival incision to the upper lid margin
during the operative procedure. /lunt dissection down e(poses the
periosteum on the orbital floor which is incised at the infra orbital rim.
3 fine catgut is used to close con#unctival incision.
Medial canthal incision
his incision is required to provide access to the bridge of the nose and
medial orbital area during +e fort 444 osteotomy. his incision can be
e(tended laterally for greater access to lateral infra orbital region.
he incision is made from a point #ust superior and medial to medial
canthus to appro(imately midpoint between the lacrimal duct and infra
orbital nerve. he incision passes through skin and superficial fascia, splitting
orbicularis oculi onto the periosteum. his provides access to the anterior
ma(illa medial to the infra orbital nerve and also to nasal bones. he
periosteum is stripped from over the infra orbital margin and along the floor
of the orbit around and behind the nasolacrimal duct. =eriosteum is also
stripped from the nasal bones superior to medial canthal ligament.
*isible scarring is minimal with this type of incision but when incision
is e(tended laterally below the infra orbital region it produces a visible scar.
Blepharoplasty incision
his incision is used for accessing the malar region and also for naso
orbital procedures in +e fort 444 osteotomy. his incision is more aesthetic
than infra orbital incision.
!ere the incision is made in the skin $ G 6 mm below the grey line at
the lid margin. he skin is undermined superficial to the orbicularis oculi
muscle which is then split at the infra orbital margin. Dissection is done
while taking care to prevent damage to the orbital septum. he periosteum
over the ma(illa is divided $ to 6 mm below the infra orbital margin. /y this
approach antromedial malar osteotomy cuts can be placed. 7hen a wider
e(posure is required the incision is e(tended laterally through crows foot
crease.
he incision is closed in layers, first the periosteum, the muscle and
finally the skin with fine subcuticular nylon sutures.
Extended eyebrow incision
his approach is for access to lateral orbit .
he incision is made through the lateral part of the eyebrow and along
its length parallel to hair follicles. his should not be e(tended beyond lateral
canthus as it produces a visible scar. his incision provides good access to
the fronto<ygomatic suture and allows for bony cuts to be placed through the
lateral orbital wall down to the inferior orbital fissure. he incision is placed
through the skin, superficial fascia, orbicularis oculi and deep fascia down to
periosteum. he periosteum is incised at the anterolateral aspect of orbital
margin. /leeding is profuse which is controlled by diathermy.
7ound closure is done in layers.
Naso orbital area exposure
B(posure of this area is difficult.
he midline vertical incision down the nose provides access to both the
medial canthus area, but often leaves a persistent scar.
3 hori<ontal or inverted J* cut e(tended from two canthal ligament
again has the scar visibility. For approach to upper nasoethmoid area a
hori<ontal incision from one eyebrow to other is preferred. For nasal
lengthening procedures as along with +e fort 44 an inverted J* or JI
incision is preferred. ension in the suture area is to be avoided as it is likely
to spread the scar.
For +e fort 444 the approach to the whole of this area is best by a
bicoronal incision.
Bicoronal incision
he bicoronal 8 bitemporal, bifrontal 9 flap probably provides the best
access to the upper face. 4t is essentially a continuation of the preauricular
incision which is carried superiorly across the scalp. 4n the midline the
incision is directed slightly anteriorly to allow for easier closure and for easy
mobilisation of soft tissues. 4t must remain within the hairline particularly in
males. 4n children this incision should not be brought forward as the scar
tends to drift anteriorly as the child grows.
he incision is first marked and it is made through the skin, superficial
fascia and galea. he line of separation is obtained in the loose areolar tissue
above the pericranium. Dissection is done anteriorly and inferiorly in a plane
temporalis fascia and pericranium. 3ppro(imately 6 cm above the orbits the
pericranium is incised in a curved fashion forward from one orbital margin to
another and this is stripped off with the anterior flap. his flap is reflected
over the bridge of the nose to e(pose the frontonasal suture, the supra orbital
rims and lateral orbital margins. Further e(posure is gained through a vertical
incision through the periosteum overlying the bridge of the nose. he supra
orbital neurovascular bundles are preserved and freed whenever necessary by
cutting a foramina with a small chisel.
For +e fort 444 osteotomy the soft tissues incision is e(tended down to
the <ygomatic arch by incising the periosteum on the temporal surface of the
orbit and the temporalis muscle retracted posterolatrally to e(pose the medial
wall of the malar bone. he periosteum is raised along the orbital margin
from the lateral, medial and superior walls. /y this approach the whole of
orbit, malar and frontonasal suture are e(posed. 4t also gives good access to
temporomadibular #oint and nasoethmoid comple( region. o avoid e(cessive
bleeding, it is important to maintain a good hemostasis with the use of Aaney
clips along the flap margins.
3fter the operations are completed the scalp flap is replaced and the
wound closed in layers with two scalp suction drain in place. =ressure
dressing are given to avoid haematoma formation.
The intraoral approach
he great ma#ority of the ma(illary procedures are performed through
an intraoral approach. "cars in the midface are to be avoided if at all possible
as they cannot be hidden well and are usually unnecessary. 2a#ority of +e
fort 4 osteotomies and segmental osteotomies of 2a(illa are done through an
intraoral incision.
B(tensive anastomosis between the terminal branches of the ma(illary
vessels allows for a wide range of buccal and palatal flaps to be raised.
Formerly tunnelling procedures have been used to maintain a dual supply
from the tissues of the cheek and palatal vessels. Cow osteotomy of ma(illa
is done based on the palatine vessels or on the labial H buccal vessels.
ncisions for !e fort osteotomy
he incisions used for +e fort 4 osteotomies include
$. unnelling approach
6. Down fracture approach
;. 3pproach in the cleft patient 1 !enderson G Eackson
&. 3pproach in the cleft patient 1 ,onverse G wake.
Tunnelling approach:
his type of incision was used during $')0 G $'.0s. !ere +e fort 4
osteotomy is done through three incisions. !ere a hori<ontal incision is
placed in the vestibule of first molar region bilaterally and a third incision is
placed vertically in the midline anteriorly. he anterolateral wall of ma(illa is
sectioned through the lateral incisions. he nasal septum is detached through
the midline incisions. he lateral nasal wall is fractured through midline
incision using Aowes disimpaction forceps. his causes tearing of nasal
mucosa. /y this approach limited repositioning is only feasible due to poor
accessibility.
Down fracture approach :
his technique developed by /ell $'.) has changed the approach to
ma(illa, aiding in positioning ma(illa in all the planes and cutting the ma(illa
into varying pieces without risk of loss of segment. his procedure can be
done under direct vision with less blood loss. !ere the incision is made high
in the ma(illary vestibule from one second molar region to other lying #ust
above the buccalH labial attached gingiva. he mucoperiosteum is raised over
the superior ma(illa, round the pyriform aperture, the malars and the infra
orbital area. Only minimal periosteal stripping is done in the dentoalveolar
region in cases of ad#utant segmental osteotomies. he nasal mucoperiosteum
is raised along the floor of the mouth which helps in detaching nasal septum
and also perform lateral nasal osteotomy cuts without tearing nasal mucosa.
Approaches in cleft lip & Palate:
!enderson and Eackson $'.) devised a useful approach for the
management of ma(illary hypoplasia in cleft lip case. hey advocated
splitting the lip through to the cleft line and then e(tending this incision into
the labial sulcus on either side. o close the fistula, a buccal flap is reflected
from the lesser segment side and it is rotated into the cleft alveolus to provide
closure to the oral layer. he nasal floor mucoperiosteum is raised from the
septum and lateral wall of the nose and closed under direct vision. "ometimes
mobilisation of palatal tissues is necessary to close the palatal cleft.
o overcome the problem of palatopharyngeal scaring and the resultant
velopharyngeal insufficiency 7ake $'.) modified the ,onverse approach to
+e fort 4 osteotomy by leaving behind the palatal tissues. !ere vertical
incisions right angle to the dental arch are placed anteriorly in the midline
and laterally in the buccal vestibule molarH premolar region. /y tunnelling
approach ma(illary osteotomy is completed. 3 palatal flap is raised a few
millimetres from the gingiva with the palatine vessels contained in it. he
palatal flaps are raised up to the greater palatine canal. he posterior
osteotomy cuts are placed anterior to the greater palatine canal and the
ma(illa is positioned anteriorly leaving behind the palatal flap. he anterior
raw area is allowed to granulate secondarily. his approach diminishes the
risk of speech changes but it is a difficult procedure and the osteotomy sites
takes longer period to unite.
ncisions for se"mental procedures
"egmental osteotomies are done on the ma(illa, these include the
anterior ma(illary osteotomy and posterior ma(illary osteotomy.
he approaches used for anterior ma(illary osteotomy are
$. 7assmunds approach
6. 7underers approach
;. Down fracture approach 8/ell down fracture modification of the ,upar
technique9.
he posterior ma(illary osteotomy is approached by
$. /uccal approach 8 :ufner9.
6. /uccal > =alatal approach 8 =erko G /ell9.
Approaches to anterior maxilla
assmund approach
he 7assmund approach relies on the buccolabial vascular pedicles and
usually an intact palatal blood supply. 3n anterior median vertical and buccal
vertical incisions are made. /uccal bone is removed through the buccal vertical
incision up to the pyriform aperture by tunnelling approach. =alatal bone is
removed by tunnelling approach under the mucoperiosteum from the socket
area. "ometimes a small midline palatal incision aids removal of palatal bone.
he nasal septum is approached through the anterior vertical incision. /y this
approach it is difficult to raise the ma(illa and to setback posteriorly.
underer approach
4n the 7underer approach, a transverse incision is placed across the hard
palate in addition to the three vertical incisions described by 7assmunds
technique. his allows better access to the palate for ma#or posterior
movements. he transverse palatal incision is arched forward so that the suture
will lie on the anterior palatal bone. he buccal bone and septum is approached
through the vertical incisions as in 7assmunds approach. he anterior
segment is hinged on its labial pedicles.
Down fracture approach
he down fracture approach is the most widely used procedure for
anterior ma(illary osteotomy as this provides good access and also reliable
blood supply. !ere a vestibular incision is placed in the labial vestibule. he
buccal osteotomy cuts are done through tunnelling approach. he nasal
mucosa is raised and the nasal septum detached through the vestibular
incision. 3ny midline splitting is done before the completion of segmental
osteotomy.
Approach to posterior maxilla
he approach to posterior ma(illa, usually for raising the buccal
segment, may be through the buccal and palatal mucoperiosteal incisions.
!ufner "#$% described a single buccal incision approach. his approach
is difficult in flat palate and when antral walls are thick. he buccal bones are
cut through the buccal incision and the vertical cut in the premolar region is
done through the tunnelling approach. he palatine bone is cut by using a fine
curved osteotome. 7hen a palatine incision is planned it should be made
medial to the palatine foramen and the osteotomy is performed lateral to the
foramen.
7hen the palate is very flat the Per&o 'ell techni(ue )"#*$+ may be
adopted. !ere both walls of the antrum are cut through the buccal approach. 3
parasagittal incision is made in the palate from premolar area to the #unction of
the hard and soft palate and the alveolar bone e(posed and cut medially to the
greater palatine foramen in an anteroposterior direction.
/esides these, a variety of techniques have been described to deal with
individual problems in ma(illa. 4t is best to choose the safest and most reliable
one for the situation.
Osteotomy techniues ! Maxilla.
3 variety of osteotomy techniques have been described to correct the
midface problems. he osteotomy techniques include either a segmental
osteotomy of ma(illa where a part of the ma(illa is osteotomised and
repositioned or total ma(illary osteotomy is done at +e fort 4, 44, or 444 level to
correct the deformity.
#e"mental sur"eries of Maxilla
he types of segmental osteotomies described for ma(illary
procedure include G single tooth osteotomy , anterior ma(illary osteotomy
and posterior ma(illary osteotomy.
#in"le tooth $steotomies
,ndication
$. he procedure is mostly used for dilacerated teeth
6. hose teeth that have been impacted into the alveolar bone following
trauma.
;. Occasionally when more than one tooth requires repositioning.
Procedure
his procedure is limited to ma(illary anterior tooth. his procedure
requires good amount of inter radicular bone. he approach to single tooth
Osteotomy is through either a small high hori<ontal labial sulcus incision or
alternatively through two vertical incisions on either side of the tooth.
7hen using two vertical incisions, these are made through the
mucoperiosteum a millimetre or two on either side of the proposed bone cut.
he incision starts high in the labial sulcus and stops 6 G; mm from the
alveolar crest. 2ucoperiosteum is not elevated over the tooth that is to be
repositioned. +abial bone cut in made with fine burr, in the centre of inter5
radicular area parallel to each other. !igh in the labial sulcus the
mucoperiosteum is elevated 8 tunnelled 9 above the root ape( of the tooth to
be moved so that a hori<ontal cut may be made at least above the ape(. he
segment is separated by the use of fine osteotomies. he osteotomies are
angled to the palate on the either side and a finger is kept in the palate to feel
the instrument penetrating the palatal bone. he supra5apical division is
similarly made through the palate with a curved osteotome. Once the tooth
segment is mobile it is best to fi( it to the ad#acent teeth by means of an
orthodontic arch and attachments.
4n hori<ontal labial incision technique care is require when
tunnelling vertically on either side of the tooth not to detach the labial
mucoperiosteum on its anterior surface. he remaining procedures are same
as described before. 4mmobilisation of tooth segment is required for several
weeks.
/asic surgical principles of single tooth osteotomies are
8$9 2aintain an adequate amount of attached, viable tissue to the
mobilised segments in order to provide sufficient vascularity to them.
869 =rovide ma(imal direct visualisation of all areas to be
osteotomised or ostectomised.
8;9 3chieve good mobilisation of the segments to allow for passive
repositioning in the predetermined position
8&9 2aintain operational periodontal health.
8)9 =rovide good bony contact between the stable and mobilised
segment to effect rapid bone union.
%nterior Maxillary $steotomy
3n initial discussion of anterior ma(illary osteotomy was
presented by ,ohn5stock in $'6$. he single state predominantly labial
approach was first reported by 7assmund in 8$'6-9. 3(hatusen added a
tunnelling procedure on the palatal side 8$';-9, "chuchhardt 8$')-9
preferred a two stage procedure, with the palatal side being treated first and
completion of surgery &5- weeks later from labial approach.
he most popular technique of segmental surgery is the down
fracture described by Bpker and 7elford 8$'%09.
he anterior ma(illary osteotomy is primarily employed
$. 5 Aeposition the dento alveolar segment posteriorly
6. 5 ,orrection of ma(illary protrusion
;. 5 /ima(illary protrusion 5 along with mandible, 8anterior
segment9
&. 5 ,orrection of openbite 8"econdary to mandibular correction9
4n certain cases the dento5alveolar protrusion with or without
vertical ma(illary e(cess, it might be difficult to decide between 3nterior
ma(illary osteotomy and a +e fort 4 osteotomy with an anterior ma(illary
osteotomy to correct the deformity. 4n these situations these guidelines might
be helpful.
4f sufficient overbite e(ists and an impaction of ;mm or less is required
then an isolated 3nterior ma(illary osteotomy would suffice.
4f more than ;mm impaction is required and even if overbite e(ists le
fort 4 osteotomy should be done in combination with anterior ma(illary
osteotomy.
4f there is negative or minimal overbite, even if the ma(illary
impaction is minimal le fort 4 with anterior ma(illary osteotomy is indicated.
4f the ma(illary impaction planned is minimal less than ; mm, but if
the gingival level between the teeth ad#acent to the osteotomy has a steep
angle, a +e fort 4 osteotomy with anterior ma(illary osteotomy should be
planned.
assmund techni(ue: - .a/ial 0ertical incision with palatal tunnelling1
he 7assmund approach relies on the buccolabial vascular
pedicles and usually an intact palatal blood supply.
3n anterior median vertical and buccal vertical incisions in the
canine G premolar regions are made e(tending to the nasal floor. he
mucoperiosteum is reflected posteriorly and superiorly. 4n the apical region
of the canine tunnelling is carried out to the inferolateral border of the nasal
pyriform aperture. 2ucoperiosteal flap raised to e(pose pyriform rim and
nasal spine.
*ertical bony cuts are made in the lateral ma(illary corte( at the
midpoint of planned osteotomy site. hese are carried superiorly to a point
appro(imately ;mm superior to canine ape(. he anterior bony cuts are
completed by continuing the cuts medially to a point on the most lateral
aspect of pyriform aperture. hese are made with tapered fissure bur.
On palatal aspect a subperiosteal tunnel is created on the area of
planned palatal osteotomy. 7hile the palatal tissue are protected with a
suitable retractor the bony cut is carried from crest of alveolar bone in one
osteotomy site across palate to opposite side. ,are must be taken to avoid
damage to nasal floor mucosa and penetration of endotracheal tube.
"ometimes a small midline palatal incision aids in the removal of palatal
bone.
he nasal septum is approached through the anterior vertical
incision. he remaining bony attachments of the anterior ma(illary segment
are severed with a narrow single bevelled osteotome along the floor of nasal
cavity.
he segment is manually freed by covering it with a gau<e
sponge, and manipulated to get free of all attachments e(cept palatal pedicle.
4t is tried into the post operative site. 4f any bony prominence
interfering this can be removed. Final positioning is done with the aid of an
occlusal splint. /efore placement of splint the palatal tissue is closed with a
hori<ontal mattress suture.
/y this approach it is difficult to raise the ma(illa and to setback
posteriorly.
underer2s techni(ue
7underer 8$'-69 developed his procedure to provide a palatally
oriented approach to the sectioning and reposition of anterior ma(illary
segment. /ecause of the segment is pedicled on labial mucoperiosteum it is
possible to rotate it anteriorly for better visualisation of surgical site. !ere
bony section may take place under direct vision. his is indicated if posterior
movement is the dominant ob#ective.
Techni(ue
*ertical incisions are placed on the labial and buccal
mucoperiosteum. "ubperiosteal tunnelling is done and osteotomy is done
through the vertical incision on the buccal and labial aspect.
On the palatal aspect an arcing incision is made through the palatal
mucosa from the inter5dental space anterior to the site of the planned
osteotomy cut. he mucoperiosteum is raised on to the posterior palatal side.
he buccal osteotomy cuts are #oined transpalatally under direct vision. ,are
is taken to prevent damage to the nasal floor mucosa. 4f a midline split is
required, it is fractured with a fine long bevelled osteotome.
he segment is freed completely by covering it with gau<e sponge and
with controlled manual force fracturing it from its remaining attachments.
he recipients site is contoured with a bur. he mucoperiosteal flap is
replaced with a hori<ontal mattress suture. he segment is fi(ed with pre5
fabricated splint.
Down fracture techni(ue3
,upar $')) modified two stage procedure of anterior ma(illary
osteotomy into single stage down fracturing technique. his technique is
mainly indicated if superior positioning is the dominant ob#ective. Bpker
described some advantage of this down fracture technique.
$. 5 4t is technically simple
6. 5 =rovides direct access to nasal crest of ma(illa and associated
nasal septal structures.
;. 5 =ermit removal of palatal bone under direct vision.
&. 5 ?ives e(cellent vascular pedicle.
he incision is made high in the labial vestibular mucosa at
least )mm above the root apices from premolar to premolar on the other side
curving slightly in the midline towards the labial mucosa. "ometimes vertical
incisions are placed anterior to the posterior osteotomy cuts.
he mucoperiosteum is raised to e(pose pyriform fossa, nasal
septum,
anterior nasal spine and the sub apical bone over the anterior tooth from
premolar to premolar tooth.
he first premolars are e(tracted on both sides. he hori<ontal
line of osteotomy is marked with bur starting from the pyriform rim up to the
region of the e(tracted socket keeping at least )mm above the root apices of
the canine and incisors. he nasal mucosa is protected through out the
procedure. hen the osteotomy cut is turned vertically down to reach the
alveolar margin by tunnelling approach or under direct vision when vertical
incisions are used. wo vertical cuts are placed depending upon the amount
of posterior setback. his buccal cortical bone is removed with a chisel.
3fter removing buccal bone the bur is directed to palatal bone in
a semiblind
fashion. 3 finger is placed on palatal aspect to feel the cutting process and
also to prevent penetration of bur through the palatal mucosa is avoided.
he same procedure is repeated on the other side. Casal mucosal
floor is raised and the nasal septum is detached using a septal osteotome. he
bone cut is completed on the palatal aspect with an osteotome by using gentle
tap. 3lternatively the palatal mucoperiosteum is raised and bur used to
complete the cut sometimes small midline vertical incisions are placed in the
midline to gain access.
he segment is then down fractured and the bone is removed
from palatal
aspect under direct vision.
he palatal mucoperiosteum is reflected slightly from the stable
part 8=osterior9. his will allow easy movement of anterior segment
posteriorly.
7hen superior positioning is planned the nasal spine is removed,
the nasal floor in the mobilised segment is grooved to accommodate, the
nasal septum,
or a segment of septum is sectioned from its anteroinferior part.
3fter the indicated amount of bone is removed the splint is
inserted. 4f the
correct position is not attained, the osteotomy site is re5e(amined and any
bony pro#ections are removed.
+ shaped miniplates are used along the pyriform rim for fi(ation.
"crews are placed at least ;mm away from root apices. 3dditional stability if
needed can be achieved by wiring using a 6- gauge wire.
. During final positioning, care is taken not to crimp the palatal
tissue between the segments as this would compromise the blood supply.
he wound toilet is done and the labial incision is closed in two
layers. 3ny palatal or nasal floor tears are sutured with ;50 vicryl. 4f alar base
widening is significant then alar cinch suturing is done before mucosal
closure.
&osterior Maxillary alveolar $steotomy
@nilateral or bilateral posterior ma(illary osteotomy or
ostectomy provides a means of surgically correcting a wide variety of
occlusal and dento alveolar deformities. he relative indication of this
procedure are.
8$9 o alter the transverse position of the posterior ma(illa 8to
correct cross bite9.
869 o superiorly position a supra erupted posterior segment.
8;9 o inferiorly position a posterior segment. 8o close a posterior
open bite9.
8&9 o move a posterior segment forward to close an edentulous
space.
Cumerous technical approaches to the posterior ma(illary
osteotomy have been advocated. "chuchart 8$'))9 described a two stage
method applicable to the closure of a posterior open bite. 4n first stage the
palatal bony cut is done and after - weeks the second stage, the buccal
osteotomy, is performed.
:ufner 8$'-%9 modified this technique to a one stage procedure.
4n this only buccal approach is done and palatal bone is divided through the
osteotomy site by a thin osteotome as in case of down fracture technique.
7est and Bpker $'.6 also described similar procedure.
Aegardless of the technique utilised, principles of surgical reposition in this
are similar to anterior segmental surgery.
The techni(ue3
3ccess to the posterior segmental osteotomy is gained through a
buccal sulcus incision e(tending from $st molar to canine region. hen it is
turned vertically down to marginal gingiva one tooth anterior to osteotomy
site. he muco periosteal flap is reflected to e(pose the lateral aspect of
alveolar portion, lower part of <ygomatic buttress and posteriorly to the
pterygoid plates if needed. 4f a tooth is planned to e(tract from the posterior
end the mucosal reflection is limited to that region.
3fter bone is e(posed the bony cut is marked by measuring with
calliper and marks with pencil. he bony cut should be at least )mm above
the root apices in order to preserve blood supply.
3 predetermined amount of bone is removed from the buccal
aspect 8lateral ma(illary wall9 and the inter5dental alveolar osteotomy is then
completed from the buccal aspect. ,arefully e(pose the sinus mucosa and
reflect it superiorly. 4n cases of e(cessive supra5eruption of dento5alveolar
segment the plane of osteotomy will be below the antral floor.
Cow the palatal bone is divided. 4t can be done using bur or
osteotome. 4n both cases a finger is placed as palatal mucosa to feel the
instrument as it breaks the palatal bone.
4f the osteotomy is e(tending posterior to 6nd molar, the level of
bone cut is lowered posteriorly. his will help easy separation or division of
pterygoid plates.
4f the osteotomy site at buccal aspect is small it will be difficult
to cut the palatal bone through this. 4n such cases a palatal incision is placed
anterior to the area of bone cut mucosa can be tunnelled and osteotomy can
be done under direct vision.
he segment is down fractured with the osteotome placed in
bone cut and lowered inferiorly. 3 small curved osteotome is used to
separate the pterygoid plates. he bone removal is now completed. 4f
needed palatal mucoperiosteum can be reflected from stable part. On
posteromedial aspect of segment palatal neurovascular bundle can be
identified. /one is removed carefully surrounding this and can be freed.
3fter the bone removal is completed the segment can be fi(ed
with preformed acrylic splint.
Total maxillary osteotomies
!e 'ort $steotomy.
Barly effort to reposition the entire ma(illa were directed at
correcting traumatically malpositioned ma(illary comple(, and also to correct
midface deformities secondary to cleft palate. he danger of ma(illary sinus
infection and fistulae as well as the possibility of necrosis of bony segment
deterred, many surgeons from attempting this correction.
7assmund 8$'6.9 performed this type of surgery to close a
posterior openbite and in this after sectioning the lateral ma(illary wall be
used elastic traction to bring the ma(illa down. 3(hausen 8$';)9 was first to
advance the lower portion of ma(illa using this technique. "chuchardt 8$'&69
applied forward traction using a pulley and weight system to produce an
advancement of sectioned ma(illary segment.
ransection of pterygoid plate in +e Fort 4 ma(illary osteotomy
was described by "chuchardt $'&6. 2oore and 7ard $'&' advocated the use
of hori<ontal transection of the pterygoid for anterior advancement of
ma(illa.
,upar and Aowe $')& reported the use of bone grafting in +e5
Fort 4 ma(illary advancement. ,erinac and associates 8$'))9 and ,erinac in
8$')%9 were also reported the use of bone grafts.
4n $')' :ole developed a two stage procedure for total
ma(illary osteotomy. 4n the first stage he performed a @ shaped palatal
osteotomy anterior to greater palatine foramen and in second stage a labial
bone cut is made. =aul 8$'--9 reported a similar procedure in a single stage.
Obwegeser $'-' introduced a technique of wedging of bone graft between
the pterygoid process and tuberosity for advancement of ma(illa after
surgery.
Dupont, ,iaburo and =revost $'.& advocated sectioning
through the tuberosity rather than at the pterygoma(illary interface. his
modification was described by rimble, ideman and "toleinga $'%;.
/ell at al $'.) described down fracture technique of +e Fort 4
Osteotomy. Bpker and 7olford 8$'%09 rectified this technique and described
it in detail. he advancement studies were done by /ell and "cheindermann
8$'%$9. he associated changes in facial muscle was studied by "chendel
8$'%;9. +uhr and Aadney $'%- described the use of rigid fi(ation by
miniplates in +e Fort 4 osteotomy.
4ndications of +e Fort 4 Osteotomy
$. 3ltering the vertical dimension of ma(illa
5 "uperior positioning in long face syndrome
5 4nferior positioning.
6. 3ntroposterior movements of ma(illa
4n cleft palate patients > congenitally deficient ma(illa
5 2a(illary advancement
5 2a(illary set back in ma(illary prognathism
8only ;5)mm is possible9
;. +evelling of occlusal plane in occlusal cant.
&. "urgical e(pansion of ma(illa
). Carrowing of ma(illa.
T4567,894
3 hori<ontal vestibular incision is made from the mesial aspect of the
ma(illary first molar from one side to the other side about )mm above the
apices of the ma(illary teeth. he incision can be made with blade or
diathermy. he mucoperiosteum is reflected to e(pose the pyriform aperture
and lateral wall of ma(illa. =osterior to <ygomatic buttress the
mucoperiosteum is tunnelled to e(pose the tuberosity. he elevation of
mucoperiosteum is e(tended to infra orbital neurovascular bundle. Casal
mucosa is reflected from lateral nasal wall, floor of the nasal cavity and from
the lower end of the nasal septum.
he osteotomy line is marked on the bone over lateral aspect. 4t
should be )mm above the apices of teeth, sloping down ward posteriorly.
*ertical reference lines can be marked to access the anteroposterior
movement of the mobilised segment. Osteotomy cuts are then completed with
a flat fissure bur or with an oscillating saw. /one division starts from lateral
wall of pyriform aperture and taken posteriorly. /risk oo<ing is sometimes
noticed along the anterior ma(illary wall. For ma(illary impaction the
planned amount of bone is removed from the lateral ma(illary walls of the
ma(illa after marking out two line anteriorly. =osteriorly these lines are
merged or kept parallel depending upon the type of movement required.
noticed /one removal should be done. his gives a narrow, well controlled
bone cut. 4n case of superior repositioning the cut can be made with bur as
some amount of bone removal is indicated.
he lateral wall of ma(illary sinus is then divided. 3 retractor is used
to protect the buccal soft tissue. his cut is taken posteriorly to
pterygoma(illary #unction. +ateral wall of nose is divided below the inferior
turbinate with a flat osteotome. he cut is directed towards the
perpendicular plate of palatine bone which is partially divided. ,omplete
division may cause e(cessive bleeding from palatine vessels.
he nasal septum is divided with a septal osteotome, along the floor of
nasal cavity. he osteotome is hold parallel to occlusal plane. he
endotracheal tube is protected now. 3fter all the walls are divided , a curved
osteotome is used to complete the bone cut at pterygoma(illary #unction.
his is separated by gentle tapping . 3 finger is kept posterior to pterygoid
hamulus to feel the separation.
2a(illa is now down fractured by thumb placed over the alveolar
bone. 3s the down fracturing progresses the nasal mucosa is reflected
posteriorly.
"ome times the separation may be achieved by disimpaction forceps or
by use of special instruments like smith split spreader.
For superior and posterior positioning elective bone removal is done
with rounger or bur. he removed bone chips can be collected in saline for
filling the gap after fi(ation as autogenous grafts. his will speed up bone
healing . =osterior repositioning with osteotomy of the pterygoid plates is
difficult. Only ) to - mm of posterior movement is possible. 4f e(cess
movement is desired then a two piece ma(illary osteotomy is to be planned or
a ma(illary tuberosity osteotomy is planned.
For ma(illary advancement the bone graft is placed between the
pterygoid process and ma(illary tuberosity. For this communication of
pterygoid plates should be prevented during separation of pterygoma(illary
#unction. 4ntact pterygoid plates will act as a posterior stop for bone grafts.
some authors described a vertical step in the lateral cut in the region of the
second premolar. his aids in measuring the movement and also to serve as
stop for any bone graft that may be placed in the region.
4n congenital ma(illary hypoplasia a ;5)mm stable advancement is
possible without placing bone grafts.
4n cases of augmentation of vertical ma(illary height the bone cut is
made a higher level with respect to pyriform aperture. his is to get )mm of
bone in sub apical region after the osteotomy of lateral and medial walls. he
ma(illa is advanced and lowered using rows disimpaction forceps. he beaks
are applied below the nasal mucosa and gentle rocking of the ma(illa will
help to relieve soft tissue resistance to anterior traction. 3fter adequate
inferior traction bone grafts ' split thickness calvarial grafts 9 are fi(ed in
position.
"egmentali<ation of the +e Fort 4 segment can be done if
necessary, taking care to preserve the vascular pedicle. he common
segmentali<ation procedure include1
$. 3nterior ma(illary osteotomy
6. "agittal midline osteotomy.
he anterior ma(illary osteotomy is combined with +e fort 4
impaction in patients who have vertical ma(illary e(cess with dento5alveolar
protrusion of moderate to severe degree. he osteotomy is usually carried out
through the socket of the e(tracted $st or 6nd premolar. he bone cuts are
made through tunnelling of the mucoperiosteum for access. ,are is taken to
preserve the pedicles.
3lterations in transverse dimension if required can be performed after
down fracture. 4n cases requiring e(pansion a mid palatal split is done using a
fissure bur. he palatal muco periosteum is protected while doing this. 3fter
bone division the 2ucoperiosteum is reflected through the osteotomy gap
and e(tended to vertical alveolar portion. "hould not damage the palatal
vessels. @p to -mm of e(pansion is possible without bone grafting. 4f
e(cessive e(pansion is done the stretching of palatal mucosa may lead to
ischaemia and necrosis of bone as well as soft tissue. 4f the bone gap is more
than -mm partial thickness parietal bone graft should be fi(ed in this gap.
4n case of narrowing of ma(illa the alveolus should be divided in
midline before down fracturing and then the down5fracturing is done and the
division of palatal midline is done posteriorly. he mucoperiosteum is
reflected from the edge of osteotomy and adequate bone is removed from
midline. hen by pushing the mucoperiosteum into oral cavity the segments
can be fi(ed together with inter osseous wiring. 3lterations of occlusal plane
may be required in some cases. Oblique occlusal plane can occur in patients
with unilateral condylar hypoH hyperplasia, hemifacial microstomia, Aomberg
syndrome etc. he assessment of this defect should done by clinical
e(amination and evaluating =3 cephalogram. his condition is treated by.
5 4ncreasing vertical !t. of ma(illa on one side.
5 Decreasing vertical height on one side.
5 or a combination
3 combined form of treatment is often more practical because of
concomitant soft tissue changes. !ence the height is increased slightly on
side of deficit and decreased on side of e(cess. his should be accompanied
by mandibular surgeries to attain complete occlusion. For levelling of
occlusal plane the ma(illa is released in +e Fort 4 plane. he e(cessive bone
is removed from one side. he other side is augmented by bone graft.
,orticocancellous grafts from iliac crest is ideal if e(cessive alteration is
required.
:ixation
3fter the required corrections, the ma(illa should be fi(ed to the basal
bone. !istorically, the mobilised ma(illa was fi(ed directly to the pyriform
rims and <ygomatic buttress with transosseous wires or suspension wires
placed at the <ygomatic buttress, the <ygoma or in the infra orbital rim.
4n cases of transverse corrections a prefabricated acrylic splint should
be placed to get three dimensional stability of the occlusal plane. 4n other
cases a temporary inter ma(illary fi(ation should be done. During this it
should be ascertained that the condyle of mandible is in glenoid fossa. 3fter
the 42F is done the segment is fi(ed superiorly.
4n cases of superior and backward positioning a circum <ygomatic
suspension can be done. his gives a postero5superior force. he wires are
tightened simultaneously on both sides.
4n ma(illary advancement without inferior positioning a infra orbital
rim suspension is recommended. his gives a upward and anterior vector of
force.
he inferior positioning is difficult to fi( by these methods. 7iring at
lateral pyriform border can be done. "imultaneous wiring of bone graft also
to be done.
4nstability of the ma(illary repositioning has been noted and these have
been attributed to various factors. hese include
$. 4nadequate bone stabilisation
6. =oor bone contact.
;. B(cessive superior repositioning or superior relapse of an inferiorly
placed ma(illa may be due to the mandibular occluding forces as
the masticatory muscles contract.
&. 2a(illary advancement is also plagued by relapse, especially
following large forward movements or due to e(cessive soft tissue
restriction after multiple or cleft surgeries.
o overcome these problems more rigid forms of fi(ation are devised.
hese include rigid ad#ustable fi(ation and rigid internal fi(ation.
;igid ad<usta/le fixation for maxillary osteotomy
hese uses mainly pins and wires to secure the ma(illa. *arious forms
of rigid ad#ustable devices had been advocated. /ays $'%) suggested the use
of 6.. mm screws in the superior segment. =ins are attached to the arch wire.
hen 0.0&) inch orthodontic wire is used to stabilise the ma(illa to the
screws and pins. his can be ad#usted postoperatively for minor ad#ustment in
ma(illary position.
/ennett > 7olford $'%) suggested another system where in they used
6mm "teinmann pin into the <ygomatic buttress area. hey secured it to the
arch wire using acrylic. hey obtained anterior stabilisation by rigid internal
fi(ation by means of miniplates.
hese pins can be removed after healing by local anaesthesia and
intravenous sedation.
,nternal rigid fixation for maxillary osteotomy3
Aigid fi(ation with screws and plates gives satisfactory stable fi(ation
in all forms of osteotomy. his is especially important in inferior positioning
of ma(illa which is least stable when other forms of fi(ation are used.
"imultaneous fi(ation of bone grafts also can be achieved with rigid fi(ation.
his will improve the graft viability. 4n +e Fort 4 osteotomy the areas
suitable for rigid fi(ation are <ygomatic buttress and pyriform margins.
hese areas having adequate bone thickness of insertion of screws. 3fter the
planned post operative position is achieved and temporarily 42F performed
straight, + shaped or shaped plates suitable for 6mm screws are passively
adapted in these areas. 4mproper adaptation will lead to alteration of
occlusion later. he holes should be perpendicular to surface in5order to
achieve ma(imum bone thickness for screws.
4an 2unro 8$'%'9 recommended at least & plates should be used for
+e5Fort 4 osteotomy. wo at <ygomatic buttresses, two at lateral pyriform
margins. Bach plates should have & holes minimum 6mm monocortical self
tapping screws are widely accepted.
2c,arthy 8$''09 recommended that if rigid fi(ation is planned the
osteotomy should be done at a higher level in order to get adequate bone at
sub apical region for placement of screws without endangering root apices.
"tella > Bpker $''& advocated semirigid fi(ation with posterior
<ygomatic buttress wiring and anterior plates in the pyriform rim. he
posterior <ygomatic buttress wiring can be ad#usted depending on the
occlusal needs of the patient.
ound closure & Soft tissue considerations3
3fter satisfactory fi(ation the area is irrigated inspected for loose bony
fragments, and any other foreign bodies. ,losure of the incision line can be
done in two layers. /efore that any mucosal tear should be sutured with & K0K
catgut. his will reduce the chance of post operative nasal bleeding.
7idening of alar base is a frequent complication of superior
positioning of ma(illa. his can be prevented by a traction suture 8 alar cinch
suturing 9 with a non observable material across the alar base. ?ahli > "inn
$''. advocated 7eir procedure or a simple lateral nostril sill e(cision with
undermining and re5appro(imation for management of increased alar base
width. Other authors have advocated the use of secondary rhinoplasty
techniques for management of the alar basal width problems. :awanato
8$'%'9 recommended separation of anterior nasal spine from ma(illa
along with nasal septum. his will retain the soft tissue contour at the nasal
base.
he upper lip length and vermilion e(posure changes drastically with
+e fort 4 osteotomy. +ip length reduces by 60 L of the planned bone
movement in a +e fort 4 impaction with reduction in vermilion e(posure. *5
I closure of the mucosa with a vertical limb of $0 G$) mm maintains the pre5
operative vermilion e(posure and lip length. 3 vertical limb of $) G 6) mm
increases lip length by about $ G6 mm and also increases vermilion e(posure.
3ppropriate use of these closure method is indicated depending upon the
treatment plan.
Total Maxillary al0eolar Osteotomy )TMAO+ )6all and ;oddy "#$=+
otal ma(illary alveolar osteotomy was described by =aul $'-' based
on the e(periences of :ole > 2ohnac. !all > Aoddy $'.), 7est and
2cCeil $'.), !all and west 8$'.)9 , 7est > Bpker $'.6 also published this
as a treatment for total ma(illary alveolar hyperplasia. 2eloney et al 8$'%69
reviewed few cases of this and concluded that 23O is a "good technique in
his time"
"terling A. "chow 8$'%-9 described few advantages
8$9 4t can be used to intrude ma(illa for hyper plastic ma(illary
alveolus, to correct posterior or total alveolar hyperplasia with or without
anterior open bite. his is particularly useful when impaction of the segment
is more than )mm.
869 4t is a substitute for +e Fort 4 surgery when there is long alveolar
process with high arched palate.
8;9 he reduction of sinus volume and possibility of air way
constriction is avoided with 23O.
8&9 Bven in absence of vertical e(cess, this can be used to e(pand,
constrict or recontour the alveolar arches. 4n such cases it provides a stable
palatal base to which the segments can be fi(ed.
8)9 4t is less suitable for inferior positioning or advancement.
Bpker and 7olford $'%0 described this technique as "superior
positioning of ma(illa with nasal floor intact". hey gave the indications for
this procedure.
8$9 7hen superior movements $05$)mm is required.
869 4n pre5e(isting decreased nasal airway function not related to
nasal septal deviation 8DC"9 or large inferior turbinate.
8;9 when segmentalisation of ma(illa is required in ; or & segments.
Techni(ue3
his may be accomplished with surgical access obtained through a
hori<ontal mucoperiosteal incision near the depth of the labial vestibule
similar to that of +e fort 4 down fracture technique or through multiple
vertical incisions with tunnelling beneath the alveolar mucosa and palatal
access through incision and elevation of a palatal "horseshoe" mucoperiosteal
flap.
3 circum5vestibular incision is made which e(tend from one
Mygomatico alveolar crest to the other. =osterior to that the soft tissue is
undermined to the pterygoma(illary #unction.
he alveolar portion and lateral ma(illary wall is e(posed by minimum
but adequate elevation of mucoperiosteal flap is done.
he nasal epithelium is elevated starting from pyriform aperture to $05
$)mm posteriorly, and also from the anterior floor of nasal cavity and inferior
portion of septal cartilage.
/y protecting the nasal mucosa with a retractor the hori<ontal
osteotomy through the lateral ma(illary wall is made e(tending from the
nasal cavity to the pterygoma(illary #unction. he anterior $0 to $) mm of
lateral nasal wall is also transected. 4f superior impaction is planned, the
inferior osteotomy is completed & to ) mm above the apices of the tooth and
this is followed by a superior osteotomy to remove the measured amount of
bone. =osteriorly the osteotomy is directed towards the pterygoma(illary
#unction or to the third molar e(tracted site which has been removed & to -
weeks prior to surgery.
4f the dentoalveolar segment is to be divided into multiple segments,
the mucoperiosteum overlying the alveolus at the site of osteotomy is
tunnelled and the osteotomy cut performed. he palatal bone at the vertical
osteotomy site is cut taking care to prevent damage to the palatal periosteum.
3 K*K shaped groove is cut from the anterior nasal floor in the midline
after separating the nasal septum from floor of nasal cavity. his should be
&mm away from root ape( of central incisor. his is to accommodate the
nasal septum during superior positioning of ma(illa. 4f this clearance is not
possible the anteroinferior portion of septum should be sectioned.
he palatal bone cuts are made. 4n the anterior region if there is large
amount of bone in the alveolar segment then bone cuts are made inferior to
the floor of the nasal cavity. 7ith a small osteotome or a fissure bur a
transnasal osteotomy is completed from right to left across the palate
appro(imately $0 to $) mm into the nasal cavity. 3 palpating finger is
placed on the palatal side to avoid damage to the palatal mucosa. +aterally
the bone cuts e(tends into ma(illary sinuses. =osteriorly the osteotomy cuts
e(tends along the medial wall of the ma(illary sinus below the level of the
nasal floor into the oral cavity.
wo osteotomes are inserted in the osteotomy gap and is levered down
wards to down fracture the ma(illa. 4f it fails a curved osteotome is used to
remove palatal bone posteriorly. his should be carefully done.
4f the ;rd molar is to be removed either due to impaction or any other
causes it can be done at this time. 4f so the osteotomy can be limited to ;rd
molar socket. Or the pterygoma(illary #unction can be disrupted by gentle
tapping with osteotome.
3fter down fracture adequate bone is removed from palatal side and
the segment can be moved to its pre5planned position.
he palatal mucoperiosteum can be undermined carefully from the
fi(ed part. his will help in easy positioning of the segments.
he mobilised segments are now repositioned by selective bone
removal and the planned postoperative position is attained.
he fi(ation can be done by a prefabricated occlusal splint made from
mock surgery on study model. Or the fi(ation can be done with orthodontic
appliance. 3 temporary inter ma(illary fi(ation is performed to ascertain the
anteroposterior relation. he segment is now fi(ed superiorly. 4n cases of
superior and posterior placement, a circum5<ygomatic suspension can be
used. 4f the repositioning is in a superior and anterior direction suspension to
infra orbital rim can be done.
3lternatively a lateral pyriform rim wiring can also be used. Cow the
temporary inter ma(illary fi(ation is removed and the wound is closed.
"ome modifications are suggested to this standard technique.
/ell $'.) used the same incision as in +e5Fort 4 Osteotomy.
/ell, 7est 8$'.)9 7est and Aoddy $'.- and 2cCeil on 8$'.)9
described a combined palatal and labial approach. 4n this on the labial aspect
; vertical incisions are used one in midline, other in premolar region on both
sides. hrough this sub mucosal tunnelling is done and osteotomy is
performed on buccal and labial aspect. 3fter the buccal osteotomy is
completed a palatal mucoperiosteal flap is raised. For this a @ shaped
incision is put about $cm apical to gingival margin starting from one 6nd
molar region lateral to the greater palatine vessels. 4t is brought anteriorly
#ust lateral to greater palatine vessels, 3nteriorly is turned to opposite site #ust
palatal to incisive papilla, and e(tend to other 6nd molar. 3 full thickness
mucoperiosteal flap is raised. Cow the palatal bony cut is done directly,
dividing the palatal wall of ma(illary sinus and anterior nasal wall. =osterior
to the greater palatine foramen the bone may fractured or divided with
osteotome. 3fter adequate bone is removed the segment can be fractured
using digital pressure or by levering instruments. "elective bone removal is
done and the segment is repositioned and fi(ed. his technique has
advantage of direct access to the palatal bone and is suitable in cases of thick
palate. /ut the palatal vascular pedicle is compromised.
3ll the authors suggested that if there is adequate bone in sub
apical region and below the nasal and antral floor, the osteotomy should be
done at this plane without entering the nasal and antral floors for impacting
the ma(illa.
8uadrangular .e :ort , osteotomy3
!ugo Obwegesser $'-' described a high +e fort 4 osteotomy for
correction of midfacial hypoplasia in cleft lip and palate patients. his was
named Duadrangular +e Fort 4 osteotomy by :eller > "ather $'%', because
of the indications, osteotomy shape and level and pro#ected clinical outcome
were quite similar to those of the quadrangular +e fort 44 osteotomy as
described by :ufner. !ere the advancement of both the infra orbital rim and
a portion of the <ygomatic comple( is done.
,ndications
his is mainly indicated in patients with ma(illary5<ygomatic
hori<ontal deficiency, with class 444 skeletal malocclusion and normal nasal
pro#ection. his is ideal in management of midface hypoplasia with midline
problems or transverse deficiency.
Procedure
he procedure is done intraorally through the down fracture
approach of +e Fort 4 osteotomy by a hori<ontal vestibular incision. he
entire surface of the anterior ma(illa is e(posed by subperiosteal dissection
e(tending from the right to left tuberosity and up to the infra orbital rim. he
infra orbital nerve is isolated and the orbital rim periosteum is reflected. he
mucosa over the floor of the nose is e(posed and also from the lateral nasal
wall.
he osteotomy cuts are placed on the lateral wall of ma(illa from the
pyriform aperture at the level of the infra orbital nerve. he osteotomy is
e(tended laterally below the level of the infra orbital nerve to the tuberosity
and pterygoid plate region. he ma(illa is down fractured after detaching the
nasal septum, pterygoma(illary dis#unction and ostectomising the lateral
nasal wall.
/one grafts are used in the infra orbital region and also in the
pterygoma(illary #unction.
.e :ort ,, Osteotomy
,onverse $'.$ described an osteotomy for correction of the
nasoma(illary hypoplasia. his was classified as "3nterior +e Fort 44
osteotomy" by "teinhFuser $'%0. !enderson and Eackson 8$'.;9 described
classical +e Fort 44 Osteotomy for patients with naso ma(illary and midface
hypoplasia. his was classified as "=yramidal +e Fort 44 osteotomy" by
"teinhauser. :ufner 8$'.$9 described an osteotomy for correction of nasal
hypoplasia and also for the infra orbital region. "imilar osteotomies were
described by "ouriyas et al $'.;and ,hampy $'%0. his was classified as
"Duadrangular +e Fort 44 osteotomy by "teinhauser. Bpker and 7olford in
$'%0 given a detailed description of standard +e Fort 44 Osteotomy.
Anterior .e :ort ,, osteotomy3 )7aso>Or/ito>maxillary osteotomy+3
4t is an initial form of +e Fort 44 osteotomy described by
converse and associates 8$'.$9. @sed to correct the nasal and ma(illary
deficiency. he principles of these procedure are1
5 he foreshortened nasal septal frame work must be advanced as
it will oppose
nasal lengthening.
5 3 forward and downward placement of nasal and ma(illary
comple( is required to correct midface deficiency.
5 he naso lacrimal apparatus must not be disturbed.
5 /one grafts should be used to restore the /one deficiencies.
5 "kin coverage and nasal lining must be provided to
accommodate the nasal
elongation.
he upper part of this osteotomy done, through a * shaped
incision with the ape( at glabella and e(tended bilaterally along both sides of
nose to reach #ust above the alar base. he cartilaginous and bony part of
nose is separated and the columella is pulled down.
Osteotomy begins at lower end of nasal bone directed medially
to the medial wall of orbit than downward to reach the floor of orbit posterior
to naso lacrimal apparatus. hen it is brought to infra orbital margin medial
to the nerve and e(tended downwards to the alveolar bone posterior to $st
premolar. hen a posteriorly based palatal flap is raised and )H) are e(tracted
the osteotomy is completed through the sockets of this dividing hard palate.
Cow the segment is mobilised and advanced. his can be fi(ed by a
prefabricated acrylic splint.
his =rocedure1
5 +engthens the nose
5 Casal tip moved anteriorly and downwards.
3dvances anterior ma(illary segment.
his technique was modified by =sillakis > ,o worker $'.; by taking
a transverse osteotomy above the apices of anterior teeth and augmenting the
nasoma(illary segment. his is not biologically sound so this technique is
hardly used nowadays.
Pyramidal .e :ort ,, osteotomy3) 5lassical .e :ort ,, +
his is indicated in Caso ma(illary abnormalities such as.
5 /inders syndrome
5 ,rou<onKs "yndrome
5 3pertKs syndrome
5 B(treme ,left palate cases
5 2idface deficiency with short nose and class 444 Occlusion.
his osteotomy is performed through a coronal incision, a
bilateral lateral nasal incision and an intraoral upper vestibular incision.
3fter subperiosteal elevation of flap the lateral aspect of nasal
bone, medial canthal ligament and lacrimal apparatus are identified.
Osteotomy begins #ust below the frontonasal suture and e(tended posteriorly,
then downwards anterior to attachment of canthal ligament.
hen behind or anterior to nasolacrimal opening to reach the
floor of orbit. he osteotomy is brought anteriorly to reach the infraorbital
margin. 4t is divided at planned position and then proceed on anterior wall
of ma(illa, posteroinferiorly to infraorbital foramen. Cow through the
intraoral sulcus incision the osteotomy proceed below the <ygomatic buttress
as in +e5Fort 4 Osteotomy. he procedure is repeated on opposite side of
using a curved osteotome the ma(illa is separated from skull base at naso
ethmoid region. he nasal septum is separated using a nasal septal osteotome
in a posterior and downward direction. Cow using AowKs forceps to ma(illa is
rocked and advanced.
/one grafting are done at the infra orbital region.
8uadrangular .e :ort ,, Osteotomy
:ufner$'.$ described an osteotomy which was in essence a
combination of +e fort 4 and +e Fort 44 osteotomy. his was modified by
"toleinga > /rouns in $''-.
he osteotomy starts from upper part of pyriform aperture to reach the
floor of orbit medial to infraorbital foramen. hen another osteotomy
starting from tuberosity e(tended along the <ygomatic buttress to reach the
infra orbital rim lateral to foramen. hese are connected in the floor or orbit.
hus a @ shaped osteotomy separates ma(illa without disturbing nasal base.
4t is indicated in patients with prominent nose with paranasal deficiency.
3fter advancing ma(illa fi(ation is done similar to +e Fort 4. 4f there is
severe nasal hypoplasia augmentation of nose is done with calvarial bone
graft and soft tissue augmented by a *5I procedure.
"toleinga > /rouns $''- advocated a modification in which the
osteotomy cut goes around and below the infra orbital foramen to prevent
damage to the nerve.
.e :ort ,,, Osteotomy
his osteotomy more or less follows the classic +e Fort 444 fracture
line. 4t is mainly used for advancing deficient midface. 2idface deficiency
can affect ma(illa, <ygoma and nasoethmoid comple( either individually or
in various combination. 3ccordingly the surgical plane must be altered. +e
Fort 444 is indicated in a combined ma(illary, <ygomatic and nasal deficiency.
4n case of normal nasal pro#ection and ma(illary and <ygomatic deficiency a
modified ma(illary malar osteotomy is suggested.
he access for +e Fort 444 osteotomy can be achieved through a
bicoronal incision, ranscon#unctival incision, ?labellar, or sub ,iliary
incisions and through an intra oral upper buccal sulcus incisions.
3fter reflecting a bicroronal flap the fronto nasoethmoidal region,
lateral orbital rims, are e(posed. he infraorbital rim and orbital floor are
then e(posed through a subciliary incision.
he infratemporal space is e(posed by reflecting temporalis inferiorly.
he medial canthal tendon are detached and tucked with suture.
Osteotomy begins #ust below the fronto nasal suture and passed
medialy to divide ethmoid bone and through the medial wall of orbit it enters
the orbital floor. he infraorbital neurovascular bundle is dissected out of
bone and osteotomy is continued laterally to reach in the inferior orbital
fissure. Cow the lateral orbital wall is e(posed and osteotomy begins at area
of deficiency. his is connected to the anterior end of inferior orbital fissure.
Cow the pterygoma(illary #unction is e(posed through intraoral incision.
@sing chisel pterygoid plate is separated from ma(illa. his is e(tended
superiorly to inferior orbital fissure. he nasal septum is separated through
the osteotomy site is the frontal region. he cut passes through perpendicular
plate of ethmoid and vomer. 3t this level bleeding is less and chance of
damage to olfactory fibres are less.
2obilisation of ma(illary malar comple( is now done by using
disimpaction forceps. /y gentle rocking movements the segment is gradually
moved to the required position.
/one grafts are placed at lateral orbital rim and glabellar region and
secured with wires. Onlay grafts are also placed for augmenting the
infraorbital rim, frontal area etcN 2edial canthal ligaments are replaced by
non absorbable suture in a figure of % manner. 2iniplates are applied at
fronto<ygomatic osteotomy site, the fronto nasal osteotomy, and between
<ygomatic arch and <ygoma. /efore placing the miniplates inter ma(illary
fi(ation is applied in a slightly over corrected position. 3fter rigid fi(ation
this is removed. he bicoronal flap is now closed 65; suction drains are
applied.
Malar maxillary ad0ancement
4t is modified +e Fort 444 osteotomy. 4t is indicated for individuals with
malar and ma(illary deficiency with normal bone pro#ection. 4n this the
osteotomy begins at medial end of inferior orbital rim #ust lateral to lacrimal
apparatus. 4t is connected to pyriform aperture. 3long the floor of orbit,
without making in#ury to inferior neurovascular bundle the osteotomy
proceed to lateral orbital wall #ust below the whitnalKs tubercle the lateral
orbital wall is divided. hen osteotomy e(tended lateral orbital wall is
divided. hen osteotomy e( tended lateral to <ygomatic eminence in an
oblique manner brought anteriorly to the inferior border root of <ygomatic
arch. Cow through an incision in posterior aspect of upper buccal sulcus the
lateral wall of sinus and pterygoid plates are divided as in +e Fort 4 surgery.
Cow through anterior sulcus incision the nasal cavity is e(posed and
the nasal septum is detached. his and division of lateral nasal wall is done
as in +e Fort 4 surgery. Cow the segment can be advanced with forceps,
slight over correction is done and fi(ation is done at fronto <ygomatic and
lateral pyriform rim regions.
5omplications of maxillary orthognathic surgeries
2a(illary surgery produces relatively few complications when the
operative procedure is well conceived, carefully planned and precisely
e(ecuted. he ma#ority of the problems that do occur result directly or
indirectly from careless and inadequate planning.
ncorrect line of fracture
4ncorrect line of fracture usually occurs during pterygoma(illary
dis#unction and also during down fracture.
he ideal fracture that separates the pterygoid and the tuberosity
should do without damage to the either parts. 4mproperly directed force
would result in fracture of superior part of ma(illary sinus, a high hori<ontal
fracture of pterygoid plates or a damage to pterygoid canal can occur.
Directing the force with a small osteotome from the posterolateral to
antromedial aspect would result in a more predictable cut. 4f the pterygoid
plates is fractured in which advancement is planned, mechanical support by
means of bone grafting at the pterygoma(illary #unction will offset the
incorrect fracture and prevent postoperative relapse.
(emorrha"e)
/leeding can be a ma#or concern in ma(illary surgeries.
During surgery blood vessels most commonly encountered are greater
palatine artery. internal ma(illary, nasoethmoidal vessels, posterior superior
alveolar artery and pterygoid venous ple(us. 4t is generally recommended
that hypotensive anaesthesia should be used for midface osteotomies.
Aichard Bllis et al $''0 reviewed cases of life threatening post5operative
bleeding after +e Fort 4 osteotomy. 4n most occasions descending palatal
artery was the source of bleeding and in some case the internal ma(illary
artery. =ressure packing with a posterior nasal pack, ligation of upper part
of e(ternal carotid artery and selective embolisation technique were used.
,losure of tear of nasal mucosa before wound closure will reduce
postoperative epista(is.
nfection
4ncreased chance of infection in midface surgery is due to
communication to nasal and oral cavities. /ehrman 8$'.69 reported only
;cases of infection out of -00 ma(illary osteotomies. 3 double blind study
of Bschelman $'%- showed a significant reduction of infection with antibiotic
prophyla(is .Obviously good surgical technique good closure of soft tissue
incisions and maintenance of good vascular supply will help to minimise the
infection 2c,arthy and ,onverse $'.6 questioned routine use of antibiotic
prophyla(is. hey listed some of the indications for prophylactic antibiotics
in orthognathic surgery.
5 3n intraoral surgical approach
5 =revious irradiation of operative sit
5 @se of bone grafts
5 @se of alloplastic implants
5 =oor oral hygiene
5 =atient prone to infection.
Oedema
B(cessive oedema is common in midface surgeries. 4t is
disappointing to the patient. 4t is due to la(ity of subcutaneous tissue of
midface. "helton and 4rby 8$'%09 recommended use of steroids in initial
post operative period. hey used de(amethasone sodium %5$0 mg. -th
hourly, first dose being started at operating room. his is continued for &%
hourly and following this methyl prednisolone acetate %0 mg. is given for
ne(t 6 days.
Loss of Segment:
Decreased blood flow may lead to loss of segment and delayed
union. his can occur in segmental surgeries. his is due to improper
vascular pedicle and subsequent ischemic necrosis. 4n case of retained buccal
mucosal pedicle this complication is rare when compared to total sulcus
incision. he damage to palatal mucosa during palatal bony cut is
common cause of this. @se of ill fitting splints which causes e(cessive
pressure can cause ischaemia. 3vascular necrosis will lead to gingival
infection, gingival recession, loss of alveolar bone, loss of teeth and total
loss of segment.
4f ischemic necrosis occurs5
5 :eep good oral hygiene.
5 =rophylactic antibiotics to be given.
5 Aetain teeth as much as possible. "ome bone may revascularise
later..
Bpker $'%& recommended the following steps to avoid ischaemic
necrosis
$. 3void transection of greater palatine vessels.
6. "tretch 8as opposed to tear9 the soft tissue during mobilisation
of ma(illa.
; 2ake appropriate palatal soft tissue rela(ing incisions for
simultaneous e(pansion.
&. ,onsider a vertical vestibular incision in potentially
troublesome cases.
Relapse:
Aelapse can occur at various stages of orthognathic surgery. 4t
can be immediate or short term relapse or long term 8delayed9 relapse.
"hort term relapse can occur during fi(ation by 4.2.F. 4f the
fi(ation of osteotomised segment is not stable and 42F is done after the
fi(ation of surgical segment this can occur. 42F should be done before
fi(ing at osteotomy site. Aelapse mostly seen with interosseous wiring. 4f
ma(illary walls are very thin the relapse is more. his should identified at
time of surgery and adequate bone grafts should be placed.
+ong term relapse is mainly due to soft tissue traction mainly
seen in advancement cases. 3nterior and inferior advancement showing
more relapse, ma(illary e(pansion, if e(ceeds more than -5. mm, shown high
relapse. he "uperior placement of ma(illa is reported to be more stable.
3mong segmental surgery posterior subapical advancement for closure of
posterior openbite shown e(cessive relapse tendency.
7ill man 8$'.09 studied $0- cases of ma(illary +e Fort 4
advancement. !e found stable results for ; years 5 $ mm posterior
movement noted in first year and the superior movement was $.% 5 6.% mm.
in first year. 2ore relapse was noted in male patients.
essier and "hiter 8$'%69 also reported a similar study. 4n his
study bone was stable after $ year, and upper lip lost &&L of its advanced
position.
,arloti and "cheudel 8$'%.9 Oaus worth $'%& where studied the
osteotomy site histologically. hey showed healing of the site with impact
bone.
7ard /ooth, /hatia and 2oose 8$'%&9 showed a relapse of
more than ;0L in +e5Forte 44 advancement. 4n a study normal patients
8without cleft palate9 /atton and 2oose showed little evidence of relapse
with +e Forte 44 3dvancement.
Nerve injury
he in#ury to infra orbital nerve is seen in high +e Fort 4, +e Fort 44 and
444 osteotomy. Damage to the nerve occurs during manipulation of incision,
bone cutting and anterior repositioning of the ma(illary segment.
Loss of tooth vitality and sensitivity.
*itality of tooth is maintained by the blood supply where as
sensitivity by the nerve supply. 7hen the blood supply is lost pulp becomes
necrotic and discoloration of tooth and periapical changes begins. /ut in
cases of loss of nerve supply alone the vascularity is maintained and tooth
will be vital. !owever some fibrosis and calcifications will result. /ell et al
8$'-'9 in an animal study shown that if the apical bony cut is done 0.) cm or
above the ape( and any of one flap 8palatal lingual or buccal9 is retained to
the segment both vitality and sensitivity will be remaining. hey
demonstrated neural and vascular ple(us connecting this flaps with apical
vessels and nerves. D. =oss 7illo 8$'.69 demonstrated progressive loss of
odontoblasts in teeth of osteotomised segment. /anks 8$'.%9 in an animal
study demonstrated progressive fibrosis and calcification in teeth involving
osteotomised segment. /ut these teeth remain vital even after )6 weeks
postoperatively. =ulpal changes also reported by !utchinson and 2c?regor,
:art and !inds 8$'.$9 in & years. Following 5up study of 6) patients with
segmental osteotomy reported that $5$) mm periodontal bone loss occurring
in one year after surgery. +ess bone loss is seen in younger individuals.
2a(imum retention of flap over segment showed better results.
=erpesack 8$'.;9 reported '&5')L of teeth regained sensitivity
after $6 months in ma(illa and .6L in mandible. 2c3rthur and urvey
8$'.%9 reported 6L loss of sensitivity, :anberge and Brgstorm 8$'%%9
reported loss of sensitivity in '0L teeth following +e Fort 4 Osteotomy.
3fter $% months all of these regained sensibility.
2ohd Bl Dep 8$'%&9 recommended following precautions to
avoid damage to root and periodontal structures.
$. 3void multiple segmentalisation if orthodontic alignment is
possible.
6. 3void segmentalisation if there is in adequate interdental space.
;. "tart interdental osteotomy with bur and finish with osteotome to
reduce
in#ury to lamina dura.
Oroantral and oronasal fistula
his usually follows a tear in palatal mucosa and in nasal
mucosa. his occurs mainly in ma(illary e(pansion with mid palatal
procedures. ,areful soft tissue handling will minimise the complication . 4f
such a communication does occur, the tissue is allowed to mature for -5'
months , during this time defect can be covered with acrylic splints. +ater
closure using local flap can be considered.
Velopharyngeal incompetence
4t is a rare complication can occur in patients with corrected
cleft palate. his is caused by e(cessive anterior traction of soft palate in
ma(illary advancements. =re5operative assessment can avoid such a
problem.
Other rare complications
hese include ophthalmic complications, vascular complications and
avulsion of a segment.
*ascular complications.
Ophthalmic Complications
his is a rare complication after +e fort 4 osteotomy this occurs mainly
during pterygoma(illary dis#unction. he ophthalmic complications of
orthognathic surgery may be divided into ; categories
$. +acrimal system G 4n#ury to the lacrimal system may lead to
inability to tear or epiphora. he epiphora is usually transient and is
due to surgical oedema.
6. Diplopia G his is due to abducens neuropra(ia H paralysis
secondary to propagation of pterygoma(illary dis#unction fracture. he
diplopia usually resolves in course of time.
;. *isual loss G his is an e(tremely rare complication.
59;;47T 5O754PT ,7 O;T6O?7AT6,5 S9;?4;@ O:
MAA,..A
Cow the principle of distraction osteogenesis have been used for
the advancement of ma(illa in midface hypoplasia patients. 3fter performing
the osteotomy the ma(illary segment is suspended to the <ygomatic arch
based distractor or to a halo frame fi(ed around the head. he ma(illa is
distracted slowly at the rate of $mm per day. 3bout $0 to $) mm
advancement is feasible by this process. he relapse tendency is minimal by
this procedure. his distraction osteogenesis represents the new advances in
bone regeneration and the fourth generation of grafting techniques in
craniofacial surgery.
4n the study conducted by !ans =eter .2. in Aeversing segmental
osteotomies of the upper #aw, mainly on patients which had undergone upper
anterior segmental surgery - months to $0 year back. 2ost of the these
patient came back with remark that they looked unduly aged because the
lower part of the face was dished in. 3uthor discussed the complications of
the reverse osteotomies and in order to restore the old situation a new
treatment plan is to be made.
4n the study by 2. A. Aeinkingh, for the transverse stability of
the +e Fort 4 Osteotomies a palatal surgical splint is made of a transpalatal
stainless steel bar with acrylic abutment against the palatal surface of the
molar and bicuspid tooth. 4t is rigid and renders e(cellent retention. 4t causes
minimal patient discomfort, and oral hygiene is hardly compromised.
3 study conducted by 3. "tewar, 3.2. 2. ,ance, D. A. Eames,
E.=. 2oss on three5dimensional nasal changes following ma(illary
advancement in cleft patients. hree dimensional laser surface, scanning of
the face was performed before and after +e Fort 4 ma(illary advancement in
6& patients with repaired clefts of the lip and palate. he surgery resulted in
advancement of the upper lip and para5alar tissues and an increase in the
relative prominence of the nose. hese changes were produced at the e(pense
of an increase in nasal width and a reduction in nasal tip protrusion. he
changes is nasal morphology showed significant variation among patients.
4n the study conducted by D. /loomquist, D /aab, I ./.
?eylikman, E. 3rtun, /. ?. +erou( evaluated the effect of +e Fort 4
osteotomy on human gingival and pulpal circulation. he ma(illary blood
flow during the first 6& and following +e fort 4 osteotomy was evaluated by
+aser Doppler flowmetry. =ulpal blood flow was recorded from two
ma(illary incisors and gingival blood flow was assessed from a site slightly
apical to the interdental papilla of the ma(illary central incisors of $6 patients
receiving +e Fort 4 osteotomy, nine control patients receiving mandibular
osteotomy, and $0 non surgical control sub#ects with out orthodontic
appliances. 2easurements were made before surgery and at time intervals
between 05%, %5$- and $-56& hrs after surgery following surgery, men
gingival 8but not pulpal9 blood flow significantly lower for patients treated
with +e Fort54 osteotomy.
5O75.9S,O7
Orthognathic surgery has made it possible to reposition of either
or both #aws in all possible directions. his has provided solution for the
patients with severe dentofacial problems and malocclusion. horough
evaluation and assessment of the defect and efficient e(ecution of the surgery
is needed for effective result. @se of more rectified technique, improvements
in instruments especially the introduction of the fine oscillating and
reciprocating saws has enabled the surgeon to precise. he development of
new techniques like distraction osteogenesis have aided in reducing relapse
after an ma(illary advancement and the need for e(tensive surgery. Aepeated
assessment and rectification of the technique are required to improve the
outcome of these aesthetic surgical procedures.
;4:4;4754S
$. he quadrangular osteotomy revisited. Paul J W Stoleinga & John J A
Brouns. Eournal of ,ranio G 2a(illofacial surgery. 6000 1 6% 1 .' G %&.
6. 2a(illary osteotomies. A. ?unaseelan. 4ndian #ournal of Oral >
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;. /lindness as a ,omplication of +e Fort Osteotomies 1 Aole of 3typical
Fracture =atterns and Distortion of the Optic ,anal. John A. Girotto, Jack
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Ro"ertson, Ja!es #inreich, $icholas %li&&, $eil Miller, Paul $. Manson.
=lastic and Aeconstructive "urgery, Oct $''%N *ol. $06N Co )N $&0' G $&6;.
&. he long5term unfavourable result in orthognathic surgery 4 1 2andibular,
2a(illary and ,ombined deformities. Douglas P. Sinn & G. '. Ghali.
,omplications in Oral and 2a(illofacial surgery. (eonard B. )a"an, M.
A$thony Pogrel & David *. Perrott. 7. /. "aunders company. $''.. 6)) G
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). 2a(illary Orthognathic surgery. Ro"ert A. Bays, Arden ). *egtvedt &
David P. i!!is. =rinciples of Oral and 2a(illofacial surgery. Ro"ert D.
Marciani, (arry J. Peter, Steven M. Roser & A. ho!as %ndresano.
+ippincott G Aaven publishers. *ol. 444. $''. 1 $;&' 5 $&$&.
-. !istorical developments of orthognathic surgery. '. W. Steinhauser. Eournal
of cranio52a(illofacial surgery. $''-1 6& 1 $') G 60&.
.. Aigid fi(ation for +e fort 4 ma(illary surgery. John Paul Stella & Bruce $
'+ker. ,ontroversies in Oral > 2a(illofacial surgery. Phili+ Worthington
& John R. 'vans. 7. /. "aunders company. $''&. $)' G $-&.
%. @nusual complications of the +e Fort 4 Osteotomy. Richard Bendor
Sa!uel. =lastic and Aeconstructive surgery. $'') 1 '- 1 $6%' G$6'..
'. 2a(illary and midface deformity. Willia! *. Bell, David Dara" & #hihao
,ou. 2odern practice of orthognathic and reconstructive surgery. Willia!
*. Bell. 7. /. "aunders company. $''6. *ol. 444. 66$$ G6;;;.
$0.Oblique modified +B fort 444 osteotomy. J. M. Garcia , Sanche-, J. .
Davila, A. B. Go!e- Pedro-o, *. S. Mendo-a & D. (. .argas. 2odern
practice of orthognathic and reconstructive surgery. Willia! *. Bell. 7. /.
"aunders company. $''6. *ol. 444. $..0 G$.%'.
$$.Duadrangular +e fort 4 and +e fort 44 osteotomies. '. '. )eller. 2odern
practice of orthognathic and reconstructive surgery. Willia! *. Bell. 7. /.
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$6.Aole of the total ma(illary alveolar osteotomy in orthognathic surgery.
Sterling R. Scho/. ,urrent advances in 2a(illofacial surgery1 Orthognathic
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