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MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I

LITERATURE REVIEW
642
MAXILLARY TOTAL OSTEOTOMIES
STUDY LE FORT I
LITERATURE REVIEW


ESTUDO DAS OSTEOTOMIAS TOTAIS
DA MAXILA LE FORT I
REVISTA DA LITERATURA *












Leandro Pttaro ZANON **
Cludio Maldonado PASTORI ***
Clvis MARZOLA ****
Joo Lopes TOLEDO FILHO *****











____________________________________________
* Monograph presented for conclusion of the Specialization Course in Maxillofacial Surgery and
Traumatology promoted by the APCD Region Bauru
** Author of the Monograph for conclusion of the Course and as part of the requirements of
Research and Teaching Methodology Discipline.
*** Professor of the Specialization Course in Maxillofacial Surgery and Traumatology promoted
by the APCD Region Bauru. Monographs guiding.
**** Surgery Titular Professor of FOB-USP and Professor of the Specialization Course in
Maxillofacial Surgery and Traumatology promoted by the APCD Region Bauru.
Coordinator of Research and Teaching Methodology Discipline.
***** Anatomy Titular Professor of FOB-USP and professor of the Maxillofacial Surgery and
Traumatology Specialization Course promoted by APCD Region Bauru. Coordinator
of the Residence and Monographs guiding.
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ABSTRACT

The human being, throughout all its existence, has searched for a
good conviviality in the community and the environments that surround it. The
advances in the Medicine, Dentistry and Cosmetic provided a better acceptance to
it, because the concern of these areas of health beyond offering to its patients the
cure of some diseases, also satisfactory aesthetic a improving substantially its
quality, life and social conviviality. The orthognathic surgery modifies the
mandible maxillary relation, taking it for an adjusted, steady and functional
position, improving many times not only aesthetic and function but the diction
too. There was a great evolution of the surgical techniques of osteotomy Le Fort I
during the years, mainly after the BELL studies on revascularization. However it
is extremely important that professionals are absolutely able to accomplish such
procedures, beyond a perfect anatomical knowledge of the region to be operated,
because despite being a subject widely studied and reported, as much in the trans-
surgical as in the postoperative severe complications can occur, providing great
upheavals to the patient.

RESUMO

O homem ao longo de toda sua existncia tem buscado um bom
convvio na comunidade e nos ambientes que o cercam. Os avanos na medicina,
odontologia e cosmtica proporcionaram melhor aceitao, porque estas reas da
sade preocupam-se em oferecer aos seus pacientes, alm da cura de determinadas
enfermidades, tambm, uma esttica satisfatria, melhorando consideravelmente
sua qualidade de vida e convvio social. A Cirurgia ortogntica altera a relao
maxilo-mandibular, levando-a para uma posio adequada, estvel e funcional,
melhorando muitas vezes alm da esttica e funo, tambm a dico. Houve
uma grande evoluo das tcnicas cirrgicas da osteotomia Le Fort I no decorrer
dos anos, principalmente aps os estudos de BELL sobre revascularizao.
Porm de fundamental importncia que o profissional esteja totalmente apto a
realizar tais procedimentos, alm de um perfeito conhecimento anatmico da
regio a ser operada, pois apesar de ser um assunto amplamente estudado e
esclarecido, tanto no trans-cirrgico como no ps-operatrio podem ocorrer
complicaes graves, trazendo grandes transtornos ao paciente e ao cirurgio.

Uniterms: Osteotomy, Le Fort I; Orthognathic surgery; Dentofacial deformity.

Unitermos: Osteotomia; Le Fort I; Cirurgia ortogntica; Deformidade
dentofacial.

INTRODUTION

Our organism is seen as a complex machine having its function in
perfect harmony, always coordinate its activities and functions. When the subject
is face harmony, the Stomatognathic System must be defined as being an
integrated entity for a heterogeneous set of organs and tissues, whose biology and
physiopathology are completely independent and have as function tasks as the
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chew, the deglutition, assisting other mechanisms as phonation and breath yet. For
its correct functioning it is in the dependence of muscular structures, joints,
ligaments, nervous propioception, beyond the dental organs (BEHSNILIAN,
1974). The problems that influence its functioning, being able until taking its
carrier to develop a sociopathy, are the bad dental occlusions, of multifactorial
etiology, anomalies of development of the maxilla and maxillary that also can
lead to dental alterations in relation with mandiblemaxillary, being able to cause
face asymmetry (REISCHENBACH, 1970 and BELL, 1975).
There are cases that cannot be solved with conservative treatments
and bloodless and, in these situations, surgical procedure is a more adjusted
behavior. The orthognatic surgery comes with the purpose to correct these face
discrepancies, returning to the patient the function and consequently the esthetic
(the MENUCI-NETO; POLISHING; MAZZOLENI et al., 2004).
The maxilla is responsible for a series of bad accented occlusions,
of varied etiologies, and when the orthodontic treatment cannot decide, the
surgery is the fastest and safe way that patients find to correct such deformities
(MENUCI-NETO; POLIDO; MAZZOLENI et al., 2004).
In the absence of notable unproportional, many techniques can be
launched allowing the surgical repositioning of dental groups or total replacement
of the maxilla. These techniques vary since unitary and series corticotomy,
previous, posterior, until the totals osteotomies of the maxilla to correct bad
occlusion and the dentofacial deformities (KOLE, 1959 e MOHNAC, 1966).
It is important that surgeon is familiar to the anatomy of the region,
for being an area highly vascularized with diverse important structures that must
be studied minutely (MENUCI-NETO; POLISHING; MAZZOLENI et al.,
2004). Even with the great development in the instrument and the surgical
technique, the risk of injuries to important anatomical structures in the posterior
region of the maxilla still exists, having been one of the most related
complications in the use of this technique (BELL, 1992 e ARAJO, 1999).
Lamentably, the surgical correction of the maxilla is still not very
frequent and, probably for the lack of indication on the part of the orthodontists
without an ideal formation, its great complexity, or the fear of some surgeons in
reaching teeth, beyond the possible complications with the maxillary sinus, nasal
cavity and pterygomaxillary regions (MENUCI-NETO; POLIDO;
MAZZOLENI et al., 2004). Although the cut of the maxilla can result in a
temporary loss of reply to the pulpal vitality tests, normally the sensitivity of the
tooth is not destroyed, when treated with the necessary care (KOLE, 1959 e
SCHUCHARDT, 1959).
The clinical success and the occasional imperfections in the use of
the several techniques had remained little divulged until the decade of 70. The
basic questions were concerned to the cure of surgical wounds of the osteotomies
of the maxilla and, of the sanguine vases that would keep its suppliment to the
bony segment, beyond the viability, keeping complete the teeth in the arches
(BELL, 1992 e ARAJO, 1999).
The use of the osteotomy of the type Le Fort I grew very much in
the last two decades due to works of bony microcirculation (BELL, 1969)
demonstrating the possibility of mobilizing the maxilla tridimensionality without
compromising the vascularization and the bony repairing (MENUCI-NETO;
POLIDO; MAZZOLENI et al., 2004).
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It was proposed in this work, through a review of literature, that the
maxillofacial surgeon makes familiar itself with the evolution of the techniques of
total osteotomy of the maxilla - Le Fort I, until nowadays, thus making, its better
application in the different cases. Moreover, they emphasize the importance of a
detailed anatomical knowledge of the region, the revascularization, the tissues
disturbs that the application of this technique will provide to the individual and,
the possible inherent complications to the technique. Thus, it is justified the
realization of this work for clarifying to the Maxillofacial Surgeon the
responsibility and the importance of the minute application of all the necessary
requirements to reach success to the end of its treatments, providing a great
benefit to all society.

LITERATURE REVIEW

The orthognathic surgery aims to restore the function and the
aesthetic to people who present dentofacial deformities, acting in set with the
orthodontics, come to make possible greaters movements in the
mandiblemaxillary complex (TOLEDO-FILHO, MARZOLA, TOLEDO-
NETO, 1998). Then, when the person presents orthodontic problems with a
complexity degree such as orthodontics simply does not offer a solution, either
through an alteration in the growth, or same a camouflage, occurs the necessity of
the surgical intervention either with the surgical realignment of the maxilla, or
still of the repositioning of the dentoalveolar segments (PROFFIT, 1991).
In patients who still are in a development stage, it has the
possibility of being applied the orthodontic treatment that will motivate the
modification of the growth and, the problem of bad occlusion is being corrected
during of the growth of the person. The camouflage of the maxillas skeletal
discrepancy is possible in less severe cases, making the extraction and promoting
the correct relation of molar and the incisive. However the patient will continue to
be class II or class III, depending on the situation (PROFFIT, 1991).
The dentofacial deformities, many times also involve aesthetic
alterations, being able to bring deep psychological implications to the patient
being necessary, by of the surgeon, to clarify all the alterations that the procedure
will bring to the patient. The surgery brings to the person dental and face
aesthetic improvements, beyond the function and, consequently psychosocial
improvement providing a better quality of life (CUNNINGHAM; HUNT;
FEINMANN; 1995 e HUNT; CUNNINGHAM, 1997).
There is a change of the mandible maxillary relation, allowing a
appropriate, steady and functional position, improving many times beyond
aesthetic and function also the speech. To get the waited results, many times is
necessary to make maxilla movements (PETERSON, 2000). However, in the
present work only the movements in the maxilla had been approached with the
different techniques of osteotomy of the type Le Fort I.
In some cases, the maxillo-mandibular alterations present
association with nasal alterations, having necessity to associate with the
osteotomy, the rhinoplasty and the rhinoseptumplasty, so that in the end of the
treatment is gotten better aesthetic result (MIRANDA, 1996).
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Another point that must be observed is its potential to solution of
some cases of temporomandibular dysfunction (DTM), therefore is possible, for
cases where the cause will be skeletal, its repositioning promoting a stimulation to
the functional matrix for rearranging the rearrange the skeletal-muscle ratio and,
for stimulating the remodeling (CORTEZZI, 1996).
There are several indications for total osteotomy of the maxilla is
emphasizing those patients carriers vertical excess, when they display excessively
the superior incisors and gengiva, beyond the labial incompetence, narrow nose,
open bite and elongation of the lower third of the face. These factors can or not
be added or to be presented separately. In patients with previous open bite, who
have premature contact of posterior teeth, the orthognatic surgery will raise the
posterior position of the maxilla, being promoted a correct occlusion, after
removal of the posterior premature contact, beyond raising the previous region,
improving the gengiva exposition and of previous teeth (PETERSON, 2000).
It has two main indications for the surgical replacement of the
maxilla, when the previous teeth excessively are displayed and when exists the
deformity of the open bite with posterior alveolar hyperplasia, determining a
disharmony between superior lip and the teeth (EPKER, 1981).
The horizontal excess of the maxilla, revealed with unilateral or
bilateral crossbite, normally is associated with a vertical deficiency of the maxilla.
Thus, it is noticed the distance between the nasal floor and the apex of maxillary
teeth indicating the transantral osteotomy that will be able to injure the root
apexes, frequently located to the level of the nasal floor (BELL;
ALESSANDRA; CANDIT, 1968).
Another indication is for patients who carriers anteroposterior
excess, presenting face with convex profile and, always associated with the
protrusion of the incisors. Patient with transversal excess has also indication for
execution of the technique, having ogival palate, nip of the posterior arc and
posterior crossbite (PETERSON, 2000).
It can also be cited as indications those patients Class I of Angle
with posterior crossbite, vertical excess to maxilla and open bite; class II of Angle
with vertical excess to maxilla, previous open bite and, Class III of Angle with
maxilla prognatism, maxilla deficiency, open bite, beyond complex deformities of
the third medium of the face (EPKER; STELLA; FISH, 1995).

DEVELOPMENT OF THE MAXILLA AND
ANATOMICAL CONSIDERATIONS

During the immediate after-birth development, the palatines bones
can freely move in relation to the maxilla and the pterygoid process of the
sphenoid bone. During the growth process, from infancy for the adolescence, the
bones articulated surfaces consist of medullar bone and, the remodeling occurs
mainly in the medial portion of the suture between the maxilla, the palatal bone
and the process pterygoid. The adolescence (between 16 and 18 years of age) is
associated with formations of small bone-bridges (sinostosis), which become
sharper in all the sutures (MELSEN, 1987).
The pyramidal process of the palatal bone is located between the
tuberous maxilla and the pterygoid process, acting as a drain plug between the
different standards of growth of these two bones. An osteotomy of the type Le
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Fort I realized in a child is complicated because of the development of the molar,
as well as for the growth of the maxilla complex. The pterygomaxillary
separation in this period could cause damage to important tissues for the growth
of the region. The suture prevents the separation of the bones due external forces,
at the same time it would allow the movement occurrence between some bones
during the growth. If the suture growth is breached, the only immediate growth
will be of the alveolar process, with the dental burst. (HERFORD;
THARANON; FINN, 2001).
In adolescents with less than 16-18 years, the pyramidal process of
the palatal bone has not been casting with the tuberous of the maxilla and the
pterygoid process of the sphenoid bone. In such a way, osteotomies carried
through at this moment could intervene with the future face growth. The
adjournment of the surgery until the bones are casted and the separation can be
reached by breaking, using an osteotomous. (WIKKELING,
KOPPENDRAAIER, 1973).
However, in studies involving 16 patients with age between 10 and
16 years submitted to the surgery with total osteotomy of the maxillary to correct
face deformities, evidenced that it is possible the new position of the maxillary in
patients who find in growth phase, being favorable for the normal growth of the
face (WASHBURN; SCHENDEL; EPKER, 1982).

MAXILLA

The maxillary is a pair, symmetrical bone, formed with the
opposite side of a boned complex called superior faced skeleton. (Fig. 1).
























Fig. 1 Anatomical aspect of the maxillary bone
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.
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This set becomes related, internally, with nasal cavities and
inferiorly with the buccal cavity. By posterior side, it is limited apophysises
pterygopalatine concurring to form pterygopalatines cavity. Superiorly it
completes the orbital cavity, constituting its inferior walls (SICHER;
TANDLER, 1981).

MAXILLARY SINUS

The maxillary sinus has a clearly pyramidal form, of quadrangular
base (Fig. 2). It has average height of 3,5 cm, width of 2,5 cm and depth of 3,0
cm. However these dimensions can vary inside of very ample limits, being found
small maxillaries sinus in contraposition to those of superior dimensions. The
diversity of dimensions has great doctor-surgical importance, mainly
odontological, which had to the relations between the radicular apexes of the
tooths, daily pay-molar and molar (SICHER; TANDLER, 1981).




















Fig. 2 Maxillary sinus, anatomical structure of fundamental importance, for directly being
reached by the osteotomy.
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.

HARD PALATE

It constitutes the superior wall of the buccal cavity being formed in
its previous third part of the palatine vault and in its posterior third of the palate
veil. The palatine vault is composed in three layers, the bone, to glandular and
mucosa. The bone layer is constituted by the palatine processes of maxillary and
horizontal blades of the palatines bones. The palatine foramen confide in the
angles postero-laterals of these horizontal blades and, the incisive foramen in the
previous region behind the incisors central offices (Fig. 3) (SICHER;
TANDLER, 1981).
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SOFT PALATE
It does not present bone part, being constituted of muscle-
membrane, where insert itself some important muscles (Fig.3) (SICHER;
TANDLER, 1981).

















Fig. 3 Anatomical aspect of the hard palate and soft palate.
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.

VOMER

Vmer possess two faces and four edges. The right and left faces
are re-covered by the nasal mucosa with some ridges for vases and nerves. The
inferior edge is lodged in the groove formed by the two palatine bones and two
maxillaries, by superior side, it contacts the sphenoid crest, later forms the
posterior edge, exempts of nasal septum and, its more prolongated previous
portion is articulated superiorly with the perpendicular ethmoid blade and,
inferiorly, with the cartilage of nasal septum (Fig. 4) (CASTRO, 1976).












Fig. 4. Nasal cavity and Vmer bone, becoming related with the maxillary, suture that will be
untied in the trans-surgical to carry through the movements necessary re-positioning of
the maxillary. The set of the Ethmoide, Sphenoid and Vmer bones forms the nasal
cavity
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.
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NASAL CAVITY

The nasal cavity is the beginning of the respiratory treatment and
where it locates the organs of the sense of smell, being intercalated with the brain
case cavity above, verbal cavity below and the orbital cavity laterally. In its
previous portion it is communicated posteriorly with the external way for the
nostrils and for the choana. It is divided in two for vomer and the perpendicular
blade of ethmoide. It is limited superiorly with the crivous blade and posteriorly
with the forebody of the sphenoid body. For its edge antero-superior the
perpendicular blade of ethmoide is articulated with the nasal spine of the frontal
and, more inferiorly with the internal face of the suture joining the two nasal
bones (Fig. 4) (CASTRO, 1976).

ARTERIES

The arteries which irrigate the maxillary are branches of the
maxillary artery which are branches of the external carotid artery. The infra-
orbital artery irrigating the soft deep parts of the previous surface of the maxillary
and, anatomizing with the branches of the face artery (Fig. 5).




















Fig. 5 Passage of the arteries in the face with basic importance due to the risk of hemorrhage in
the trans-surgical, with prominence for the Maxillary artery and descending Palatine
artery.
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.

Through the passage of the infra-orbital artery by the canal which
has the same name the previous superior alveolar artery can be detached following
for the fine small canals excavated in the maxilla and, joining itself with the
branches of the posterior superior alveolar artery that run for the posterior face of
the maxillary tuberous. The superior alveolar artery originates in its passage
antral branches, pulpal and bone. The anastomotic net of the alveolus-dental
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space exactly assures sanguine suppliment to the periodontal region when it
occurs the necessity of making an apicoplasty, pulpectomy or another surgical
maneuver in which the apical vasculonervous beam is extinguished
(LASCALLA; MOUSSALLI, 1980).
The sanguine suppliment of superior teeth and support tissues
would be proceeding from the arterial branches alveolar superiors and palatines
vases. In studies of the periodontal vascularization in Rhesus monkey, they show
that, in the neighboring region to the epithelial tack, it has numerous balled
capillaries forming a vascular crown (BELL, 1969). Probably the pressure
generated for the circulating liquid, in this dense hair net, would be one of the
factors in the maintenance of the epithelial tack (LASCALLA; MOUSSALLI,
1980).
In the palatine vault, the arteries proceed from the esphenopalatine
artery, in previous region and from superior palatine arteries in the posterior
region. The final branches of maxillary artery are palatine descendent artery and
esphenopalatine (main artery of nasal cavity). The bigger palatine artery comes to
palate through bigger palatine foramens and its branches irrigate the soft palate
and palatine tonsil, supplying bunches which irrigate the palatine mucosa too. In
its terminal branch, the nasopalatine artery penetrates in nasal cavity for the
incisive canal (FVERO, 1986).

VEINS

The maxillary region veins walk together with arteries, however in
the contrary direction, directing for pterygoid plexus and later to maxillary vein,
retromandibular and external jugular veins. (Fig. 6) (FVERO, 1986).




















Fig. 6 Passage of the sanguineous return for the veins, with prominence for the Pterygoid Plexus,
responsible for great part of the hemorrhagic complications during the release of the
Pterygoid Process of the Maxillary.
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.
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NERVES

The maxillary division of the triplet nerve has absolutely a sensitive
function. It penetrates for pterygopalatine cavity after leaving cranium cavity,
covering this space and sending ramifications for the esphenopalatine ganglion,
posterior superior alveolar nerve and the zygomatic branch. The division to
maxillary transmits sensitive impulses of the skin on the forebody of the secular
region, of the zygomatic bulk, the inferior eyelid, the lateral portions of the nose
and the superior lip, superior teeth and gengiva in the same region. It also
sensitizes great part of the mucosa of the nasal cavity, hard palate and soft palate,
parts of the tonsil region and the pharynx region. (SICHER; TANDLER, 1981).
In its passage, from the semilunar ganglion, the maxillary division of the triplet
covers four regions, medium cranium cavity pterygopalatine, the infra-orbital
canal and the face (branches terminals). The biggest interest of the surgeon who
will carry through the osteotomy Le Fort I mentions the three last regions to it
(FVERO, 1986).
The infraorbital Nerve originates the superior alveolar nerves
during its passage in the infraorbital canal. The posterior superior alveolar nerve
nerves the vestibular gengiva and the molar; the alveolar superior medium nerve
nerves the daily pay-molar region and, finally, the previous branch nerves
previous of nasal cavity , superior previous teeth and gengiva portion. The
infraorbital nerve emerges for the infraorbital foramen dividing in three branches
terminals, the inferior eyelids nerves nerving the inferior eyelid, the external and
lateral nasal nerves, that tends to the skin for nasal region and those that they emit
sensitivity to the superior lip (Fig. 7) (FVERO, 1986).






















Fig. 7 Face nerving, with prominence to maxillary division of the triplet, which has bigger
interest for the surgeon who will carry out the Le Fort I osteotomy.
Font: SOBOTTA, J. Atlas de Anatomia Humana. 2000.
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LE FORT I OSTEOTOMY
EVOLUTION OF THE TECHNIQUE

VON LANGENBECH in 1859 was the first author to describe the
maxillary osteotomy, being, initially modified by WASSMUND e
SCHUCHARDT and latter by WEST e EPKER, beyond other alterations in
elapsing of the time (FVERO, 1986).
The first techniques developed for the Le Fort I osteotomies did not
separate the maxillary of the plateaus pterygoid, requiring postoperative elastic
traction for its separation. But from years 30 AXHAUSEN e SCHUCHARDT
recommended the pterigomaxillary separation and the technique comes being
used since then with few modifications (MENUCI-NETO; POLIDO;
MAZZOLENI et al., 2004).
AXHAUSEN (1934) used the method to correct badly consolidated
maxillary fractures by using hard palate division.
One of the first interventions Le Fort I was made by WASSMUND
(1935), when he described the osteotomy realized in 1927, being effected by
means of pillars canine and zygomatic and the partial section of the sidewall of
the cavity and nasal septum (ARAJO, 1999). BELL; FONSECA; KENNEDY
et al., (1975), demonstrated that the total osteotomy of the maxilla could be
carried through without it had greaters damages to the sanguineous of region,
preserving pedicles of soft tissue suppliment in the palate regions and maxilla.
The total osteotomy of the maxillary was developed in two surgical
times (KOLE, 1959). A similar procedure was told, however with the surgery in
only one surgical time (PAUL, 1969). Another procedure following the same
technique to re-position a breaking to maxillary consolidated (MOHNAC, 1967).
Modification was told in Le Fort I cases to the correction of the
congenital or acquired deficiencies in the third average of the face as for use of
Rowe forceps for maxillary desimpaction (WESSBERG; SCHENDEL;
EPKER, 1982).
From years 70 there were a great evolution on dentofacial
deformities treatment a time that Le Fort I osteotomy allows to the
accomplishment of almost all the movements, respecting the limitations of each
case. Transverse anomalies, anteroposterior and vertical of the maxillary can be
solved using this technique. It has also indications for jib or advance of the
maxilla, beyond the increase or reduction of the vertical (GRAZIANI, 1986).
This technique is executed working with the maxilla in an only
block, after the separation of nasal septum, the medial and lateral walls of the
maxillary sinus, beyond the pterygoid process. Thus, the maxilla could
completely be put into motion in some directions. It has some specific cases
despite the maxilla can be broken in lesser segments allowing more movements
(GRAZIANI, 1986 e S JNIOR, 2001).
The techniques had suffered modifications in elapsing of the years,
aiming to supply the necessities of each case. In the sequence the present work
shows initially described techniques and, also those praised in the present time.

SURGICAL TECHNIQUE
1. QUADRANGULAR LE FORT I OSTEOTOMY
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OBWEGESSER (1969)

It is indicated to horizontal deficiency patients,
zygomaticmaxillary, with an exacerbated nasal projection. The incision is made
approximately 4 mm above of the junction mucus gengiva until the height of the
daily pay-molar. Previous portion of the maxilla is exposed and later dissects the
periosteum until the bilateral posterior tuberous and infraorbital foramen (as well
as it is made for accomplishment of Le Fort II osteotomy). The infra-orbital nerve
is completely isolated. It is necessary to take very well-taken care to do not violate
the periorbital or the infraorbital nerve. The mucosa of the sidewall of the nose is
raised to display a bigger portion of the maxilla. It is important to keep the
integrity of the nasal mucosa, especially in patients in which a surgical significant
widening is carried through. At this moment, gristly septum and Vmer are
separate of the median line of the palate for curette previously and, with chisel
later. The lateral nasal wall and the posterior portion of the nasal floor are
displayed by a under periosteum dissection and frequent turbinectomy is carried
through, where the posterior nasal spine will be displayed and after
downfracture is situated the palatine artery.
For the accomplishment of the osteotomy oscillatory movements
with the mountain range from the pear-shaped opening to the level of the
infraorbital nerve are made extending laterally, above of the infraorbital foramen,
until tuberous-pterygoid region in the posterior region. An inferior step in the
osteotomy is frequent necessary in the previous edge of the maxillary
proeminence. Due to raised position, the posterior osteotomy may need to be
carried through with chisel.
Downfracture with digital pressure or forceps is effected,
depending on the case. The intermaxillary blockade is carried through and the
maxilla reposition in the planned place after the removal of possible interferences
(Fig. 8).


















Fig. 8 Localization of the quadrangular osteotomy.
Font: BELL, W. H. Modern practice in orthognathic and reconstructive surgery. 1992.
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2. LE FORT I HIGH OSTEOTOMY
KUFNER (1971)

When the nasofrontal projection and the position of the ocular
globe are abnormal, main aesthetic components to be addressed are the maxillo-
mandibular unproportion, the zygomatic bone and the infra-orbital region.
Although a combination of the Le Fort I osteotomy and auxiliary procedures was
used frequently to correct these deformities, the ideal would be an osteotomy that
obtained to brighten up these deformities by itself. Due to the fact of the aesthetic
epicenter of the zygomatic bone be placed approximately 2 cm laterally and 1,5
cm inferiorly to lateral corner of the eye, the horizontal and posterior extension of
this osteotomy in zygoma must be posteriorly and superiorly located in relation to
this area. The previous horizontal portion of this osteotomy must be situated
superiorly enough to include the paranasal parcel of the maxillary bone. The
horizontal osteotomy, initiating in the maxillary bone is extended for posterior in
the zygomatic arc, below of zygomatictextemporaneous suture e, approximately
the 6 to 10 millimeters of the previous region of the zygomatic arc. The superior
and posterior extension of this technique will not only supply an aesthetic base,
but it will also make that it has a good stability and setting for the fact of zygoma
to be a dense bone (Fig. 9).
















Fig. 9 - A. Localization of Le Fort I high osteotomy. B. Maxillary re-position and settled with
plate and screw. C. Frontal aspect after the setting.
Font: BELL, W. H. Modern practice in orthognathic and reconstructive surgery. 1992.

3. TRADICIONAL LE FORT I OSTEOTOMY
BELL (1975)

Through this technique is possible to reduce the face height, the
exposition of incisive teeth and the interlabial space, putting the maxilla into
motion for a class I occlusion. In the execution of this technique, adds that the
horizontal excess of the maxilla revealed with one-sided or bilateral crossbite, in a
classified way is associated with a vertical deficiency of the maxillary bone. Thus
it is observed that there is an approach of the nasal floor and the dental apexes of
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the maxillary bone, contraindicating transantral osteotomy, therefore it will be
able to injure the apexes of the teeth that frequently are located to the level of the
nasal floor (Fig. 10).
The horizontal incision is made through the mucoperiosteum of the
vestibule of the maxillary, above of the mucogengival fold and the second molar
until the correspondent of the opposing side. In horizontal previous osteotomies
and vertical posterior, the reference lines are marked in the sidewall of the
maxillary bone with spherical drills of fine bore. With a retractor placed to
protect the nasal mucoperiosteum in the horizontal section of the bone for the
sidewall of the maxilla of pear-shaped opening and later until the fiction to
pterigomaxillary. Previously the horizontal bone cut is lead through the sidewalls
and medial of the maxilla. The medial floor of the maxillary sinus is parted above
of the palate roots and nasal floor through an osteotomy of the buccal side. The
posterior portion of the antral wall is parted with deliberated beaten with
osteotomous.
























Fig. 10 Frontal aspect, after accomplishment of the osteotomy in the sidewall and medial of the
maxilla.
Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. 1980.

The posterior wall of the maxillary sinus is separate using a chisel,
as well as nasal septum, moving away the superior portion from the maxillary
bone with chisel. The maxilla is separated of the apophysis pterygoid with one
arched chisel directed medial and previously, later it is broken underneath with a
mucoperiosteum separated of the nasal side of the maxillary bone in the horizontal
plan and of the palatal bone (Fig. 11).
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Fig. 11 Lateral aspect showing the separation of the pterygoid process with an arched cinzel.
Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. 1980.

The vertical dimension nasal lateral and posterior walls of the sinus
are reduced with a bone drill. Later, the mucoperiosteum is separated of nasal
septum, the height of septum is reduced, facilitating the superior movement of the
maxillary bone. After putting into motion the superior plan of the maxillary bone,
a rabbet is made in the floor of nasal cavity to accomodate the septum. The height
of septum nasal is reduced to facilitate the repositioning of the floor of nasal
cavity without folding septum. The maxillary bone is fixed, an interdental
blockade is made with wire between the interdental bars or orthodontic devices.
The mucosa will be re-positioned and sutured with continuous points.

4. LE FORT I OSTEOTOMY IN STEPS
BENNET E WOLFORD (1985)

In an effort to improve the exactness and the previsibility of the
surgery of advance of the maxillary bone and to eliminate the effect of slope of
the traditional osteotomy, the technique in step form was presented. In this
technique, the lateral maxillary osteotomy is made parallel to the horizontal or
natural plan of Frankfurt. It is initiated in the high of the zygomatic pillar where a
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vertical stage is made. The horizontal osteotomy is continued later until the
pterygoid process, parallel to the previous. It is important to keep parallel the
previous and posterior osteotomies to minimize interferences during the re-
positioning to maxillary (Fig.12).


















Fig. 12 - A. Localization of the osteotomy in step, detaching to be parallel to the plan of Frankfurt.
B. Movement already carried through and settled with plates and screws. C. Osteotomy
in step carried through more superiorly.
Font: BELL, W. H. Modern practice in orthognathic and reconstructive surgery. 1992.

5. LE FORT I OSTEOTOMY ON RAMP
REYNEKE E MOSUREIK (1985)

The technique in slope is a variation of the high Le Fort I.
Patients with vertical and anteroposterior deficiency are liable to
the application of this technique. When the deficiency to anteroposterior
maxillary bone is associated with the deficiency to vertical maxillary bone, the
surgical planning must include the advance to maxillary bone, beyond the
correction of the vertical discrepancy (Fig.13).
In some cases, both corrections can be obtained by the descending
sliding movement and for front of the maxillary bone. The osteotomy of the
sidewall of the maxillary bone will have to be individualized for each case, that is,
the inclination of the incision must vary depending on what will be necessary to
get in vertical dimension.
The length of the edge of the pear-shaped opening to the lateral
portion of zygoma is measured through the lateral telerradiografies. From this
measure the descending angular inclination of the osteotomy and the position of
the vertical incision are calculated.
In the previous region, angled cut is extended of the lateral portion
of zygoma to the inferior portion of the pear-shaped opening. Later, the
osteotomy is directed 45 degrees vertically, of the lateral portion of zygoma, in
direction to the pear-shaped opening. In more severe cases of vertical discrepancy
graft can be carried through interpositional.
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Fig. 13 A. Angle of the osteotomy, in which it will vary depending on the vertical dimension
that the surgeon needs for the case. B. Interpositional graft used for more severe cases.
Font: BELL, W. H. Modern practice in orthognathic and reconstructive surgery. 1992.

6. TECHNIQUE RECOMMENDED BY KRUGER (1984)

It is become fulfilled incision 2 mm above of the mucosa that they
form deep of ridge leaving from the region of the molar, through the median line
until the opposing side of the same region, mucoperiosteum detachment in the
superior direction, being displayed the process of the maxilla and the pear-shaped
opening zygomatic
It carries through osteotomy with fiction drill since the zygomatic
process of the maxilla, in previous direction, until a point approximately 1 cm
above of the floor of the nasal cavity continuously for the opposing side. The
pterygoid blades are broken in the posterior position of the short maxilla by means
of one chisel of Obwegesser. The cartilage of nasal septum and the insertions of
Vmer are separate of the maxilla by means of a thin chisel. It must be taken care
to protect the nasopharynx region with a finger, because of the possibility of
perforation of the nasotracheal pipe. The sidewall of the nasal cavity is parted in
an inferior level to the insertion of inferior cornet by means of thin chisel.
The maxilla can be set free of its remaining linkings for any one of
the methods, through forceps of Rowe, arched chisels or inserted instruments of
Tessier inserted subsequent to the maxillaries tuberous breaking them for release.
In some cases the maxilla can total be set free, placing a gauze compress on teeth
and manipulating the segment in all the directions by manual pressure.
Finally the maxilla is placed in its planned position in the daily
preoperative using intermaxillary elastics to be kept this occlusion. The incisions
are closed with horizontal continuous suture.
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7. TECHNIQUE RECOMMENDED BY PEDERSEN MODIFIED
BY OBWEGESSER (1972)

Obwegesser says there are two anatomical situations that must be
considerate retromaxilla that is a condition in which the maxilla is situated
much in the back in relation to the base of the skull and the micromaxilla where
the maxillary bone is very small in relation to the maxilla.
The surgical technique advocates incision extending itself
circumferentially from the distal surface of the second molars bilaterally from the
mucogengival junction. Incisions of relief of 1 cm of length can be carried
through in the distal portions right and left of the primary circumferential incision.
The mucoperiosteum is struck displaying the total sidewall of the maxilla until the
zygomatic christians, displaying infra-orbital foramens, previously and the third
part of infero-lateral of the pear-shaped opening.
It becomes fulfilled osteotomies with drill horizontally binding to
the cracks pterigomaxillary with the lateral edges of the pear-shaped opening.
The pterygoid plateaus are separate of the tuberous maxillaries with one arched
osteotomous. Nasal septum and Vmer are divided of the superior part of the
maxilla and of the palatine bones with osteotomous. After the nasal mucosa is
struck of the sidewalls, and these are parted below of cornet inferior with drills.
The maxilla then is mobilized with manual and placed pressure in its new
position. It is used continuous horizontal suture to close the incision.

8. TECHNIQUE RECOMMENDED BY KAMINISH (1983)

The technique consists of extending the superior bone cut of the
pear-shaped opening until the portion of the zygomatic arc, with high cut and after
going down until the apophysis pterygoid for the lateral of the maxilla. The
author firms that such procedure has greater stability of the segment after it has
been repositioned. (KAMINISH; DAVIS; HOCHWALD et al., 1983).

9. TECHNIQUE RECOMMENDED BY MANGANELLO-
SOUZA (1998)

It makes an incision in the background of ridge initial of maxilla,
about 2 mm above of the inserted gengiva, from the second superior molar of one
side until it reaches the opposing second superior molar. Then disjoins the
remnant mucoperiosteum until displaying the zygomatic pillars, canine cavities
and the pear-shaped opening. In this phase, a bilateral soaked of is proceeded
from the posterior region of the maxilla in direction to pterigomaxillary cavity,
forming a tunnel from where an arched chisel will be introduced later. By using
drills or saw it is promoted osteotomy of the initial board of the maxilla. The use
of chisel in this region can lead to the breaking of the previous wall of the
maxillary sinus. The landmark must be made about 3 5 mm above of the dental
roots using as reference the tooth. Complete it previous osteotomy of the maxilla
with a thin chisel of region of zygomatic pillar, canine cavity and pear-shaped
opening bilaterally. Then the cut is extended in the posterior region until it finds
the pterygoid process of the sphenoid bone.
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The osteotomy of the background region is made with an arched
chisel adapted in the pterigomaxillary cavity. To separate bilaterally the maxilla
and the pterygoid it must be taken a so special care with the palatine artery and the
vases of venous plexus pterygoid, keeping the posterior and the anterior
osteotomy at the same level, they must never be in the up of it. The surgeon must
previously introduce a chisel for vestibular contest through unglued tunnel e, with
the other hand palpated for palatal the junction to pterigomaxillary, preventing as
soon as chisel exceeds the palatine mucosa.
After the initial osteotomy and of the pterygoid blades, disjoins the
nasal floor through the pear-shaped opening, preventing to breach the nasal
mucosa that will provoke undesirable bleed. After the exposition of nasal septum
and nasal floor, with one chisel straight cuts medial wall to it of the maxilla and
nasal septum, breaking up to all the maxilla. For this, can be used forceps of
Rowe or traction by means of hooks aparters in the pear-shaped region.

10. TECHNIQUE RECOMMENDED BY S JNIOR (2001)

This technique must be initiated with a deep incision in of vestibule
maxillary bone bilaterally extending itself until the first molar region. It will not
have to be extended beyond the first molar, with intention to prevent deficiency in
the irrigation of the maxilla. Made the incision correctly, all the mucoperiosteum
that recovers the previous, lateral walls from the maxilla until the posterior
portion and nasal mucosa must be moved away with a periosteums aparter.
Initiating the osteotomy of the sidewall of the maxilla, it must be
extended of the pear-shaped opening until the zygomatic pillar, being able to be
used a rotatory instrument with a 702 carbide drill or a reciprocate saw. In the
posterior sidewall it can be effected with a thin osteotomous of the type spatula.
For the separation of nasal septum is used an osteotomous which
contain guides and, the junction of the tuberous of the maxilla with the pterygoid
process with arched osteotomous e, finally after the execution of all these
processes, becomes fulfilled downfracture, thus locating the maxilla in the
desired position as the planned in the daily pay-operatory.

REVASCULARIZATION OF THE MAXILLA

The sanguine suppliment of the face is profuse, with an abundant
collateral circulation. The main suppliment is through branches of the external
carotid arteries (Fig. 14) (GERHARDT DE OLIVEIRA, 1998). In the previous
region, it is irrigated mainly by the apical vases, labial artery, and periodontal
palatal and gengiva plexus (Fig.15) (BELL, 1975).
It has been made a study about revascularization and bony
correction post total osteotomy of the maxilla realized in 12 Rhesus monkeys and,
three of them had its palatine arteries intentionally connected. After sacrifice of
the animals was carried through a microangiografic examination in different
intervals, observing that one day the surgery ischemic areas had been after noticed
in them canine pillars and the region of the osteotomies. After one week, had an
increase of the endostal and periosteal fulfilling vascular, beyond fibrous tissue
that already occupied the space of the osteotomies. In the second week, vases
from the periosteum penetrated in the cortical vestibular contests anatomizing
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with the endostal vases. On both sides of the osteotomy, bone tissue neoshaped
could be identified. After 4 to 6 weeks, it was noticed the increase of the
vascularization and the presence mature bone tissue. Then it was evidenced that it
did not have differences between the monkeys that had palatine artery connected
and those that had not (BELL; FONSECA; KENNEDY, 1975).





















Fig. 14 Schematical composition to illustrate the sanguineous suppliment of the maxilla.
Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. 1980.


















Fig. 15 Irrigation of the previous portion of the maxilla.
Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. 1980.
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After excellent studies some authors affirm that to diminishing the
risk of an lacking blood vessels necrosis of the maxilla, it must be preserved the
descending palatinos vases, beyond being kept the muscular insertions
(LANIGAN; HEY; WEST, 1990).
The inter-bone ischaemia and the necrosis of the osteotomized
segments had been significantly reduced when the mucoperiosteum and the
insertion of the muscles pterygoid medial and Masseter had been more preserved
(BELL; FONSECA; KENNEDY et al., 1975).
After the Le Fort I osteotomy, the sanguine irrigation is derived
from vascular palatal pedicle through the descending palatine artery and from the
palatine branches of arteries pharyngeal ascending and face and, also, from
vascular pedicle vestibular through the postero-superior alveolar artery. Amongst
these sources, the descending palatine artery is the biggest vase, with average
diameter of 1,7 mm, being one of the main responsible for the bleed during the
osteotomies. Damages to these vases generally do not show none sequel due to
fast revascularization and to the good collateral circulation (MENUCCI-NETO;
POLIDO; MAZOLENI et al., 2004).

SOFT TISSUES ALTERATIONS

Since the decade of 50, the orthodontists have shown an increasing
concern not only with the occlusion, but also with face aesthetics (BLOOM, 1961
e PASTORI; MARZOLA; MENDES et al., 2005).
The necessity to quantify the changes in the soft tissue of the face
and to foresee surgical results, searchers had tried to establish evaluation methods
of these results gotten by means of radiographic comparisons or of computer
programs. They had objectified to create a forecast of the interrelation between
the changes from soft tissue and bone of the face, to assist in the attainment of the
biggest face harmony and the possible previsibility for each patient (Fig. 16)
(BELL; PROFFIT; WHITE, 1980).
Studies analyzed the alterations of the face profile in the
orthodontic treatment of 60 leukoderma patients in growth phase and, treated by
means of orthognatic surgery. Through after-surgical and daily pay cefalometrical
measures of six months, revealed the existence of a very next relation between the
pure orthodontic movement of tissues and, the answers of soft tissues, with
possibility of forecast of these changes (BLOOM, 1961).
Work using lateral telerradiografies in the postoperative and daily
pay of 21 patients had been able to evidence that the rise of the nasal apex and the
base of the superior lip had been noticed the most. In 40% of the cases, there was
a reduction of the width of the vermillion of the superior lip, occurring a superior
vertical alteration of all the points of soft tissues, since the nasal apex until the
inferior lip. The nasolabial angle increased in retrusion of the maxilla,
diminishing in advance and, in profile analysis it did not have significant
alteration in the tip of the nose (MANSOUR; BURSTONE; LEGAN, 1983).
About the changes of the soft tissue associates with a total advance
of the maxilla, using daily pay-surgical telerradiografies cefalometrical and
immediate after-surgical, with six months of postoperative, of eight patients, were
observed that some measures had been statistical insignificant because the
sampling was very small. One high positive correlation in the horizontal change
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was noticed and the superior lip had an average ratio of 0,5:1 +0,09 in relation to
the superior incisor, in the horizontal axle. In the vertical axle 0,3:1 was observed
average +0,14, with small correlation between alteration of the superior and
incisive lip, having, also, a reduction of the nasolabial angle, which has next
relation with the superior incisor, with average ratio of -1,2: 1.0 mm +0,26. It
was noticed, also, an uniform reduction in the thickness of the lip, with average of
-1.9mm, and, a uniformity was not observed among patients until the six
postoperative months, only occurring after this period, with the lips tending to
keep certain stability (DANN; FONSECA; BELL, 1976).
























Fig. 16 Reference points, in soft and bone tissue.
Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. 1980.

Studies of the stability of the maxilla and the relation of the soft tissue
and bone in its superior repositioning, using a morphologic analysis of a tracing
done by hand and analyzed by the computer in 30 patients were effected. The
average of postoperative of 14 months was gotten as satisfactory resulted, in the
patients with vertical excess of maxilla, a correlation of 0,76 in the relation
between superior lip and incisive superior. Moreover, was evidenced a shortening
of the lip with correlation of 0,38 without alteration in the contour, but with a
rotation around of the subnasal point. The nasal apex was softly raised by the
surgery. Throughout the 14 months, the authors had noticed small movements,
especially in the point of the maxilla. In the patients with maxillary bi-protrusion,
got a correlation of 0,66 between the posterior movement of the superior lip in
relation to the superior incisor, a correlation of 0,51 between the movement, for
top, of the superior lip and incisive superior. The profile did not change, only
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turned around of the subnasal point after the surgery. Throughout the 14 months
of postoperative of this group was not observed any change in the position of the
maxilla (SCHENDEL; EISENFELD; BELL et al., 1976).
Cefalometrical analysis of the nasal morphology after Le Fort I
osteotomy was carried through in 50 patients who had postoperative and daily
pay-operatories cefalometrical telerradiografies of six months at least. It was
evidenced that the nasal apex was moved for top, next to the previous and
superior movement of the point of the maxilla and, for low with posterior and
inferior movement of the point. Although to be small, this correlation is
responsible for only 20% of the postoperative alterations in the nasal apex. The
rotation of the maxilla did not show significant relation with the changes of the
nasal apex. It was also observed, in its statistical analysis, that did not have
alterations in soft tissues when these was sutured by different techniques, or when
the nasal previous spine was removed (GASSMANN; NISHIOK; THRAS et al.,
1989).
The repercussions in soft tissues of the face are seen mainly in the
nasal and lips structures, supplying its correlations in alteration coefficients;
however a significant variation can be seen in the results and conclusions of the
great majority of them (BELL; PROFFIT; WHITE, 1980).
Evaluating the soft tissue movement together with hard tissues after
osteotomies of maxilla in lateral telerradiografies were evidenced to be possible,
in the daily pay-operatory, to foresee the changes that will occur in soft tissues
(DANN; FONSECA; BELL, 1976).
The changes associates to the total surgical intrusion of the maxilla in
patients with long faces, characterized for the vertical excess of maxilla, had been
studied in 10 cases, with a minimum of six months of accompaniment, where
manual tracings had been carried through postoperative and daily pay in lateral
telerradiografies of face. They had been gotten as resulted that the vertical change
of the points in soft tissues of the maxilla was related in a significant way with the
vertical changes in bone portions and, with the change of the position of superior
incisive as a support, having still changes on the superior lip and nose. Authors
had verified that, in case that comes to occur the intrusion of the superior incisor,
the superior lip comes to occupy an also superior position in relation to the daily
pay-operatory (RADNEY; JACOBS, 1981).
It was also evaluated the stability and alterations in soft tissues of the
face in corrections of the vertical deficiency of the maxilla, in 13 patients. Its
cefalometrical telerradiografies of daily pay, postoperative immediate, six weeks,
12 and with six months of postoperative, done tracings manually, had been
studied, concluding the authors who changeable amounts of returns had occurred
in the majority of the cases, in the first two or three months after the surgery. It
did not have any correlation between the amount of carried through movement
and the return. The length of the superior lip was not modified significantly with
the amount of movement carried through in the maxilla. It has been also noticed
that the exposition of the superior incisor increased in the patients having positive
repercussion in the aesthetic. In the horizontal movement of the maxilla a
percentage of 66% of accompaniment of the fabric soft in relation to the bone
tissue was seen, with great variability of results inside of the sample (BELL;
SCHEIDEMAN, 1981).
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Searching for the previsibility of soft tissues in the repositioning to
maxilla in orthognatics surgery with the Le Fort I technique, study it was followed
in 46 patients. In its immediate postoperative and daily pay-operatories
cefalometrical telerradiografies, traced manually and later digitalized, no
significant difference was found between the points of the forecast and the after-
surgical, being thus, considered a previsible surgery. In another analysis, the
average of the differences between the measures was very next to zero and only
the point located in the molar tended to be inferior to the of the planning, showing
significant difference between planned and the postoperative (JACOBSON;
SARVER, 2002).
In relation to the muscular orientation after total osteotomy of the
maxilla, studies show that in any orofacial surgery the alteration of the form,
aesthetic and function can be recognized. The muscles can be manipulated for
advantage of the surgeons and, with this, the possible effect undesirable to occur
in the perioral area after the osteotomies of the maxilla can be prevented. The
postoperative forecast of the lip in rest can be found (SCHENDEL;
EISENFELD; BELL et al., 1976).
Professionals must not forget themselves, however, that exists
limitations in the search for the improvement of the aesthetics and that the patients
many times do not have conscience of them, so that it can prevent false
expectations transmitted to the patient (JACOBSON; SARVER, 2002).

COMPLICATIONS

Some complications already had been described in literature in
relation to the Le Fort I osteotomy and that present a bigger occurrence are
hemorrhages and the bad positioning of the maxilla. However, with lesser
frequency can also occur fistulas arteriovenous, orofacial and nasoantrals,
shunting lines of septum, velopharyngeal incompetence, maxillary sinusitis,
ischemic necrosis, pseudo-artrosis of the maxilla, undesirable breakings, damages
to the nervous system, damages to the nasolacrimal system and ocular and
dysplasia (ARAJO, 1999).
Fistulas arteriovenous are possibly caused by the rupture of an
artery next to venous plexus, with spontaneous anastomosis. The patient can tell
buzzed and pulse sensations in the face and the eyes. Its treatment consists of the
selective embolisation of the vases that feed the fistula. The aseptic necrosis is
established due to an interruption of the vascularization, being able to be
devastator for the patient and the professional, a time that is very difficult to reach
the rehabilitation (ALMEIDA-JNIOR; CAVALCANTE, 2004).
The occurrence of the bad positioning to maxilla has a bigger
frequency for being a technical order problem. Carrying through an adjusted
planning, with splints without distortions and a correct surgery of models, this
complication can be minimized (ARAJO, 1999).
The trans-operatory hemorrhage is one of the most frequent
complications told in the Le Fort I osteotomy, being the most common cause of
associated hemorrhage to the orthognatics surgery. It consists of the lack of trans-
operatory hemostasy and, in most of cases, it occurres due to an imperfection of
the surgeon about fully knowing the anatomy of the area where he is working.
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However, the bone anatomy, vascular anatomy or modified soft tissues can
present problems even to the most experienced surgeons (LANIGAN, 1997).
The vases more common associated with arterial hemorrhages are
the terminals branches of the maxillary artery, especially the descending palatine
artery and the esphenopalatine, even though the proper maxillary artery and the
internal carotid can also be involved. The anastomosis between the branches of
the arteries carotid internal and external or between the other side corresponding
branches of the external carotid can perpetuate the bleed, although the surgical tie
of the main vase. The maxillary artery and its branches are more vulnerable to the
injuries during the pterigomaxillary disjunction or still during the inferior
breaking of the maxilla. The descending palatine artery is the most vulnerable
vase during these surgical moments, due to the relationship between the
descending palatines vases and the Le Fort I posterior and medial osteotomies.
Therefore, the majority of the studies related to the posterior region of the maxilla
says about the standard of the maxilla pterygoid separation process during the
osteotomy (RENICK; SYMINGTON, 1991 e LANIGAN; GUEST, 1993).
The venous bleed after the Le Fort I osteotomies involves mainly
venous plexus, which corresponds to a venous net juxtaposed to the pterygoid
muscles. It is important to point out that this plexus communicates with the
cavernous sinus, of intracranial localization, draining the blood saturated in
carbon dioxide from meninges through the oval foramen. To this plexus
converges the draining of the veins that correspond to the branches of the two
forebodies maxillary arteries, the medium meninge, the palatine biggest, the
esphenopalatine, the buccal, the alveolar e the inferior ophthalmic (GERHARDT
DE OLIVEIRA, 1998).
A Le Fort I case is presented where when is carried through the
desimpaction of the maxilla, occurred the disruption of vases becoming necessary
to bind the carotidal external and internal arteries (NEWHOUSE; SCHOW;
KRAUT et al., 1982).
The bleed can vary from light to intense, being able to arrive until
the hypovolemic shocked, thus it is very important in the daily pay-operatory to
be taken some prevention writs in relation to the hemorrhage, as adjusted
sanguineous suppliment attainment for an eventual transfusion and, also, the
possibility to carry through the surgery in induced and controlled hypotension
(LANINGAM; HEY; WEST, 1991). The German school does not praise to bind
or to cauterize the sanguine vases, aiming at a minor fibrosis and tecidual
reaction, therefore the sanguineous losses can be diminished through the reduced
and controlled hypotension, thus providing better operatory field visualization and
diminishing the surgical time (GRANDO; PURICELLI; CHIAO et al., 1990).
The controlled hypotension was induced and had a great impulse
when the Sodium Nitroprussiate was introduced (MORACA, 1962). This
modality in the general anesthesia is based on the position of the patient and the
vasodilatation causing alterations of the daily pay-load and the after-load. The
cardiac debit and the systemical vascular resistance are the variable manipulated
without real alterations of the volemy, making possible the accomplishment of the
surgery with diminished levels of cardiac frequency, preventing bigger bleeds. It
is important to emphasize that the surgeon promotes a correct vascular tie,
contrary to it, when reestablishing the pressure and the normal cardiac frequency,
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can occur bleeds in the postoperative (GRANDO; PURICELLI; CHIAO et al.,
1990).
By occurring septum shunting line, it can have very ackward
functional and aesthetic problems, in the postoperative one. It can occur by the
insufficient removal of the septal crest of the maxilla and septum gristly during
the trans-operatory, or even during the cannulas placement and/or during the nasal
cavity aspiration, or still during the extubation. Some shunting lines offer the
possibility of reduction, however, it has those that can need a posterior
septumplastia (ARAJO, 1999).
Studies show that signals and symptoms in the postoperative one
can occur as posterior nasal secretions, nasal congestion, fever and headaches.
Aiming at to prevent these facts, if the patient presents some disease in the daily
pay-operatory must be used nasal laxatives to promote the fast exit of the blood of
the maxillary sinus in the postoperative one (YOUNG; EPKER, 1972).
The occurrence of the maxillary sinusitis is a rarer complication in
the use of this technique, however in occurring it, it must be managed
therapeutical medication with the use of nasal laxatives, antibiotics and
antihistaminic (ARAJ O, 1999).
Amongst the ophthalmic injuries, the xerophthalmia, blindness
with the injury of II cranial pair, oculomotor with the III cranial pair, beyond
injury of the abducent nerves with the VI cranial pair. Corneal xerosis or
xerophthalmia consists of a disease of the ocular globe, promoting disappearance
of lachrymal secretion and, in such a way, the ocular globe becomes dry, rough,
without brightness and, with parchment aspect (NEWLANDS; DIXON;
ALTMANM, 2004).

DISCUSSION

Literature is unanimous in saying that the orthognatic surgery
supplies to the patient face harmony, beyond reestablishing the function and, thus
bringing a psychosocial improvement, coming to provide a better quality of life
(CUNNINGHAM; HUNT; FEINMANN; 1995 e HUNT; CUNNINGHAM,
1997 and PETERSON, 2000).
The orthodontics can decide the problem in some situations,
providing to the patients even a camouflage, however, when there is a discrepancy
in the base bone, the orthodontic treatment cannot supply, having necessity of the
surgical intervention. Remembering that the surgery always must be preceded of
non-compensatory orthodontic treatment, as some authors agree (PROFFIT,
1991 and TOLEDO-FILHO; MARZOLA; TOLEDO-NETO, 1998).
MIRANDA (1996) and CORTEZZI (1996) agree when affirming
that the patients with maxillary alterations, can present, concomitantly, nasal
alterations or even though temporomandibular dysfunction.
Many are the indications for the execution of the technique of the
total osteotomy of the maxilla with diverse stories in literature agreeing to such
indications as the extreme exposition of the previous incisors, the horizontal
excess, the anteroposterior excess, the vertical excess, the crossbite unilateral or
bilateral and the maxillary hypoplasia (BELL; ALESSANDRA; CANDIT,
1968; EPKER, 1981; EPKER; STELLA; FISH, 1995 and PETERSON,
2000).
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
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669
The deep anatomical knowledge of the maxillary region, beyond its
development, has basic importance for the success of the surgeon and the surgical
maneuver (WIKKELING, KOPPENDRAAIER, 1973; WASHBURN;
SCHENDEL; EPKER, 1982; MELSEN, 1987 and HERFORD;
THARANON; FINN, 2001).
Some authors agree that Le Fort I osteotomy carried through in
child can be complicated by the development of the molar beyond the growth of
the maxillary complex, being able to intervene with the future bone development
(WIKKELING, KOPPENDRAAIER, 1973 and HERFORD; THARANON;
FINN, 2001). However, there is a discord of authors, affirming that, after studies
in 16 patients between 10 and 16 years, had not been evidenced alterations in the
face development (WASHBURN; SCHENDEL; EPKER, 1982).
Amongst the bones and involved anatomical structures directly in
the execution of the techniques cited in the present work authors affirm as main,
beyond the maxilla, the maxillary sinus, the hard/soft palate, the Vmer bones,
Ethmoide, sphenoid (CASTRO, 1976 and SICHER; TANDLER, 1981).
FVERO (1986) affirms having a great interest to the surgeon the
division to maxillary of the triplets that covers pterigopalatine cavity, infra-orbital
canal and face being these the terminal branches. However the branches of the
triplet nerve are vastly cited in literature because they are all directly joined to the
diverse techniques and possible manipulations to be carried through in the
maxillary bone complex (SICHER; TANDLER, 1981).
It is possible to meets in literature the first technique of maxillas
total osteotomy described (VON LANGENBECH, 1859) and, until then the
maxilla was not separate of the pterygoid plateaus, what started to occur from the
decade of 30 with AXHAUSEN, using it to correct breakings maxilla and, also,
for WASSMUND, carrying through the osteotomy of canine pillars, being the
authors revised unanimous when affirming such pioneering (AXHAUSEN, 1934;
FVERO, 1986; ARAJO, 1999 and MENUCI-NETO; POLIDO;
MAZZOLENI et al., 2004).
Initially osteotomy was realized in two surgical times (KOLE,
1959), however, with the evolution of the technique, it is possible to find
described the same procedure realized in only one surgical time (MOHNAC,
1967 and PAUL, 1969), situation followed by great part of authors of the present
time.
After all studies elucidating the maxillary revascularization
(BELL, 1969), many authors from literature affirm that Le Fort I osteotomy
comes to be widely used for the fact of provide an enormous variety of movement
Thus, advances, increase /reduction of vertical dimension are cited, having still
the possibility of accomplishment of a segmentation of the maxilla, promoting
still bigger movements (GRAZIANI, 1986 and S JNIOR, 2001).
OBWEGESSER (1969) described the technique of Le
quadrangular Fort I osteotomy, indicating for patients with horizontal deficiency
and, to zygomaticmaxillary with an exacerbated nasal projection.
The technique of the high osteotomy is very defended also using as
argument the fact of the zygomatic bone to be dense, bringing a higher stability
and setting (KUFNER, 1971). Although to occur a great stability, it is possible to
meet in literature, until the current days, few and restricted cases with this
indication.
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
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670
Traditional osteotomy (BELL, 1975), today is used for the
majority of the authors, due to its indication for diverse types of cases. Through
this technique is possible to reduce the face height, the exposition of incisive teeth
and inter-labial space and, thus, to put into motion the maxilla for a class I
occlusion (PEDERSEN, 1972; KRUGER, 1984; BARROS; MANGANELLO-
SOUZA, 1998 and S-JNIOR 2001).
For patients with agreed horizontal and anteroposterior
deficiencies, the osteotomy in slope can be applied, getting an advance to the
maxillary and at the same time a descenso (REYNEKE; MOSUREIK, 1985).
However great part of the authors uses the traditional technique of BELL, making
descenso after to carry through the straight line osteotomy, with the argument to
get greater exactness in the carried through movement (PEDERSEN, 1972;
KRUGER, 1984; MANGANELLO-SOUZA, 1998 and S-JUNIOR, 2001).
Studies affirm that the maxilla during the mobilization process
suffers great deficit from sanguine suppliment, however this transitory ischemia
does not cause damages to the region, therefore has a fast revascularization after
the stabilization. This fact suggests that if there is the necessity of being carried
through the tie of the descending palatines arteries, will not have problems with
the heal (BELL, 1975). However, it has discords because authors affirm to have
great risk of necrosis occurrence to lacking blood vessels of the maxilla in case
that it has the tie, recommending that the descending palatine vases must be
preserved, what would increase the security of the Le Fort I osteotomy
(LANIGAN; HEY; WEST, 1990). However they agree when affirming that the
maintenance of the muscular insertions is basic to diminish the necrosis risk to
lacking blood vessels of the maxilla (BELL; FONSECA, KENNEDY et al.,
1975 and LANIGAN; HEY; WEST, 1990).
Authors agree when saying that the orthodontists have shown a
bigger interest in providing to the patients a better picture of the harmony and face
function, increasing the surgical indications, when they are (BLOOM, 1961 e
PASTORI; MARZOLA; MENDES et al., 2005).
Many works had been carried through aiming at to foresee the
alterations of soft tissues in relation to the bone movements, however the authors
affirm to occur great variations in the results (BELL; PROFFIT; WHITE,
1980). Disagreeing with the above-mentioned authors, some of them affirm that
the orthognatics surgery is a total previsible procedure in relation to the alterations
of face soft tissues (JACOBSON; SARVER, 2002).
Amongst the searched authors for accomplishment of the present
work, all agree, when they are mentioned to the minimum of six months so that
they are gotten resulted more necessary in the alterations of soft tissues
(BLOOM, 1961; DANN; FONSECA; BELL, 1976; SCHENDEL;
EISENFELD; BELL et al., 1976; BELL; PROFFIT; WHITE, 1980 and
MANSOUR; BURSTONE; LEGAN, 1983).
In studies on the movement of soft tissues with hard tissues after
the osteotomies of the maxilla in lateral telerradiografies they had evidenced to be
possible, in the daily pay-operatory, to foresee the changes that will occur in soft
tissues (DANN; FONSECA; BELL, 1976).
Analyzing lateral telerradiografies in the postoperative and daily
pay the authors are vast affirming that the structures that had suffered to greaters
movements after osteotomy had been the superior lip and the nasal apex, reducing
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
LITERATURE REVIEW
671
the vermillion of the superior lip to a large extent of the cases (PEDERSEN,
1972; DANN; FONSECA; BELL 1976; SCHENDEL; EISENFELD; BELL et
al., 1976 and MANSOUR; BURSTONE; LEGAN, 1983).
All the authors tell the hemorrhage as being the most common
complication to occur to the carried through the osteotomy, related to the
maxillary bone artery, in its terminal branches and, more specifically the
descending palatine artery and the esphenopalatine artery (NEWHOUSE;
SCHOW; KRAUT et al., 1982; GRANDO; PURICELLI; CHIAO et al., 1990;
RENICK; SYMINGTON, 1991; LANIGAN; GUEST, 1993; LANIGAN, 1997
and ARAJO, 1999).
They agree when they affirm to have other serious complications as
the ophthalmic, the xerophthalmia, the blindness, injury of the oculomotor nerve
and abducent injuries, being able to occur with a higher frequency and, with lesser
occurrence the maxillary sinusitis, fistulas arteriovenous oroantrals and
nasoantrals, the shunting lines of septum, pseudo-arthrosis, the velopharynx
incompetence, beyond damage to the nervous system and ischemic necrosis
(YOUNG; EPKER, 1972; ARAJO, 1999 and NEWLANDS; DIXON;
ALTMANM, 2004).

CONCLUSIONS

Based in literature review, since the beginning of the use of Le Fort
I total osteotomy of the maxilla technique, it can be concluded that:
1. Orthognatic surgery is a positive treatment when it aims to
reestablish the facial aesthetic, dental harmony and psychosocial improves.
2. The possibilities for the accomplishment of the Le Fort I
osteotomy are vast, with basic importance for the correct indication for each case,
therefore the techniques developed until today search to take care of to the diverse
occurrences of dentofacial deformities.
3. A minute knowledge of the anatomy of the maxillary region is
necessary, thus preventing higher complications in the trans-surgical.
4. After studies related to the microcirculation, the execution of the
technique can be carried through with bigger security for the surgeons, a time that
the revascularization is total gotten.
5. The soft tissues that suffer to greater alterations because of the
execution of this surgical technique are the superior lip and the nasal apex.
6. The hemorrhage is the main complication, mainly happened
from the maxillary artery and its terminal branches, especially the descending
palatine artery and esphenopalatine.


REFERENCES *

ALMEIDA-J UNIOR, J . C.; CAVALCANTE, J . R. Osteotomia sagital do ramo
mandibular e osteotomia total de maxila: Uma reviso de literatura. Pesq. bras.
Odontoped. Clin. Integr., v. 4, n. 3, p. 249-58, 2004.

_____________________________
* In accordance with the ABNT norms.
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
LITERATURE REVIEW
672
ARAJ O, A. Cirurgia Ortogntica. So Paulo: Ed. Santos, 1999.
AXHAUSEN, G. Zur Behandlung veralteter disloziert verheite oberkiefer bruche.
Deust. Zahn Mund. Kief., v. 1, p. 332-8, 1934.
BEHSNILIAN, V. Occlusin e rehabilitacin. Montevideo: Ed. Montevideo
Papelera, 1974.
BELL, W. H.; ALESSANDRA, P. A. CANDIT, C. L. Surgical orthodontic
correction of class II malocclusion. J. oral Surg., p. 265-72, 1968.
BELL V. H. Revascularization and bone healing after anterior maxillary
osteotomy: a study using adult rhesus monkeys. J. oral Surg., v. 27, p. 249-55,
1969.
BELL, W. H. Le Fort I osteotomy for correction of maxillary deformities. J. oral
Surg., v. 33, p. 412-26, 1975.
BELL, W. H.; FONSECA, R. J .; KENNEDY, J . W. et al., Bone healing and
revascularization after total maxillary osteotomy, J. oral Surg., v. 33, n. 4, p. 253-
60, 1975.
BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. Phiadelphia: Ed. W. B. Saunders Company, 1980.
BELL, W. H.; SCHEIDEMAN, G. B. Correction of vertical maxillary deficiency:
stability and soft tissue changes. J. oral Surg., v. 39, p. 666-70, 1981.
BELL, W. H. Modern practice in orthognathic and reconstructive surgery.
Philadelphia: Ed. W. B. Saunders Company, 1992.
BENNET, M. A.; WOLFORD, L. M. The maxillary step osteotomy and
Steinmann pin stabilization. J. oral Maxillofac. Surg., v. 43, p. 307-11, 1985.
BLOOM, L. A. Perioral profile changes in orthodontic treatment. Am. J. Orthod.,
v. 47, n. 5, p. 371-8, 1961.
CASTRO, S. U. Anatomia fundamental. 2 ed., So Paulo: Ed. Mcgraw-Hill do
Brasil, 1976.
CORTEZZI, W. Cirurgia ortogntica e desordens temporomandibulares. Oral
Surg. Oral Med. Oral Pathol., v. 83, p. 177-83, 1996.
CUNNINGHAM, S. J ; HUNT, N. P; FEINMANN, C. Psychological aspects of
orthognathic surgery: a review of the literature. J. Adult Orthodon. Orthognath.
Surg., v. 10, n. 3, p. 159-72, 1995.
DANN, J . J .; FONSECA, R. J .; BELL, W. H. Soft tissue changes associated with
total maxillary advancement: a preliminary study. Am. J. Orthod., v. 34, n. 1, p.
19-23, 1976.
EPKER, B. N. Superior surgical repositioning of the maxilla: long term results. J.
oral Maxillofac. Surg., v. 9, p. 237-46, 1981.
EPKER, B. N.; STELLA, J . P.; FISH, L. C. Dentofacial deformities - Integrated
orthodontic and surgical correction, v. I, 2 ed., St Louis: C. V. Mosby Co., 1995
In: MARZOLA, C. Fundamentos de Cirurgia Buco-Maxilo-Facial. CDR., Bauru:
Ed. Independente, 2005.
FVERO, V. H. Estudos das tcnicas cirrgicas nas osteotomias de maxila.
Dissertao apresentada para obteno do ttulo de Mestre em Cirurgia e
Traumatologia Bucomaxilofacial pela Pontifcia Universidade Catlica do Rio
Grande do Sul da cidade de Porto Alegre, 1986.
GASSMANN, C. J .; NISHIOK, G. J .; THRAS, W. J . et al., A lateral
cephalometric analysis of nasal morphology following Le Fort I osteotomy
applying photometric analysis techniques, J. oral Maxillofac. Surg., v. 47, p. 926-
30, 1989.
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
LITERATURE REVIEW
673
GERHARDT DE OLIVEIRA, M. Manual de anatomia da cabea e do pescoo.
3 ed., Porto Alegre: Ed. EDIPUCRS, 1998.
GRANDO, T. A.; PURICELLI, E.; CHIAO, I. U. et al., Hipotenso induzida e
controlada pelo halotano e nitroprussiato de sdio na cirurgia ortogntica. Rev.
bras. Anestesiol., v. 40, n. 5, p. 325-30, 1990.
GRAZIANI, M. Cirurgia buco-maxilo-facial. 7 ed. Rio de J aneiro: Ed.
Guanabara / Koogan, 1986.
HERFORD, A. S.; THARANON, W.; FINN, R. A. The pterygopalatomaxillary
region in relation to the Le Fort I osteotomy. Oral Maxillofac. Surg., v. 9, p. 1-10,
2001.
HUNT, N. P; CUNNINGHAM, S. J . The influence of orthognathic surgery on
occlusal force in patients with vertical facial deformities. Int. J. oral Maxillofac.
Surg., v. 26, n. 2, p. 87-91, 1997.
J ACOBSON, R.; SARVER, D. M. The predictability of maxillary repositioning in
Le Fort I orthognathic surgery. Am. J. Orthodon. Dentofac. Orthop., v. 122, n. 2,
p. 142-54, 2002.
KAMINISH, R. M.; DAVIS, H. W.; HOCKWALD, D. A. et al., Improved
maxillary stability with modified Le Fort I technique. J. oral Maxillofac. Surg., v.
41, p. 203-5, 1983.
KOLE, H. Surgical operations on the alveolar ridge to correct oclusal
abnormalities. Oral Surg. Oral Med. Oral Pathol., v. 12, n. 3, p. 277-88, 1959.
KRUGER, G. O. Cirurgia oral e maxilo-facial. 5
a
ed. Ed. Guanabara / Koogan,
1984.
KUFNER, J . Four year experience with major maxillary osteotomy for retrusion.
J. oral Surg., v. 29, p. 549-53, 1971.
LANGENBECH, B. V. Beitrage zur osteoplastikdie osteoplastische resektion des
oberkiefers In: Goshen, A. Deustche Klinik. Berlin: Ed. Reimer, 1859.
LANIGAN, D. T.; HEY, J .; WEST, R. A. Hemorrhage following mandibular
osteotomies: a report of 21 cases. Int. J. oral Maxillofac. Surg., v. 49, n. 7, p. 713-
24, 1991.
LANIGAN, D. T. GUEST, P. Alternative approaches to pterygomaxillary
separation. Int. J. oral Maxillofac. Surg., v. 22, p. 131-8, 1993.
LANIGAN, D. T. Vascular complications associated with orthognathic surgery.
Oral Maxillofac. Surg. Clin. North Amer., v. 9, p. 231-50, 1997.
LASCALLA, N. T.; MOUSSALLI. N. H. Periodontia clnica. So Paulo: Ed.
Artes Mdicas, 1980.
MANGANELLO-SOUZA, L. C. Cirurgia ortogntica e ortodontia. So Paulo:
Ed. Santos, 1998.
MANSOUR, S.; BURSTONE, C.; LEGAN, H. An evaluation of soft-tissue
changes resulting from Le Fort I maxillary surgery. Am. J. Orthod., v. 84, n. 1, p.
37-47, 1983.
MELSEN, B.; OUSTERHOUT, D. K. Anatomy and development of the
pterygopalatomaxillary region, studied in relation to Le Fort osteotomies. Ann.
Plast. Surg., v. 9, p. 16-23, 1987.
MENUCCI-NETO, A.; POLIDO, C. B.; MAZZOLENI, D. S. et al., A anatomia
da regio posterior da maxila e a osteotomia Le Fort I. Rev. bras. Cir. Traumatol.
Buco-Maxilo-Fac., v. 1, p. 15-20, 2004.
MIRANDA, S. L. Rinoplastia associada cirurgia ortogntica. Rev. Odontol.
Univ. Sant. Am., v. 1, n. 1, p. 36-9, 1996.
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
LITERATURE REVIEW
674
MOHNAC, A. M. Maxillary osteotomy for the correction of malpositioned
fractures: Report of case. J. oral Surg., v. 45, p. 460-3, 1967.
MORACA, P. P.; BITTE. E. M.; HALE, D. E. Clinical evaluation of sodium
nitroprusside as hypotensive agent. Anesthesiology v. 23, p. 11-23, 1962.
NEWHOUSE, R. F.; SCHOW, S. R.; KRAUT, R. A. et al. Life threatening
hemorrhage from a Le Fort I osteotomy. Am. Assoc. oral Maxillofac. Surg., v. 40,
p. 117-9, 1982.
NEWLANDS, C.; DIXON, A.; ALTMAN, K. Ocular palsy following Le Fort I
osteotomy: a case report. Int. J. oral Maxillofac. Surg., v. 33, n. 1, p. 101-4, 2004.
OBWEGESSER, H. L. Surgical correction of small or retrodisplaced maxillae:
The dish-face deformity. Plast. Reconstr. Surg., v. 43, p. 351-9, 1969.
PASTORI, C. M.; MARZOLA, C.; MENDES, E. B. et al., Alterao dos tecidos
moles faciais aps osteotomia Le Fort I Revista da literatura. Rev. Odontol.
(Academia Tiradentes de Odontologia-ATO), v. 9, n. 1, jun. 2005. Acesso em
03/10/08.
PAUL, J . K. Correction of maxillary retrognatia: report of case. J. oral Surg., v.
27, n. 1, p. 57-62, 1969.
PEDERSEN, G. H. Horizontal osteotomy for correction of maxillary rertusion. J.
oral Surg., v. 30, n. 8, p. 581-4, 1972.
PETERSON, L. J . Cirurgia oral e maxilofacial. 3 ed., Rio de J aneiro: Ed.
Guanabara / Koogan, 2000.
PROFFIT, W. R. Ortodontia contempornea. So Paulo: Ed. Pancast, 1991.
RADNEY, L. J .; J ACOBS, J . D. Soft-tissue changes associated with surgical total
maxillary intrusion. Am. J. Orthod., v. 80, n. 1, p. 191-212, 1981.
RENICK, B.; SYMINGTON, J . M. Postoperative computed tomography study of
pterygomaxillary separation during Le Fort I osteotomy. J. oral Maxillofac. Surg.,
v. 49, p. 1061-5, 1991.
REYNEKE, J . P. MOSUREIK, C. V. Treatment of maxillary deficiency by a Le
Fort I downsliding technique. J. oral Maxillofac. Surg., v. 45, p. 914-6, 1985 In:
BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial
deformities. Phiadelphia: Ed. W. B. Saunders Company, 1980.
S J NIOR, N. N. Iniciao odontologia sistmica. Rio de J aneiro: Ed. Pedro
I, 2001.
SCHENDEL, S. A.; EISENFELD, J . H.; BELL, W. H. et al., Superior
repositioning of the maxilla: stability and soft tissue-osseous relations. Am. J.
Orthod., v. 70, p. 663-74, 1976.
SICHER, H.; TANDLER, J . Anatomia para dentistas. So Paulo: Ed. Atheneu,
1981.
SCHUCHARDT K. Experiences with the surgical treatment of deformities of the
jaws: prognathic, micrognathic, and open bite. In: Wallace A. B. Int. Soc. Plastic.
Surg., Second Congres: London, 1959.
TOLEDO FILHO, J . L; MARZOLA, C; TOLEDO NETO, J . L. Estudo
morfomtrico seccional da mandbula aplicado a tcnicas de implantodontia,
cirurgia buco-maxilo-facial. Rev. Fac. Odontol. Bauru, v. 6, n. 1, p. 23-9, 1998.
WASHBURN, M. C.; SCHENDEL, S. A.; EPKER, B. N. Superior reposiotioning
of the maxilla during grouth. Am. Assoc. oral Maxillofac. Surg., v. 3, p. 142-9,
1982.
WASSMUND, M. Lehrbuch der praktischen chirurgie des mundes und der kiefer.
Leipzig: Ed. J ohann Ambrosius Barth, 1935.
MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I
LITERATURE REVIEW
675
WESSBERG, G. A.; SCHENDEL, S. A.; EPKER, B. N. Disipaction splint for
midfacial advancement surgery. J. oral Maxillofac. Surg., v. 40, p. 607-11, 1982.
WEST, R. A, EPKER, B. N. Posterior maxillary surgery: its place in the treatment
of dentofacial deformities. J. oral. Surg., v. 30, p. 562-5, 1972.
WIKKELING, O. M. E, KOPPENDRAAIER, J . In vitro studies of lines of
osteotomy in the pterygoid region. J. Maxillofac. Surg., v. 1, p 209-12, 1973.
YOUNG, R. A.; EPKER, B. N. The anterior maxillary ostectomy: A retrospective
avaluation of sinus health patient acceptance, and relapses. J. oral Surg., v. 30, p.
69-72, 1972.

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