CHAPTER 5 Maxillary Orthognathic Surgery Vincent J. Perciaccante, DDS Robert A. Bays, DDS History Orthognathic surgery of the maxila was first described in 1859 by von Langenbeck for the removal of nasopharyngeal polyps! The first American report of a rauillary osteotomy was by Cheever in 1867 for the treatment of complete nasal obstruction secondary to recurrent epis- taxis for which a right hemimaxillary own-fracture was wed? Over the next 70 years numerous authors described fsteotomy techniques that mobilized the entire maxila forthe trentment of patho- logic processes In 1901 Le Fort published his classic description ofthe natural planes of maxi- lary fracture? In 1927 Wassmund first Gescribed the Le Fort I osteotomy for the correction of midface deformities How eve, total mobilization of the manila with immediate repositioning was not per- formed until 934 by Athausen’ Separi- tion of the pteryzomaxillay janction was advocated by Schuchardt in 1942. Moore and Ward in 1949 recommenéed hortzon- tal transection of the pterygoid plates for advancement.’ Willmar reported on over 40 cases treated this way and of severe ‘leeding in most, thereby abandoning this ‘procedure in favor of separation at the pterygomanilaryjunction.* Most of these techniques simply mobilized the maxila ‘to ene degree or another, and then placed orthopedic forces on it to achieve the desired repositioning—a sort of untaten- tional distraction osteogenesis. These methods were associated with high levels of elapse. In 1965 Obwegeser suguested. com- plete mobilization of the maxilla so that repositioning con be accomplished without tension’ This proved to be a major advance tn stabilization, as docu mented by Hogemann and Willmar, de Haller, and Perko, espectvel!-!2 Anterior segmentalization of the max ila was aso addressed inthe early descrip- tions, including those by Wassmand, by Cohn-Stock, and by Spanier.'®* Again, complete mobilization of the maxila with vascular compromise was avoided, and ‘multiple segments contributed to poor stability. Cupar, Kole, and Wanderer, respectively reported more direct surgical acces to these provedures with improved mobilization and maintenance of blood supply Posterior segmentalization of ‘the maxilla was used by Schuchardt but it hhad limited stability also owing to incom plete mobilization.” Kufner improved on this technique by completely mobilizing the ostotomized segment prior to repost ‘ioning.” Logically anterior and posterior segmental osteotomies were combined to accomplish total maxillary alveolar osteotomy for repostioning and segmen tal manipulation simultaneously”? Sev- cal forms of total maxillary osteotomies ‘were described by Cupar, Converse and Sapir, and Kole, respectively:922" Will ‘mar farther established the stability of the Le Fort I osteotomy, and Bell and col Jeagues documented the overall superior ty of the total down-fracture Le Fort [ jsteotomy for segmental and one-piece rmusillary osteotomy" Bone grafting to enhance stabilization was advocated by Capar, Gillies and Rowe, and Obwegeser, respectively, who fist advocated grafting in the pterygomaxilary fissure51052" Interestingly, Willmar did not find adi ference in stability with and without bone grafting in nonclefted cases! Early descriptions of the rigid fixation of maxillary osteotomies were pablished by “Michelet and colleagues in 1973, Horster in 1980, Drommer and Inr in 1981, and Luyk and Ward Booth in 198525 Since Ht tine, many methods have been advo- cated for the rigid fisation of maxillary osteotomies, These have included bone phtes, metalic mesh, pins, the rig ad. justable pin (RAP) system, and reworbeble fisation™ Since these ndmark papers ‘volumes have been writen regarding 2 ‘wide variety of technical factors, many of Which reflect operater preference. Basic Principles “Maxillary deformities may manifest in any of the three planes of space: sagital axial and coronal. Patients displaying abnormal1180 Pan &:Orthognathic Surgery facial anatomy offen exhibit clements of ‘maxillary and mandibalar deformities Therefore, the clinician must recognize and be prepared to west manillary and smidface deformities. Sabjectivaly, patients with maxillary deformities often describe their problem in terms of the relative smandibalar appearance, Patient expecta tions clearly demonstrate the importance of the chin in patent sausfaction.® This perceptual preaccupation with spparent rmandibalar excess or deficiency in the absence ofa sgnifcant absolute mandibu- lar abnormality may necesitate extensive consultation and guidance from the sir ge0m 10 asst the patent in recognition oF the contrbation made by the midface and ‘maxilla to overall facial appearance. Simi larly the patient may tdate theimportance of nasal prominence ot deficiency in Aescribing hie or her chief complain Scrutiny of physical characteristics, ‘model surgery and cephalometric analysis with prediction tracings will assist in obtaining a satisfactory treatment plan These important dagnostic and treatment planning modilites are discussed exten sively elsewhere in the text: however, ‘model surgery isthe most valuable tool in preparing for orthognathic correction of Sholetal fail deformitios While: model surgery is essential for immediate preoper: ative surgical simulation and splint com: struction, t may be even more important in early trentment planning. Prior to any orthodontic or surgical treatment, model surgery is the best method to determine the postoperative position ofthe mani as well as the maxtla. No cephalometric prediction (computer generated or hand |rawn) or photographic manipulation can reveal ll of the three-dimensional and teelasa! information gleaned from accu rate model surgery. In the pretreatment state the teeth may not fit together perect ly daring this preliminary model surgery but orthedontics can be simalata to per iit an accurate projection of the specific movements required of the manila and mandible to achieve the desired results, The model measurements made at the time of this exercise should be exactly the same as those used forthe actaal preoper- ative modal surgery (see blow}. retreat ‘ment mode surgery is essential when con- templaung maxilary surgery alone and very useful when planning two-jaw surgery, Pretreatment model sepery per- mits the three-dimensional evaluation of the masila and the mandible, whether the mandible ie autorotatad without surgery or aso ostotomized. ‘Model Surgery, Reference ‘Marks, and Intraoperative Positioning, The parposcs of preoperative model sorgery are to (1) mark the mndals to facilitate thre-dimensional measurement ofthe pre-and postoperative positioning: (2) place the jw mods into the desired postions based om all of the database Inchuding three-dimenstonal clinical assessment (the mest important), radi fgraphic anaiysis, modal studios and patient desires: (3) evaluat the feasibility of the planned surgical moves using the smeasaromenisand make nesesary ast rments: (4) determine the vertical change that will beachievedat the ume of samgery in aach a way that it ca be accaratly dlplicated intraoperatively: and (5) com- stroct the sargical splat} “The following method has been axed success for aver 20 years by the senior author (RAR). The technique is hased on thee simple principles 1, A meacurement ie made from 2 point hove the osteotomy toa point below it at model surgery and intraopera tively, Aer the maxila is moved the same saperior point is used but the point on the maxila has been moved along a predetermined plane. This cre ater triangle defined by one superior point and two inferior points (pre- and postoperaively), This langle can bbe measured accurately on models and on the patent at surgery. 2. Central incisor vertical measurements can be made directly on the models. 3. If the measurements made on the ‘models and at surgery have the same pre- and postoperative diffrence, the incisor vertical will be comrect. Centric relation mounted models are rmarked to record all possible suigical ‘movements anteriorly and posteriorly (Figure 57-1), For the purpose of ilustra- tion Figure 57-18 and B demonstrate the ‘measurements that are necessary for intra ‘operative control of the vertical postion of the maxilla The vertical measurements at the manillary canines and frst molars arethe critical one for use intraoperative 1y (ee Figure $7-10). Thebiateral vertical ‘measurements must be made ftom stable points on the top of the mounting ring, fot jst anywhere along the mounting ring (points A and P) to cusp tips. Gingi- val cuffs wll be used intraoperatively (Fig. ture £7-2) on the canines (point 8) and first molars (point C), ‘The maxillary ‘mod is then moved to the desited post- tion, inclading vertical. The measurement fof the vertical position of the incisor i ‘made by placing the Boley gauge flat on the top of the mounting rig (parallel to the Frankfort horizontal) te the tip ofthe incisor (see Figure 57-1D). This vertical ‘measurement of the muaillary central incisor is constantly controlled while the ‘maxi is positioned in all other planes of space (see Figure $7-2A). After the maxil- lary model has been fized in the proper postion, an imaginary triangle ie created by points A, B, and Band by points PC, and C’.The ines A-B and P-Care the pre- ‘operative vertical vahtesand the lines A-B” and PC'are the hypotenuses othe trian- sles and the postoperative vertical values (ace Figure 57-28). The differences between ines A Band A Band lines D-C and P-C’ are the important values. The ahsolute aumbets ate not,car STL A,Mounted madele marked fer athogicthiceungery with vertical presperat I's place, Sraight lie meenuement re nie Fem py eins Pte C om each side. D, Drounvingring (Not Intraoperstively marks ere made ahve the proposed ostantomy sites inthe piriform rims and the first molaributtress ‘reas (points A and P) (se Figure 5 ‘Measurements are made from point A to the gingival cuf of the canine (pcint B) ‘and fiom point P to the fst molar (point The gingival cuffs are used because the ccesps wil he hidden tinder the splint and the brackets may come loose during surgery. During musillary positioning, lines AB’ and P-C’ can be measured until the difference between lines A-B and A-B’ ‘and lines P-C and P-C’ are as predicted by the models (sce Figures 57-2D and E) When this is accomplished the anterior vertical changes ofthe central inasors will be as they were on the modeb, s0 that n direct mescurement of incisors is neces sary. Usually the maxilla is repositioned anteropesteriorly and sometimes medio- laterally as it is moving vertically, This method of measurement is especially Important when large anteroposterior or mediolateral moves ate included (Our experience and that of others shown that external reference marks add nothing w the accuracy of veri maui Maxillary Orthognathic Surgery 1181 iis cede. vi hi lary positioning if the internal reference method is as outlined above Surgical Anatomy Osseous Structures The body of the maxila contains the axillary sinus in its entirety, except rarely when the apex extends into the zygomatic bone. The anterior surface of the maxilla isthe anterolateral wall of the snus, The infraoebital foramen is located at variable distances below the interior forbital im, Continuing inferiorly i theL182 Pari 22 Orthogeathic Sun HOLME 57.2.4, Mautlary medel has ben mere iat desired postion icing vrial.Maxlary incr i agnin measured perpen erisntal i om top of the unt ig) By Sagi ine msareromen ane mand ow pos Ate Band Pf lta. Cy suger ae are me inthe pirfor rn ae olson the utr fo vimaltepetnts A and ®blteraly. The pega cof the cannes and rt molars reset pnts B end. Lk Felleringretlcton of erat placed otha the fferences beter ines AD and A-B a these they mere on he models Lines PHC and PLC" carb ese Simi Note ss de prety the vera charg tthe cena incors wl he sme it won the modes thal teres wo Ned tomate dive measur! of thecetral Etat ej rawarcrnet rch ars to the Freafes canine fossa lateral to the canine tooth, form the saperolaeral boundary of the typically presents the openings of four The anterior alveolar process of each piriform aperture asa thin edge of bone canals through which the nasopalatine ‘maxilla surrounds the piriform aperture, (Figure 37-3 arteries and nerves are conducted, and they unite in the midlineto form the In the midline the nasil cret of the The palate is formed by the palatine anterior nasal spine, This bory spine is manila articulates withthe septal or quad- process the two maxi and the hor\- the most anterior ané inferior attach rangularcartiage and vomet™® The septal zontal mina of the palatine bones‘* The iment for the mobile anterior cartlagt-cartlage ress in a central grocve, which transverse suture between the manila and ows nasa septum. An elevated sharp extends posterorto theanteriornasa spine. palatine bones les roughly 1 cm anterior ‘est atthe junction of the anterior and Thisartculation sieve butstengthened to the posterior margin of the hard palate. nasal surfaces of the maxilla, which by te perichondriam-perioteum contina- AL its lateral extent the suture widens into forms the nasil foor, inclines iis struc- ny and imerposed coanectne tssue. In the the greater palatine foramen, which Is ture supertorly at the aperture. The body midine atthe junction ofthe maxfla and approximately 1 cm posteromedl to the Df the maxilla and fs frontal process the premanila ts the incstve fossa, which second molar (Figure 57-4)oun $73 Crasctionl anatomy of the nestle the pirjoem rim “The grater palatine canal is formed similar boteen the perpendicalar l= sae of the palatine and milary bones, which form te inferior lateral nasi wall. The inferior nasal concha alo articulates with the masilary and palatine compo sent ofthe ater nasal al eseroateraly the masilary tuberos- sty 4 boing the think molar. Above ths tuberosity the posterior superior alveolar foramina maybe observed through wich the nerves and vessels emerge. The pyra- rial proces of the palatine hone unites the two pterygoid plates ofthe sphanold bone with cach othr and to the mss The perrgosilayjuetion, formed by te palatine bore. ends supersry m the perygooaxilary Barure lading into the plecpopalatine fess. The foramen ‘oundu enters the posterlar wal ofthe erygopalatine fossa andthe pterygoid or ‘dian canal Mecaly the sphenopalatine foramen leads tothe Intra nasal ceity posterior tothe mide nasal cone of the état bone. Anterior the insert nd syoratic neve nd infaceital vs ‘cle run i the infsorital canal, anc inf tioly the descending palatine artery and yee: pabtine nerves couse witha the fester palitne coral Vascular Structures Although mumerous texts describe the anatomy of the intact manila, several ‘spect of maxillary blood flow remain ia doubt following maxillary osteotomy. ‘The La ort | masillary osteotomy had been performed for over 100 ysars before Tell Gist identified the exact nature of blood vessels in the osteotomized max: ill, which providad information regard. ing the viebility to the pediced maxi 128 Tr was ebvious that even thoagh ‘the direct blood supply to the maxillary teeth and peridontiam was intermapted, collateral circulation existed to perfuse ‘he dental pulp and surrounding strc: tes (Figures $7-5 and 57-9). This same Coienlation was also responsible for the ‘survival of the rest ofthe mills bowev. cr the exact nature of the various factors affecting maxllary persion Is still not well documented or understood, Bes sucies revealed that saving the descend ing palatine arteries mede litle differ fence, indicating that a collateral vas ‘lature existed, probably ftom the soft Palate, which was adequate for mavillary perfusion. The down fractured meaill ‘hava rich blood supply vie the ascending pharyayeal artery and the ascending palatine branch ofthe facial artery Ball alo verified the revsscalarization cof nterior maxilary ostectomics wsing the microangiographic technique inact’ and ottol performed revnscaae ‘nation studies similar to thore of Bell and found quite diferent rests.” They found eam 57, Crucaetionl anton of the enon jinn. aethepon e Fiepeletictne Maxilary Orthognathic Surgery 1183 FHoUME S75 Pati of the esconding pole fine ascending pharyngaa, xed descending Deltinewrtro a they contin te grester peltinc toca the tunneling tecamique to De superior in ‘maintaining the blood supply, espacial to ‘the pulpal tistues, when compared with the bial pecicled anterior maxillary pro- cedures?" This was Just the opposie from the findings of Kell® A possible explanation for this discrepancy ie that Bell used monkeys wheross Brositi and Bovtol used dogs, which they claimed pos- sess 2 more similar maxillary vaccuatane to that of the human. The clinical signif icance of these diferences is not deer to this day Revacularization does not necessarily represent blood flow, and therfore Nel, and colleagues ased a radioactive miro sphere technique to evaluate maillary blood flow. Untorrunately several van hls wate protnt in this stad that mabe interpretation difficult, In none of the above-mentioned studio were the mails moved to a new posidon, whieh may rep- resent the largest insult to the blood sappy at the time of actual masilary osteotomy. ‘Additionally, in Nelson's study, severance of te descending pula vessels was inaver tent and no ligation was performed. ® Ths. allowed beedingto accor through thelacer atod vessels and prevented a presure head1184 part 8 Orhognathic Surgery rem 5.8 if pt acting hry batt ieee eine re Soe ee ‘sectioned and tied. The arrows signify direction of ia ‘om developing fo mamtain aistal tow 19 the anterior manila. Also there were large dliferences in the preoperative microsphere vanes hetwsen animals sach that postoper- ative comparisons were impossible. In other studies involving anterior maxillary ‘osteotomies, Nelson and colleagues found ‘no significant diffrences among three dif ferent techniques that were similar to the ‘ones described by Brusattand Bott, plusa third procedure using only a palatal pedi- cle! Although no statiticl diference vwas seen, the palatal fp seemed to be sighily superior to the others. Again the same problers existed with this stady a5 before, rendering conclusions imposible Soft Tissue Envelope of the Maxilla “The midfacial sperfcial fascia or subot- tancows tissue contains o varisle amoant fof adipose tissue with the mascls of facial expression in its deep layer. This is tightly ‘bound te bone except adjacent to the buc- cal fat ped and in the lawer eysids, Follinchead divided the mimic or facial ‘muscles into five chie groups eoncesning the mouth, nos, onbit, ear and scalp!” OF concern te the present discassion are the mascls of the mouth and nose, which are innervated at their posterior inferior aspect by the ficial nerve. They inset into the skin and most arse from periasteum of the ficial skeleton, The upper oral roup of muscles radi- ates from their insertions near the corner ‘of the labial commissure, From a horizon. tal to vertical orientation and inferior to superior the rorlus, zygomaticus major and minor, and the levators (levator labli supsriris alseque nad) insert and blend with the skin and orhicularis oris. The sortus does notarse from bone but orig- inates from the superficial facia over the parotid gland. The risorius, zygomaticus major. and zygomaticus minor elevate and retract the corner ofthe mouth and upper lip lnteraly. The superficial levator mius- cles and a third deeper one, the levator nga ois, elevate the lateral upper lip. It addition the levator abil superioris alaeque nasi attaches to the skin and {greater alr cartilage ofthe nose, thus lit ing the ala and widening the nari, ‘The orbicularis ors is composed of sary multidirectional ber groups that blend with other earrounding facial mus cles, enciedle the moath, originate from periosteum covering the roots of the ‘canine teeth, insert laterally at the corner ‘of the mouth, and passat right angles to the encircling sphincter filles connacting skin to labial mucosa, This diverse muscle draws the lips together, purses the lps, _preses the lps agains the teth, and pulls the corners of the lips inward, The buccinator arises from the mandible and maxila and the pterygo- smandibalar raphe, by which its separated from the superior pharyngeal constrictor. “The fibers pass forward and ight infar- oriy to blend withthe orbicalaris ons ané attadh tothe mucesa and skin ofthe lial region. The buccinator tens the check against the teh, Both Lightoller and Nairn place ‘emphass on the modiolus, which is the ppointat the lateral aspect and just saperi- fr to the comer of the mouth where mus- cles of the oral group ofthe mimetic mas- cles converge? The orbicuaris ore and ‘baccimator joined 2 the modioius form a continuous muscular sheet on etter side oof the midline. The zygomaticus major, levator anguli ori, and deprestor angali cris (as a group referred to as “modiolar stays") immobilize the modiots in any position, Addivonally die mauginal and peripheral parts of the orbicalaris oris ‘musde are distinguished. The peripheral aspect of the muscle lies parallel withthe ‘nner labial mucosal surface, and the mar- ginal part curls outward following the ver- rilion surfce. As tension ie express in the orhicuaris ors. the marginal aspect of the muscle is thought to serighten and decrease vermilion exposure, tnercky polling the upper and lower lips towand cach other and against the dentition. ‘The nasal group of faclal muscles dllates and compresses the nares. The ‘nasils aries from the maxi ateral and inferior to the ala, The transverse portion unites with the contralateral muscle over the dorsum of the nose, The alar part inserts into the groatr ala cartilage Thus, thetwo part compressand dilate the nasal apertares respectively. The depressor sept ‘muscle es beneath the orbicularisoris and attaches to the base ofthe columella and posterior ala. Ite action narrows the nari. The posterior and anterior lator muscles are inirnsic muscles of the nose that ‘course fiom the slr cartilages to the rar- ‘gin of the pads, Themasal mucoperiosteam ic firmly fied to the elevated piriform sim above the floor of the nose, to the lateral ‘margin of the nasal aperture andthe ante- ror nasil spine, The premaxilary wings that lace laterally from the anterior mig line nasal crest provide an irregular atiach- ‘ment of the mucoperiestewm along the inferoanterior nasal Boot “The palate is covered by mmcosa frm | adherent tothe periosteum and contain- ‘ng macous minor salivary glands, The ‘cost is thin ia the central palate andthickens toward the alveolar process The palaune crest isa transverse elevation at {he posterior boider of tehorLontal plate Of the palatine bone that gives attachment to the tensor vei pati muscle. The larg- crlateral pterygoid plat s the origin ofthe inferior head of the lateral andthe mecisl plengoid muscles, A small part of the ‘medial pterygoid also arts from the max_ illary mberosity. The tensor well paatini _muscle curves around the Raman, which 1s the mferior end ofthe medial pterygoid plate. From the hamulus the tensor muscle (of the palate enters the soft palatal Ussue. ‘The tensor aponcurosisisan adherent con- ctive tissue sheath continaoue with the periosteum, which covers the posterior hard palate attaching laterally to the aub- ‘mucosal layer ofthe pharyne and the ten- sor vel paatin tendon Surgical Techniques Soft Tissue Incision and Surgical Exposure of the Maxilla Exposure of the anterior, Isteral, and plecygomarillary ragions i most com- 'moniy achieved hy incising horirontlly through the buccolabial mucoperiosteurn above the attached gingival margin at the level of the maxillary teeth apices (Figure 7A). The vestibular incision courses from the fist molir to the contralateral first molar (Figure 57-7B), The parotid papilla ie identified and retracted supero- laterally daring completion of the incision posteriorly The incision can he made with clectrecautery or steel as there have been ‘no studies performed that show 2 differ- fence between the two. After inital pene- uation of the mucese the nanaral tenden- to cal more supetiody with deeper penetration mast be avoided, This is par- ticularly important in the incor area, as this would carry one into the nasal cavity. “The superior tissnes are refleted sub periestealy, first at the piriform aperture margins (Figure 57-7C). Progressively ‘more superior exposure lateral tothe nasal \ 5 aperture will expose the infuorbital nerve ‘exiting ftom is foramen, Bosterior rflc- tion procesding from the dslnested infra ‘orbital foramen reveals the zygomatico masillary suture, zygomatic buttress, and the most anterior aspect of the zygomatic arch, Inferior. ith subperiosteal tannel- ing, the Interal aspect of the maxillary tuberosty and its junction with palatine bone and pterygoid plates of the sphencid hone are identified. Care should be taken to direct thie subperiostel section infe Hlovy, toward the mucogingial junction, as it i carriad back toward the pterygo- mavillary fissure, to avoid vascular strc tures, Meticulous maintenance of the sub- Periosteal plane of dissection will prevent lwoublesome exposure of buccal fat pad isu, which impairs visualization and retraction of soft tsa daring subsequent ‘osscous surgery. A retractor with a carvi- linear end is placed in the ptorygomaxil lary junction to falitate exposure, Aten tion shold be paid to the placement of this retractor, as it too can he responsible for periosteal rents and exposure of the buccal fat. Maxilry Onthopuoshic Surgery 1185 bet 527°, The oft in inn f acy ges Bi epee Sirctel fee dean pierre ian ato one pp Tae pak cept elerh puemer Superolaicrasufoce of the pir i ‘Tastes inerior tothe horigontal inci sion are clevatod minimally, In areas of interdental ceteotomies for segmentaliza tion of the manilary arch the inferior attachad gingiva and peiostsum ae slvat- ed conservatively. with a Woodson elevator. “tile retraction laterally provided by skin hooks (Rgure 57-84), Since the alveolar ‘osteotomy will be accomplished with thin, ‘steotomes, osseous exposure requirements a the aleoar crest level are minimal. ‘When intersagmental movement will be great and may result in tearing of the gingival papilla an alternative approach 10 the interdental region may be ased. Addi- "uonallya wider exposure of alrolar bone 4s frequently needed when an osteotomy is to be performed in an edentulous or extraction space In these situations a ver~ tical mucosa incision at the line ange, ‘one-tooth distant from the ostactomy site (Figure 57-88), will facilitate wider expo: sre for ostaous procedures. This incision should be usad only when an antariorabi- al pedicle is maintained to maximize the labial vascular pedicle during. multseg- mental osteotomy,1186 Fares: Orthasnathic Surgery fat 528 Pent ener tbat to pee ater oem re foi gerab nega grime 20 prion pond ask yarteri sions alin or doa Por one two-y and most roatine theee-piece maxilary osteotomies, a cir sumvestibular incision with minimal Interdental exposure is preferred. For three-piece maxillary osteotomies that Involve exceptionally wide expunsion or fatreme changes at the Interdental she, four-piece maxillary osteotomies, and ‘esteolomles in soane ex-lft patents, soft tissue incisions can be modified fiom sec. fond molar w fist premolar to malnialn an anterior bial pedicle (Figure 37-9). A ‘midline vertical indian ts placed to gain ‘acces to the midline ofthe maxilla, (Once the labial incisions are complet- ed thenzsal mucopertosteum iseevated to complete soft tissue exposure of the osseous surgical ste (see Figure 57-70). Inital establishment of a subperiosceal ‘dissection planets imperattre for comple- ton of nasal tissue dbsection without dis ruption of mucoperiosteal_ integrity. Because the nasal crit is more volum- ‘ous inside the piriform rim than atthe piriform aperture, the elevator should be held at an oblique ange w the surround- ‘ng maxillary bone adjacent to the nasal perce. While maintaining the elevator lip against bone, the mucoperiostem is reflected from the nasal floor lateral nasal ‘wall and nasal crest of the maxilla, The dissection should continue superiorly fora ‘centimeter up dhe vertical nasal walls 10 prevent tearing during osteotomy or ‘dowa-fiacure of the maxila, particularly at the superior reflections of tbe nasal oor medially and laterally. The anteroposterior depth of this soft tssue dissection is approximately 15 to 20 mm. ‘The remaining posterior soft tissue is ‘elected mare precsey after initial down- fracture ofthe mazil, Osseous Surgery ‘After recording the reference measure- ‘ments oullined eal (see Flgure7-2), the oseotony ts performed. The design of the osteotomy will depend on the maxil- lary movement desired. Regardless of the ‘design of the osteotomy the measurement ‘marks are used as strated in Figure 37- 2. tally the basic horizontal osteotomy ‘ill be discussed and then alterations wil be described for specie situations. Sey- ‘menralfavion ofthe maxilla may be neces- Su tn certain cases, Specifics of tis pro- cedure wil be discussed atthe end of the basic orvontal technique. The lateral rmasilary osteotomy (Figure 57-10) is sMarted at the greatet convexity of the ygomatic butress becanse thats the ea lest starting surface for the reciprocating sav. It is advanced anteriorly through the lateral piriform rim below the inferior turbinate while the nasal muacoperiosteurn is retracted and protected using a petiosteal elevator, For the basic maxillary ‘osteotomy this horizoatal osteotomy & parallel tothe maxillary arch wice approx- iamately coincident with the ext performed previously duing model srgery. After the anterior osteotomy is complete, it i ont tinued posteriorly by tapering inferiorly toward the plerygomaaillary janction, A thin reciprocating saw blade and copicas irrigation are wed for this osseous cul The most posterior centimeter ors ofthe lateral wall can be cut with the same saw, boat fom inside oat (Figure 57-11), Nest 2 nasal septal osteotome is Airected slightly downward and posterior (Figure 57-12) beginning just above the anterior nasal spine while the anterior nasal mucoperlosteuin is retracted. Pro- ‘ceeding posteriorly the osteotome is cae- ‘ally malntaned in dhe midline. Tae ten- dency towasd superior deviation while Separating the cartlaginoas and vorerine sepcum from the nasal crest ofthe maxilla cua 57-9 tera yetbalar aise are le ow he fot promelar tr formed Inala shown with amine vertical isonsictms 57-10. Tater wall xetoy Bogen tiga cme of hates aed ee amend tpi nth pede ‘or pow the nasal mucosa andthe endo tracheal abe necessitates maintenance of a slight downward incination of the septal fstcotome, The lateral nasal wall is er= fred using a thin osteotome directed pos- teriorly while medial retraction of the nasal mucopertosteum 1 accomplished with a periosteal elevator. The asieotome 's gently malleted postertcrly for a dis- tance of approximately 20 mm to avid premature injury to the descending pala- ‘une neurovascalar bundle that resides in ‘the lateral posterior nasa wal ‘After the above osteotomies have been performed. the pterygoid plates are separated from the maxillary taberosity (Figore 57-13) using a small sharp curved osteotome, This instrament is preferred over the traditional thick pterygomanillary asteotome because the ‘thin cutting edge limits fracture and pro- motes precise divsion of this bony janc~ ‘ton.® The tip of the asteotome is di- rected as anteriorly, inferiorly, and ‘medially as the tunneled bwaccal soft tis sue allows. A finger placed palatal and posterior to the maxillary tuberosity will facilitate early verification of the com- plete separation of bone while avoiding ‘trauma to the palatal vascular pedicle ‘The authors prefer to have this instra- ‘ment sharpened before each case, resume 57-11 The say ie thw tured isle ‘ut and the etestony fom the bets. Piengomailary junction (2 made angling Serrreeder tec potas, Downward pressure Is placed on tne anterior maxila using thesharp hooks of Senn retractor to faciitate inital down- fracture of the maxilla (Figure 57-18). If moderate pressure does not result in mobilization of te inferior segment, the completeness of the above ostectomies must be suspect. The cement spatula osteotome fs used to ensure complete bony severance of the anterior lateral nasa wall and zygomaticonaxdlary portions of the osteotomy. The curved osteotome 1s again placed into the plerygomanilary junction, malleed gently, and then torqued to mobilize the maxilla. IFno sig nificant movement 1s detected, then the GORE S712 Seperation ofthe nasal stu fromthe ep rene the rela with pee Masilary Orshognathic Surgery W187 ‘osteniome may be stepped slightly superi- rly diectedantetory, and mlleted unt the separation is complete ‘When mobility occurs the nasal mucoperioseum is elevated progressively ‘more posterionly until the posterior edge of the hard palates encountered (see Fig- ‘ure 57-14), Portions of the pterygoid plates or perpendicular process of the palatine bone that resist fracture may be completely separated from the maxila ‘usingan osteotome under direct vsualza- tion (Figare 57-15). The descending palz- tine nenrevascalar bundle s isolate. g- ated, and divided. Significant movement ofthe posterior manila can cause tensile forces on the descending palatine neurovascular compo- nents. Superior repostioning ofthe maxilia may also compress the exposed vesels and nerve between the Inferior and superior ‘osseous Segments. Severe postoperative bleeding ater Le Fort] maxilary stztomry has been reported. Atempisto preserve the neurovascular bundle may increase this possibilty. Ligtion 2nd dWvséon of this structure bas been shown to have ao dlete- tious influence on perfusion or newo- sensory function’ The bone of the per pendicalar plate of the palatine bone ‘surrounding the neurovascular bandle is retms57-13. Perygomailry prion vith ‘ronal dar carved setome deta medial1188 part a: Orrhopnathic Surgery cus STAM Down fracture ie acomplia With sharp-oorad Sen retractor withsimal- pena rs ae pceiny carly removed using « Woodson eevee toqburs-androngeurs. and tbenewsovascu- lar bundles igated and divided (see Fine 57-15), Afer down-facture, complete ‘mobilization of the maxtlh 1s the next objective. A J stripper normally used for periosteal elevation in sigital esieotomles ‘engages the posterior border of the midline ‘nasal flor atthe posterior nasal spine (Fig- tue 57-16), and anterolateral presse is avne 57-15 Complete removal of bone sound the perpetuate of etn he ‘The dexending plate ar lato ligt chenddved 7 = rene S7-16. Mobilization ofthe mala with SUetrpe: exerted to progressively increase mobility of the manila The goal of the maneavers tw move the masila imo the appeaximate ‘fal postion with only gentle digital pres- ‘sue. After mobivation from the cranial ‘uses completed, 2 reasessment ofthe sur geal move 1s considered, Rased on the ‘movement planned anypossble bony inter- ferences pestrior tothe second! molar must be removed befre application of maxi ‘mandhibaiar fication (MMF). When all pos. ssble interferences posterior to the second rmoler have been removed, the masill is ‘ized to the mandible with the occkul splint interposed. ‘We profer to have the patient com pletely paralyzed during the period of ‘maxillary positioning, Condylar position- jing while rotating the maxilla and ‘mandible is paramoant to success. The physlologic position of the condyles Is thought to be a superoanterfor orleata- ‘tom relative to the glenoid fossie against ‘the posterior slopes of the arucular er ‘ences, with the disk interposed between the condyle and the fossa. The surgeon ‘must position the condyies ofthe maxilo- mandibular complex in this upward and forward direction prior to atorotation (Figure 57-17). The importance of thi stage of the surgery canaot be overesti ncvRsS7-17 Marea pst ofthe mac laminar complex wih conde saa Note AC ptr ie pei thd tbe creed. ‘mated. The most likely points of unrcog- nized bony interforences are in the areas fof the pterygoid plates, the maxillary tubarowitis, and the perpendicular plate of the palatine hone Its quite possible to rotate the maxillomandivalar complex inappropriataly while being unaware of a premature pivot point in these posterior bony areas (Figace 57-184). This will result in Class TI open bite discrepancy once the patent i released from MME. If 2 significant petiod of MMF or training elastics is used postoperatively, this dis- ‘crepancy may not become apparent for ‘weeks or months (Figure 57-188). Once these posterior interferences have been removed, the surgeon continues to rotate the entire complex around the tem- poromandibular joints until the appro- priate vertical relationship is achieved 25 described above. The cartilaginous sep-PARE S7-1B_A,Inapproprieposion- ing of the conde arewnd porn poe ‘pont wil sl in pen te afer ease frm mstltardlaie aati tam and voreras well asthe nasal crest of the marill are reduced in height equal to the planned movement of the maxilla This may entail a submucosa: resection of the cartilaginous nasal sep tam to prevent buckling of the septum from pressure as the maxilla is reposi- tioned. A groove can be fashioned in the midline of the nasal floor to accorama- dlate the recontoured septum, ‘A portion of the inferior edge of the ‘urtllginous septum should be removed. The tendency is to remove too litle because of the iregular inferior contact between septum and mani. Even ifthe ‘maul 8 tnfertorly positioned, buckling of the septum may occur becanse the car- flaginons septum extends anterior and inferior to the anterior nasil spine and thersfare can be buckled a6 the mail mover forward even if there ie some downward movement (Figure 57-19). All ‘of the maxillary positioning has besn pre determined by the model surgery and splint constraction, except forthe vertical ‘Ac the milla i rotated upward around, the condyles, bone i only removed at the point of contact, not a Fll wedge (Figure Masitery Orthognthc Surgery 1189 57-20). This factitates ideal bone-to-bone ‘contact and avoids large gaps in between, (Once the desired vertical relationship has been achieved based on the measurements described above, the maxilla should be fixed in postion with intemal rigid fsa- ‘von, Seqnentially eliminating only inter- toring osseotsstractazes ensures optimal bone contact. This method is praferred lover a wedge ostactomy.® Maxllo. ‘mandibular Saation is removed and the mandible is rotated into the eplint while held tothe maxilla Ifthe occlusion i cor rect, the splint is removed and not left in place postoperative ‘Variations in the above basic ostato- sy design may enhance osseous contact, facilitate bone graft placement or aid fae tion device application, and result in Improved stably of de superiony, invest ory, or anteriorly repesidoned maxilla “These variations will be described below as ‘they apply 10 specific maxillary move. ‘ments. To prevent septal devation despite adequate bone and cartilage removal. it ffien desirable to snare the nasal seprom to the anterior nasa spine This scans by deiling 2 hole through the anterior natal spine and passing a 1-0 polyglycolic acid PORE 57-9 A, Aner ae of the alegre a Ae ee fe Pasar es et pa (lowland enh1190 Part 8 Orthopnathic Surgery 857-20 nr oy walle ST pefee nia a sarure dough the ole and then thou the cariagnous septum (Figure 57-2). “This will abo prevet postoperative dis Placement of te septum during extuba- ‘Won or inthe Post-anethesia Cate Unit Segmentalization ‘A wide range of permutations may be undertaken if segmentation i nse “Tee pies marly osteotomy i perhaps the most comamon, The decisions regarding, ‘whi f the many options wil be wad ae rade by pretreatment and preoperave rode! surge. The ace for craton: i als determines at this tage If 0 exes tions are neve, ntrdental esteotomicn canbe sly made between pall oot of the canines and lateral canines and pre roles If exactions are decided om by the oondinated tors of ortodontst and sar sons they may bedone cryin treatmentce caring the ototomy, A complet dicasion of the indications and considerations tht infuence thae dections i covered che ‘wher inthis ook However if thes ae no specific orthodontic reasons entra teh, {thas been our experince that aay ocesary extat jst fr he parpose oF surgery. The mest common need for se seatiaion & w widen the mauila and adjust the angulalons of the posterior na ‘lary seummens If db anestor sx maxllary tech ft well with the lower anterior ect, the interdenial esteotory is performed between the canine and premolar teeth This pce the potential fora periodontal deft atthe nterdontal eneotomy site more peste. oly inthe mouth. Dut if the canines peed to be widened slong wih the posterior ses- ‘mens, the interdental osteotomy is placed between canine and lateral incisor teeth. We prefer to make thie osteotomy with a thin ‘coment spatals ortotome while palpsting palatal The standard circumvectbalar incision can be made with conservative tun reling fro the incision inferiorly to the alveolar crest on the buccal surface of the ‘maxis, The extatome is mallstadtheongh ‘unl palpated andr the palatal mca (se Figure 57-84). Wah care the osteotamy can becarriad speriory tothe level af the her ‘zontal maxilary osteotomy and medialy to the horizontal surface of the palate This ‘Should be ane heforeany ofthe other max- ilary oseotemies aredonehecamsethe max- ila mast be stale atthe time of malting. [teeth are to be extracted at the ume of ‘osteotomy, an alterative to tunneling isto Jay a fap Int the gingival sulcus for beter acces (see Figure 37-88). However, if tis Js done, its recommended that an anterior pedicle be retained for blood supply (see Bure 57-9) Segmentation using thls or any thes technique fs more dificult when sgnicant- Iy alee estcotomy designs are used, such ‘a high Le Tort Uh oe HL When the Z oxeotamies (see below) are used inter- dental segmentalization between canines and Lateral feasible, bat amore dial ‘tempt between canines and premolar, cure 57.21 A and B, Te ssi septal devioe fon the cartiloginons spon shoe stared the anterior meal spiesFollowing the down-tractare and ful ‘mobilization of the manilla, the remaia- det of the sogmentalization can be per formed. The palatal soft tissoe is very thin in the midline and the bone is very thick, but the opposite is true 6 to 8 mim lateral to the midline, For that reason two parasagittal osteotomies are made along the floor of the nose using a bar with a rounded tp, such asa Steiger bar (Figure 57-22). The parasagittal cuts are jolned with the Interdental ones 10 free the throe dentoalvsolar segments. IF any significant torquing of the anterior seg- ‘ment is to be done, the two parasagitial cuts must be joined across the midline so that there are three dentoalveolar seg ‘ments and one midpaatal bony trag- tment, In two-piece osteotomies the two parasagittal cuts are joined with the interdental cut hetween the central {incisors atthe inclsve canal, ‘The orthodontic arch wire is cut at the imterdental osteotomy sites, and the segments are mobilized appropriately, “The segments are wired tothe preformed surgical splint. Ifbone grafting is needed fom the palate it must be cone before the ‘maxilla is positioned and stabilized vert cally. Interdental and buccal bone grat {ng can he done jast here closate of the rncune 57-22. Following dewnfastre the axl sgmentalzed witha rounded end tuting bur sock es «Seige bur by making tw, ares ct tht jor ecm he tlie aed fonnet with the interdentlostestoie, Masillary Orthognsthic Surgery V19L SRE 57.25 the esl lof eu si tl ary abe, Jer tity eto ok tefl score baer (rothorsxgnontaloteolonten, soft tsaus wounds, Felloing spin fics tion the orthodontic arch wire can be Tted back together with quick curing acrylic if necesary This avoids the time ensoming practice of tying im a pre. formed sarge arch wire. I towo-pice maxillary entetomny i 10 be performed inthe midline, we stl pre ferlousetwo parasagittal osteotomies that ae brought together atte incisive canal. ‘The interdental catetomy is also per formed with a coment spatla oteotome before the other eseotomies. Four place rmasillay oxeotomy is practically never indicated with a compstent orthodontic set-up fits attempted, a tanneting tech niguefs recommended in which an antert- or pedicle of mucoperisteur i tained to asi i the perfsion of the anterior segments “Tae lngth of time that the splint set in placedopencs on theamonntandtype of movements made by the varons seents “The range of tine te plat set a place ‘would be 3 weeks fr smaller movernente and up to 8 week for seater expansion. The patent is reine tthe onbodontist ienmeaitely afer removal of the split fer faprication of theappropriate retention and resumption of onhodenc weaument. i bcbelgoe cs bee Finclly if large interdental bone removal is necessary to close large extraction spaces, access may be needed fon the palate, especially in the midline. In this case we prefer to retain an ante or labial macoperiosteal pedicle with a ssmall midline yertical incision to accexs the anterior nasal spine (Figures 57-23, ‘and 57-24). This allows for a midline paial incision and conservative cir- ms to access the palatal ‘samdental ints bone removal eves 5124 The tational tial mavillry (arcs cries pltelnceerth Yt the anterior epect can be used wah csion1192 Part 8: Orthognathie Surgery Superior Repositioning Lateral maxillary weige ostectomy prior to maxillary repostioning often leaves lange gaps between the bony interfaces as the maxila is moved superiorly Shit {ng iting, or advancing the mille may reduce bone-to-bone contact. Seque removal of osseous contacts avoids this needless lass of hone and provides moce secure contact between the mails and the cranial base (Gee Figure 57-20), “Therefore,only one horizontal osteotomy fs made and no bone is removed until (MME is established and vertical repost- tioning is beeun With MME in place the maxila and imandible are moved through the are of rwlation as dicated by the seated mandibular condyle (sce Figures 57-17 and 57-18). The area of bone contact ean ‘ow he seen 2s the maxilla is positioned superiorly. st enough bone is removed at the contact points to permit the superior repositioning planned. In many cases this will elt in the formation of slo oF grooves in the zygomatic buttress wall of fliewhere along. the mazillary wall (see Figure 57-20). One mus be care thatthe grooves do not inhibit the free rorational movement of the maxillo- ‘mandibular compen. This technique is partcalrly valuable when the maxilla is hing shifed laterally or torgued in a transerse direction, which makes predic- tion ofan osectomy dif. The maxilla ‘srigily fixed andthe MMF removed, the ‘mandible sucorotated imo occlusion, and correct masillary position confirmed. Anterior Repositioning ‘The traditional Le Fort I osteotomy is inclined inferiorly trom anterior to poste- or in oider to avoid the reathely large imaxilary cuspid tooth mot and place iment of the cut inferior to the lateral extent of the mgomatic buttress. The resaitant inclined plane may he problem- atic if this does not coincide with the desired movernens. A variety of straight, stepped, and Zosteotomies can be designed to accom: ‘modate the planned moves (Figures 57 25-57-28) If grafting (Figure 57-29) estrable, the steps or Z osteotomies pro- Vide much beter grafting sites than the plerygomasillary fissure. Inferior Repositioning Inferior repositioning ofthe manila offers a special challenge in orthognathicsgery because there is a great relapse tenden- ox Various mechanisms have been advocated for stabilization and fixation of| the maxila after inferior repositioning ‘There have been a variety of techniques ‘used to stabilize the inferior positioned maxilla, including suspension wires, interosseous wires, bone plates Steinmann, Pins, Wessberg pins, and RAPS282 Stabilization of the inferiorly repesi- oned mavila may not require bone graft- ing from a distant site if a series of slanted Zor sep osteotomies are wed (se Figure 57.25) The angulations of the osteotomies are planned so thatthe maxt!- ta wl side dowa the tndine plane of the cats, maintaining bone contact as it repositioned anteriorly and inferiorly Depending on the inclination of the ante rior versus posterior osteotomies, the max ila may be positioned more anteriorly oF ‘more inferiorly (see Figares$7-26-57-28) Most surgeons prefer to use bone tals and rigid fration to stabilize the ‘maxilla that has been inferiorly re- positioned and tas no bone-to-bone won fact. Grafts can be secured with bone screes or plates if saiicient bone i avail- able or with wire (soe Figare 57-29).Can-

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