1.
‫باال‬ ‫فک‬ ‫استئوتومی‬ ‫های‬ ‫تکنیک‬
Orthognathic Surgery:
Maxillary Osteotomies
‫گردآوری‬:
‫حسینی‬ ‫هادی‬ ‫سید‬ ‫دکتر‬
‫صورت‬ ‫و‬ ‫فک‬ ‫جراحی‬ ‫متخصص‬

2.
Maxillary Osteotomy:
 Lefort 1 Osteotomy
 Lefort 1 Segmental Osteotomy
 Lefort 3 Osteotomy
 Subcranial Lefort 3 Osteotomy
 Modified (subtotal)Lefort 3 Osteotomy
 Transverse Maxillary Distraction Osteogenesis
 Maxillary Osteotomies for Asymetry And Plan
Rotation

3.
Lefort 1 Osteotomy

4.
History
 Based on rene lefort classification-1901
 Bernard Von L B- 1859
 M Wasamund- 1927
 Obwegesser- 1960

5.
Surgical Anatomy
 Bones
 Muscels

6.
Vascular Anatomy

7.
Surgical Technique
 Patient position

8.
Surgical Technique
 Insicion line

9.
Surgical Technique
 Reference points
 Internal
 External

10.
Surgical Technique
 Disection techniques
 Anterior
 Superior
 Inferior
 posterior

11.
Surgical Technique
 Line of osteotomy

12.
Surgical Technique
 Anterior Rep.
 Posterior Rep.
 Impaction -Sup. Rep.
 Inferior Rep. –Downgrafting
 Less than 3mm
 More than 3mm

13.
Surgical Technique
 Nasal Septal Osteotomy
30 -25 mm from ANS
 Lateral nasal osteotomy

14.
Surgical Technique

15.
Surgical Technique
 Peterigomaxillary disjunction
 Curved osteotome
 Osteotome angle
 Inferior and anterior
DPA= 10 mm

16.
Surgical Technique
 Downfracture
 Systolic BP= 90
 MAP=70-75

17.
Surgical Technique
 Disection and corections
disimpaction forceps
Rowe Forceps

18.
Surgical Technique

19.
Surgical Technique
 Deletion of bones

20.
Surgical Technique
Excessive bone removal
1. Segmental instability
2. Lack of bone contanct
3. Excessive post. Impaction
4. Telescopic contact

21.
Surgical Technique

22.
Surgical Technique
 Condylar reduction

23.
Surgical Technique
 Septum preparation

24.
Surgical Technique
 Torbinectomy
Acsess: 3-2 cm

25.
Surgical Technique
 Osteosynthesis

26.
Surgical Technique

27.
Surgical Technique

28.
Rules of Fixation

29.
Post Surgical management
 Elastic theraphy 6-8 weeks
 Splints
 Nasal spray
 Steroids
 Anti Biotics

30.
Hierarchy of stability
 stability
 Amount of displacement
 Vertical position
 RF
 Bone Grafts

31.
Soft Tissue Changes
 One years
Structures Change:
 Clomella show
 Nasal tip
 Upper lip
 Nasolabial angle
 Alar width
Change factors:
Time
Soft tissue width
Wound closure
technique

32.
Complications
 Bleeding
 Avascular necrosis
 Septum deviation
 Ununion and gap
 Ligation
 Iscemic changes
 Hemorage
 cavernous sinus fistula
 Maxillary artery pesudoaneurysm
 Mobilization

33.
Maxillary Osteotomy:
Lefort 1 Segmental
Osteotomy

34.
History

35.
Indications

36.
Transverse Deficency Treatments
 SARPE- SAME-SARME
 Lefort 1 multisegmental
 Mandibular narowing
 Orthodency
 OME

37.
Diagnosis
 Leteral ceph
 OPG
 CT***
 PA

38.
Surgical Technique
 Vasoconstrictions
 Hypotensive GA

39.
Surgical Technique
 Incision

40.
Surgical Technique
 Lefort 1 osteotomy

41.
Surgical Technique

42.
Surgical Technique

43.
Surgical Technique
 Downfracture

44.
Surgical Technique
 Mocusal reflecting

45.
Surgical Technique
 Bone structures

46.
Surgical Technique
Segmental osteotomy patterns(palatal)

47.
Surgical Technique

48.
Surgical Technique
Segmental osteotomy patterns(palatal)
 curve osteotomy- 3 fragements

49.
Surgical Technique
Segmental osteotomy patterns(palatal)
 Square osteotomy- 4 fragementss

50.
Surgical Technique
Segmental osteotomy patterns(palatal)
 Curve osreotomy not involving Nasal Spine

51.
Surgical Technique
 splints

52.
Surgical Technique
 Bone plates and fixation
 Splint fixation

53.
Postsurgical Care
 Retainers
 Smokers

54.
postsurgery
 Instaling transpalatal arch without splint
 Obtained expantion

55.
Periparation for surgery
 Intermolar distance
 Rate of expansion

56.
Complications
 Ischemic zone
MarginalGingival necrosis

57.
Complications
 Gum retraction

58.
Complications
 Osteotomy site

59.
Lefort 3 Osteotomy
Subcranial Lefort 3 Osteotomy
Modified (subtotal)Lefort 3 Osteotomy

60.
Indications
 Osteotomy
 Nose.orbits.zygomas.maxilla
 Modified version: kufner
 Craniofacial disostosis
 Apert
 Crozun
 Pfeiffer
 Seathre chotzen
 carpenter

61.
Midface Deficiency
 Frontal bossing
 Petosis
 Dystopy lateral canthal
 Exorbitism-exotropia
 Maxillary hypopalsia
 Maybe hypertelorism
 Tarnsverse deficiency
 C3 malloclusion
 Apertognathia
 Beatencooper
 Clefts

62.
Technique
 Nasal intubation
 Subcranial LF3
 Coronal incision
 Lower eyelid
 Intra oral
 Modified
 Intra oral
 Peri orbital

63.
Technique
 Coronal incision
 Supra orbital rim
 Nasal bones
 Lateral rims
 Zygomas
 Infraorbit

64.
Technique
 Transconjectival incision
 Lower subciliary

65.
Technique
 Subcranial L F 3 osteotomy
1. Zygomatic osteotomy
2. Frontozygomatic sutures – 1cm
3. Orbital floor
4. Nazofrontal suture
5. Intraoral incision
6. Intraoral disection
7. Ptrygoid osteotomy
8. Vomer osteotomy
9. Disimpaction by forceps
10. LF 1 osteotomy if needed
11. Resuspention and forced duction test

66.
Technique
 Modified LF 3 osteotomy
 Frontozygomatic osteotomy
 Maxillary osteotomy
 Zygomatic osteotomy
 Septum osteotomy
 Fixation

67.
Postoperative
 Steroids
 Anti biotics
 NG tube
 Extubation
 Avoid nasal packing
 Nasal spray
 Diet
 Complications
 Diplopia- amnosia- sensory diorders

68.
Transverse Maxillary
Distraction Osteogenesis

69.
Incidence and Origins
 Incidence 8 – 18 %
 Origins
 Iatrogenic
 Traumatic
 Developmental

70.
Diagnosis
 Alar base
 Nasolabial fold
 maxilla

71.
Clinical Evidenses
 Posterior crossbite
 Crowding
 Hourglass arch
 Deep palate
 Dental or skeletal

72.
 Skeletal discerpancy
 Narrow maxilla- normal mandible
 Normal maxilla- wide mandible
 Narrow maxilla- wide mandible
 Transverse deficiency
 Maxillary hypoplasia
 Mandibular prognatism and sagital deficiency
 Apertognathie
 Repaired clefts

73.
Radiographic
 Rocky Mountain Analysis
Maxillomandibular
Transverse Differential
Index
 More than 5mm: surgery
 Less than 5mm: orthodecy

74.
Options
 SDE
 Slow Dentoalveolar Expansion
 ORME
 Orthopedic Rapid Maxillary expansion
 SAME
 Surgically Assisted Maxillary Expansion
 SMO
 Segmental maxillary Osteotomy
 Primary dentition
 Mixed Dentition
 Adults
 Adults

75.
Technique
 SDE

76.
Technique
 ORME

77.
Technique
 SAME
 Advanteges
 Stability
 Non ex
 Negative space control
 Good breathing
 No periodontal complications
 Indications
 More than 5 discerpancy
 Narrow maxilla and wide mandible
 Orthodentic failure
 More than 7mm need
 Perio Complications
 Estenosis
 Clefts complications

78.
Technique
1. Decompensation
2. Applaience instal
3. Osteottomy---pM-nasal—midline—PM
4. Activation
5. Suturing

79.
Complications
 Hemorrhage
 Maxillary Inadequate disjunction
 Pain
 Tiping
 Perio
 Palatal necrosis
 Relapse
 Device
 Necrosis
 Deformity

80.
Modifications
 Older patients
 Palatal Tori surgery
 Modified incision
 Patient with open bite