1. BY :DR. NIKIL JAIN
KIIT UNIVERSITY
Maxillary Osteotomy
Procedures

2. Introduction
 Dentofacial deformities affect 20%of the population.
 Orthognathic surgery is a team work.
 This team must
 Correctly diagnose existing deformities
 Establish an appropriate treatment plan
 Execute recommended treatment.
 Basic theraputic goals
 Function
 Aesthetics
 Stability
 Minimizing the treatment time.

3. History
 In 1859 by Von Langenbeck -- for the removal of nasopharyngeal
polyps.
 The first American report -- Cheever in 1867 -- for the treatment
of complete nasal obstruction secondary to recurrent epistaxis for
which a right hemimaxillary downfracture was used.
 In 1927 Wassmund -- LeFort I osteotomy for the correction of
the midfacial deformities and used orthopedic force
postsurgically
 In 1934 Axhausen described total mobilization of the maxilla
with immediate repositioning for an open bite case

4.  In 1942 Schuchardt first advocated the pterygomaxillary
dysjunction.
 In 1949 Moore and Ward -- horizontal transaction of the
pterygoid plates for advancement
 In 1965 Obwegeser -- complete mobilization of the maxilla so
that repositioning could be accomplished without tension.
 Bone grafting to enhance stabilization for LeFort and anterior
osteotomies -- by Cupar, Gilles and Rowe and Obwegeser.
 Early description of the rigid fixation of maxillary osteotomies
were published by Michelet and colleagues in 1973, Horster
in 1980, Drommer and Luhr in 1981, and Luyk and Ward-
Booth in 1985.

5. SEQUENCE OF TREATMENT PLANNING
 1} Dental and periodontal treatment
 2} Extractions
 3} Presurgical orthodontics
 Position teeth over their respective basal bone
 Align and level the teeth
 Adjust for tooth size discrepancies
 Connect related teeth
 Divergence of roots adjacent to surgical sites.

6.  4} Orthognathic surgery
 5} Post-surgical orthodontics
 Final tooth alignment and root parallelism
 Maximal interdigitation
 Ideal over bite and overjet
 Centric occlusion - centric relation

7. Various Maxillary Osteotomies
Segmental maxillary surgeries
 i. Single tooth dento-osseous osteotomies.
 ii. Corticotomy
 iii. Anterior segmental maxillary osteotomy
 iv.Posterior segmental maxillary osteotomy
 v.Horse shoe osteotomy.
Total maxillary osteotomies:
 I) Le Fort I osteotomies
 II) Le Fort II osteotomies
 III) Le Fort III osteotomies

8.  Surgicaly assisted maxillary expansion
 Quadraangular lefort I and lefort II osteotomy
 High level midface osteotomy

9. Surgical anatomy of maxilla
Osseous structures
 Maxillary sinus
 Infraorbital rim
 Anterior nasal spine
 Palate
 Maxillary tuberosity
 Pyramidal process of
palatine bone
 Pterygomaxillary
junction

10. Vascularization
Pathway of the
Ascending palatine,
Ascending pharyngeal,
and Descending
palatine arteries as they
continue into the
greater palatine
arteries.

13. Reference Marks, and IntraoperativePositioning
At surgery, slots are made
in the piriform rim and holes
in the buttress to simulate
points A and P bilaterally.
The gingival cuffs of the
canines and first molars
represent points B and C.
Following mobilization of the maxilla
it is placed so that the differences
between lines A–B and A–B' are
the same as they were on the
models.

14. Biological basis of maxillary osteotomy
 Revascularization studies of bell and fonseca
indicates that’ the maxilla may be mobilized and
repositioned and survival continue as long as
mobilized maxilla attached to a broad soft tissue
pedicle’ .
 Healing occur even if maxilla segmented into several
pieces .
 Necrosis occurs only when vascular pedicles are
damaged

15.  Mucoperiosteal arterial system –cortical bone-
supply maxilla Vascular connections- arteries and
veins
 The multiple sources of blood supply to maxilla and
the abundant vascular communications between the
hard and soft tissues constitute the biologic
foundations for maintaining dento-osseous viability
despite transcetion of medullary blood supply after
osteotomies

16.  The soft tissue of the palate ,lateral pharyngeal walls
and buccal mucosa provide the vascular network that
permits the healing.
 The rich ,freely anastomosing vasculature of the face
is responsible for this healing
 Loss of bony segments due to vascular ischemia is
result of poor surgical technique or violation of basic
biological principles.

17.  Poor incision design ,extensive detachment of palatal
mucoperiosteum, excessive pressure by splint,
excessive and continue manipulation of surgical site,
traumatic manipulation of maxilla during down
fracture also associated with post operative
complications.

18. Blood flow in gingival tissue after osteotomy
Soft palatal, ascending
pharyngeal, and
ascending palatal vessels
anastomose with the
greater palatine artery.
Major vessels have been
sectioned and tied. The
arrows signify direction
of blood flow.

19.  Bell et.al (1970s) – early osseous union and minimal
osteonecrosis
 You et.al (1991) -- no histologic evidence of
osteonecrosis
 Siebert et.al (1997) – ascending palatine and
pharyngeal artery major contribution to palatal
blood supply

20.  In segmental maxillary osteotomy the blood supply
is via the buccal and palatal mucoperiosteum and the
intraalveolar vessels

21. Technique to preserve the vascular supply
 Horizontal incision ,through buccolabial mucoperiosteum
above the level of keratinized gingiva or attached gingiva
margin at the level of maxillary teeth apices,extending from
first molar one side to first molar contralateral side

22.  The superior tissues are reflected subperiosteally, first at
the piriform aperture margins . Progressively more
superior exposure lateral to the nasal aperture will
expose the infraorbital nerve exiting from its foramen.
 Posterior reflection proceeding from the delineated
infraorbital foramen reveals the zygomaticomaxillary
suture, zygomatic buttress, and the most anterior aspect
of the zygomatic arch.
 Inferiorly, with subperiosteal tunneling, the lateral
aspect of the maxillary tuberosity and its junction with
palatine bone and pterygoid plates of the sphenoid bone
are identified

23. The nasal mucosa is elevated beginning on the
superolateral surface of the piriform rim.

24.  Curved Freer elevator used for this dissection,angles
inward and downward,keeping in mind that nasal cavity
is greater in volume interiorly than at the piriform
apprature
 Dissection carried out up to 15 to 20 mm
 The mucoperiosteum is reflected from the nasal floor,
lateral nasal wall, and nasal crest of the maxilla.
 The dissection should continue superiorly for a
centimeter up the vertical nasal walls to prevent tearing
during osteotomy or down-fracture of the maxilla,
particularly at the superior reflections of the nasal floor
medially and laterally

25. Osteotomy
 Obtaining appropriate access to maxillary segment
,apices of root identified by the bony protuberance or by
using peria apical or panoramic radiographs
 Osteotomy kept 5-6 mm apical to apical to roots of
maxillary teeth, it means 30- 35 mm from the tip of the
crown
 During osteotomy lateral nasal wall,great attension to
protect nasal mucosa medially, so osteotomy terminated
after 20 mmto avoid injury to descending palatine artery.

26. 1. Pterygomaxillary dysjunction- Obwegeser
osteotome to separate the maxillary tuberosity and
pterygoid plates, as previously described by
ROBINSON & HENDY
The osteotome was positioned parallel
to the occlusal plane

28. Relationship between maxillary artery &
maxillary osteotomies
 • Turvey & Fonseca (J.Oral Surg. 1980; 38: 92-95)
 16 cadavers/32 sides
 Measured distance from inf. pterygomax. junc. to
max. artery
 Mean distance25mm (range 23-28mm)
 Mean height of pterygomax junc. 14.6mm (range 11-
18mm)
 Width of pterygoid chisel 10-15mm

30.  Curved pterygomaxillary osteotome was used
except that the pterygomaxillary dysjunction was
achieved through the maxillary tuberosity itself,
rather than between the maxillary tuberosity and
the pterygoid plates, by the technique advocated by
TRIMBLE,STOELINGA JOMS VOL 41 ISSUE 8
1983,544-546

31.  No incision was made and the osteotome was
placed on the tuberosity, distal to the second
molar, and approximately 0.5-1.0 cm above the
crest of the tuberosity. Better visibility and easier
access were achieved by this approach than by
attempting to position the osteotome through the
tunnel created under the posterior buccal soft-
tissue pedicle

32.  Care must be taken to angulate the osteotome
properly, so that it does not penetrate too far
anteriorly; this could cause a separation at the
junction of the horizontal process of the palatine
bones and the palatal process of the maxilla, or
create a fracture through the greater palatine
foramen which could damage the descending
palatine artery.

35. Surgically Assisted Maxillary Expansion
 Assists to correct deformities in transverse
dimension.
 First described by Angell in 1860
 This procedure is in essence combination of
distraction osteogenisis and controlled soft tissue
expansion.

36.  Diagnosis and clinical evaluation:
 paranasal hallowing
 narrowed alar base
 deepening of nasolabial folds
 zygomatic difficiancy

37.  Treatment options:
 Based on skeletal maturity
 Slow dentoalveolar expansion
 Orthopedic rapid maxillary expansion
 SAME
 Segmental maxillary osteotomy

38.  Advantages of SAME
 improved stability
 non extraction alignment of dentition
 elimination of negative space
 improved periodontal health and nasal
respiration

39.  Indications:
 skeletal discrepancy greater than 5mm
assossiated with wide mandible
 failed orthodontic expansion
 extremely thin, delicate gingival tissue
 significant nasal stenosis.

40.  Technique:
 First the mandibular dentition should be
decompensated
 Expansion appliance should be placed
preoperatively

41.  Steps:
 Bilateral osteotomy from pyriform rim to
pterygomaxillary fissure
 Release of nasal septum
 Midline palatal osteotomy
 Osteotomy of the anterior 1.5mm lateral nasal
wall
 Bilateral release of pterygoid plates
 Activation of appliance by 1 to 1.5mm
 Soft tissue closure

42. S A M E-
PROCEDURE

43. APPLIANCE IN PLACE

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

45. Modified SAME
 Unilateral or asymmetric deformities
 Osteotomy done on one side
 Non operated site buccal bone bending and dental
tipping
 Relapse occure non operated site
 Six month for midpalatal healing

46.  Complications:
a)Those due to inadequate surgery:
 pain
 dental tipping
 periodontal breakdown
 post orthodontic relapse
b)Those due to expansion
 lack of appliance expansion
 deformation of the appliance due to processing
errors
 stripping or loosening of midpalatal screw

47. Segmental Osteotomies
 Single tooth osteotomy:
 Indicated in tooth mal
position.
 Dental ankylosis.
 closure of diastema.

48.  Two vertical cuts,1-2mm
either side of proposed
bony cut.
 Mucoperiosteum not
elevated over the tooth.
 Labial bone scored.
 Horizontal cut is made
3mm above the apex.
( when nasal floor is
relatively low, cuts may
be extended into it )

49. Advantages:
 Reduction in the treatment time.
 Lower incidance of relapse.
Disadvantages:
 Injury to teeth
 Periodontal compromise
 Devitalization of teeth

50. Corticotomy
 Cortical bone remove both labialy and palatally
 Supra apical region , 5mm above the apices of teeth
 palatal bone is removed in radial fashion, taking out
the cortex in wide strips between each tooth
 Repositioning of teeth with in arch obtained in 6-12
weeks

52. Anterior maxillary osteotomy
 Cohn Stock 1921- first report
 Indications:
 Bimaxillary protrusion
 Protruded maxillary teeth with normal
inclination to alveolar bone.
 Anterior open bite.
 When orthodontic teeth movement not possible.
 To reduce the prominence of the upper lip.

53. Wassmund technique(1935)
 Preserves both buccal
and palatal pedicle.
 Buccal as well as
anterior verticle incision
 Tunneling between
anterior and buccal
incisions
 Trans palatal osteotomy
through buccal vertical
osteotomy.
 Occasional mid palatal
sagittal incision.

54. Wunderer method(1963)
 Relies on intact buccal
pedicle.
 Transpalatal incision
combined with buccal
verticle incision.
 Modification:
 Midline vertical
incision combined with
buccal vertical incision.

56. Cupar method
 Buccal vestibular incision
 Nasal septum is first released
 Horizontal osteotomy
followed by vertical buccal
osteotomy.
 Trans palatal osteotomy
under direct vision.

57.  Advantages:
 Direct access to the nasal structures and superior
maxilla
 Preservation of the palatal pedicle
 Ease of placement of rigid fixation
 Ability to remove bone from palate.

58.  Complications of the AMO:
 Loss of teeth vitality.
 Persistant periodontal defects
 Communication with nasal cavity or antrum
 Occlusal steps formation.

59. Posterior maxillary osteotomy
 Schuchardt 1959 first report
 Indications:
 Posterior maxillary hyperplasia.
 Distal repositioning of the posterior segment.
 Posterior open bite.
 Transverse excess or deficiancy
 Spacing in the dentition.

60.  Surgical technique:
 Buccal vestibular incision below the buttress.
 Platal osteotomy through the buccal osteotomy
site.
 Occasional palatal incision.
 Principles are same as for the total maxillary
osteotomies.

61.  Complications:
 Same as that for other osteotomies.
 Blind procedure.
 Technically challenging

62. POSTERIOR SEGMENTAL OSTEOTOMY

64. PTERYGO MAXILLARY DISJUNCTION

65.  Summary:
 Segmental osteotomies are indicated for isolated
dento facial deformities when there is good dento
skeletal relationships in the non affected areas.
 Decreased morbidity when compared to total
maxillary osteotomies.
 For isolated dentofacial deformities and prosthetic
problems, the segmental osteotomies should be in
the armamentarium of the surgeon.

66. Lefort I Line
 Line runs horizontally above the floor of nasal
cavity, involves the lower third of septum ,palate
,alveolar proces sof maxilla and lower third of
pterygoid plates of sphenoid

67. Le-Fort 1 osteotomy
 Work horse of the orthognathic surgical
procedures.
 Broad application to resolve many functional and
aesthetic problems.
 Biologic basis:
 Rich anastamosing vasculature of the face.
 Maxilla is clothed by wide soft tissue.
 Osteotomised segment should remain attached to
soft tissue pedicle.

68. Indications
 Vertical maxillary excess in bimax protrusion.
 Superior re positioning of the maxilla to correct
open bites.
 To advance maxilla in cleft palate and post
traumatic patients.
 To correct open bites when combined with
mandibular procedures.
 Correction of cants.
 Advancement of the maxilla in class III
patients.

69. Surgical technique
 Patient position: head end elevation by 10degree.
 Reference pins should be placed when vertical
changes are planned.
 Incision: Maxillary vestibular incision high in the
muco buccal fold.
 Incision traverses the mucosa, muscles and the
periosteum.

70. LE FORT I OSTEOTOMY

71.  Sub periosteal dissection.
 Infra orbital nerve identified and preserved
 Nasal mucosa dissected from nasal wall and floor.
 Dissection in buttress region kept inferiorly.
 Vertical reference points placed in pyriform
aperture and buttress.

72. VESTIBULAR
INCISION
OSTEOTOMY
MARKINGS

73.  Osteotomy should be kept below the pyriform
aperture region.
 Initial cuts in the buttress region progressing
towards the nose.
 Next the posterior cuts in the pterygo maxillary
region kept inferiorly.
 Minimum of 5mm above the root apices.
 The next cut in the sinus from inside out.
 Same procedure for the opposite side.

74. POSTERIOR CUTS
SINUS CUTS
USING
RECIPROCATING
SAW

75. SEPTAL
OSTEOTOMY
LATERAL NASAL
OSTEOTOMY

76. SEPTAL CLEARANCE

77.  Septal cartilage and the septum freed from the
maxilla.
 Lateral nasal cut is then performed all the way till
perpendicular plate of palatine bone.
 Final step is seperation of maxilla from pterygoid
plate.
 Care should be taken to preserve the descending
palatine vessels.

78. PTERYGO MAXILLARY
DISJUNCTION

79.  In case of superior repositioning of the maxilla
sufficient bone and cartilage should be removed from
the septum.
 Mobilization of the maxilla is done.
 Occlusal splint b/n maxilla and mandible is then
fixed.
 Maxillo mandibular complex is rotated supporting
the condyles in the fossa.

80. CONDYLAR REPOSITIONING

81.  Correct vertical re positioning is ensured using
reference pins.
 Stabilization:
 Small bone plates (1.5mm) or intra osseous wiring
applied at pyriform aperture and buttress region.

82. WIRE FIXATION
PLATE FIXATION

83.  Segmenting the maxilla:
 Indications:
 Transverse discrepancies between the dental arches
 Vertical steps in the maxillary occlusal plane
 Space remaining in the maxillary arch.

84.  Two para median osteotomies and one transverse
osteotomy are used.
 Midline sectioning of the palate is avoided.
 Osteotomised segments should never be stripped off
the nourishing mucosa.

85. SEGMENTING THE MAXILLA

87.  Bone grafts:
 Indicated when large defects in the walls of
maxilla are present.
 Critical in buttress and lateral walls.
 Advantages:
 Greater stabilization
 promote healing and
 Consolidation of the osteotomy sites.

88.  Autogenous bone grafts preferred
 Cranial bone, iliac crest and sometimes mandibular
buccal cortex.

89. BONE GRAFTING

90.  Wound closure:
 Done in layers
 Periosteum and muscle layer closed first in buttress
and nasal base.
 Mucosa of the lip closed with a horizontal mattress
suture in v-y pattern.
 This helps to maintain the height of the exposed
vermilion and lip length.

91. V-Y CLOSURE

92. Alar sinch Suture

93. MODIFIED LE FORT I OSTEOTOMIES
 Quadrangular osteotomy - (Kufner 1971)

95.  This technical note should be kept in mind whenever
an anterior and downward movement is planned and
vertical stability might be compromised.

96. LE FORT II OSTEOTOMY
(HENDERSON AND JACKSON, 1973
 Indications
 Naso-maxillary hypoplasia, such as Binder syndrome
 Retruded naso-maxillary complex resulting from mal or non
treated Le Fort II fracture
 Cleft lip and palate deformity

97. INCISIONS
 Nasal root and medial orbital wall approached by a coronal incision or
paranasal incision or medial brow incision

98.  Coronal incision runs from upper anterior attachment of helix over the
cranial vault passing behind the hair line
 Dissection carried forward in loose connective tissue plane deep to
galea
 Incision to pericranium 3 cm posterior to supraorbital rim to expose
supraorbital rim and orbit
 Conjunctival or subciliary incision is required to gain access to
infraorbital rim and orbital floor
 Subperiosteal dissection through subciliary incision should join the
dissection above to enable bone cut under direct vision
 Access to canine fossa and posterior maxilla by routine buccal
vestibular incision

99. OSTEOTOMIES
 Horizontal cut over nasal bridge passing below the anterior ethmoidal
foramen
 Vertical cut is continued by a cut in the orbital floor medial to the exit of
infraorbital nerve
 Bony nasal septum is split at nasal bridge by a forked septum chisel
 Posterior separation by pterygomaxillary dysjunction

100.  Bone cut around zygomatic
buttress downward and
posteriorly
 A Sagittal cut by thin
fissure bur passing
behind the lacrimal sac to
the orbital floor

101. Repositioning of maxilla
Fixation

102. MODIFIED LE FORT II OSTEOTOMY
 Psillakis, Lapa and Spina (1973) designed modified Le fort II, which
leaves tooth bearing area behind

103. LE FORT III OSTEOTOMY(GILLIES, 1940)
 INDICATIONS
 Naso-maxillary hypoplasia along with
underdevelopment of malar bone
 A retruded midface due to trauma
 Pseudo-exophthalmos as a result of shallow orbit
 Mild hypertelorism and telecanthus

104. Incision
 Orbit and nasal root is approached by coronal incision
 Subperiosteal dissection from FZ suture to expose lateral orbital wall
 Periosteum is split vertically at nasal root and malar area to accommodate
anticipated advancement
 Orbital floor is approached by separate conjunctival or subciliary incision
 Buccal vestibular incision to complete osteotomy in posterior maxillary
area

105. Osteotomy
 Ostoetomy starts at lateral orbital wall by reciprocal saw extending
to the inferior orbital fissure
 Cut extended through orbital floor crossing the pathway of
infraorbital nerve
 Bone cut at nasal bridge links up with osteotomy in the floor behind
lacrimal duct
 Osteotomy in lateral orbital wall carried downward tangentially
through zygomatic bone passing below the buttress
 Posterior separation by pterygomaxillary dysjunction

107. Complications
 1} Relapse:
 most commonly with advancements and downgrafts
 patients with parafunctional habits
 prevention – rigid fixation
 grafting
 control of parafunctional habits
 2} Settling:
 differs from relapse
 movement regardless of original position
 seen with # grafts and wire osteosynthesis
 prevention – rigid fixation
 control of parafunctional habits

108. 3} Transverse relapse:
-- common with segmental osteotomies and transverse expansion
-- lack of soft tissue mobilization at the time of expansion
-- inadequate grafting and stabilization along the palatal midline
-- poorly adapted bone plates
-- unstable presurgical orthodontic movements
-- hyperfunctional buccinator muscle activity
Prevention
-- a bone plate placed across the nasal floor
-- a heavy guage circumferential arch wire in the molar head gear
bracket tubes
-- a transpalatal arch bar to maintain the palatal width
-- an occlusal coverage splint
-- a palatal splint without occlusal coverage

109. 4} Condylar distraction:
-- occurs when there are interferences in the tuberosity or
pterygoid plate area
Prevention
-- elimination of bony interferences
5} Bleeding:
-- common areas include – descending palatine vessels and
anterior or posterior palatine vessels; PSA vessels; pterygoid
plexus; incisive canal vessels; internal maxillary artery; vessels
associated with the nasal septum and turbinates.

110. 6} Avascular necrosis:
-- initially – gingiva – dusky appearance
-- no refill after tissue blanching
-- sloughing within 12 to 24 hrs
-- exposure of bone/ roots without infection
Prevention and management
-- careful flap design and surgery
-- HBO therapy – 20 to 30 dives
-- conservative debridement and good oral hygiene
-- reconstructive procedures if needed

111. 7} Periodontal defects:
-- trauma to adjacent soft tissues and bone
-- avascular necrosis
-- tearing of interdental soft tissue through the papilla
-- removal of the bony collar around the neck of the teeth
-- vertical incisions at interdental areas
8} Nerve injury
9} Infection
10} Non-union

112. Epiphora

113. Illustration of lateral wall,
showing the distance from the
anterior attachment of the
inferior turbinate to the
nasolacrimal canal orifice
OLD- ostium of nasolacrimal
duct
OL- high lefort 1 osteotomy line
IT- inferior turbinate
MT- medial turbinate

114. The meatal portion of
the nasolacrimal duct
can be protected by
detaching the mucosa
from the lateral nasal
wall and placing and
elevator between the
mucosa and the lateral
nasal wall as the
osteotomy is
accomplished. IT-
inferior turbinate MT-
medial turbinate

115. SOFT TISSUE CHANGES
 Several investigators have suggested that the etiology of
these soft tissue changes is attributable to three factors
Elevation of the periosteum and muscle attachments
adjacent to nose without adequate replacement
Postsurgical edema
Increased bony support in advancement cases

116. TECHNIQUES TO CONTROL THE SOFT
TISSUES
V-Y CLOSURE

117. ALAR CINCH

118. CONTOURING THE ANS

119. DOUBLE V-Y CLOSURE

120. Conclusion
 Orthognathic surgery has made it possible to
reposition of either or both jaws in all possible
directions. This has provided solution for the
patients with severe dentofacial problems and
malocclusion. Thorough evaluation and assessment
of the defect and efficient execution of the surgery is
needed for effective result.
 Repeated assessment and rectification of the
technique are required to improve the outcome of
these aesthetic surgical procedures.

121. References
 Fonseca – Oral and Maxillofacial Surgery – Vol. 2
 Dentofacial Deformities – Bruce N Epker
John P Stella, Leward C Fish
 Orthognathic Surgery – Varghese Mani
 Principles of oral and maxillofacial surgery –
Peterson
 Surgery of mouth and jaw – Moore
 Text book of otrhognathic surgery - Reyenke

122. THANK YOU