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
Minimizing the treatment time.
In 1859 by Von Langenbeck -- for the removal of nasopharyngeal
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
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
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
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
Ideal over bite and overjet
Centric occlusion - centric relation
7. Various Maxillary Osteotomies
Segmental maxillary surgeries
i. Single tooth dento-osseous osteotomies.
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
Anterior nasal spine
Pyramidal process of
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
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
Healing occur even if maxilla segmented into several
Necrosis occurs only when vascular pedicles are
15. Mucoperiosteal arterial system –cortical bone-
supply maxilla Vascular connections- arteries and
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
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
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
18. Blood flow in gingival tissue after osteotomy
Soft palatal, ascending
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
You et.al (1991) -- no histologic evidence of
Siebert et.al (1997) – ascending palatine and
pharyngeal artery major contribution to palatal
20. In segmental maxillary osteotomy the blood supply
is via the buccal and palatal mucoperiosteum and the
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
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
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
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
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 &
• Turvey & Fonseca (J.Oral Surg. 1980; 38: 92-95)
16 cadavers/32 sides
Measured distance from inf. pterygomax. junc. to
Mean distance25mm (range 23-28mm)
Mean height of pterygomax junc. 14.6mm (range 11-
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
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-
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
35. Surgically Assisted Maxillary Expansion
Assists to correct deformities in transverse
First described by Angell in 1860
This procedure is in essence combination of
distraction osteogenisis and controlled soft tissue
36. Diagnosis and clinical evaluation:
narrowed alar base
deepening of nasolabial folds
37. Treatment options:
Based on skeletal maturity
Slow dentoalveolar expansion
Orthopedic rapid maxillary expansion
Segmental maxillary osteotomy
38. Advantages of SAME
non extraction alignment of dentition
elimination of negative space
improved periodontal health and nasal
First the mandibular dentition should be
Expansion appliance should be placed
Bilateral osteotomy from pyriform rim to
Release of nasal septum
Midline palatal osteotomy
Osteotomy of the anterior 1.5mm lateral nasal
Bilateral release of pterygoid plates
Activation of appliance by 1 to 1.5mm
Soft tissue closure
44. Maxilla should remain stationary for 5 days
Pt should feel discomfort while activation.
Expansion at a rate of 0.5 mm/day
Over correction is not recommended.
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
Relapse occure non operated site
Six month for midpalatal healing
a)Those due to inadequate surgery:
post orthodontic relapse
b)Those due to expansion
lack of appliance expansion
deformation of the appliance due to processing
stripping or loosening of midpalatal screw
48. Two vertical cuts,1-2mm
either side of proposed
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 )
Reduction in the treatment time.
Lower incidance of relapse.
Injury to teeth
Devitalization of teeth
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
52. Anterior maxillary osteotomy
Cohn Stock 1921- first report
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
anterior and buccal
Trans palatal osteotomy
through buccal vertical
Occasional mid palatal
54. Wunderer method(1963)
Relies on intact buccal
combined with buccal
incision combined with
buccal vertical incision.
56. Cupar method
Buccal vestibular incision
Nasal septum is first released
followed by vertical buccal
Trans palatal osteotomy
under direct vision.
Direct access to the nasal structures and superior
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
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
Occasional palatal incision.
Principles are same as for the total maxillary
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
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
Broad application to resolve many functional and
Rich anastamosing vasculature of the face.
Maxilla is clothed by wide soft tissue.
Osteotomised segment should remain attached to
soft tissue pedicle.
Vertical maxillary excess in bimax protrusion.
Superior re positioning of the maxilla to correct
To advance maxilla in cleft palate and post
To correct open bites when combined with
Correction of cants.
Advancement of the maxilla in class III
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
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.
73. Osteotomy should be kept below the pyriform
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.
77. Septal cartilage and the septum freed from the
Lateral nasal cut is then performed all the way till
perpendicular plate of palatine bone.
Final step is seperation of maxilla from pterygoid
Care should be taken to preserve the descending
79. In case of superior repositioning of the maxilla
sufficient bone and cartilage should be removed from
Mobilization of the maxilla is done.
Occlusal splint b/n maxilla and mandible is then
Maxillo mandibular complex is rotated supporting
the condyles in the fossa.
87. Bone grafts:
Indicated when large defects in the walls of
maxilla are present.
Critical in buttress and lateral walls.
promote healing and
Consolidation of the osteotomy sites.
88. Autogenous bone grafts preferred
Cranial bone, iliac crest and sometimes mandibular
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.
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
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
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
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
Horizontal cut over nasal bridge passing below the anterior ethmoidal
Vertical cut is continued by a cut in the orbital floor medial to the exit of
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
A Sagittal cut by thin
fissure bur passing
behind the lacrimal sac to
the orbital floor
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)
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
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
Orbital floor is approached by separate conjunctival or subciliary incision
Buccal vestibular incision to complete osteotomy in posterior maxillary
Ostoetomy starts at lateral orbital wall by reciprocal saw extending
to the inferior orbital fissure
Cut extended through orbital floor crossing the pathway of
Bone cut at nasal bridge links up with osteotomy in the floor behind
Osteotomy in lateral orbital wall carried downward tangentially
through zygomatic bone passing below the buttress
Posterior separation by pterygomaxillary dysjunction
most commonly with advancements and downgrafts
patients with parafunctional habits
prevention – rigid fixation
control of parafunctional habits
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
-- a bone plate placed across the nasal floor
-- a heavy guage circumferential arch wire in the molar head gear
-- 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
-- elimination of bony interferences
-- 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
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
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
inferior turbinate MT-
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
Increased bony support in advancement cases
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.
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 –
Surgery of mouth and jaw – Moore
Text book of otrhognathic surgery - Reyenke