Orthognathic surgery-Mid face procedures

GITAM DENTAL COLLEGE & HOSPITAL
DEPARTMENT OF
Oral & Maxillofacial Surgery
SEMINAR
On
Orthognathic Surgery – Midface procedures
Presented By:
Dr. Satyajit Sahu
III MDS
Orthognathic Surgery – Midface procedures

Introduction
Orthognathic surgery has evolved over many years to correct
both facial deformity and oral dysfunction. Facial beauty is difficult to
define in precise terms because subtle differences between individuals
can produce marked aesthetic contrasts. Furthermore, different racial
forms of beauty are not comparable and so ethnic norms are required
to correct the abnormality. Despite this skeletal abnormality is
recognisable, measurable, and usually correctable by orthognathic
surgery.
Orthognathic surgery started as "Orthodontic surgery’ as an aid
to orthodontics, later graduated to orthognathic surgery as a remedial
measure to orthodontic limitations.
Orthognathic surgery is mainly directed at the correction of
basal bone defects. The aim is to attain aesthetic, psychological and
functional rehabilitation of the patient. However fine tooth
movements for the optimum results are difficult to obtain with
orthognathic surgery alone. Such finer adjustments can be achieved
by orthodontics. Orthognathic surgery along with rhinoplasty and
orthodontics can rehabilitate patients with facial deformities and oral
dysfunction.
Historical events
Hullihen was the first person to correct jaw deformity surgically
in 1849, when he corrected an anterior open bite by mandibular
subapical osteotomy. Orthognathic surgery of the maxilla was first
described in 1859 by Von Langenbeck for the removal of
nasopharyngeal polyps. Cheever 1867 reported a maxillary osteotomy
for complete nasal obstruction secondary to epistaxis, he used a right

hemimaxillary down fracture. Later many maxillary osteotomy
techniques were described for the treatment of pathological process.
Blair in the early 1900’s was the first to classify jaw deformity
into five classes as : Mandibular prognathism, Mandibular
retrognathism, Alveolar mandibular protrusion, Alveolar maxillary
protrusion and open bite.
In 1901, Le Fort published his classic description of the natural
planes of maxillary fracture. Cohn-stock 1921 described segmental
osteotomy of maxilla which was modified by Wassmund (1926) by a
labial approach. Cupar 1954, Kole 1959 and Wunderer 1963 reported a
direct surgical access to these procedures which improved
mobilisation and maintained blood supply. Wassmund (1927)
described a total horizontal maxillary osteotomy to close a posterior
open bite and this constitute earliest work of Le fort I surgery.
Axhausen (1934) performed the first total mobilisation of the maxilla.
Posterior segmentalization of the maxilla was first used by
Schuchardt 1959 for correction of open bite. This had limited stability
owing to its incomplete mobilisation. Kufner 1970 improved on this
technique by completely mobilising the osteotomized segment prior
to repositioning.
Paceno (1922) published some basic principles of
roentgenographic cephalometry which was later modified and
popularised by Broadbent and Holfrath (1935). Down (1945) put
forward some standard measurements which helped the diagnosis of
deformities of midface. Burstone et al 1978 & 1980 gave an analysis for
the assessment of dentofacial deformity using cephalometric
radiographs " The cephalometric analysis for Orthognathic surgery"
(COGS).

Use of bone grafts in midface surgical advancement were
reported by Rowe (1954), Cernea and associates (1955), Lerinac (1958).
Separation of the pterygomaxillary junction was first advocated
by Schuchardt in 1942. Moore and Ward 1949 recommended
horizontal transection of the pterygoid plates for advancement. This
technique was associated with severe bleeding so Wilmar advocated
the pterygomaxillary disjunction technique for Le fort I osteotomy.
A combined form of anterior and posterior subapical
osteotomies "total subapical maxillary osteotomy" were reported by
Paul 1969 for midface hypoplasia.. This technique was further
described by West & Epker 1972, Hall & Roddy 1975, Wolford &
Epker 1975, West and McNeil 1975 and Hall & West 1976. Maloney
(1982) reviewed this technique and described it as a good technique
during his time. This technique is hardly in use now.
Hugo Obwegesser 1965 advocated complete mobilisation of
maxilla so that maxilla could be repositioned without tension. This
aided in stabilisation which was documented by Haller, Hogemann &
Wilmar and Perko.
Hugo Obwegesser 1969 described a high quadrangular Le Fort I
osteotomy for midface deficiency correction. This technique was later
named as Quadrangular Le Fort I osteotomy by Keller & Sather 1989.
Converse & Colleagues in 1970 described an osteotomy at Le
Fort II level but this had several biologic and anatomical flaws so this
technique did not have appreciation later. Henderson & Jackson 1973
described a classic Le Fort II osteotomy for correction of midface
deficiency.
Kufner 1971 described an osteotomy procedure for midface
deficiency correction, which was named as quadrangular Le fort II

osteotomy by Steinhäuser 1980. This technique was modified by
Stoleinga & Brown in 1996 which prevents damage to infra orbital
nerve.
Vascular supply of lower maxilla and alveolar portion was
extensively studied by Bell and Levi (1971) and Bell et al (1979). They
concluded that the vitality of segment will not be affected if either
palatal or buccal flaps were retained undisturbed.
Epker and Woodford 1980 gave a detailed down fracture
technique for Le fort I maxillary osteotomy based on palatal flap.
They advocated the use of same for anterior maxillary segment
0steotomy.
Sir Harold Gillies & Harrison 1950 performed Le Fort III
osteotomy for midface deficiency.
Paul Tessier 1967 described various techniques for correction of
orbito-craniofacial deformities.
The first use of bone plating was carried out by Soerensen in
1917 for fracture mandible. Bernd Spiessl 1974 was the first to use
rigid fixation after sagittal split osteotomy. Use of rigid fixation to
stabilise osteotomised segment was reported by Champy & associates
1976, Mischelet, Leyoness & Desus 1973, Dromer and Luhr 1981,
Steinhäuser 1986 etc. Miniaturised plates were used by Luhr 1981,
Steinhäuser 1986 etc. Miniaturised plates by Luhr, 1989 solved the
problem of excessive bulk of miniplates for use in midface.
The latest developments in orthognathic surgery is the use of
adjutant plastic surgical procedures like blepharoplasty, rhinoplasty,
rhitidectomy, liposuction , lip correction and the use of the principle
of distraction osteogenesis for correction of jaw deformities.

Anatomy of midface
The skeleton of midface is made up of intricate attachment of
various bones, these include two maxilla, two nasal bones, two
palatine bones, two zygoma and their temporal process, two inferior
nasal conchae, the vomer, the ethmoid and the pterygoid process of
the sphenoid bones. The articulation of these bones give the projection
to midface. Any excess or deficiency in this region produces an
unaesthetic deformity.
The midface is in relation to important aesthetic and functional
landmarks such as the orbit, nasal cavity, maxillary sinus and the oral
cavity.
The maxilla is a paired bone of the upper jaw, fused to form one
central focus of the midface. It acts as a base for containing the teeth,
support for nasal cartilages, gives attachments to muscles and forms
the major bony plate for palate and orbit. Each hemimaxilla contain a
large pyramidal shaped body, the maxillary sinus and four prominent
process – the frontal, alveolar, zygomatic and palatine process. The
body of maxilla is hollow and contains the maxillary sinus. The infero
lateral walls of the maxilla are thinner and are directed in a angular
fashion with narrower bottom and gradually increasing in size
superiorly. So an osteotomy cut in this area would result in
telescoping of the inferior segment into the antrum and resulting in
instability. The frontal process arises from the anteromedial corner of
the body of maxilla and it articulates with nasal bone, frontal bones to
form the medial wall of the orbit. The zygomatic process of the
maxilla arises from the anterolateral corner of the maxilla and
articulates with zygoma laterally. They together form the floor and
lateral wall of the orbit. The highly vascular nasal mucosa is loosely
attached to the rim of the pyriform ring of the maxilla. This can be

easily raised from the palatine process of the maxilla. The infraorbital
nerve and vessels pass through the infraorbital foramen which lies at
the anterior surface of the maxilla below the infraorbital rim. A
damage to this nerve is most likely in Le fort II and III procedures and
this would produce profound paresthesia / anaesthesia of the upper
lip and part of nose.
The zygoma is a paired bone and makes up the essence of the
cheek prominence. It is diamond shaped bone. Its deficiency along
with infraorbital deficiency would result in increased visibility of
sclera. This has four process by which it attaches to frontal bone,
maxilla and temporal bone.
Nasal bones are rectangular and articulate with frontal bone and
process of frontal and maxilla. This gives the anatomic projection to
the nasal bridge.
Palatine bones are paired bones which connect the maxilla with
the sphenoid bone through pterygoid plates. It has a body and two
process the horizontal and vertical. The greater and lesser palatine
nerves and vessels pass through this bone. Posteriorly this bone
articulates with pterygoid plates. This articulation is disjuncted
during total maxillary osteotomies when maxilla is to be advanced or
impacted superiorly.
The inferior nasal concha is a paired bone that form the bony
support of the inferior turbinates bilaterally. In some instances this
might be enlarged which makes superior impaction of maxilla
difficult.
Biological basis for maxillary osteotomies.
The delivery of an adequate amount of blood to the tissue
capillaries for normal function of the organ is the primary purpose of

the vascular system. Successful transportation of the maxillary dento-
osseous segments by Le fort I osteotomy depends on preserving the
vitality of the segment by proper design of the soft tissue and bone
cuts.
Extensive studies on the blood supply of maxilla by Bell & Levy 1969
and others have shown an extensive anastomosis between the
terminal branches of the maxillary vessels. This allows a wide range of
buccal and palatal flaps to be raised. Formerly tunnelling procedures
have been used to maintain a dual supply from the tissues of the
cheek and palatal vessels. Studies by Bell & Levy 1969 have shown
that interruption of these, for example the palatine vessels, will not
lead to necrosis of bony segments, provided adequate buccolabial
periosteal flaps retained.
Maxilla receives its blood supply from branches of maxillary
artery – the palatine artery and superior alveolar arteries. It also
receives collateral supply from the branches of facial artery. The
collateral circulation within the maxilla and its evolving soft tissues
and the many vascular anastomosis in the maxilla, permit numerous
technical modifications of the Le fort I osteotomy.
You et al 1991 studied the vasculature of the maxilla. He stated
that
1. normal blood supply of the maxilla originates centrifugally
from the alveolar medullary arterial system.
2. The mucoperiosteal arterial system also gives off many
branches that penetrate the cortical bone and supply the
maxilla.

3. The vascular connections between the maxilla and the
surrounding soft tissues consist of not only the capillaries but
also arteries and veins.
These multiple source of blood supply to the maxilla and
abundant vascular communications between the hard and soft tissues
constitute the biological foundation for maintaining dento-osseous
viability despite transection of the medullary blood supply after
maxillary osteotomies.
So for anterior maxillary osteotomy when a labial
mucoperiosteal flap is reflected , the collateral circulation is from the
palatal vessels, care has to be taken not to damage the palatal vessels.
When a palatal mucoperiosteal flap is raised for osteotomy then the
labial vessels has to be preserved.
Bell 1969, Bell & levy 1971 have demonstrated the viability of
large or small segments of the maxilla when vascular pedicles from
the palatal, facial or both mucosal surfaces were not detached from
the osteotomised segments. They also observed that ligation of the
greater palatine arteries bilaterally did not adversely affect the
outcome of the surgery when adequate palatal mucosa and
labiobuccal gingival pedicles were maintained.
Azaz & Shteyer 1977 and Westwood & Tilson 1975 observed
that the most common complication in surgery with multiple
segments is the loss or devitalization of an occasional tooth adjacent to
the interradicular osteotomy site.
Studies by Justin et al 2001 has shown that there is a hyper-
vascularity in the pulpal and gingival tissue during healing ( 2nd
–3rd
week) after maxillary osteotomies.

Timing of surgery
As a rule of thumb it is better to wait till the skeletal growth is
completed before doing orthognathic surgery. There has been report
in literature to support the corrective surgical measure even during
the growth period, specially if there is compelling psychological need
for such intervention in the patient.
Maxillary growth usually ceases 2 years before mandibular
growth completion but there is a difference of 6 years in late maturers.
Post menarche growth of maxilla is negligible. Radius epiphyseal
fusion is a definite indicator of completion of maxillary growth.
Surgical correction for maxillary excess is not contraindicated
during growth period as reduction in growth of maxilla helps in the
surgical measure for the patient.
Surgical approach to Midface.
Surgical treatment of dentofacial deformity was not undertaken
until the beginning of the twentieth century due to difficulties in
access to facial bones and the problems of anaesthesia.
Early surgeries were directed towards mandible mainly through
the extra oral approach which had the disadvantage of visible scar.
The maxillary procedures were initially linked to the management of
cleft problems. Wasmund 1935, Axhausen 1937 & 1939 and
Schuchardt 1942 developed approaches initially to anterior maxilla
and later to posterior and whole maxilla.
Requirements of approach to facial bones.
There are number of prerequisites for approach to facial bones, these
include.

1. This must be a safe approach which allows a clear view for
placement of bone cuts and gives a good access for instruments.
2. While placing incisions thought must be given to possible
problems such as proximity to vital structures, scarring and
infection.
The important structures include large vessels and nerves like
facial nerve and vessels, infra orbital nerves and mental nerve,
nasolacrimal duct, canthal ligaments, external auditory canal etc.
The access to the facial bones can be broadly classified into two
categories : transcutaneous and intraoral.
The best access is through skin but this leaves a visible scar. The
skin incisions should be placed in such a way that it is hidden or
follow natural skin creases.
The intraoral approach avoids scarring but it provides relatively
poor visibility and access difficulties. Often special instruments are
required with this technique.
Extra oral approaches to midface.
Le fort I osteotomy is approached entirely through the intraoral
approach, while Le fort II and Le fort III might require incisions
around the orbit. These incisions are to be placed in such a way that it
minimises scarring and also does not effect functional limitations. A
variety of incision have been used for accessing midface. These
include.
1. Trans conjunctival incision.
2. Medial canthal incision.
3. Infra orbital incision.

4. Blepharoplasty incision.
5. Extended eyebrow incision.
6. Bicoronal incision.
7. Incisions to approach naso-orbit area.
Trans conjunctival incision
This incision is used when access to the infra orbital region is
needed during Le fort II and III osteotomies.
Here the incision is placed in the inferior fornix. Care is taken to
avoid damage to lower lid tarsal plate and also to cornea. Cornea is
protected by suturing the upper edge of conjunctival incision to the
upper lid margin during the operative procedure. Blunt dissection
down exposes the periosteum on the orbital floor which is incised at
the infra orbital rim.
A fine catgut is used to close conjunctival incision.
Medial canthal incision
This incision is required to provide access to the bridge of the
nose and medial orbital area during Le fort III osteotomy. This
incision can be extended laterally for greater access to lateral infra
orbital region.
The incision is made from a point just superior and medial to
medial canthus to approximately midpoint between the lacrimal duct
and infra orbital nerve. The incision passes through skin and
superficial fascia, splitting orbicularis oculi onto the periosteum. This
provides access to the anterior maxilla medial to the infra orbital
nerve and also to nasal bones. The periosteum is stripped from over
the infra orbital margin and along the floor of the orbit around and

behind the nasolacrimal duct. Periosteum is also stripped from the
nasal bones superior to medial canthal ligament.
Visible scarring is minimal with this type of incision but when
incision is extended laterally below the infra orbital region it produces
a visible scar.
Blepharoplasty incision
This incision is used for accessing the malar region and also for
naso orbital procedures in Le fort III osteotomy. This incision is more
aesthetic than infra orbital incision.
Here the incision is made in the skin 1 – 2 mm below the grey
line at the lid margin. The skin is undermined superficial to the
orbicularis oculi muscle which is then split at the infra orbital margin.
Dissection is done while taking care to prevent damage to the orbital
septum. The periosteum over the maxilla is divided 1 to 2 mm below
the infra orbital margin. By this approach antromedial malar
osteotomy cuts can be placed. When a wider exposure is required the
incision is extended laterally through crow’s foot crease.
The incision is closed in layers, first the periosteum, the muscle
and finally the skin with fine subcuticular nylon sutures.
Extended eyebrow incision
This approach is for access to lateral orbit .
The incision is made through the lateral part of the eyebrow and
along its length parallel to hair follicles. This should not be extended
beyond lateral canthus as it produces a visible scar. This incision
provides good access to the frontozygomatic suture and allows for
bony cuts to be placed through the lateral orbital wall down to the
inferior orbital fissure. The incision is placed through the skin,

superficial fascia, orbicularis oculi and deep fascia down to
periosteum. The periosteum is incised at the anterolateral aspect of
orbital margin. Bleeding is profuse which is controlled by diathermy.
Wound closure is done in layers.
Naso orbital area exposure
Exposure of this area is difficult.
The midline vertical incision down the nose provides access to
both the medial canthus area, but often leaves a persistent scar.
A horizontal or inverted ‘V’ cut extended from two canthal
ligament again has the scar visibility. For approach to upper
nasoethmoid area a horizontal incision from one eyebrow to other is
preferred. For nasal lengthening procedures as along with Le fort II
an inverted ‘V’ or ‘Y’ incision is preferred. Tension in the suture area
is to be avoided as it is likely to spread the scar.
For Le fort III the approach to the whole of this area is best by a
bicoronal incision.
Bicoronal incision
The bicoronal ( bitemporal, bifrontal ) flap probably provides
the best access to the upper face. It is essentially a continuation of the
preauricular incision which is carried superiorly across the scalp. In
the midline the incision is directed slightly anteriorly to allow for
easier closure and for easy mobilisation of soft tissues. It must remain
within the hairline particularly in males. In children this incision
should not be brought forward as the scar tends to drift anteriorly as
the child grows.
The incision is first marked and it is made through the skin,
superficial fascia and galea. The line of separation is obtained in the

loose areolar tissue above the pericranium. Dissection is done
anteriorly and inferiorly in a plane temporalis fascia and pericranium.
Approximately 2 cm above the orbits the pericranium is incised in a
curved fashion forward from one orbital margin to another and this is
stripped off with the anterior flap. This flap is reflected over the
bridge of the nose to expose the frontonasal suture, the supra orbital
rims and lateral orbital margins. Further exposure is gained through a
vertical incision through the periosteum overlying the bridge of the
nose. The supra orbital neurovascular bundles are preserved and
freed whenever necessary by cutting a foramina with a small chisel.
For Le fort III osteotomy the soft tissues incision is extended
down to the zygomatic arch by incising the periosteum on the
temporal surface of the orbit and the temporalis muscle retracted
posterolatrally to expose the medial wall of the malar bone. The
periosteum is raised along the orbital margin from the lateral, medial
and superior walls. By this approach the whole of orbit, malar and
frontonasal suture are exposed. It also gives good access to
temporomadibular joint and nasoethmoid complex region. To avoid
excessive bleeding, it is important to maintain a good hemostasis with
the use of Raney clips along the flap margins.
After the operations are completed the scalp flap is replaced and
the wound closed in layers with two scalp suction drain in place.
Pressure dressing are given to avoid haematoma formation.
The intraoral approach
The great majority of the maxillary procedures are performed
through an intraoral approach. Scars in the midface are to be avoided
if at all possible as they cannot be hidden well and are usually
unnecessary. Majority of Le fort I osteotomies and segmental
osteotomies of Maxilla are done through an intraoral incision.

Extensive anastomosis between the terminal branches of the
maxillary vessels allows for a wide range of buccal and palatal flaps to
be raised. Formerly tunnelling procedures have been used to maintain
a dual supply from the tissues of the cheek and palatal vessels. Now
osteotomy of maxilla is done based on the palatine vessels or on the
labial / buccal vessels.
Incisions for Le fort I osteotomy
The incisions used for Le fort I osteotomies include
1. Tunnelling approach
2. Down fracture approach
3. Approach in the cleft patient : Henderson – Jackson
4. Approach in the cleft patient : Converse – wake.
Tunnelling approach:
This type of incision was used during 1950 – 1970s. Here Le fort
I osteotomy is done through three incisions. Here a horizontal incision
is placed in the vestibule of first molar region bilaterally and a third
incision is placed vertically in the midline anteriorly. The anterolateral
wall of maxilla is sectioned through the lateral incisions. The nasal
septum is detached through the midline incisions. The lateral nasal
wall is fractured through midline incision using Rowe’s disimpaction
forceps. This causes tearing of nasal mucosa. By this approach limited
repositioning is only feasible due to poor accessibility.
Down fracture approach :
This technique developed by Bell 1975 has changed the
approach to maxilla, aiding in positioning maxilla in all the planes
and cutting the maxilla into varying pieces without risk of loss of

segment. This procedure can be done under direct vision with less
blood loss. Here the incision is made high in the maxillary vestibule
from one second molar region to other lying just above the buccal/
labial attached gingiva. The mucoperiosteum is raised over the
superior maxilla, round the pyriform aperture, the malars and the
infra orbital area. Only minimal periosteal stripping is done in the
dentoalveolar region in cases of adjutant segmental osteotomies. The
nasal mucoperiosteum is raised along the floor of the mouth which
helps in detaching nasal septum and also perform lateral nasal
osteotomy cuts without tearing nasal mucosa.
Approaches in cleft lip & Palate:
Henderson and Jackson 1975 devised a useful approach for the
management of maxillary hypoplasia in cleft lip case. They advocated
splitting the lip through to the cleft line and then extending this
incision into the labial sulcus on either side. To close the fistula, a
buccal flap is reflected from the lesser segment side and it is rotated
into the cleft alveolus to provide closure to the oral layer. The nasal
floor mucoperiosteum is raised from the septum and lateral wall of
the nose and closed under direct vision. Sometimes mobilisation of
palatal tissues is necessary to close the palatal cleft.
To overcome the problem of palatopharyngeal scaring and the
resultant velopharyngeal insufficiency Wake 1975 modified the
Converse approach to Le fort I osteotomy by leaving behind the
palatal tissues. Here vertical incisions right angle to the dental arch
are placed anteriorly in the midline and laterally in the buccal
vestibule molar/ premolar region. By tunnelling approach maxillary
osteotomy is completed. A palatal flap is raised a few millimetres
from the gingiva with the palatine vessels contained in it. The palatal
flaps are raised up to the greater palatine canal. The posterior
osteotomy cuts are placed anterior to the greater palatine canal and

the maxilla is positioned anteriorly leaving behind the palatal flap.
The anterior raw area is allowed to granulate secondarily. This
approach diminishes the risk of speech changes but it is a difficult
procedure and the osteotomy sites takes longer period to unite.
Incisions for segmental procedures
Segmental osteotomies are done on the maxilla, these include
the anterior maxillary osteotomy and posterior maxillary osteotomy.
The approaches used for anterior maxillary osteotomy are
1. Wassmund’s approach
2. Wunderer’s approach
3. Down fracture approach (Bell down fracture modification of the
Cupar technique).
The posterior maxillary osteotomy is approached by
1. Buccal approach ( Kufner).
2. Buccal & Palatal approach ( Perko – Bell).
Approaches to anterior maxilla
Wassmund approach
The Wassmund approach relies on the buccolabial vascular pedicles
and usually an intact palatal blood supply. An anterior median vertical
and buccal vertical incisions are made. Buccal bone is removed through
the buccal vertical incision up to the pyriform aperture by tunnelling
approach. Palatal bone is removed by tunnelling approach under the
mucoperiosteum from the socket area. Sometimes a small midline
palatal incision aids removal of palatal bone. The nasal septum is

approached through the anterior vertical incision. By this approach it is
difficult to raise the maxilla and to setback posteriorly.
Wunderer approach
In the Wunderer approach, a transverse incision is placed across
the hard palate in addition to the three vertical incisions described by
Wassmund’s technique. This allows better access to the palate for major
posterior movements. The transverse palatal incision is arched forward
so that the suture will lie on the anterior palatal bone. The buccal bone
and septum is approached through the vertical incisions as in
Wassmund’s approach. The anterior segment is hinged on its labial
pedicles.
Down fracture approach
The down fracture approach is the most widely used procedure
for anterior maxillary osteotomy as this provides good access and also
reliable blood supply. Here a vestibular incision is placed in the labial
vestibule. The buccal osteotomy cuts are done through tunnelling
approach. The nasal mucosa is raised and the nasal septum detached
through the vestibular incision. Any midline splitting is done before
the completion of segmental osteotomy.
Approach to posterior maxilla
The approach to posterior maxilla, usually for raising the buccal
segment, may be through the buccal and palatal mucoperiosteal
incisions.
Kufner 1970 described a single buccal incision approach. This
approach is difficult in flat palate and when antral walls are thick. The
buccal bones are cut through the buccal incision and the vertical cut in
the premolar region is done through the tunnelling approach. The
palatine bone is cut by using a fine curved osteotome. When a palatine

incision is planned it should be made medial to the palatine foramen
and the osteotomy is performed lateral to the foramen.
When the palate is very flat the Perko – Bell technique (1967)
may be adopted. Here both walls of the antrum are cut through the
buccal approach. A parasagittal incision is made in the palate from
premolar area to the junction of the hard and soft palate and the
alveolar bone exposed and cut medially to the greater palatine foramen
in an anteroposterior direction.
Besides these, a variety of techniques have been described to deal
with individual problems in maxilla. It is best to choose the safest and
most reliable one for the situation.
Osteotomy techniques – Maxilla.
A variety of osteotomy techniques have been described to
correct the midface problems. The osteotomy techniques include
either a segmental osteotomy of maxilla where a part of the maxilla is
osteotomised and repositioned or total maxillary osteotomy is done at
Le fort I, II, or III level to correct the deformity.
Segmental surgeries of Maxilla
The types of segmental osteotomies described for
maxillary procedure include – single tooth osteotomy , anterior
maxillary osteotomy and posterior maxillary osteotomy.
Single tooth Osteotomies
Indication
1. The procedure is mostly used for dilacerated teeth
2. Those teeth that have been impacted into the alveolar bone
following trauma.

3. Occasionally when more than one tooth requires repositioning.
Procedure
This procedure is limited to maxillary anterior tooth. This
procedure requires good amount of inter radicular bone. The
approach to single tooth Osteotomy is through either a small high
horizontal labial sulcus incision or alternatively through two vertical
incisions on either side of the tooth.
When using two vertical incisions, these are made through
the mucoperiosteum a millimetre or two on either side of the
proposed bone cut. The incision starts high in the labial sulcus and
stops 2 –3 mm from the alveolar crest. Mucoperiosteum is not
elevated over the tooth that is to be repositioned. Labial bone cut in
made with fine burr, in the centre of inter-radicular area parallel to
each other. High in the labial sulcus the mucoperiosteum is elevated (
tunnelled ) above the root apex of the tooth to be moved so that a
horizontal cut may be made at least above the apex. The segment is
separated by the use of fine osteotomies. The osteotomies are angled
to the palate on the either side and a finger is kept in the palate to feel
the instrument penetrating the palatal bone. The supra-apical
division is similarly made through the palate with a curved
osteotome. Once the tooth segment is mobile it is best to fix it to the
adjacent teeth by means of an orthodontic arch and attachments.
In horizontal labial incision technique care is require when
tunnelling vertically on either side of the tooth not to detach the labial
mucoperiosteum on its anterior surface. The remaining procedures
are same as described before. Immobilisation of tooth segment is
required for several weeks.
Basic surgical principles of single tooth osteotomies are

(1) Maintain an adequate amount of attached, viable tissue to
the mobilised segments in order to provide sufficient vascularity to
them.
(2) Provide maximal direct visualisation of all areas to be
osteotomised or ostectomised.
(3) Achieve good mobilisation of the segments to allow for
passive repositioning in the predetermined position
(4) Maintain operational periodontal health.
(5) Provide good bony contact between the stable and
mobilised segment to effect rapid bone union.
Anterior Maxillary Osteotomy
An initial discussion of anterior maxillary osteotomy was
presented by Cohn-stock in 1921. The single state predominantly
labial approach was first reported by Wassmund in (1926). Axhatusen
added a tunnelling procedure on the palatal side (1936), Schuchhardt
(1956) preferred a two stage procedure, with the palatal side being
treated first and completion of surgery 4-6 weeks later from labial
approach.
The most popular technique of segmental surgery is the
down fracture described by Epker and Welford (1980).
The anterior maxillary osteotomy is primarily employed
1. - Reposition the dento alveolar segment posteriorly
2. - Correction of maxillary protrusion
3. - Bimaxillary protrusion - along with mandible, (anterior
segment)

4. - Correction of openbite (Secondary to mandibular
correction)
In certain cases the dento-alveolar protrusion with or
without vertical maxillary excess, it might be difficult to decide
between Anterior maxillary osteotomy and a Le fort I osteotomy with
an anterior maxillary osteotomy to correct the deformity. In these
situations these guidelines might be helpful.
If sufficient overbite exists and an impaction of 3mm or less is
required then an isolated Anterior maxillary osteotomy would suffice.
If more than 3mm impaction is required and even if overbite
exists le fort I osteotomy should be done in combination with anterior
maxillary osteotomy.
If there is negative or minimal overbite, even if the maxillary
impaction is minimal le fort I with anterior maxillary osteotomy is
indicated.
If the maxillary impaction planned is minimal less than 3 mm,
but if the gingival level between the teeth adjacent to the osteotomy
has a steep angle, a Le fort I osteotomy with anterior maxillary
osteotomy should be planned.
Wassmund technique: [ Labial vertical incision with palatal
tunnelling]
The Wassmund approach relies on the buccolabial
vascular pedicles and usually an intact palatal blood supply.
An anterior median vertical and buccal vertical incisions
in the canine – premolar regions are made extending to the nasal floor.
The mucoperiosteum is reflected posteriorly and superiorly. In the
apical region of the canine tunnelling is carried out to the inferolateral

border of the nasal pyriform aperture. Mucoperiosteal flap raised to
expose pyriform rim and nasal spine.
Vertical bony cuts are made in the lateral maxillary cortex
at the midpoint of planned osteotomy site. These are carried
superiorly to a point approximately 3mm superior to canine apex.
The anterior bony cuts are completed by continuing the cuts medially
to a point on the most lateral aspect of pyriform aperture. These are
made with tapered fissure bur.
On palatal aspect a subperiosteal tunnel is created on the area of
planned palatal osteotomy. While the palatal tissue are protected with
a suitable retractor the bony cut is carried from crest of alveolar bone
in one osteotomy site across palate to opposite side. Care must be
taken to avoid damage to nasal floor mucosa and penetration of
endotracheal tube. Sometimes a small midline palatal incision aids in
the removal of palatal bone.
The nasal septum is approached through the anterior
vertical incision. The remaining bony attachments of the anterior
maxillary segment are severed with a narrow single bevelled
osteotome along the floor of nasal cavity.
The segment is manually freed by covering it with a gauze
sponge, and manipulated to get free of all attachments except palatal
pedicle.
It is tried into the post operative site. If any bony
prominence interfering this can be removed. Final positioning is done
with the aid of an occlusal splint. Before placement of splint the
palatal tissue is closed with a horizontal mattress suture.
By this approach it is difficult to raise the maxilla and to
setback posteriorly.

Wunderer's technique
Wunderer (1962) developed his procedure to provide a palatally
oriented approach to the sectioning and reposition of anterior
maxillary segment. Because of the segment is pedicled on labial
mucoperiosteum it is possible to rotate it anteriorly for better
visualisation of surgical site. Here bony section may take place under
direct vision. This is indicated if posterior movement is the dominant
objective.
Technique
Vertical incisions are placed on the labial and buccal
mucoperiosteum. Subperiosteal tunnelling is done and osteotomy is
done through the vertical incision on the buccal and labial aspect.
On the palatal aspect an arcing incision is made through the
palatal mucosa from the inter-dental space anterior to the site of the
planned osteotomy cut. The mucoperiosteum is raised on to the
posterior palatal side. The buccal osteotomy cuts are joined
transpalatally under direct vision. Care is taken to prevent damage to
the nasal floor mucosa. If a midline split is required, it is fractured
with a fine long bevelled osteotome.
The segment is freed completely by covering it with gauze
sponge and with controlled manual force fracturing it from its
remaining attachments. The recipients site is contoured with a bur.
The mucoperiosteal flap is replaced with a horizontal mattress suture.
The segment is fixed with pre-fabricated splint.
Down fracture technique.
Cupar 1955 modified two stage procedure of anterior
maxillary osteotomy into single stage down fracturing technique. This
technique is mainly indicated if superior positioning is the dominant

objective. Epker described some advantage of this down fracture
technique.
1. - It is technically simple
2. - Provides direct access to nasal crest of maxilla and
associated nasal septal structures.
3. - Permit removal of palatal bone under direct vision.
4. - Gives excellent vascular pedicle.
The incision is made high in the labial vestibular mucosa
at least 5mm above the root apices from premolar to premolar on the
other side curving slightly in the midline towards the labial mucosa.
Sometimes vertical incisions are placed anterior to the posterior
osteotomy cuts.
The mucoperiosteum is raised to expose pyriform fossa,
nasal septum,
anterior nasal spine and the sub apical bone over the anterior tooth
from premolar to premolar tooth.
The first premolars are extracted on both sides. The
horizontal line of osteotomy is marked with bur starting from the
pyriform rim up to the region of the extracted socket keeping at least
5mm above the root apices of the canine and incisors. The nasal
mucosa is protected through out the procedure. Then the osteotomy
cut is turned vertically down to reach the alveolar margin by
tunnelling approach or under direct vision when vertical incisions are
used. Two vertical cuts are placed depending upon the amount of
posterior setback. This buccal cortical bone is removed with a chisel.
After removing buccal bone the bur is directed to palatal
bone in a semiblind

fashion. A finger is placed on palatal aspect to feel the cutting process
and also to prevent penetration of bur through the palatal mucosa is
avoided.
The same procedure is repeated on the other side. Nasal
mucosal floor is raised and the nasal septum is detached using a
septal osteotome. The bone cut is completed on the palatal aspect with
an osteotome by using gentle tap. Alternatively the palatal
mucoperiosteum is raised and bur used to complete the cut
sometimes small midline vertical incisions are placed in the midline to
gain access.
The segment is then down fractured and the bone is
removed from palatal
aspect under direct vision.
The palatal mucoperiosteum is reflected slightly from the
stable part (Posterior). This will allow easy movement of anterior
segment posteriorly.
When superior positioning is planned the nasal spine is
removed, the nasal floor in the mobilised segment is grooved to
accommodate, the nasal septum,
or a segment of septum is sectioned from its anteroinferior part.
After the indicated amount of bone is removed the splint
is inserted. If the
correct position is not attained, the osteotomy site is re-examined and
any
bony projections are removed.
L shaped miniplates are used along the pyriform rim for
fixation. Screws are placed at least 3mm away from root apices.

Additional stability if needed can be achieved by wiring using a 26
gauge wire.
. During final positioning, care is taken not to crimp the
palatal tissue between the segments as this would compromise the
blood supply.
The wound toilet is done and the labial incision is closed
in two layers. Any palatal or nasal floor tears are sutured with 3-0
vicryl. If alar base widening is significant then alar cinch suturing is
done before mucosal closure.
Posterior Maxillary alveolar Osteotomy
Unilateral or bilateral posterior maxillary osteotomy or
ostectomy provides a means of surgically correcting a wide variety of
occlusal and dento alveolar deformities. The relative indication of this
procedure are.
(1) To alter the transverse position of the posterior maxilla (to
correct cross bite).
(2) To superiorly position a supra erupted posterior segment.
(3) To inferiorly position a posterior segment. (To close a
posterior open bite).
(4) To move a posterior segment forward to close an
edentulous space.
Numerous technical approaches to the posterior maxillary
osteotomy have been advocated. Schuchart (1955) described a two
stage method applicable to the closure of a posterior open bite. In first
stage the palatal bony cut is done and after 6 weeks the second stage,
the buccal osteotomy, is performed.

Kufner (1968) modified this technique to a one stage
procedure. In this only buccal approach is done and palatal bone is
divided through the osteotomy site by a thin osteotome as in case of
down fracture technique.
West and Epker 1972 also described similar procedure.
Regardless of the technique utilised, principles of surgical reposition
in this are similar to anterior segmental surgery.
The technique.
Access to the posterior segmental osteotomy is gained
through a buccal sulcus incision extending from 1st molar to canine
region. Then it is turned vertically down to marginal gingiva one
tooth anterior to osteotomy site. The muco periosteal flap is reflected
to expose the lateral aspect of alveolar portion, lower part of
zygomatic buttress and posteriorly to the pterygoid plates if needed.
If a tooth is planned to extract from the posterior end the mucosal
reflection is limited to that region.
After bone is exposed the bony cut is marked by
measuring with calliper and marks with pencil. The bony cut should
be at least 5mm above the root apices in order to preserve blood
supply.
A predetermined amount of bone is removed from the
buccal aspect (lateral maxillary wall) and the inter-dental alveolar
osteotomy is then completed from the buccal aspect. Carefully
expose the sinus mucosa and reflect it superiorly. In cases of
excessive supra-eruption of dento-alveolar segment the plane of
osteotomy will be below the antral floor.

Now the palatal bone is divided. It can be done using bur
or osteotome. In both cases a finger is placed as palatal mucosa to feel
the instrument as it breaks the palatal bone.
If the osteotomy is extending posterior to 2nd molar, the
level of bone cut is lowered posteriorly. This will help easy separation
or division of pterygoid plates.
If the osteotomy site at buccal aspect is small it will be
difficult to cut the palatal bone through this. In such cases a palatal
incision is placed anterior to the area of bone cut mucosa can be
tunnelled and osteotomy can be done under direct vision.
The segment is down fractured with the osteotome placed
in bone cut and lowered inferiorly. A small curved osteotome is used
to separate the pterygoid plates. The bone removal is now completed.
If needed palatal mucoperiosteum can be reflected from stable part.
On posteromedial aspect of segment palatal neurovascular bundle can
be identified. Bone is removed carefully surrounding this and can be
freed.
After the bone removal is completed the segment can be
fixed with preformed acrylic splint.
Total maxillary osteotomies
Le Fort I Osteotomy.
Early effort to reposition the entire maxilla were directed
at correcting traumatically malpositioned maxillary complex, and also
to correct midface deformities secondary to cleft palate. The danger of
maxillary sinus infection and fistulae as well as the possibility of
necrosis of bony segment deterred, many surgeons from attempting
this correction.

Wassmund (1927) performed this type of surgery to close
a posterior openbite and in this after sectioning the lateral maxillary
wall be used elastic traction to bring the maxilla down. Axhausen
(1935) was first to advance the lower portion of maxilla using this
technique. Schuchardt (1942) applied forward traction using a pulley
and weight system to produce an advancement of sectioned maxillary
segment.
Transection of pterygoid plate in Le Fort I maxillary
osteotomy was described by Schuchardt 1942. Moore and Ward 1949
advocated the use of horizontal transection of the pterygoid for
anterior advancement of maxilla.
Cupar and Rowe 1954 reported the use of bone grafting in
Le-Fort I maxillary advancement. Cerinac and associates (1955) and
Cerinac in (1958) were also reported the use of bone grafts.
In 1959 Kole developed a two stage procedure for total
maxillary osteotomy. In the first stage he performed a U shaped
palatal osteotomy anterior to greater palatine foramen and in second
stage a labial bone cut is made. Paul (1966) reported a similar
procedure in a single stage. Obwegeser 1969 introduced a technique of
wedging of bone graft between the pterygoid process and tuberosity
for advancement of maxilla after surgery.
Dupont, Ciaburo and Prevost 1974 advocated sectioning
through the tuberosity rather than at the pterygomaxillary interface.
This modification was described by Trimble, Tideman and Stoleinga
1983.
Bell at al 1975 described down fracture technique of Le
Fort I Osteotomy. Epker and Wolford (1980) rectified this technique
and described it in detail. The advancement studies were done by Bell
and Scheindermann (1981). The associated changes in facial muscle

was studied by Schendel (1983). Luhr and Radney 1986 described the
use of rigid fixation by miniplates in Le Fort I osteotomy.
Indications of Le Fort I Osteotomy
1. Altering the vertical dimension of maxilla
- Superior positioning in long face syndrome
- Inferior positioning.
2. Antroposterior movements of maxilla
In cleft palate patients & congenitally deficient maxilla
- Maxillary advancement
- Maxillary set back in maxillary prognathism
(only 3-5mm is possible)
3. Levelling of occlusal plane in occlusal cant.
4. Surgical expansion of maxilla
5. Narrowing of maxilla.
TECHNIQUE
A horizontal vestibular incision is made from the mesial aspect
of the maxillary first molar from one side to the other side about 5mm
above the apices of the maxillary teeth. The incision can be made with
blade or diathermy. The mucoperiosteum is reflected to expose the
pyriform aperture and lateral wall of maxilla. Posterior to zygomatic
buttress the mucoperiosteum is tunnelled to expose the tuberosity.
The elevation of mucoperiosteum is extended to infra orbital
neurovascular bundle. Nasal mucosa is reflected from lateral nasal

wall, floor of the nasal cavity and from the lower end of the nasal
septum.
The osteotomy line is marked on the bone over lateral aspect.
It should be 5mm above the apices of teeth, sloping down ward
posteriorly. Vertical reference lines can be marked to access the
anteroposterior movement of the mobilised segment. Osteotomy cuts
are then completed with a flat fissure bur or with an oscillating saw.
Bone division starts from lateral wall of pyriform aperture and taken
posteriorly. Brisk oozing is sometimes noticed along the anterior
maxillary wall. For maxillary impaction the planned amount of bone
is removed from the lateral maxillary walls of the maxilla after
marking out two line anteriorly. Posteriorly these lines are merged or
kept parallel depending upon the type of movement required. noticed
Bone removal should be done. This gives a narrow, well controlled
bone cut. In case of superior repositioning the cut can be made with
bur as some amount of bone removal is indicated.
The lateral wall of maxillary sinus is then divided. A retractor is
used to protect the buccal soft tissue. This cut is taken posteriorly to
pterygomaxillary junction. Lateral wall of nose is divided below the
inferior turbinate with a flat osteotome. The cut is directed towards
the perpendicular plate of palatine bone which is partially divided.
Complete division may cause excessive bleeding from palatine
vessels.
The nasal septum is divided with a septal osteotome, along the
floor of nasal cavity. The osteotome is hold parallel to occlusal plane.
The endotracheal tube is protected now. After all the walls are
divided , a curved osteotome is used to complete the bone cut at
pterygomaxillary junction. This is separated by gentle tapping . A
finger is kept posterior to pterygoid hamulus to feel the separation.

Maxilla is now down fractured by thumb placed over the
alveolar bone. As the down fracturing progresses the nasal mucosa
is reflected posteriorly.
Some times the separation may be achieved by disimpaction
forceps or by use of special instruments like smith split spreader.
For superior and posterior positioning elective bone removal
is done with rounger or bur. The removed bone chips can be
collected in saline for filling the gap after fixation as autogenous
grafts. This will speed up bone healing . Posterior repositioning with
osteotomy of the pterygoid plates is difficult. Only 5 to 6 mm of
posterior movement is possible. If excess movement is desired then a
two piece maxillary osteotomy is to be planned or a maxillary
tuberosity osteotomy is planned.
For maxillary advancement the bone graft is placed between the
pterygoid process and maxillary tuberosity. For this communication
of pterygoid plates should be prevented during separation of
pterygomaxillary junction. Intact pterygoid plates will act as a
posterior stop for bone grafts. some authors described a vertical step
in the lateral cut in the region of the second premolar. This aids in
measuring the movement and also to serve as stop for any bone graft
that may be placed in the region.
In congenital maxillary hypoplasia a 3-5mm stable advancement
is possible without placing bone grafts.
In cases of augmentation of vertical maxillary height the bone
cut is made a higher level with respect to pyriform aperture. This is to
get 5mm of bone in sub apical region after the osteotomy of lateral
and medial walls. The maxilla is advanced and lowered using rows
disimpaction forceps. The beaks are applied below the nasal mucosa
and gentle rocking of the maxilla will help to relieve soft tissue

resistance to anterior traction. After adequate inferior traction bone
grafts 9 split thickness calvarial grafts ) are fixed in position.
Segmentalization of the Le Fort I segment can be done if
necessary, taking care to preserve the vascular pedicle. The common
segmentalization procedure include:
1. Anterior maxillary osteotomy
2. Sagittal midline osteotomy.
The anterior maxillary osteotomy is combined with Le fort
I impaction in patients who have vertical maxillary excess with dento-
alveolar protrusion of moderate to severe degree. The osteotomy is
usually carried out through the socket of the extracted 1st or 2nd
premolar. The bone cuts are made through tunnelling of the
mucoperiosteum for access. Care is taken to preserve the pedicles.
Alterations in transverse dimension if required can be
performed after down fracture. In cases requiring expansion a mid
palatal split is done using a fissure bur. The palatal muco periosteum
is protected while doing this. After bone division the
Mucoperiosteum is reflected through the osteotomy gap and
extended to vertical alveolar portion. Should not damage the palatal
vessels. Up to 6mm of expansion is possible without bone grafting. If
excessive expansion is done the stretching of palatal mucosa may lead
to ischaemia and necrosis of bone as well as soft tissue. If the bone
gap is more than 6mm partial thickness parietal bone graft should be
fixed in this gap.
In case of narrowing of maxilla the alveolus should be divided
in midline before down fracturing and then the down-fracturing is
done and the division of palatal midline is done posteriorly. The
mucoperiosteum is reflected from the edge of osteotomy and

adequate bone is removed from midline. Then by pushing the
mucoperiosteum into oral cavity the segments can be fixed together
with inter osseous wiring. Alterations of occlusal plane may be
required in some cases. Oblique occlusal plane can occur in patients
with unilateral condylar hypo/ hyperplasia, hemifacial microstomia,
Romberg syndrome etc. The assessment of this defect should done by
clinical examination and evaluating PA cephalogram. This condition
is treated by.
- Increasing vertical Ht. of maxilla on one side.
- Decreasing vertical height on one side.
- or a combination
A combined form of treatment is often more practical because of
concomitant soft tissue changes. Hence the height is increased
slightly on side of deficit and decreased on side of excess. This should
be accompanied by mandibular surgeries to attain complete occlusion.
For levelling of occlusal plane the maxilla is released in Le Fort I
plane. The excessive bone is removed from one side. The other side is
augmented by bone graft. Corticocancellous grafts from iliac crest is
ideal if excessive alteration is required.
Fixation
After the required corrections, the maxilla should be fixed to the
basal bone. Historically, the mobilised maxilla was fixed directly to
the pyriform rims and zygomatic buttress with transosseous wires or
suspension wires placed at the zygomatic buttress, the zygoma or in
the infra orbital rim.
In cases of transverse corrections a prefabricated acrylic splint
should be placed to get three dimensional stability of the occlusal
plane. In other cases a temporary inter maxillary fixation should be

done. During this it should be ascertained that the condyle of
mandible is in glenoid fossa. After the IMF is done the segment is
fixed superiorly.
In cases of superior and backward positioning a circum
zygomatic suspension can be done. This gives a postero-superior
force. The wires are tightened simultaneously on both sides.
In maxillary advancement without inferior positioning a infra
orbital rim suspension is recommended. This gives a upward and
anterior vector of force.
The inferior positioning is difficult to fix by these methods.
Wiring at lateral pyriform border can be done. Simultaneous wiring
of bone graft also to be done.
Instability of the maxillary repositioning has been noted and
these have been attributed to various factors. These include
1. Inadequate bone stabilisation
2. Poor bone contact.
3. Excessive superior repositioning or superior relapse of an
inferiorly placed maxilla may be due to the mandibular
occluding forces as the masticatory muscles contract.
4. Maxillary advancement is also plagued by relapse, especially
following large forward movements or due to excessive soft
tissue restriction after multiple or cleft surgeries.
To overcome these problems more rigid forms of fixation are
devised. These include rigid adjustable fixation and rigid internal
fixation.

Rigid adjustable fixation for maxillary osteotomy
These uses mainly pins and wires to secure the maxilla. Various
forms of rigid adjustable devices had been advocated. Bays 1985
suggested the use of 2.7 mm screws in the superior segment. Pins are
attached to the arch wire. Then 0.045 inch orthodontic wire is used to
stabilise the maxilla to the screws and pins. This can be adjusted
postoperatively for minor adjustment in maxillary position.
Bennett & Wolford 1985 suggested another system where in
they used 2mm Steinmann pin into the zygomatic buttress area. They
secured it to the arch wire using acrylic. They obtained anterior
stabilisation by rigid internal fixation by means of miniplates.
These pins can be removed after healing by local anaesthesia
and intravenous sedation.
Internal rigid fixation for maxillary osteotomy.
Rigid fixation with screws and plates gives satisfactory stable
fixation in all forms of osteotomy. This is especially important in
inferior positioning of maxilla which is least stable when other forms
of fixation are used. Simultaneous fixation of bone grafts also can be
achieved with rigid fixation. This will improve the graft viability. In
Le Fort I osteotomy the areas suitable for rigid fixation are zygomatic
buttress and pyriform margins. These areas having adequate bone
thickness of insertion of screws. After the planned post operative
position is achieved and temporarily IMF performed straight, L
shaped or T shaped plates suitable for 2mm screws are passively
adapted in these areas. Improper adaptation will lead to alteration of
occlusion later. The holes should be perpendicular to surface in-order
to achieve maximum bone thickness for screws.

Ian Munro (1989) recommended at least 4 plates should be used
for Le-Fort I osteotomy. Two at zygomatic buttresses, two at lateral
pyriform margins. Each plates should have 4 holes minimum 2mm
monocortical self tapping screws are widely accepted.
McCarthy (1990) recommended that if rigid fixation is planned
the osteotomy should be done at a higher level in order to get
adequate bone at sub apical region for placement of screws without
endangering root apices.
Stella & Epker 1994 advocated semirigid fixation with posterior
zygomatic buttress wiring and anterior plates in the pyriform rim. The
posterior zygomatic buttress wiring can be adjusted depending on the
occlusal needs of the patient.
Wound closure & Soft tissue considerations.
After satisfactory fixation the area is irrigated inspected for loose
bony fragments, and any other foreign bodies. Closure of the incision
line can be done in two layers. Before that any mucosal tear should be
sutured with 4 '0' catgut. This will reduce the chance of post operative
nasal bleeding.
Widening of alar base is a frequent complication of superior
positioning of maxilla. This can be prevented by a traction suture
( alar cinch suturing ) with a non observable material across the alar
base. Gahli & Sinn 1997 advocated Weir procedure or a simple lateral
nostril sill excision with undermining and re-approximation for
management of increased alar base width. Other authors have
advocated the use of secondary rhinoplasty techniques for
management of the alar basal width problems. Kawanato (1989)
recommended separation of anterior nasal spine from maxilla along
with nasal septum. This will retain the soft tissue contour at the
nasal base.

The upper lip length and vermilion exposure changes drastically
with Le fort I osteotomy. Lip length reduces by 20 % of the planned
bone movement in a Le fort I impaction with reduction in vermilion
exposure. V- Y closure of the mucosa with a vertical limb of 10 –15
mm maintains the pre-operative vermilion exposure and lip length. A
vertical limb of 15 – 25 mm increases lip length by about 1 –2 mm and
also increases vermilion exposure. Appropriate use of these closure
method is indicated depending upon the treatment plan.
Total Maxillary alveolar Osteotomy (TMAO) (Hall and Roddy
1975)
Total maxillary alveolar osteotomy was described by Paul 1969
based on the experiences of Kole & Mohnac. Hall & Roddy 1975, West
and McNeil 1975, Hall and west (1975) , West & Epker 1972 also
published this as a treatment for total maxillary alveolar hyperplasia.
Meloney et al (1982) reviewed few cases of this and concluded that
TMAO is a "good technique in his time"
Sterling R. Schow (1986) described few advantages
(1) It can be used to intrude maxilla for hyper plastic
maxillary alveolus, to correct posterior or total alveolar hyperplasia
with or without anterior open bite. This is particularly useful when
impaction of the segment is more than 5mm.
(2) It is a substitute for Le Fort I surgery when there is long
alveolar process with high arched palate.
(3) The reduction of sinus volume and possibility of air way
constriction is avoided with TMAO.
(4) Even in absence of vertical excess, this can be used to
expand, constrict or recontour the alveolar arches. In such cases it
provides a stable palatal base to which the segments can be fixed.

(5) It is less suitable for inferior positioning or advancement.
Epker and Wolford 1980 described this technique as
"superior positioning of maxilla with nasal floor intact". They gave
the indications for this procedure.
(1) When superior movements 10-15mm is required.
(2) In pre-existing decreased nasal airway function not related
to nasal septal deviation (DNS) or large inferior turbinate.
(3) when segmentalisation of maxilla is required in 3 or 4
segments.
Technique.
This may be accomplished with surgical access obtained
through a horizontal mucoperiosteal incision near the depth of the
labial vestibule similar to that of Le fort I down fracture technique or
through multiple vertical incisions with tunnelling beneath the
alveolar mucosa and palatal access through incision and elevation of a
palatal "horseshoe" mucoperiosteal flap.
A circum-vestibular incision is made which extend from one
Zygomatico alveolar crest to the other. Posterior to that the soft tissue
is undermined to the pterygomaxillary junction.
The alveolar portion and lateral maxillary wall is exposed by
minimum but adequate elevation of mucoperiosteal flap is done.
The nasal epithelium is elevated starting from pyriform aperture
to 10-15mm posteriorly, and also from the anterior floor of nasal
cavity and inferior portion of septal cartilage.
By protecting the nasal mucosa with a retractor the horizontal
osteotomy through the lateral maxillary wall is made extending from

the nasal cavity to the pterygomaxillary junction. The anterior 10 to 15
mm of lateral nasal wall is also transected. If superior impaction is
planned, the inferior osteotomy is completed 4 to 5 mm above the
apices of the tooth and this is followed by a superior osteotomy to
remove the measured amount of bone. Posteriorly the osteotomy is
directed towards the pterygomaxillary junction or to the third molar
extracted site which has been removed 4 to 6 weeks prior to surgery.
If the dentoalveolar segment is to be divided into multiple
segments, the mucoperiosteum overlying the alveolus at the site of
osteotomy is tunnelled and the osteotomy cut performed. The palatal
bone at the vertical osteotomy site is cut taking care to prevent
damage to the palatal periosteum.
A 'V' shaped groove is cut from the anterior nasal floor in the
midline after separating the nasal septum from floor of nasal cavity.
This should be 4mm away from root apex of central incisor. This is to
accommodate the nasal septum during superior positioning of
maxilla. If this clearance is not possible the anteroinferior portion of
septum should be sectioned.
The palatal bone cuts are made. In the anterior region if there is
large amount of bone in the alveolar segment then bone cuts are made
inferior to the floor of the nasal cavity. With a small osteotome or a
fissure bur a transnasal osteotomy is completed from right to left
across the palate approximately 10 to 15 mm into the nasal cavity. A
palpating finger is placed on the palatal side to avoid damage to the
palatal mucosa. Laterally the bone cuts extends into maxillary sinuses.
Posteriorly the osteotomy cuts extends along the medial wall of the
maxillary sinus below the level of the nasal floor into the oral cavity.
Two osteotomes are inserted in the osteotomy gap and is
levered down wards to down fracture the maxilla. If it fails a curved

osteotome is used to remove palatal bone posteriorly. This should be
carefully done.
If the 3rd molar is to be removed either due to impaction or any
other causes it can be done at this time. If so the osteotomy can be
limited to 3rd molar socket. Or the pterygomaxillary junction can be
disrupted by gentle tapping with osteotome.
After down fracture adequate bone is removed from palatal side
and the segment can be moved to its pre-planned position.
The palatal mucoperiosteum can be undermined carefully from
the fixed part. This will help in easy positioning of the segments.
The mobilised segments are now repositioned by selective bone
removal and the planned postoperative position is attained.
The fixation can be done by a prefabricated occlusal splint made
from mock surgery on study model. Or the fixation can be done with
orthodontic appliance. A temporary inter maxillary fixation is
performed to ascertain the anteroposterior relation. The segment is
now fixed superiorly. In cases of superior and posterior placement, a
circum-zygomatic suspension can be used. If the repositioning is in a
superior and anterior direction suspension to infra orbital rim can be
done.
Alternatively a lateral pyriform rim wiring can also be used.
Now the temporary inter maxillary fixation is removed and the
wound is closed.
Some modifications are suggested to this standard technique.
Bell 1975 used the same incision as in Le-Fort I Osteotomy.
Bell, West (1975) West and Roddy 1976 and McNeil on (1975)
described a combined palatal and labial approach. In this on the

labial aspect 3 vertical incisions are used one in midline, other in
premolar region on both sides. Through this sub mucosal tunnelling
is done and osteotomy is performed on buccal and labial aspect. After
the buccal osteotomy is completed a palatal mucoperiosteal flap is
raised. For this a U shaped incision is put about 1cm apical to
gingival margin starting from one 2nd molar region lateral to the
greater palatine vessels. It is brought anteriorly just lateral to greater
palatine vessels, Anteriorly is turned to opposite site just palatal to
incisive papilla, and extend to other 2nd molar. A full thickness
mucoperiosteal flap is raised. Now the palatal bony cut is done
directly, dividing the palatal wall of maxillary sinus and anterior nasal
wall. Posterior to the greater palatine foramen the bone may fractured
or divided with osteotome. After adequate bone is removed the
segment can be fractured using digital pressure or by levering
instruments. Selective bone removal is done and the segment is
repositioned and fixed. This technique has advantage of direct access
to the palatal bone and is suitable in cases of thick palate. But the
palatal vascular pedicle is compromised.
All the authors suggested that if there is adequate bone in
sub apical region and below the nasal and antral floor, the osteotomy
should be done at this plane without entering the nasal and antral
floors for impacting the maxilla.
Quadrangular Le Fort I osteotomy.
Hugo Obwegesser 1969 described a high Le fort I
osteotomy for correction of midfacial hypoplasia in cleft lip and palate
patients. This was named Quadrangular Le Fort I osteotomy by Keller
& Sather 1989, because of the indications, osteotomy shape and level
and projected clinical outcome were quite similar to those of the
quadrangular Le fort II osteotomy as described by Kufner. Here the

advancement of both the infra orbital rim and a portion of the
zygomatic complex is done.
Indications
This is mainly indicated in patients with maxillary-zygomatic
horizontal deficiency, with class III skeletal malocclusion and normal
nasal projection. This is ideal in management of midface hypoplasia
with midline problems or transverse deficiency.
Procedure
The procedure is done intraorally through the down
fracture approach of Le Fort I osteotomy by a horizontal vestibular
incision. The entire surface of the anterior maxilla is exposed by
subperiosteal dissection extending from the right to left tuberosity and
up to the infra orbital rim. The infra orbital nerve is isolated and the
orbital rim periosteum is reflected. The mucosa over the floor of the
nose is exposed and also from the lateral nasal wall.
The osteotomy cuts are placed on the lateral wall of maxilla
from the pyriform aperture at the level of the infra orbital nerve. The
osteotomy is extended laterally below the level of the infra orbital
nerve to the tuberosity and pterygoid plate region. The maxilla is
down fractured after detaching the nasal septum, pterygomaxillary
disjunction and ostectomising the lateral nasal wall.
Bone grafts are used in the infra orbital region and also in the
pterygomaxillary junction.
Le Fort II Osteotomy
Converse 1971 described an osteotomy for correction of
the nasomaxillary hypoplasia. This was classified as "Anterior Le Fort
II osteotomy" by Steinhäuser 1980. Henderson and Jackson (1973)

described classical Le Fort II Osteotomy for patients with naso
maxillary and midface hypoplasia. This was classified as "Pyramidal
Le Fort II osteotomy" by Steinhauser. Kufner (1971) described an
osteotomy for correction of nasal hypoplasia and also for the infra
orbital region. Similar osteotomies were described by Souriyas et al
1973and Champy 1980. This was classified as "Quadrangular Le Fort
II osteotomy by Steinhauser. Epker and Wolford in 1980 given a
detailed description of standard Le Fort II Osteotomy.
Anterior Le Fort II osteotomy. (Naso-Orbito-maxillary
osteotomy).
It is an initial form of Le Fort II osteotomy described by
converse and associates (1971). Used to correct the nasal and
maxillary deficiency. The principles of these procedure are:
- The foreshortened nasal septal frame work must be
advanced as it will oppose
nasal lengthening.
- A forward and downward placement of nasal and
maxillary complex is required to correct midface deficiency.
- The naso lacrimal apparatus must not be disturbed.
- Bone grafts should be used to restore the Bone
deficiencies.
- Skin coverage and nasal lining must be provided to
accommodate the nasal
elongation.
The upper part of this osteotomy done, through a V
shaped incision with the apex at glabella and extended bilaterally
along both sides of nose to reach just above the alar base. The

cartilaginous and bony part of nose is separated and the columella is
pulled down.
Osteotomy begins at lower end of nasal bone directed
medially to the medial wall of orbit than downward to reach the floor
of orbit posterior to naso lacrimal apparatus. Then it is brought to
infra orbital margin medial to the nerve and extended downwards to
the alveolar bone posterior to 1st premolar. Then a posteriorly based
palatal flap is raised and 5/5 are extracted the osteotomy is completed
through the sockets of this dividing hard palate. Now the segment is
mobilised and advanced. This can be fixed by a prefabricated acrylic
splint.
This Procedure:
- Lengthens the nose
- Nasal tip moved anteriorly and downwards.
Advances anterior maxillary segment.
This technique was modified by Psillakis & Co worker 1973 by
taking a transverse osteotomy above the apices of anterior teeth and
augmenting the nasomaxillary segment. This is not biologically sound
so this technique is hardly used nowadays.
Pyramidal Le Fort II osteotomy.( Classical Le Fort II )
This is indicated in Naso maxillary abnormalities such as.
- Binders syndrome
- Crouzon's Syndrome
- Apert's syndrome
- Extreme Cleft palate cases

- Midface deficiency with short nose and class III
Occlusion.
This osteotomy is performed through a coronal incision, a
bilateral lateral nasal incision and an intraoral upper vestibular
incision.
After subperiosteal elevation of flap the lateral aspect of
nasal bone, medial canthal ligament and lacrimal apparatus are
identified. Osteotomy begins just below the frontonasal suture and
extended posteriorly, then downwards anterior to attachment of
canthal ligament.
Then behind or anterior to nasolacrimal opening to reach
the floor of orbit. The osteotomy is brought anteriorly to reach the
infraorbital margin. It is divided at planned position and then
proceed on anterior wall of maxilla, posteroinferiorly to infraorbital
foramen. Now through the intraoral sulcus incision the osteotomy
proceed below the zygomatic buttress as in Le-Fort I Osteotomy. The
procedure is repeated on opposite side of using a curved osteotome
the maxilla is separated from skull base at naso ethmoid region. The
nasal septum is separated using a nasal septal osteotome in a posterior
and downward direction. Now using Row's forceps to maxilla is
rocked and advanced.
Bone grafting are done at the infra orbital region.
Quadrangular Le Fort II Osteotomy
Kufner1971 described an osteotomy which was in essence
a combination of Le fort I and Le Fort II osteotomy. This was modified
by Stoleinga & Brouns in 1996.
The osteotomy starts from upper part of pyriform aperture to
reach the floor of orbit medial to infraorbital foramen. Then another

osteotomy starting from tuberosity extended along the zygomatic
buttress to reach the infra orbital rim lateral to foramen. These are
connected in the floor or orbit. Thus a U shaped osteotomy separates
maxilla without disturbing nasal base. It is indicated in patients with
prominent nose with paranasal deficiency.
After advancing maxilla fixation is done similar to Le Fort I. If
there is severe nasal hypoplasia augmentation of nose is done with
calvarial bone graft and soft tissue augmented by a V-Y procedure.
Stoleinga & Brouns 1996 advocated a modification in which the
osteotomy cut goes around and below the infra orbital foramen to
prevent damage to the nerve.
Le Fort III Osteotomy
This osteotomy more or less follows the classic Le Fort III
fracture line. It is mainly used for advancing deficient midface.
Midface deficiency can affect maxilla, zygoma and nasoethmoid
complex either individually or in various combination. Accordingly
the surgical plane must be altered. Le Fort III is indicated in a
combined maxillary, zygomatic and nasal deficiency. In case of
normal nasal projection and maxillary and zygomatic deficiency a
modified maxillary malar osteotomy is suggested.
The access for Le Fort III osteotomy can be achieved through a
bicoronal incision, Transconjunctival incision, Glabellar, or sub Ciliary
incisions and through an intra oral upper buccal sulcus incisions.
After reflecting a bicroronal flap the fronto nasoethmoidal
region, lateral orbital rims, are exposed. The infraorbital rim and
orbital floor are then exposed through a subciliary incision.

The infratemporal space is exposed by reflecting temporalis
inferiorly. The medial canthal tendon are detached and tucked with
suture.
Osteotomy begins just below the fronto nasal suture and passed
medialy to divide ethmoid bone and through the medial wall of orbit
it enters the orbital floor. The infraorbital neurovascular bundle is
dissected out of bone and osteotomy is continued laterally to reach in
the inferior orbital fissure. Now the lateral orbital wall is exposed
and osteotomy begins at area of deficiency. This is connected to the
anterior end of inferior orbital fissure. Now the pterygomaxillary
junction is exposed through intraoral incision. Using chisel pterygoid
plate is separated from maxilla. This is extended superiorly to inferior
orbital fissure. The nasal septum is separated through the osteotomy
site is the frontal region. The cut passes through perpendicular plate
of ethmoid and vomer. At this level bleeding is less and chance of
damage to olfactory fibres are less.
Mobilisation of maxillary malar complex is now done by using
disimpaction forceps. By gentle rocking movements the segment is
gradually moved to the required position.
Bone grafts are placed at lateral orbital rim and glabellar region
and secured with wires. Onlay grafts are also placed for augmenting
the infraorbital rim, frontal area etc; Medial canthal ligaments are
replaced by non absorbable suture in a figure of 8 manner. Miniplates
are applied at frontozygomatic osteotomy site, the fronto nasal
osteotomy, and between zygomatic arch and zygoma. Before placing
the miniplates inter maxillary fixation is applied in a slightly over
corrected position. After rigid fixation this is removed. The bicoronal
flap is now closed 2-3 suction drains are applied.

Malar maxillary advancement
It is modified Le Fort III osteotomy. It is indicated for
individuals with malar and maxillary deficiency with normal bone
projection. In this the osteotomy begins at medial end of inferior
orbital rim just lateral to lacrimal apparatus. It is connected to
pyriform aperture. Along the floor of orbit, without making injury to
inferior neurovascular bundle the osteotomy proceed to lateral orbital
wall just below the whitnal's tubercle the lateral orbital wall is
divided. Then osteotomy extended lateral orbital wall is divided.
Then osteotomy ex tended lateral to zygomatic eminence in an
oblique manner brought anteriorly to the inferior border root of
zygomatic arch. Now through an incision in posterior aspect of upper
buccal sulcus the lateral wall of sinus and pterygoid plates are divided
as in Le Fort I surgery.
Now through anterior sulcus incision the nasal cavity is
exposed and the nasal septum is detached. This and division of
lateral nasal wall is done as in Le Fort I surgery. Now the segment
can be advanced with forceps, slight over correction is done and
fixation is done at fronto zygomatic and lateral pyriform rim
regions.
Complications of maxillary orthognathic surgeries
Maxillary surgery produces relatively few complications when
the operative procedure is well conceived, carefully planned and
precisely executed. The majority of the problems that do occur result
directly or indirectly from careless and inadequate planning.
Incorrect line of fracture
Incorrect line of fracture usually occurs during pterygomaxillary
disjunction and also during down fracture.

The ideal fracture that separates the pterygoid and the
tuberosity should do without damage to the either parts. Improperly
directed force would result in fracture of superior part of maxillary
sinus, a high horizontal fracture of pterygoid plates or a damage to
pterygoid canal can occur. Directing the force with a small osteotome
from the posterolateral to antromedial aspect would result in a more
predictable cut. If the pterygoid plates is fractured in which
advancement is planned, mechanical support by means of bone
grafting at the pterygomaxillary junction will offset the incorrect
fracture and prevent postoperative relapse.
Hemorrhage:
Bleeding can be a major concern in maxillary surgeries.
During surgery blood vessels most commonly encountered are
greater palatine artery. internal maxillary, nasoethmoidal vessels,
posterior superior alveolar artery and pterygoid venous plexus. It is
generally recommended that hypotensive anaesthesia should be
used for midface osteotomies. Richard Ellis et al 1990 reviewed cases
of life threatening post-operative bleeding after Le Fort I osteotomy.
In most occasions descending palatal artery was the source of
bleeding and in some case the internal maxillary artery. Pressure
packing with a posterior nasal pack, ligation of upper part of
external carotid artery and selective embolisation technique were
used. Closure of tear of nasal mucosa before wound closure will
reduce postoperative epistaxis.
Infection
Increased chance of infection in midface surgery is due
to communication to nasal and oral cavities. Behrman (1972)
reported only 3cases of infection out of 600 maxillary osteotomies. A
double blind study of Eschelman 1986 showed a significant reduction

of infection with antibiotic prophylaxis .Obviously good surgical
technique good closure of soft tissue incisions and maintenance of
good vascular supply will help to minimise the infection McCarthy
and Converse 1972 questioned routine use of antibiotic prophylaxis.
They listed some of the indications for prophylactic antibiotics in
orthognathic surgery.
- An intraoral surgical approach
- Previous irradiation of operative sit
- Use of bone grafts
- Use of alloplastic implants
- Poor oral hygiene
- Patient prone to infection.
Oedema
Excessive oedema is common in midface surgeries. It is
disappointing to the patient. It is due to laxity of subcutaneous
tissue of midface. Shelton and Irby (1980) recommended use of
steroids in initial post operative period. They used dexamethasone
sodium 8-10 mg. 6th hourly, first dose being started at operating
room. This is continued for 48 hourly and following this methyl
prednisolone acetate 80 mg. is given for next 2 days.
Loss of Segment:
Decreased blood flow may lead to loss of segment and
delayed union. This can occur in segmental surgeries. This is due to
improper vascular pedicle and subsequent ischemic necrosis. In case
of retained buccal mucosal pedicle this complication is rare when
compared to total sulcus incision. The damage to palatal mucosa

during palatal bony cut is common cause of this. Use of ill fitting
splints which causes excessive pressure can cause ischaemia.
Avascular necrosis will lead to gingival infection, gingival recession,
loss of alveolar bone, loss of teeth and total loss of segment.
If ischemic necrosis occurs-
- Keep good oral hygiene.
- Prophylactic antibiotics to be given.
- Retain teeth as much as possible. Some bone may
revascularise later..
Epker 1984 recommended the following steps to avoid
ischaemic necrosis
1. Avoid transection of greater palatine vessels.
2. Stretch (as opposed to tear) the soft tissue during
mobilisation of maxilla.
3 Make appropriate palatal soft tissue relaxing incisions
for simultaneous expansion.
4. Consider a vertical vestibular incision in potentially
troublesome cases.
Relapse:
Relapse can occur at various stages of orthognathic
surgery. It can be immediate or short term relapse or long term
(delayed) relapse.
Short term relapse can occur during fixation by I.M.F. If
the fixation of osteotomised segment is not stable and IMF is done
after the fixation of surgical segment this can occur. IMF should be

done before fixing at osteotomy site. Relapse mostly seen with
interosseous wiring. If maxillary walls are very thin the relapse is
more. This should identified at time of surgery and adequate bone
grafts should be placed.
Long term relapse is mainly due to soft tissue traction
mainly seen in advancement cases. Anterior and inferior
advancement showing more relapse, maxillary expansion, if exceeds
more than 6-7 mm, shown high relapse. The Superior placement of
maxilla is reported to be more stable. Among segmental surgery
posterior subapical advancement for closure of posterior openbite
shown excessive relapse tendency.
Will man (1970) studied 106 cases of maxillary Le Fort I
advancement. He found stable results for 3 years - 1 mm posterior
movement noted in first year and the superior movement was 1.8 -
2.8 mm. in first year. More relapse was noted in male patients.
Tessier and Shiter (1982) also reported a similar study. In
his study bone was stable after 1 year, and upper lip lost 44% of its
advanced position.
Carloti and Scheudel (1987) Oaus worth 1984 where
studied the osteotomy site histologically. They showed healing of the
site with impact bone.
Ward Booth, Bhatia and Moose (1984) showed a relapse of
more than 30% in Le-Forte II advancement. In a study normal
patients (without cleft palate) Batton and Moose showed little
evidence of relapse with Le Forte II Advancement.
Nerve injury
The injury to infra orbital nerve is seen in high Le Fort I, Le Fort
II and III osteotomy. Damage to the nerve occurs during manipulation

of incision, bone cutting and anterior repositioning of the maxillary
segment.
Loss of tooth vitality and sensitivity.
Vitality of tooth is maintained by the blood supply where
as sensitivity by the nerve supply. When the blood supply is lost pulp
becomes necrotic and discoloration of tooth and periapical changes
begins. But in cases of loss of nerve supply alone the vascularity is
maintained and tooth will be vital. However some fibrosis and
calcifications will result. Bell et al (1969) in an animal study shown
that if the apical bony cut is done 0.5 cm or above the apex and any of
one flap (palatal lingual or buccal) is retained to the segment both
vitality and sensitivity will be remaining. They demonstrated neural
and vascular plexus connecting this flaps with apical vessels and
nerves. D. Poss Willo (1972) demonstrated progressive loss of
odontoblasts in teeth of osteotomised segment. Banks (1978) in an
animal study demonstrated progressive fibrosis and calcification in
teeth involving osteotomised segment. But these teeth remain vital
even after 52 weeks postoperatively. Pulpal changes also reported by
Hutchinson and McGregor, Kart and Hinds (1971) in 4 years.
Following -up study of 25 patients with segmental osteotomy
reported that 1-15 mm periodontal bone loss occurring in one year
after surgery. Less bone loss is seen in younger individuals.
Maximum retention of flap over segment showed better results.
Perpesack (1973) reported 94-95% of teeth regained
sensitivity after 12 months in maxilla and 72% in mandible.
McArthur and Turvey (1978) reported 2% loss of sensitivity,
Kanberge and Ergstorm (1988) reported loss of sensitivity in 90% teeth
following Le Fort I Osteotomy. After 18 months all of these regained
sensibility.

Mohd El Dep (1984) recommended following precautions
to avoid damage to root and periodontal structures.
1. Avoid multiple segmentalisation if orthodontic alignment
is possible.
2. Avoid segmentalisation if there is in adequate interdental
space.
3. Start interdental osteotomy with bur and finish with
osteotome to reduce
injury to lamina dura.
Oroantral and oronasal fistula
This usually follows a tear in palatal mucosa and in nasal
mucosa. This occurs mainly in maxillary expansion with mid palatal
procedures. Careful soft tissue handling will minimise the
complication . If such a communication does occur, the tissue is
allowed to mature for 6-9 months , during this time defect can be
covered with acrylic splints. Later closure using local flap can be
considered.
Velopharyngeal incompetence
It is a rare complication can occur in patients with
corrected cleft palate. This is caused by excessive anterior traction of
soft palate in maxillary advancements. Pre-operative assessment can
avoid such a problem.
Other rare complications
These include ophthalmic complications, vascular complications
and avulsion of a segment.

Vascular complications.
Ophthalmic Complications
This is a rare complication after Le fort I osteotomy this occurs
mainly during pterygomaxillary disjunction. The ophthalmic
complications of orthognathic surgery may be divided into 3
categories
1. Lacrimal system – Injury to the lacrimal system may lead
to inability to tear or epiphora. The epiphora is usually transient
and is due to surgical oedema.
2. Diplopia – This is due to abducens neuropraxia / paralysis
secondary to propagation of pterygomaxillary disjunction
fracture. The diplopia usually resolves in course of time.
3. Visual loss – This is an extremely rare complication.
CURRENT CONCEPT IN ORTHOGNATHIC SURGERY OF
MAXILLA
Now the principle of distraction osteogenesis have been
used for the advancement of maxilla in midface hypoplasia patients.
After performing the osteotomy the maxillary segment is suspended
to the zygomatic arch based distractor or to a halo frame fixed around
the head. The maxilla is distracted slowly at the rate of 1mm per day.
About 10 to 15 mm advancement is feasible by this process. The
relapse tendency is minimal by this procedure. This distraction
osteogenesis represents the new advances in bone regeneration and
the fourth generation of grafting techniques in craniofacial surgery.
In the study conducted by Hans Peter .M. in Reversing
segmental osteotomies of the upper jaw, mainly on patients which

had undergone upper anterior segmental surgery 6 months to 10 year
back. Most of the these patient came back with remark that they
looked unduly aged because the lower part of the face was dished in.
Author discussed the complications of the reverse osteotomies and in
order to restore the old situation a new treatment plan is to be made.
In the study by M. R. Reinkingh, for the transverse
stability of the Le Fort I Osteotomies a palatal surgical splint is made
of a transpalatal stainless steel bar with acrylic abutment against the
palatal surface of the molar and bicuspid tooth. It is rigid and renders
excellent retention. It causes minimal patient discomfort, and oral
hygiene is hardly compromised.
A study conducted by A. Stewar, A.M. M. Cance, D. R.
James, J.P. Moss on three-dimensional nasal changes following
maxillary advancement in cleft patients. Three dimensional laser
surface, scanning of the face was performed before and after Le Fort I
maxillary advancement in 24 patients with repaired clefts of the lip
and palate. The surgery resulted in advancement of the upper lip and
para-alar tissues and an increase in the relative prominence of the
nose. These changes were produced at the expense of an increase in
nasal width and a reduction in nasal tip protrusion. The changes is
nasal morphology showed significant variation among patients.
In the study conducted by D. Bloomquist, D Baab, Y .B.
Geylikman, J. Artun, B. G. Leroux evaluated the effect of Le Fort I
osteotomy on human gingival and pulpal circulation. The maxillary
blood flow during the first 24 and following Le fort I osteotomy was
evaluated by Laser Doppler flowmetry. Pulpal blood flow was
recorded from two maxillary incisors and gingival blood flow was
assessed from a site slightly apical to the interdental papilla of the
maxillary central incisors of 12 patients receiving Le Fort I osteotomy,
nine control patients receiving mandibular osteotomy, and 10 non

surgical control subjects with out orthodontic appliances.
Measurements were made before surgery and at time intervals
between 0-8, 8-16 and 16-24 hrs after surgery following surgery, men
gingival (but not pulpal) blood flow significantly lower for patients
treated with Le Fort-I osteotomy.

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. Use of
more rectified technique, improvements in instruments especially the
introduction of the fine oscillating and reciprocating saws has enabled
the surgeon to precise. The development of new techniques like
distraction osteogenesis have aided in reducing relapse after an
maxillary advancement and the need for extensive surgery. Repeated
assessment and rectification of the technique are required to improve
the outcome of these aesthetic surgical procedures.

REFERENCES
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16.Maxillary and midface deformity. William H. Bell, William R. Proffit,
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Surgical correction of dentofacial deformities. William H. Bell,
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