MAXILLARY

ORTHOGNATHIC
PROCEDURES & SOFT
TISSUE CHANGES
Part
II

Part I
Introduction
Transverse
Maxillary

Maxillary expansion

osteotomies

- Le Fort I Osteotomy
- Segmental Osteotomies
Anterior Segmental Osteotomy
Posterior Segmental Ostetomy
Soft

tissue changes

Part II
Le

fort II

Le

fort III

Quadrangular
Cleft

osteotomies

osteotomies

Complications

in maxillary procedures
3

Le Fort II Osteotomy
Steinhauser 1980
1.
2.
3.

Anterior L F II Osteotomies
Pyramidal L F II Osteotomies
Quadrangular L F II Osteotomies

1. Anterior Le Fort II osteotomies

Indication - Nasomaxillary hypoplasia
Surgical procedure
Pyramidal nasomaxillary osteotomies

Premaxillary osteotomy
4

Le Fort II Osteotomy

Le Fort II Osteotomy
2. Pyramidal Le Fort II osteotomy
Henderson and Jackson 1973
Indication

Nasomaxillary hypoplasia : 4 types

- Involving dentoalveolar segment
- Excluding dentoalveolar segment
(Binders syndrome)
- Cleft palate patients
- Pan facial problems
6

Le Fort II
Surgical procedure
Intra

oral muco gingival incision

Oblique para nasal incisions
Orbital rim osteotomy continued
downwards and posteriorly
Medial wall osteotomy sparing
the lacrimal sac
Nasal bridge osteotomy
Septal osteotomy
7

Le Fort II Osteotomy
3. Quadrangular Le Fort II
Indications
Similar to quadrangular Le Fort 1
osteotomies.
Patients with significant maxillary
deficiency that includes the infraorbital
rims and zygomas but also who have
normal nasal projection
Surgical Procedure
Similar to Le Fort I

Quadrangular Le fort II

Le Fort III Osteotomy

Sir Harold Gillies 1942
Popularised by Tessier
High level midface osteotomy surgery
Midface anteriorly or inferiorly or both

1.
2.
3.

Indications
Total midface hypoplasia primarily in AP &
vertical dimens
Syndromic synostosis (Aperts, Crouzens
syndrome)
Post traumatic deformity
Timing : When growth is completed

10

Le Fort III Osteotomy

Earlier operation - dislocation of eyes,
corneal exposure, severe functional or
psychological problem
Surgical Procedure
Incisions
1. Coronal flap
2. intra oral degloving incision
3. Infra orbital incision
11

Le Fort III

Osteotomies & Fixation

Zygomatic arch
F-Z region
Inferior orbital fissure
Medial wall of the orbit
Bridge of the nose
Pterygomaxillary dysjunction
Mobilization of the maxilla.
Bone grafting mandatory
Splint fixation.
Fixation at FZ and arch, also at
nasal bridge

12

Le Fort III Osteotomy

13

Modifications of Le Fort III

Simultaneous

Le Fort I Osteotomy

Advantages
Option to correct un equal maxillary
hypoplasia
Possibility of rotational movements
Trans

cranial Le Fort III

Advantages
Option of advancing frontal bone & and mid
face simultaneously.
Hypertelorism can be corrected
- Next slide

14

Le Fort III Osteotomy

Advancement of frontal bone &

ACF

15

Le Fort III
Kufners Modification
of Le Fort III
Indications
Mild to moderate
zygomatico maxillary
hypoplasia with a
normal nose.
16

Porous Poly ethelene implants

17

Quadrangular osteotomies
First described by Obwegeser
Makes use of bone grafts - interpositioning
better esthetics as well as stability
Surgical indications
1. Maxillary zygomatic horizontal
deficiency
2. Class lll skeletal malocclusion
3. Maxillary vertical excess or deficiency
4. Maxillary transverse deficiency
5. Maxillary midline shifts
18

Quadrangular Osteotomies
Surgical procedure
High level Le Fort 1 that incorporates
almost all anterolateral aspects of maxilla
below infraorbital nerve and parts of body
of malar

Extending to the orbital floor

19

Extending to the lateral orbit &

Quadrangular Le fort I

20

Cleft Osteotomies
Traditionally a two stage approach alveolar
bone grafting and fistula closure followed
in 6-12 months by osteotomy
More recently a one stage
approach( Henderson and Jackson and
modified by Posnick)
To revise/correct lip closure
Palatal Fistula correction
Maxillary osteotomy.
21

Cleft Osteotomies
Maxillofacial growth in children
Retruded maxillae and mandible.
Steeper mandibular plane angle.
Maxillary protrusion in un operated
b/l cleft lip and palate.
Transverse deficiency in operated
palate pts.
Generally decreased vertical and
horizontal growth of maxilla.
22

Special problems of cleft

patient

Alveolar clefting.

Oro nasal fistula

Malposed teeth
Mobile individual maxillae
Scarring of the labial vestibule.
Shallow vestibule
Decreased lip length.
Associated congenital anamolies.

23

Basic Principles Of Cleft Orthognathic

Surgery

It is more an art than science

Perfusion of the mobilized maxilla is from the scarred
and fibrotic palatal tissues . Avoid stripping and
perforations
Design of incisions Vertical Vs Circum vestibular
In bilateral cleft patients an anterior buccal pedicle
must be maintained. In this situation visualisation is
reduced and mobilisation is not by down fracturing
but rather in fracturing combined with anterior
traction
Divide the maxilla into as few segments as possible
If transverse expansion is required consider
surgically assisted othodontic palatal expansion 24

Basic Principles Of Cleft

Orthognathic Surgery

Consider horse shoe shaped palatal cut rather

than midpalatal split.
Area of greatest resistance to mobilising the
maxilla is the vertical portion of the palatine bone
in the postero-medial aspect of the maxillary sinus
Greater palatine vessels are bound to tear and
cause hemorrhage during mobilisation
Avoid disimpaction forceps . Use finger pressure.
Throughout watch for ischemic changes in tissues.
If ischemia occurs stop procedure return maxilla to
original place and reverse hypotensive anesthesia
Over correction
Creativity and care
25

Cleft osteotomies in growing

patient

Decrease in vertical, AP and transverse maxillary

growth.
Growth vector can change.
Outcome most predictable following completion of
growth.

Indications for Orthognathic surgery in

growing patients
1. Significant functional deformities
2. Significant aesthetic deformities
3. Psychological problems

26

Bone Grafting
Helps

maintain the position

of the maxilla during
healing( pterygomaxillary
fissure)

Encourages

bony healing
and reduces risk of fibrous
union ( osteotomy site)

Cleft
To

site

contour the mid face

27

Cleft Osteotomies
Timing of surgery
Bone grafting before canine root development.
Similar to the non cleft pts for orthognathic
surgery.
Orthodontics
Dental de compensation
Transverse stability challenging
Banding and brackets to the molars.
28

Unilateral Cleft Osteotomies

Incision design
Tunneling vs
Direct exposure

Osteotomy design
Lefort 1
Lefort 2

29

Unilateral Cleft osteotomies

Occlusal & Palatal views before and after Orthognathic Surgery

30

Unilateral Cleft Osteotomies

Profile views before and after Orthognathic Surgery

LeFort I Osteotomy with Advancement
31

Bilateral Cleft Oteotomies

3-Segment Repositioning Allows for

Oro-nasal Fistula
Closure of
Alveolar Defect
Cleft Dental Gap

32

Osteotomy with reciprocating saw through vomer tooutfracture pre-maxilla

33

Bilateral Cleft Oteotomies

34

Occlusal views before and after Orthognathic Surgery

with Stabilization of maxillary segments

Palatal views before and after Extractions

& Modified Le Fort I (3 segments) with Iliac Graft)

35

Frontal and lateral profile views

Pre and post operative views

36

Complications
Malpositioning

Accurate models
Avoid deviation from the surgical treatment
plan
Position of the mandibular condyles

Bleeding

Hypotensive anesthesia Head position Descending palatine artery Packing 37

Complications
Perfusion deficiencies
Ligation

of D P A
Palatal and posterior soft tissue
Necrosis

Periodontal defects
Attached

gingiva and interdental papilla

Good hygiene and nutrition
Periodontist consultation
38

Complications
Devitalized tooth
Osteotomies

5mm
Endodontic therapy
Follow up

Nerve injury
Anatomy
Neurosensory

changes
Careful retraction
Follow up of the patient
Consider re-exploration ?

39

Complications
Nasolacrimal injuries
Epiphora
Dacryocystorhinostomy

Oronasal and oroantral fistulas

Large

expansion
Intact nasal mucosa
Decongestants, nasal sprays,
antibiotics
Oral hygiene
Surgical closure.

40

Complications
Nasal septal deviation
Pre

op evaluation
Nasolacrimal obstruction
Septal crest
Post op treat as early as possible.

Maxillary sinusitis
Decongestants,
Antihistamines
Antibiotics
Nasal

spray.

41

Complications
Unaesthetic soft tissue changes
Informed

consent
Down turned or unsupported oral
commissures
Excessive impaction should be avoided
Periosteal suturing
V-Y closure

Unfavorable fracture
Osteotomies
Ideal

splitting.
42

Complications
Non union

R I F technique
Occlusion
Eustachian tube dysfunction
Intubation
Palatal muscles
Decongestants, nasal sprays, reassure the
patient
Infection
Antibiotic cover

43

References
Oral

and maxillofacial surgery vol -2

fonseca
Oral and maxillofacial surgery peter ward
booth vol -2
Surgical correction dento facial deformities
Bell,White and proffitt.
Principles of Oral and maxillofacial surgery
L.J.Peterson vol -3
Contemporary views of Oral and maxillofacial
surgery .L.J.Peterson
Surgery of jaws and mouth J.R.Moore
44

Thank you

45