Slide 1

In the name of GOD

Orthognathic Surgery:Maxillary Osteotomies

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Maxillary Osteotomy:Lefort 1 OsteotomyLefort 1 Segmental OsteotomyLefort 3 OsteotomySubcranial Lefort 3 OsteotomyModified (subtotal)Lefort 3 OsteotomyTransverse Maxillary Distraction OsteogenesisMaxillary Osteotomies for Asymetry And Plan Rotation

Lefort 1 Osteotomy

HistoryBased on rene lefort classification-1901

Bernard Von L B- 1859

M Wasamund- 1927

Obwegesser- 1960

Surgical AnatomyBones

Muscels

Vascular Anatomy

Surgical TechniquePatient position

Surgical TechniqueInsicion line

Surgical TechniqueReference pointsInternalExternal

Surgical TechniqueDisection techniquesAnteriorSuperiorInferiorposterior

Surgical Technique

Line of osteotomy

Surgical TechniqueAnterior Rep.Posterior Rep.Impaction -Sup. Rep. Inferior Rep. DowngraftingLess than 3mmMore than 3mm

Surgical TechniqueNasal Septal Osteotomy30 -25 mm from ANSLateral nasal osteotomy

Surgical Technique

Surgical TechniquePeterigomaxillary disjunctionCurved osteotomeOsteotome angleInferior and anteriorDPA= 10 mm

Surgical TechniqueDownfractureSystolic BP= 90MAP=70-75

Surgical TechniqueDisection and corections

disimpaction forcepsRowe Forceps

Surgical Technique

Surgical TechniqueDeletion of bones

Surgical TechniqueExcessive bone removalSegmental instabilityLack of bone contanctExcessive post. ImpactionTelescopic contact

Surgical Technique

Surgical TechniqueCondylar reduction

Surgical TechniqueSeptum preparation

Surgical TechniqueTorbinectomyAcsess: 3-2 cm

Surgical TechniqueOsteosynthesis

Surgical Technique

Surgical Technique

Rules of Fixation

Post Surgical managementElastic theraphy 6-8 weeksSplintsNasal spraySteroidsAnti Biotics

Hierarchy of stabilitystabilityAmount of displacementVertical positionRFBone Grafts

Soft Tissue ChangesOne years

Structures Change:Clomella showNasal tipUpper lipNasolabial angleAlar width

Change factors:

TimeSoft tissue widthWound closuretechnique

ComplicationsBleedingAvascular necrosisSeptum deviationUnunion and gapLigationIscemic changesHemoragecavernous sinus fistulaMaxillary artery pesudoaneurysmMobilization

Maxillary Osteotomy:

Lefort 1 Segmental Osteotomy

History

Indications

Transverse Deficency TreatmentsSARPE- SAME-SARMELefort 1 multisegmentalMandibular narowing OrthodencyOME

DiagnosisLeteral cephOPG

CT***PA

Surgical TechniqueVasoconstrictionsHypotensive GA

Surgical TechniqueIncision

Surgical TechniqueLefort 1 osteotomy

Surgical Technique

Surgical Technique

Surgical TechniqueDownfracture

Surgical TechniqueMocusal reflecting

Surgical TechniqueBone structures

Surgical TechniqueSegmental osteotomy patterns(palatal)

Surgical Technique

Surgical TechniqueSegmental osteotomy patterns(palatal)curve osteotomy- 3 fragements

Surgical TechniqueSegmental osteotomy patterns(palatal)Square osteotomy- 4 fragementss

Surgical TechniqueSegmental osteotomy patterns(palatal)Curve osreotomy not involving Nasal Spine

Surgical Techniquesplints

Surgical TechniqueBone plates and fixationSplint fixation

Postsurgical CareRetainersSmokers

postsurgeryInstaling transpalatal arch without splintObtained expantion

Periparation for surgeryIntermolar distanceRate of expansion

ComplicationsIschemic zoneMarginalGingival necrosis

ComplicationsGum retraction

ComplicationsOsteotomy site

Lefort 3 Osteotomy

Subcranial Lefort 3 OsteotomyModified (subtotal)Lefort 3 Osteotomy

IndicationsOsteotomyNose.orbits.zygomas.maxillaModified version: kufnerCraniofacial disostosisApertCrozunPfeifferSeathre chotzencarpenter

Midface DeficiencyFrontal bossingPetosisDystopy lateral canthalExorbitism-exotropiaMaxillary hypopalsiaMaybe hypertelorismTarnsverse deficiencyC3 malloclusionApertognathiaBeatencooperClefts

TechniqueNasal intubation

Subcranial LF3Coronal incisionLower eyelidIntra oralModifiedIntra oralPeri orbital

TechniqueCoronal incision

Supra orbital rimNasal bonesLateral rimsZygomasInfraorbit

TechniqueTransconjectival incision

Lower subciliary

TechniqueSubcranial L F 3 osteotomyZygomatic osteotomyFrontozygomatic sutures 1cmOrbital floorNazofrontal sutureIntraoral incisionIntraoral disectionPtrygoid osteotomyVomer osteotomyDisimpaction by forcepsLF 1 osteotomy if neededResuspention and forced duction test

TechniqueModified LF 3 osteotomyFrontozygomatic osteotomyMaxillary osteotomyZygomatic osteotomySeptum osteotomyFixation

PostoperativeSteroidsAnti bioticsNG tubeExtubationAvoid nasal packingNasal sprayDietComplicationsDiplopia- amnosia- sensory diorders

Transverse Maxillary Distraction Osteogenesis

Incidence and OriginsIncidence 8 18 %OriginsIatrogenicTraumaticDevelopmental

Diagnosis Alar baseNasolabial foldmaxilla

Clinical EvidensesPosterior crossbiteCrowdingHourglass archDeep palate

Dental or skeletal

Skeletal discerpancyNarrow maxilla- normal mandibleNormal maxilla- wide mandibleNarrow maxilla- wide mandible

Transverse deficiencyMaxillary hypoplasiaMandibular prognatism and sagital deficiencyApertognathieRepaired clefts

RadiographicRocky Mountain Analysis

Maxillomandibular Transverse Differential Index

More than 5mm: surgeryLess than 5mm: orthodecy

OptionsSDESlow Dentoalveolar ExpansionORMEOrthopedic Rapid Maxillary expansionSAMESurgically Assisted Maxillary ExpansionSMOSegmental maxillary Osteotomy

Primary dentition

Mixed Dentition

Adults

Adults

TechniqueSDE

TechniqueORME

TechniqueSAME

AdvantegesStabilityNon exNegative space controlGood breathingNo periodontal complications

IndicationsMore than 5 discerpancyNarrow maxilla and wide mandibleOrthodentic failureMore than 7mm needPerio ComplicationsEstenosisClefts complications

TechniqueDecompensationApplaience instalOsteottomy---pM-nasalmidlinePMActivationSuturing

ComplicationsHemorrhageMaxillary Inadequate disjunctionPainTipingPerioPalatal necrosisRelapseDeviceNecrosisDeformity

ModificationsOlder patientsPalatal Tori surgeryModified incisionPatient with open bite