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*“Lefort I osteotomy has become the work horse
of Orthognathic surgical procedures .Its technical
ease ,its broad application to resolve many
functional and aesthetic problems and the
dependability of its results support this evolution.”
Blood supply, nasal airway problems and sinus
problems*- no adverse consequences
* walker, turvey joms1988
Orthognathic surgery of the maxilla was first described in 1859 by
von langenbeck for the removal of nasopharyngeal polyps.
The first American report of a maxillary osteotomy was by David
Cheever in 1867 for the treatment of complete nasal obstruction
secondary to recurrent epistaxis for which a right hemi maxillary
down fracture was used.
Wasmund in 1927 introduced lefort I or total maxillary osteotomy
technique for correction of skeletal open bite deformity.
Axhausen in 1934 was the first to advance the maxilla at the Le Fort
Separation of the pterygomaxillary junction was advocated by
Schuchardt in 1942
Moore and Ward in 1949 recommended horizontal transection of the
pterygoid plates for the advancement. However, this technique was
abandoned due to incidence of severe bleeding in most cases
• Hugo Obwegesser 1965 advocated complete mobilisation of
maxilla so that maxilla could be repositioned without tension.
• 1969-75 Bell, Lefort I downfracture & formed the BIOLOGICAL
• Bennett & Wolford (1985) described cutts Parallel FH plane to
prevent ramping effect.
• The correct used of curved osteotome described by Turvey and
Fonseca in 1980
• Precious et al described pterygomaxillary dysjunction without the
use of osteotome (1991)
• Use of Swan neck osteotome by cheng ( 1993)
• Use of Saw by cheng (1993)
• Use of Shark Fin osteotome by laster (2002)
• Twist technique by fredricko (2012)
Design soft tissue to maintain adequate
collateral blood supply to the ostetomised
segment and to avoid injury to vital structures.
Provide optimum exposure.
Minimum periosteal stripping.
Gentle soft tissue handling.
Avoid injury to neurovascular bundle.
Make osteotomy cuts under constant irrigation
with normal saline.
Plan interdental osteotomy cuts with out
damaging periodontal status of adjoining teeth.
Studies by Bell and colleagues
In the early 1970s, demonstrated that early osseous union with
minimal osteonecrosis occurred following total maxillary osteotomy,
indicating that the palatal soft tissue pedicle and the labial buccal
gingival provide an adequate nutrient pedicle for single stage
In 1975 provided evidence through micro angiographic studies that
bilateral transection of the descending palatine vessels did not
adversely affect the lefort I osteotomy procedure if basic surgical
principles were followed.
In 1995 continued to investigate the limits of this surgical technique
by performing the lefort I osteotomy using a standard circum
vestibular incision, segmentalizing the maxilla, stretching the
palatal vascular pedicle and transecting the descending palatine
arteries. The result was uncomplicated post operative healing, with
only transient vascular ischemia.
Restoration of blood supply 1 week post operatively-
Dodson -1994 JOMS
1 week –increase in periosteal-endosteal blood supply
2 weeks –vessels connecting segments
4 weeks restores blood circulation in segments
Dodson in 1997 JOMS stated that no statistically significant
differences in mean maxillary GBF between patients having
the DPA ligated and those having the DPA preserved as
measured using LDF during Le Fort I osteotomy in a study of
Indications of Le Fort I
1. Altering the vertical dimension of maxilla
- Superior positioning in long face syndrome
- Inferior positioning.
2. Anteroposterior 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.
4. Surgical expansion of maxilla
5. Narrowing of maxilla.
Outline of treatment
Immediate presurgical planning
• Surgical cephalometric prediction tracing.
• Model surgery
• Splint construction
Orthognathic reconstructive surgery
• Lefort I maxillary advancement or set back
with expansion or superiorly or inferiorly
• Esthetic control of the upper lip & nose
• Step 1. Models mounted.
• Step 2. Models marked
– Vertical reference
– Facial midline
– Horizontal reference
– Palatal reference
• Step 3. The following numerical measurements are made &
recorded on the models:
– Horizontal distance.
– Distance from the max. mounting ring
– Intercanine, interpremolar & molar distances.
• Step 4. The maxillary model is sectioned from its base
at the level previously marked.
• Step 5. Where midline split with widening is planned,
the maxillary cast is separated in the midline by sawing
• step 6. Once maxilla is in the desired location, maxilla is
secured to the base with heavy wax, the location of the
maxillary incisor & 1st molar are rechecked for accuracy
& skeletal movements are recoded.
• Splint reconstruction
Anterior LF II
Pyramidal LF II
Quadrangular LF IILefort III
Malar - Maxillary
1. Positioning of the patient-10 degree head
2. Hypotension GA (90mm/Hg systolic*)
3. Infiltration of the soft tissue with a
vasoconstrictor 2% lidocaine (1;100000)
*Anderson-delibrate hypotensive anesthesia for orthoganthic surgery.adult orthodontic orthognathic surgery 1986;1;133
V-Y closure of a lip incision. A skin hook is
placed in the midline and tissue is gathered for
approximately 1 cm with suture
Effect of the alar cinch technique of the
width of the alar base. Note the
difference after tying the suture.
The surgical splint placed for 6 weeks.
Elastics should be worn for at the time for 6 to 8 weeks.
Non – exertional activity for 6 to 8 weeks.
Hierarchy of stability
Maxillary advancement, posterior and superior movements
are shown to be stable whereas inferior & transverse
movements are unstable.
Quadrangular Le Fort I
• 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. Here the advancement of both the infra orbital rim and
a portion of the zygomatic complex is done.
• 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.
• 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
Surgical Assisted Maxillary
Brown first described SAME in 1938 - midpalatal split
A LeFort I type of osteotomy with a segmental split of the
maxilla and the placement of a triangular unicortical iliac graft
for correction of maxillary constriction was presented by
Steinhauser in 1972.
Skeletal maxillomandibular transverse discrepancy greater than
Significant TMD associated with a narrow maxilla and wide
Failed orthodontic expansion
Necessity for a large amount more than 7mm of expansion
Extremely thin and delicate gingival tissues with buccal gingival
Significant nasal stenosis
Widening of the arch following collapse associated with the cleft
1921 – Cohn Stock.
Transverse palatal incision
Wedge shaped osteotomy green stick fracture retracted
the anterior segment Relapsed within 4 weeks
Various incision designs for desired osseous movements .
*Bell- overall procedure is predictable from standpoint of
dental stability and soft tissue changes.
* Stability and soft tissue changes in anterior part of jaw surgery A J ORDNTCS;1973
Correction of bimaxillary protrusion.
Marked protrusion of the maxillary teeth (normal
incisor axial inclination to alveolar bone)
Anterior open bite
To retract the anterior teeth when that cannot be
accomplished by conventional orthodontic
When orthodontic tooth movement is
inadvisable.(ankylosis, root resorption)
Improvement in appearance.
*Radioactive microsphere techq used assess the blood flow in
AMO in macaque monkeys.
Variation in flap design didn’t affect the postop blood supply to
ant maxillary segment.
This study gives scientific credence to different incisions for
Blood supply can be maintained by-
labial-buccal & palatal tissues ,
labial –buccal tissues alone
palatal tissues alone
*Nelson –quantation of blood flow after AMO in three teq- JOS, 1978;36:108-112
Wunderer technique : 1963
Similar to wassmund, except the palate is
exposed by a transverse palatal incision
with the margins away from the
A buccal vestibular incision is created, allowing
direct access to the anterior lateral maxillary walls,
piriform aperture, nasal floor and septum.
Most commonly used for AMO*
Direct access to the nasal structures
Unhampered access – bone grafting
Ability to remove bone under direct visualization
Preservation of blood supply
Ease of placement of rigid internal fixation.
Posterior Segmental Osteotomy
Kufner (1971) - described a single buccal incision approach.
1. Post maxillary alveolar hyperplasia
2. Total maxillary hyperplasia (when combined with AMO)
3. Distal repositioning of the post maxillary alveolar fragment
to provide space for proper eruption of an impacted canine
or bicuspid tooth
4. Spacing in the dentition that can be closed by ant
repositioning of the posterior segment
5. Transverse excess or deficiency
6. Posterior open bite
7. Posterior cross bite
Combination Anterior & Posterior
Also called Horseshoe 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.
Maxillary alveolar hyperplasia with or without an anterior open bite deformity
Transverse hypolplasia without a vertical component
This procedure creates a three piece maxilla, with the central nasal portion left
undisturbed, through the use of palatal parasagittal osteotomies
1. Incision design & closure
2. Unfavourable osteotomy
- # at the junction of the horizontal process of the
palatine bone with the palatal process of the
- horizontal # of the pterygoid plates
Greater palatine artery
Pterygoid venous plexus
( Panula K, JOMS2001)
Localized pressure packing directed at the bleeding point
Cauterization with either chemical or with diathermy
Ligation of the ECA
Transantral ligation of maxillary artery
4. Improper maxilary repositioning
- failure to seat one or both of the mandibular condyles
during maxillary repositioning will cause improper
maxillary positioning & a malocclusion
- insufficient bone removal
• 20 yrs period – 1000 Le Fort I osteotomies
• Anatomical complication – 26 pt.
– 16- deviation of nasal septum
– 10 non union of osteotomy gap
• Extensive bleeding
– Require transfusion- 11
– Ligation of ECA – 1
• Significant infection – abscess & sinusitis-11
• Ischemic complication -10
• Aseptic necrosis – 2
• Insufficient fixation - 5
• Behrman (1972) reported only 3 cases of infection out of 600
maxillary osteotomies. A double blind study of Eschelman 1986
showed a significant reduction of infection with antibiotic
prophylaxis . They listed some of the indications for prophylactic
antibiotics in orthognathic surgery.
• - An intraoral surgical approach
• - Previous irradiation of operative site
• - Use of bone grafts
• - Use of alloplastic implants
• - Poor oral hygiene
• - Patient prone to infection.
• These complications are related to the degree of vascular compromise and
occur in fewer than 1% of cases. Rupture of the descending palatine artery
(DPA) during surgery, postoperative vascular thrombosis, perforation of
palatal mucosa when splitting the maxilla into segments, or partial stripping of
palatal soft tissues to increase maxillary expansion may impair blood supply
to the maxillary segments. Sequellae of compromised vasculature include
loss of tooth vitality, development of periodontal defects, tooth loss, or loss of
major segments of alveolar bone or the entire maxilla. (Felipe Ladeira Pereira
• The treatment of avascular necrosis of the maxilla is not easily attained.
Although no treatment protocol has been established, aseptic necrosis of the
maxilla should be treated by maintenance of optimal hygiene, antibiotic
therapy to prevent secondary infection, heparinization, and hyperbaric
oxygenation. A recent report described treatment of avascular necrosis of the
maxilla related to a previously performed orthognathic surgery by hyperbaric
oxygenation, bone grafting, and oral rehabilitation by an implant-supported
fixed prostheses, with a successful outcome.( Singh J, BJOMS 2008)
• Maxillary advancement : 5-9% , mean 11%(FU-
• Maxillary superior repositioning – most stable
– Anterior – 0-18% mean – 11%
– Posterior – 7-24% mean – 3%
• Maxillary inferior repositioning
– Anterior – 9-54% mean -28%
– Posterior – 21-167% mean – 70%
• Maxillary expansion : 8-14% mean-11% (FU-
• The incidence of infraorbital nerve neurosensory deficits at 12
months has been reported to be as high as 6% when tested
• During Le Fort osteotomy it is recognized that the nasopalatine
and posterior, middle, and anterior superior alveolar nerves are
completely severed as an intrinsic part of the surgical procedure.
Management of the descending palatine neurovascular bundle is
• Despite ligation and division of the neurovascular bundle, sensory
recovery does occur and is most likely to represent collateral
axonal sprouting from adjacent nerves. (Gary F. Bouloux, Oral
Maxillofacial Surg Clin N Am 2003)
• Epker Stella Fish – Dentofacial Deformities (volume 2).
• Fonseca othognathic surgey – (volume 2)
• The quadrangular osteotomy revisited. Paul J W Stoleinga &
John J A Brouns. Journal of Cranio Maxillofacial surgery. 2000 : 28
: 79 2013; 84.
• Maxillary osteotomies. R. Gunaseelan. Indian journal of Oral &
Maxillofacial surgery. 1998 : VIII : 9 -14.
• Johan P. Reyneke, Oral Maxillofacial Surg Clin N Am 19 (2007)
• Brian A. Vandersea, Oral Maxillofacial Surg Clin N Am 19 (2007)