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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
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