27RevistaATO Osteotomies 2009

8/12/2019 27RevistaATO Osteotomies 2009

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MAXILLARY TOTAL OSTEOTOMIES STUDY LE FORT I

LITERATURE REVIEW642

MAXILLARY TOTAL OSTEOTOMIESSTUDY LE FORT I

LITERATURE REVIEW

ESTUDO DAS OSTEOTOMIAS TOTAISDA MAXILA LE FORT I

REVISTA DA LITERATURA *

Leandro Pttaro ZANON **Cludio Maldonado PASTORI ***

Clvis MARZOLA ****

Joo Lopes TOLEDO FILHO *****

____________________________________________*Monograph presented for conclusion of the Specialization Course in Maxillofacial Surgery and

Traumatology promoted by the APCD Region Bauru** Author of the Monograph for conclusion of the Course and as part of the requirements of

Research and Teaching Methodology Discipline.***Professor of the Specialization Course in Maxillofacial Surgery and Traumatology promoted

by the APCD Region Bauru. Monographs guiding.**** Surgery Titular Professor of FOB-USP and Professor of the Specialization Course in

Maxillofacial Surgery and Traumatology promoted by the APCD Region Bauru.Coordinator of Research and Teaching Methodology Discipline.

*****Anatomy Titular Professor of FOB-USP and professor of the Maxillofacial Surgery and

Traumatology Specialization Course promoted by APCD Region Bauru. Coordinatorof the Residence and Monographs guiding.


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ABSTRACT

The human being, throughout all its existence, has searched for agood conviviality in the community and the environments that surround it. The

advances in the Medicine, Dentistry and Cosmetic provided a better acceptance toit, because the concern of these areas of health beyond offering to its patients thecure of some diseases, also satisfactory aesthetic a improving substantially itsquality, life and social conviviality. The orthognathic surgery modifies themandible maxillary relation, taking it for an adjusted, steady and functional

position, improving many times not only aesthetic and function but the dictiontoo. There was a great evolution of the surgical techniques of osteotomy Le Fort Iduring the years, mainly after the BELL studies on revascularization. However itis extremely important that professionals are absolutely able to accomplish such

procedures, beyond a perfect anatomical knowledge of the region to be operated,because despite being a subject widely studied and reported, as much in the trans-surgical as in the postoperative severe complications can occur, providing greatupheavals to the patient.

RESUMO

O homem ao longo de toda sua existncia tem buscado um bomconvvio na comunidade e nos ambientes que o cercam. Os avanos na medicina,odontologia e cosmtica proporcionaram melhor aceitao, porque estas reas dasade preocupam-se em oferecer aos seus pacientes, alm da cura de determinadasenfermidades, tambm, uma esttica satisfatria, melhorando consideravelmentesua qualidade de vida e convvio social. A Cirurgia ortogntica altera a relaomaxilo-mandibular, levando-a para uma posio adequada, estvel e funcional,melhorando muitas vezes alm da esttica e funo, tambm a dico. Houveuma grande evoluo das tcnicas cirrgicas da osteotomia Le Fort I no decorrerdos anos, principalmente aps os estudos de BELL sobre revascularizao.Porm de fundamental importncia que o profissional esteja totalmente apto arealizar tais procedimentos, alm de um perfeito conhecimento anatmico daregio a ser operada, pois apesar de ser um assunto amplamente estudado eesclarecido, tanto no trans-cirrgico como no ps-operatrio podem ocorrercomplicaes graves, trazendo grandes transtornos ao paciente e ao cirurgio.

Uniterms:Osteotomy, Le Fort I; Orthognathic surgery; Dentofacial deformity.

Unitermos: Osteotomia; Le Fort I; Cirurgia ortogntica; Deformidadedentofacial.

INTRODUTION

Our organism is seen as a complex machine having its function inperfect harmony, always coordinate its activities and functions. When the subjectis face harmony, the Stomatognathic System must be defined as being an

integrated entity for a heterogeneous set of organs and tissues, whose biology andphysiopathology are completely independent and have as function tasks as the


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chew, the deglutition, assisting other mechanisms as phonation and breath yet. Forits correct functioning it is in the dependence of muscular structures, joints,ligaments, nervous propioception, beyond the dental organs (BEHSNILIAN,1974). The problems that influence its functioning, being able until taking its

carrier to develop a sociopathy, are the bad dental occlusions, of multifactorialetiology, anomalies of development of the maxilla and maxillary that also canlead to dental alterations in relation with mandiblemaxillary, being able to causeface asymmetry (REISCHENBACH, 1970 and BELL, 1975).

There are cases that cannot be solved with conservative treatmentsand bloodless and, in these situations, surgical procedure is a more adjusted

behavior. The orthognatic surgery comes with the purpose to correct these facediscrepancies, returning to the patient the function and consequently the esthetic(the MENUCI-NETO; POLISHING; MAZZOLENI et al., 2004).

The maxilla is responsible for a series of bad accented occlusions,of varied etiologies, and when the orthodontic treatment cannot decide, the

surgery is the fastest and safe way that patients find to correct such deformities(MENUCI-NETO; POLIDO; MAZZOLENI et al., 2004).

In the absence of notable unproportional, many techniques can belaunched allowing the surgical repositioning of dental groups or total replacementof the maxilla. These techniques vary since unitary and series corticotomy,

previous, posterior, until the totals osteotomies of the maxilla to correct badocclusion and the dentofacial deformities (KOLE, 1959 e MOHNAC, 1966).

It is important that surgeon is familiar to the anatomy of the region,for being an area highly vascularized with diverse important structures that must

be studied minutely (MENUCI-NETO; POLISHING; MAZZOLENI et al.,2004). Even with the great development in the instrument and the surgicaltechnique, the risk of injuries to important anatomical structures in the posteriorregion of the maxilla still exists, having been one of the most relatedcomplications in the use of this technique (BELL, 1992 e ARAJO, 1999).

Lamentably, the surgical correction of the maxilla is still not veryfrequent and, probably for the lack of indication on the part of the orthodontistswithout an ideal formation, its great complexity, or the fear of some surgeons inreaching teeth, beyond the possible complications with the maxillary sinus, nasalcavity and pterygomaxillary regions (MENUCI-NETO; POLIDO;MAZZOLENI et al., 2004). Although the cut of the maxilla can result in atemporary loss of reply to the pulpal vitality tests, normally the sensitivity of the

tooth is not destroyed, when treated with the necessary care (KOLE, 1959 eSCHUCHARDT, 1959).The clinical success and the occasional imperfections in the use of

the several techniques had remained little divulged until the decade of 70. Thebasic questions were concerned to the cure of surgical wounds of the osteotomiesof the maxilla and, of the sanguine vases that would keep its suppliment to the

bony segment, beyond the viability, keeping complete the teeth in the arches(BELL, 1992 e ARAJO, 1999).

The use of the osteotomy of the type Le Fort I grew very much inthe last two decades due to works of bony microcirculation (BELL, 1969)demonstrating the possibility of mobilizing the maxilla tridimensionality without

compromising the vascularization and the bony repairing (MENUCI-NETO;POLIDO; MAZZOLENI et al., 2004).


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Another point that must be observed is its potential to solution ofsome cases of temporomandibular dysfunction (DTM), therefore is possible, forcases where the cause will be skeletal, its repositioning promoting a stimulation tothe functional matrix for rearranging the rearrange the skeletal-muscle ratio and,

for stimulating the remodeling (CORTEZZI, 1996).There are several indications for total osteotomy of the maxilla isemphasizing those patients carriers vertical excess, when they display excessivelythe superior incisors and gengiva, beyond the labial incompetence, narrow nose,open bite and elongation of the lower third of the face. These factors can or not

be added or to be presented separately. In patients with previous open bite, whohave premature contact of posterior teeth, the orthognatic surgery will raise the

posterior position of the maxilla, being promoted a correct occlusion, afterremoval of the posterior premature contact, beyond raising the previous region,improving the gengiva exposition and of previous teeth (PETERSON, 2000).

It has two main indications for the surgical replacement of the

maxilla, when the previous teeth excessively are displayed and when exists thedeformity of the open bite with posterior alveolar hyperplasia, determining adisharmony between superior lip and the teeth (EPKER, 1981).

The horizontal excess of the maxilla, revealed with unilateral orbilateral crossbite, normally is associated with a vertical deficiency of the maxilla.Thus, it is noticed the distance between the nasal floor and the apex of maxillaryteeth indicating the transantral osteotomy that will be able to injure the rootapexes, frequently located to the level of the nasal floor (BELL;ALESSANDRA; CANDIT, 1968).

Another indication is for patients who carriers anteroposteriorexcess, presenting face with convex profile and, always associated with the

protrusion of the incisors. Patient with transversal excess has also indication forexecution of the technique, having ogival palate, nip of the posterior arc and

posterior crossbite (PETERSON, 2000).It can also be cited as indications those patients Class I of Angle

with posterior crossbite, vertical excess to maxilla and open bite; class II of Anglewith vertical excess to maxilla, previous open bite and, Class III of Angle withmaxilla prognatism, maxilla deficiency, open bite, beyond complex deformities ofthe third medium of the face (EPKER; STELLA; FISH, 1995).

DEVELOPMENT OF THE MAXILLA AND

ANATOMICAL CONSIDERATIONS

During the immediate after-birth development, the palatines bonescan freely move in relation to the maxilla and the pterygoid process of thesphenoid bone. During the growth process, from infancy for the adolescence, the

bones articulated surfaces consist of medullar bone and, the remodeling occursmainly in the medial portion of the suture between the maxilla, the palatal boneand the process pterygoid. The adolescence (between 16 and 18 years of age) isassociated with formations of small bone-bridges (sinostosis), which becomesharper in all the sutures (MELSEN, 1987).

The pyramidal process of the palatal bone is located between thetuberous maxilla and the pterygoid process, acting as a drain plug between thedifferent standards of growth of these two bones. An osteotomy of the type Le


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Fort I realized in a child is complicated because of the development of the molar,as well as for the growth of the maxilla complex. The pterygomaxillaryseparation in this period could cause damage to important tissues for the growthof the region. The suture prevents the separation of the bones due external forces,

at the same time it would allow the movement occurrence between some bonesduring the growth. If the suture growth is breached, the only immediate growthwill be of the alveolar process, with the dental burst. (HERFORD;THARANON; FINN, 2001).

In adolescents with less than 16-18 years, the pyramidal process ofthe palatal bone has not been casting with the tuberous of the maxilla and the

pterygoid process of the sphenoid bone. In such a way, osteotomies carriedthrough at this moment could intervene with the future face growth. Theadjournment of the surgery until the bones are casted and the separation can bereached by breaking, using an osteotomous. (WIKKELING,KOPPENDRAAIER, 1973).

However, in studies involving 16 patients with age between 10 and16 years submitted to the surgery with total osteotomy of the maxillary to correctface deformities, evidenced that it is possible the new position of the maxillary in

patients who find in growth phase, being favorable for the normal growth of theface (WASHBURN; SCHENDEL; EPKER, 1982).

MAXILLA

The maxillary is a pair, symmetrical bone, formed with theopposite side of a boned complex called superior faced skeleton. (Fig. 1).

Fig. 1 Anatomical aspect of the maxillary boneFont: SOBOTTA, J.Atlas de Anatomia Humana.2000.


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This set becomes related, internally, with nasal cavities andinferiorly with the buccal cavity. By posterior side, it is limited apophysises

pterygopalatine concurring to form pterygopalatines cavity. Superiorly itcompletes the orbital cavity, constituting its inferior walls (SICHER;

TANDLER, 1981).

MAXILLARY SINUS

The maxillary sinus has a clearly pyramidal form, of quadrangularbase (Fig. 2). It has average height of 3,5 cm, width of 2,5 cm and depth of 3,0cm. However these dimensions can vary inside of very ample limits, being foundsmall maxillaries sinus in contraposition to those of superior dimensions. Thediversity of dimensions has great doctor-surgical importance, mainlyodontological, which had to the relations between the radicular apexes of thetooths, daily pay-molar and molar (SICHER; TANDLER, 1981).

Fig. 2 Maxillary sinus, anatomical structure of fundamental importance, for directly beingreached by the osteotomy.

Font: SOBOTTA, J.Atlas de Anatomia Humana.2000.

HARD PALATE

It constitutes the superior wall of the buccal cavity being formed inits previous third part of the palatine vault and in its posterior third of the palateveil. The palatine vault is composed in three layers, the bone, to glandular andmucosa. The bone layer is constituted by the palatine processes of maxillary andhorizontal blades of the palatines bones. The palatine foramen confide in theangles postero-laterals of these horizontal blades and, the incisive foramen in the

previous region behind the incisors central offices (Fig. 3) (SICHER;TANDLER, 1981).


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SOFT PALATEIt does not present bone part, being constituted of muscle-

membrane, where insert itself some important muscles (Fig.3) (SICHER;TANDLER, 1981).

Fig. 3 Anatomical aspect of the hard palate and soft palate.Font: SOBOTTA, J.Atlas de Anatomia Humana.2000.

VOMER

Vmer possess two faces and four edges. The right and left facesare re-covered by the nasal mucosa with some ridges for vases and nerves. Theinferior edge is lodged in the groove formed by the two palatine bones and twomaxillaries, by superior side, it contacts the sphenoid crest, later forms the

posterior edge, exempts of nasal septum and, its more prolongated previousportion is articulated superiorly with the perpendicular ethmoid blade and,inferiorly, with the cartilage of nasal septum (Fig. 4) (CASTRO, 1976).

Fig. 4. Nasal cavity and Vmer bone, becoming related with the maxillary, suture that will beuntied in the trans-surgical to carry through the movements necessary re-positioning ofthe maxillary. The set of the Ethmoide, Sphenoid and Vmer bones forms the nasalcavity



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NASAL CAVITY

The nasal cavity is the beginning of the respiratory treatment andwhere it locates the organs of the sense of smell, being intercalated with the brain

case cavity above, verbal cavity below and the orbital cavity laterally. In itsprevious portion it is communicated posteriorly with the external way for thenostrils and for the choana. It is divided in two for vomer and the perpendicular

blade of ethmoide. It is limited superiorly with the crivous blade and posteriorlywith the forebody of the sphenoid body. For its edge antero-superior the

perpendicular blade of ethmoide is articulated with the nasal spine of the frontaland, more inferiorly with the internal face of the suture joining the two nasal

bones (Fig. 4) (CASTRO, 1976).

ARTERIES

The arteries which irrigate the maxillary are branches of themaxillary artery which are branches of the external carotid artery. The infra-orbital artery irrigating the soft deep parts of the previous surface of the maxillaryand, anatomizing with the branches of the face artery (Fig. 5).

Fig. 5 Passage of the arteries in the face with basic importance due to the risk of hemorrhage inthe trans-surgical, with prominence for the Maxillary artery and descending Palatineartery.


Through the passage of the infra-orbital artery by the canal whichhas the same name the previous superior alveolar artery can be detached followingfor the fine small canals excavated in the maxilla and, joining itself with the

branches of the posterior superior alveolar artery that run for the posterior face ofthe maxillary tuberous. The superior alveolar artery originates in its passageantral branches, pulpal and bone. The anastomotic net of the alveolus-dental


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space exactly assures sanguine suppliment to the periodontal region when itoccurs the necessity of making an apicoplasty, pulpectomy or another surgicalmaneuver in which the apical vasculonervous beam is extinguished(LASCALLA; MOUSSALLI, 1980).

The sanguine suppliment of superior teeth and support tissueswould be proceeding from the arterial branches alveolar superiors and palatinesvases. In studies of the periodontal vascularization in Rhesus monkey, they showthat, in the neighboring region to the epithelial tack, it has numerous balledcapillaries forming a vascular crown (BELL, 1969). Probably the pressuregenerated for the circulating liquid, in this dense hair net, would be one of thefactors in the maintenance of the epithelial tack (LASCALLA; MOUSSALLI,1980).

In the palatine vault, the arteries proceed from the esphenopalatineartery, in previous region and from superior palatine arteries in the posteriorregion. The final branches of maxillary artery are palatine descendent artery and

esphenopalatine (main artery of nasal cavity). The bigger palatine artery comes topalate through bigger palatine foramens and its branches irrigate the soft palateand palatine tonsil, supplying bunches which irrigate the palatine mucosa too. Inits terminal branch, the nasopalatine artery penetrates in nasal cavity for theincisive canal (FVERO, 1986).

VEINS

The maxillary region veins walk together with arteries, however inthe contrary direction, directing for pterygoid plexus and later to maxillary vein,

retromandibular and external jugular veins. (Fig. 6) (FVERO, 1986).

Fig. 6 Passage of the sanguineous return for the veins, with prominence for the Pterygoid Plexus,

responsible for great part of the hemorrhagic complications during the release of thePterygoid Process of the Maxillary.Font: SOBOTTA, J.Atlas de Anatomia Humana.2000.


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NERVES

The maxillary division of the triplet nerve has absolutely a sensitivefunction. It penetrates for pterygopalatine cavity after leaving cranium cavity,

covering this space and sending ramifications for the esphenopalatine ganglion,posterior superior alveolar nerve and the zygomatic branch. The division tomaxillary transmits sensitive impulses of the skin on the forebody of the secularregion, of the zygomatic bulk, the inferior eyelid, the lateral portions of the noseand the superior lip, superior teeth and gengiva in the same region. It alsosensitizes great part of the mucosa of the nasal cavity, hard palate and soft palate,

parts of the tonsil region and the pharynx region. (SICHER; TANDLER, 1981).In its passage, from the semilunar ganglion, the maxillary division of the tripletcovers four regions, medium cranium cavity pterygopalatine, the infra-orbitalcanal and the face (branches terminals). The biggest interest of the surgeon whowill carry through the osteotomy Le Fort I mentions the three last regions to it

(FVERO, 1986).The infraorbital Nerve originates the superior alveolar nerves

during its passage in the infraorbital canal. The posterior superior alveolar nervenerves the vestibular gengiva and the molar; the alveolar superior medium nervenerves the daily pay-molar region and, finally, the previous branch nerves

previous of nasal cavity , superior previous teeth and gengiva portion. Theinfraorbital nerve emerges for the infraorbital foramen dividing in three branchesterminals, the inferior eyelids nerves nerving the inferior eyelid, the external andlateral nasal nerves, that tends to the skin for nasal region and those that they emitsensitivity to the superior lip (Fig. 7) (FVERO, 1986).

Fig. 7 Face nerving, with prominence to maxillary division of the triplet, which has biggerinterest for the surgeon who will carry out the Le Fort I osteotomy.Font: SOBOTTA, J.Atlas de Anatomia Humana.2000.


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LE FORT I OSTEOTOMYEVOLUTION OF THE TECHNIQUE

VON LANGENBECH in 1859 was the first author to describe the

maxillary osteotomy, being, initially modified by WASSMUND eSCHUCHARDT and latter by WEST e EPKER, beyond other alterations inelapsing of the time (FVERO, 1986).

The first techniques developed for the Le Fort I osteotomies did notseparate the maxillary of the plateaus pterygoid, requiring postoperative elastictraction for its separation. But from years 30 AXHAUSENe SCHUCHARDTrecommended the pterigomaxillary separation and the technique comes beingused since then with few modifications (MENUCI-NETO; POLIDO;MAZZOLENI et al., 2004).

AXHAUSEN (1934)used the method to correct badly consolidatedmaxillary fractures by using hard palate division.

One of the first interventions Le Fort I was made by WASSMUND(1935), when he described the osteotomy realized in 1927, being effected bymeans of pillars canine and zygomatic and the partial section of the sidewall ofthe cavity and nasal septum (ARAJO, 1999). BELL; FONSECA; KENNEDYet al., (1975), demonstrated that the total osteotomy of the maxilla could becarried through without it had greaters damages to the sanguineous of region,

preserving pedicles of soft tissue suppliment in the palate regions and maxilla.The total osteotomy of the maxillary was developed in two surgical

times (KOLE, 1959). A similar procedure was told, however with the surgery inonly one surgical time (PAUL, 1969). Another procedure following the same

technique to re-position a breaking to maxillary consolidated (MOHNAC, 1967).Modification was told in Le Fort I cases to the correction of thecongenital or acquired deficiencies in the third average of the face as for use ofRowe forceps for maxillary desimpaction (WESSBERG; SCHENDEL;EPKER, 1982).

From years 70 there were a great evolution on dentofacialdeformities treatment a time that Le Fort I osteotomy allows to theaccomplishment of almost all the movements, respecting the limitations of eachcase. Transverse anomalies, anteroposterior and vertical of the maxillary can besolved using this technique. It has also indications for jib or advance of themaxilla, beyond the increase or reduction of the vertical (GRAZIANI, 1986).

This technique is executed working with the maxilla in an onlyblock, after the separation of nasal septum, the medial and lateral walls of themaxillary sinus, beyond the pterygoid process. Thus, the maxilla couldcompletely be put into motion in some directions. It has some specific casesdespite the maxilla can be broken in lesser segments allowing more movements(GRAZIANI, 1986 e S JNIOR, 2001).

The techniques had suffered modifications in elapsing of the years,aiming to supply the necessities of each case. In the sequence the present workshows initially described techniques and, also those praised in the present time.

SURGICAL TECHNIQUE1. QUADRANGULAR LE FORT I OSTEOTOMY


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OBWEGESSER (1969)

It is indicated to horizontal deficiency patients,zygomaticmaxillary, with an exacerbated nasal projection. The incision is made

approximately 4 mm above of the junction mucus gengiva until the height of thedaily pay-molar. Previous portion of the maxilla is exposed and later dissects the

periosteum until the bilateral posterior tuberous and infraorbital foramen (as wellas it is made for accomplishment of Le Fort II osteotomy). The infra-orbital nerveis completely isolated. It is necessary to take very well-taken care to do not violatethe periorbital or the infraorbital nerve. The mucosa of the sidewall of the nose israised to display a bigger portion of the maxilla. It is important to keep theintegrity of the nasal mucosa, especially in patients in which a surgical significantwidening is carried through. At this moment, gristly septum and Vmer areseparate of the median line of the palate for curette previously and, with chisellater. The lateral nasal wall and the posterior portion of the nasal floor aredisplayed by a under periosteum dissection and frequent turbinectomy is carriedthrough, where the posterior nasal spine will be displayed and afterdownfracture is situated the palatine artery.

For the accomplishment of the osteotomy oscillatory movementswith the mountain range from the pear-shaped opening to the level of theinfraorbital nerve are made extending laterally, above of the infraorbital foramen,until tuberous-pterygoid region in the posterior region. An inferior step in theosteotomy is frequent necessary in the previous edge of the maxillary

proeminence. Due to raised position, the posterior osteotomy may need to becarried through with chisel.

Downfracture with digital pressure or forceps is effected,depending on the case. The intermaxillary blockade is carried through and themaxilla reposition in the planned place after the removal of possible interferences(Fig. 8).

Fig. 8 Localization of the quadrangular osteotomy.Font: BELL, W. H.Modern practice in orthognathic and reconstructive surgery. 1992.


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2. LE FORT I HIGH OSTEOTOMYKUFNER (1971)

When the nasofrontal projection and the position of the ocular

globe are abnormal, main aesthetic components to be addressed are the maxillo-mandibular unproportion, the zygomatic bone and the infra-orbital region.Although a combination of the Le Fort I osteotomy and auxiliary procedures wasused frequently to correct these deformities, the ideal would be an osteotomy thatobtained to brighten up these deformities by itself. Due to the fact of the aestheticepicenter of the zygomatic bone be placed approximately 2 cm laterally and 1,5cm inferiorly to lateral corner of the eye, the horizontal and posterior extension ofthis osteotomy in zygoma must be posteriorly and superiorly located in relation tothis area. The previous horizontal portion of this osteotomy must be situatedsuperiorly enough to include the paranasal parcel of the maxillary bone. Thehorizontal osteotomy, initiating in the maxillary bone is extended for posterior inthe zygomatic arc, below of zygomatictextemporaneous suture e, approximatelythe 6 to 10 millimeters of the previous region of the zygomatic arc. The superiorand posterior extension of this technique will not only supply an aesthetic base,

but it will also make that it has a good stability and setting for the fact of zygomato be a dense bone (Fig. 9).

Fig. 9 - A.Localization of Le Fort I high osteotomy. B. Maxillary re-position and settled withplate and screw. C.Frontal aspect after the setting.Font: BELL, W. H.Modern practice in orthognathic and reconstructive surgery. 1992.

3. TRADICIONAL LE FORT I OSTEOTOMYBELL (1975)

Through this technique is possible to reduce the face height, theexposition of incisive teeth and the interlabial space, putting the maxilla intomotion for a class I occlusion. In the execution of this technique, adds that thehorizontal excess of the maxilla revealed with one-sided or bilateral crossbite, in a

classified way is associated with a vertical deficiency of the maxillary bone. Thusit is observed that there is an approach of the nasal floor and the dental apexes of


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the maxillary bone, contraindicating transantral osteotomy, therefore it will beable to injure the apexes of the teeth that frequently are located to the level of thenasal floor (Fig. 10).

The horizontal incision is made through the mucoperiosteum of the

vestibule of the maxillary, above of the mucogengival fold and the second molaruntil the correspondent of the opposing side. In horizontal previous osteotomiesand vertical posterior, the reference lines are marked in the sidewall of themaxillary bone with spherical drills of fine bore. With a retractor placed to

protect the nasal mucoperiosteum in the horizontal section of the bone for thesidewall of the maxilla of pear-shaped opening and later until the fiction to

pterigomaxillary. Previously the horizontal bone cut is lead through the sidewallsand medial of the maxilla. The medial floor of the maxillary sinus is parted aboveof the palate roots and nasal floor through an osteotomy of the buccal side. The

posterior portion of the antral wall is parted with deliberated beaten withosteotomous.

Fig. 10 Frontal aspect, after accomplishment of the osteotomy in the sidewall and medial of themaxilla.

Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacialdeformities. 1980.

The posterior wall of the maxillary sinus is separate using a chisel,as well as nasal septum, moving away the superior portion from the maxillary

bone with chisel. The maxilla is separated of the apophysis pterygoid with onearched chisel directed medial and previously, later it is broken underneath with a

mucoperiosteum separated of the nasal side of the maxillary bone in the horizontalplan and of the palatal bone (Fig. 11).


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Fig. 11 Lateral aspect showing the separation of the pterygoid process with an arched cinzel.Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial

deformities. 1980.

The vertical dimension nasal lateral and posterior walls of the sinusare reduced with a bone drill. Later, the mucoperiosteum is separated of nasalseptum, the height of septum is reduced, facilitating the superior movement of themaxillary bone. After putting into motion the superior plan of the maxillary bone,a rabbet is made in the floor of nasal cavity to accomodate the septum. The heightof septum nasal is reduced to facilitate the repositioning of the floor of nasal

cavity without folding septum. The maxillary bone is fixed, an interdentalblockade is made with wire between the interdental bars or orthodontic devices.The mucosa will be re-positioned and sutured with continuous points.

4. LE FORT I OSTEOTOMY IN STEPSBENNET E WOLFORD (1985)

In an effort to improve the exactness and the previsibility of thesurgery of advance of the maxillary bone and to eliminate the effect of slope ofthe traditional osteotomy, the technique in step form was presented. In this

technique, the lateral maxillary osteotomy is made parallel to the horizontal ornatural plan of Frankfurt. It is initiated in the high of the zygomatic pillar where a


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vertical stage is made. The horizontal osteotomy is continued later until thepterygoid process, parallel to the previous. It is important to keep parallel theprevious and posterior osteotomies to minimize interferences during the re-positioning to maxillary (Fig.12).

Fig. 12 - A.Localization of the osteotomy in step, detaching to be parallel to the plan of Frankfurt.B.Movement already carried through and settled with plates and screws.C. Osteotomyin step carried through more superiorly.

Font: BELL, W. H.Modern practice in orthognathic and reconstructive surgery. 1992.

5. LE FORT I OSTEOTOMY ON RAMPREYNEKE E MOSUREIK (1985)

The technique in slope is a variation of the high Le Fort I.Patients with vertical and anteroposterior deficiency are liable to

the application of this technique. When the deficiency to anteroposteriormaxillary bone is associated with the deficiency to vertical maxillary bone, thesurgical planning must include the advance to maxillary bone, beyond thecorrection of the vertical discrepancy (Fig.13).

In some cases, both corrections can be obtained by the descending

sliding movement and for front of the maxillary bone. The osteotomy of thesidewall of the maxillary bone will have to be individualized for each case, that is,the inclination of the incision must vary depending on what will be necessary toget in vertical dimension.

The length of the edge of the pear-shaped opening to the lateralportion of zygoma is measured through the lateral telerradiografies. From thismeasure the descending angular inclination of the osteotomy and the position ofthe vertical incision are calculated.

In the previous region, angled cut is extended of the lateral portionof zygoma to the inferior portion of the pear-shaped opening. Later, theosteotomy is directed 45 degrees vertically, of the lateral portion of zygoma, indirection to the pear-shaped opening. In more severe cases of vertical discrepancygraft can be carried through interpositional.


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Fig. 13 A.Angle of the osteotomy, in which it will vary depending on the vertical dimensionthat the surgeon needs for the case. B.Interpositional graft used for more severe cases.

Font:BELL, W. H.Modern practice in orthognathic and reconstructive surgery. 1992.

6. TECHNIQUE RECOMMENDED BY KRUGER (1984)It is become fulfilled incision 2 mm above of the mucosa that they

form deep of ridge leaving from the region of the molar, through the median lineuntil the opposing side of the same region, mucoperiosteum detachment in thesuperior direction, being displayed the process of the maxilla and the pear-shapedopening zygomatic

It carries through osteotomy with fiction drill since the zygomaticprocess of the maxilla, in previous direction, until a point approximately 1 cmabove of the floor of the nasal cavity continuously for the opposing side. The

pterygoid blades are broken in the posterior position of the short maxilla by means

of one chisel of Obwegesser. The cartilage of nasal septum and the insertions ofVmer are separate of the maxilla by means of a thin chisel. It must be taken careto protect the nasopharynx region with a finger, because of the possibility of

perforation of the nasotracheal pipe. The sidewall of the nasal cavity is parted inan inferior level to the insertion of inferior cornet by means of thin chisel.

The maxilla can be set free of its remaining linkings for any one ofthe methods, through forceps of Rowe, arched chisels or inserted instruments ofTessier inserted subsequent to the maxillaries tuberous breaking them for release.In some cases the maxilla can total be set free, placing a gauze compress on teethand manipulating the segment in all the directions by manual pressure.

Finally the maxilla is placed in its planned position in the dailypreoperative using intermaxillary elastics to be kept this occlusion. The incisionsare closed with horizontal continuous suture.


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7. TECHNIQUE RECOMMENDED BY PEDERSEN MODIFIEDBY OBWEGESSER (1972)

Obwegesser says there are two anatomical situations that must be

considerate retromaxilla that is a condition in which the maxilla is situatedmuch in the back in relation to the base of the skull and the micromaxilla wherethe maxillary bone is very small in relation to the maxilla.

The surgical technique advocates incision extending itselfcircumferentially from the distal surface of the second molars bilaterally from themucogengival junction. Incisions of relief of 1 cm of length can be carriedthrough in the distal portions right and left of the primary circumferential incision.The mucoperiosteum is struck displaying the total sidewall of the maxilla until thezygomatic christians, displaying infra-orbital foramens, previously and the third

part of infero-lateral of the pear-shaped opening.It becomes fulfilled osteotomies with drill horizontally binding to

the cracks pterigomaxillary with the lateral edges of the pear-shaped opening.The pterygoid plateaus are separate of the tuberous maxillaries with one archedosteotomous. Nasal septum and Vmer are divided of the superior part of themaxilla and of the palatine bones with osteotomous. After the nasal mucosa isstruck of the sidewalls, and these are parted below of cornet inferior with drills.The maxilla then is mobilized with manual and placed pressure in its new

position. It is used continuous horizontal suture to close the incision.

8. TECHNIQUE RECOMMENDED BY KAMINISH (1983)

The technique consists of extending the superior bone cut of thepear-shaped opening until the portion of the zygomatic arc, with high cut and aftergoing down until the apophysis pterygoid for the lateral of the maxilla. Theauthor firms that such procedure has greater stability of the segment after it has

been repositioned. (KAMINISH; DAVIS; HOCHWALD et al.,1983).

9. TECHNIQUE RECOMMENDED BY MANGANELLO-SOUZA (1998)

It makes an incision in the background of ridge initial of maxilla,about 2 mm above of the inserted gengiva, from the second superior molar of oneside until it reaches the opposing second superior molar. Then disjoins theremnant mucoperiosteum until displaying the zygomatic pillars, canine cavitiesand the pear-shaped opening. In this phase, a bilateral soaked of is proceededfrom the posterior region of the maxilla in direction to pterigomaxillary cavity,forming a tunnel from where an arched chisel will be introduced later. By usingdrills or saw it is promoted osteotomy of the initial board of the maxilla. The useof chisel in this region can lead to the breaking of the previous wall of themaxillary sinus. The landmark must be made about 3 5 mm above of the dentalroots using as reference the tooth. Complete it previous osteotomy of the maxillawith a thin chisel of region of zygomatic pillar, canine cavity and pear-shaped

opening bilaterally. Then the cut is extended in the posterior region until it findsthe pterygoid process of the sphenoid bone.


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The osteotomy of the background region is made with an archedchisel adapted in the pterigomaxillary cavity. To separate bilaterally the maxillaand the pterygoid it must be taken a so special care with the palatine artery and thevases of venous plexus pterygoid, keeping the posterior and the anterior

osteotomy at the same level, they must never be in the up of it. The surgeon mustpreviously introduce a chisel for vestibular contest through unglued tunnel e, withthe other hand palpated for palatal the junction to pterigomaxillary, preventing assoon as chisel exceeds the palatine mucosa.

After the initial osteotomy and of the pterygoid blades, disjoins thenasal floor through the pear-shaped opening, preventing to breach the nasalmucosa that will provoke undesirable bleed. After the exposition of nasal septumand nasal floor, with one chisel straight cuts medial wall to it of the maxilla andnasal septum, breaking up to all the maxilla. For this, can be used forceps ofRowe or traction by means of hooks aparters in the pear-shaped region.

10. TECHNIQUE RECOMMENDED BY S JNIOR (2001)

This technique must be initiated with a deep incision in of vestibulemaxillary bone bilaterally extending itself until the first molar region. It will nothave to be extended beyond the first molar, with intention to prevent deficiency inthe irrigation of the maxilla. Made the incision correctly, all the mucoperiosteumthat recovers the previous, lateral walls from the maxilla until the posterior

portion and nasal mucosa must be moved away with a periosteums aparter.Initiating the osteotomy of the sidewall of the maxilla, it must be

extended of the pear-shaped opening until the zygomatic pillar, being able to be

used a rotatory instrument with a 702 carbide drill or a reciprocate saw. In theposterior sidewall it can be effected with a thin osteotomous of the type spatula.For the separation of nasal septum is used an osteotomous which

contain guides and, the junction of the tuberous of the maxilla with the pterygoidprocess with arched osteotomous e, finally after the execution of all theseprocesses, becomes fulfilled downfracture, thus locating the maxilla in thedesired position as the planned in the daily pay-operatory.

REVASCULARIZATION OF THE MAXILLA

The sanguine suppliment of the face is profuse, with an abundant

collateral circulation. The main suppliment is through branches of the externalcarotid arteries (Fig. 14) (GERHARDT DE OLIVEIRA, 1998). In the previousregion, it is irrigated mainly by the apical vases, labial artery, and periodontal

palatal and gengiva plexus (Fig.15)(BELL, 1975).It has been made a study about revascularization and bony

correction post total osteotomy of the maxilla realized in 12 Rhesus monkeys and,three of them had its palatine arteries intentionally connected. After sacrifice ofthe animals was carried through a microangiografic examination in differentintervals, observing that one day the surgery ischemic areas had been after noticedin them canine pillars and the region of the osteotomies. After one week, had anincrease of the endostal and periosteal fulfilling vascular, beyond fibrous tissue

that already occupied the space of the osteotomies. In the second week, vasesfrom the periosteum penetrated in the cortical vestibular contests anatomizing


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with the endostal vases. On both sides of the osteotomy, bone tissue neoshapedcould be identified. After 4 to 6 weeks, it was noticed the increase of thevascularization and the presence mature bone tissue. Then it was evidenced that itdid not have differences between the monkeys that had palatine artery connected

and those that had not (BELL; FONSECA; KENNEDY, 1975).

Fig. 14 Schematical composition to illustrate the sanguineous suppliment of the maxilla.Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial

deformities. 1980.

Fig. 15 Irrigation of the previous portion of the maxilla.

Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacialdeformities. 1980.


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After excellent studies some authors affirm that to diminishing therisk of an lacking blood vessels necrosis of the maxilla, it must be preserved thedescending palatinos vases, beyond being kept the muscular insertions(LANIGAN; HEY; WEST, 1990).

The inter-bone ischaemia and the necrosis of the osteotomizedsegments had been significantly reduced when the mucoperiosteum and theinsertion of the muscles pterygoid medial and Masseter had been more preserved(BELL; FONSECA; KENNEDY et al., 1975).

After the Le Fort I osteotomy, the sanguine irrigation is derivedfrom vascular palatal pedicle through the descending palatine artery and from the

palatine branches of arteries pharyngeal ascending and face and, also, fromvascular pedicle vestibular through the postero-superior alveolar artery. Amongstthese sources, the descending palatine artery is the biggest vase, with averagediameter of 1,7 mm, being one of the main responsible for the bleed during theosteotomies. Damages to these vases generally do not show none sequel due to

fast revascularization and to the good collateral circulation(MENUCCI-NETO;POLIDO; MAZOLENI et al., 2004).

SOFT TISSUES ALTERATIONS

Since the decade of 50, the orthodontists have shown an increasingconcern not only with the occlusion, but also with face aesthetics (BLOOM, 1961e PASTORI; MARZOLA; MENDES et al., 2005).

The necessity to quantify the changes in the soft tissue of the faceand to foresee surgical results, searchers had tried to establish evaluation methods

of these results gotten by means of radiographic comparisons or of computerprograms. They had objectified to create a forecast of the interrelation betweenthe changes from soft tissue and bone of the face, to assist in the attainment of the

biggest face harmony and the possible previsibility for each patient (Fig. 16)(BELL; PROFFIT; WHITE, 1980).

Studies analyzed the alterations of the face profile in theorthodontic treatment of 60 leukoderma patients in growth phase and, treated bymeans of orthognatic surgery. Through after-surgical and daily pay cefalometricalmeasures of six months, revealed the existence of a very next relation between the

pure orthodontic movement of tissues and, the answers of soft tissues, withpossibility of forecast of these changes (BLOOM, 1961).

Work using lateral telerradiografies in the postoperative and dailypay of 21 patients had been able to evidence that the rise of the nasal apex and thebase of the superior lip had been noticed the most. In 40% of the cases, there wasa reduction of the width of the vermillion of the superior lip, occurring a superiorvertical alteration of all the points of soft tissues, since the nasal apex until theinferior lip. The nasolabial angle increased in retrusion of the maxilla,diminishing in advance and, in profile analysis it did not have significantalteration in the tip of the nose (MANSOUR; BURSTONE; LEGAN,1983).

About the changes of the soft tissue associates with a total advanceof the maxilla, using daily pay-surgical telerradiografies cefalometrical andimmediate after-surgical, with six months of postoperative, of eight patients, were

observed that some measures had been statistical insignificant because thesampling was very small. One high positive correlation in the horizontal change


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was noticed and the superior lip had an average ratio of 0,5:1 + 0,09 in relation tothe superior incisor, in the horizontal axle. In the vertical axle 0,3:1 was observedaverage + 0,14, with small correlation between alteration of the superior andincisive lip, having, also, a reduction of the nasolabial angle, which has next

relation with the superior incisor, with average ratio of -1,2: 1.0 mm + 0,26. Itwas noticed, also, an uniform reduction in the thickness of the lip, with average of-1.9mm, and, a uniformity was not observed among patients until the six

postoperative months, only occurring after this period, with the lips tending tokeep certain stability (DANN; FONSECA; BELL, 1976).

Fig. 16 Reference points, in soft and bone tissue.Font: BELL, W. H.; PROFFIT, W. R.; WHITE, R. P. Surgical correction of dentofacial

deformities. 1980.

Studies of the stability of the maxilla and the relation of the soft tissueand bone in its superior repositioning, using a morphologic analysis of a tracingdone by hand and analyzed by the computer in 30 patients were effected. Theaverage of postoperative of 14 months was gotten as satisfactory resulted, in the

patients with vertical excess of maxilla, a correlation of 0,76 in the relationbetween superior lip and incisive superior. Moreover, was evidenced a shorteningof the lip with correlation of 0,38 without alteration in the contour, but with arotation around of the subnasal point. The nasal apex was softly raised by thesurgery. Throughout the 14 months, the authors had noticed small movements,especially in the point of the maxilla. In the patients with maxillary bi-protrusion,got a correlation of 0,66 between the posterior movement of the superior lip inrelation to the superior incisor, a correlation of 0,51 between the movement, fortop, of the superior lip and incisive superior. The profile did not change, only


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turned around of the subnasal point after the surgery. Throughout the 14 monthsof postoperative of this group was not observed any change in the position of themaxilla (SCHENDEL; EISENFELD; BELL et al., 1976).

Cefalometrical analysis of the nasal morphology after Le Fort I

osteotomy was carried through in 50 patients who had postoperative and dailypay-operatories cefalometrical telerradiografies of six months at least. It wasevidenced that the nasal apex was moved for top, next to the previous andsuperior movement of the point of the maxilla and, for low with posterior andinferior movement of the point. Although to be small, this correlation isresponsible for only 20% of the postoperative alterations in the nasal apex. Therotation of the maxilla did not show significant relation with the changes of thenasal apex. It was also observed, in its statistical analysis, that did not havealterations in soft tissues when these was sutured by different techniques, or whenthe nasal previous spine was removed (GASSMANN; NISHIOK; THRAS et al.,1989).

The repercussions in soft tissues of the face are seen mainly in thenasal and lips structures, supplying its correlations in alteration coefficients;however a significant variation can be seen in the results and conclusions of thegreat majority of them (BELL; PROFFIT; WHITE, 1980).

Evaluating the soft tissue movement together with hard tissues afterosteotomies of maxilla in lateral telerradiografies were evidenced to be possible,in the daily pay-operatory, to foresee the changes that will occur in soft tissues(DANN; FONSECA; BELL, 1976).

The changes associates to the total surgical intrusion of the maxilla inpatients with long faces, characterized for the vertical excess of maxilla, had beenstudied in 10 cases, with a minimum of six months of accompaniment, wheremanual tracings had been carried through postoperative and daily pay in lateraltelerradiografies of face. They had been gotten as resulted that the vertical changeof the points in soft tissues of the maxilla was related in a significant way with thevertical changes in bone portions and, with the change of the position of superiorincisive as a support, having still changes on the superior lip and nose. Authorshad verified that, in case that comes to occur the intrusion of the superior incisor,the superior lip comes to occupy an also superior position in relation to the daily

pay-operatory(RADNEY; JACOBS, 1981).It was also evaluated the stability and alterations in soft tissues of the

face in corrections of the vertical deficiency of the maxilla, in 13 patients. Its

cefalometrical telerradiografies of daily pay, postoperative immediate, six weeks,12 and with six months of postoperative, done tracings manually, had beenstudied, concluding the authors who changeable amounts of returns had occurredin the majority of the cases, in the first two or three months after the surgery. Itdid not have any correlation between the amount of carried through movementand the return. The length of the superior lip was not modified significantly withthe amount of movement carried through in the maxilla. It has been also noticedthat the exposition of the superior incisor increased in the patients having positiverepercussion in the aesthetic. In the horizontal movement of the maxilla a

percentage of 66% of accompaniment of the fabric soft in relation to the bonetissue was seen, with great variability of results inside of the sample (BELL;

SCHEIDEMAN, 1981).


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Searching for the previsibility of soft tissues in the repositioning tomaxilla in orthognatics surgery with the Le Fort I technique, study it was followedin 46 patients. In its immediate postoperative and daily pay-operatoriescefalometrical telerradiografies, traced manually and later digitalized, no

significant difference was found between the points of the forecast and the after-surgical, being thus, considered a previsible surgery. In another analysis, theaverage of the differences between the measures was very next to zero and onlythe point located in the molar tended to be inferior to the of the planning, showingsignificant difference between planned and the postoperative (JACOBSON;SARVER, 2002).

In relation to the muscular orientation after total osteotomy of themaxilla, studies show that in any orofacial surgery the alteration of the form,aesthetic and function can be recognized. The muscles can be manipulated foradvantage of the surgeons and, with this, the possible effect undesirable to occurin the perioral area after the osteotomies of the maxilla can be prevented. The

postoperative forecast of the lip in rest can be found (SCHENDEL;EISENFELD; BELLet al., 1976).

Professionals must not forget themselves, however, that existslimitations in the search for the improvement of the aesthetics and that the patientsmany times do not have conscience of them, so that it can prevent falseexpectations transmitted to the patient (JACOBSON; SARVER, 2002).

COMPLICATIONS

Some complications already had been described in literature in

relation to the Le Fort I osteotomy and that present a bigger occurrence arehemorrhages and the bad positioning of the maxilla. However, with lesserfrequency can also occur fistulas arteriovenous, orofacial and nasoantrals,shunting lines of septum, velopharyngeal incompetence, maxillary sinusitis,ischemic necrosis, pseudo-artrosis of the maxilla, undesirable breakings, damagesto the nervous system, damages to the nasolacrimal system and ocular anddysplasia (ARAJO, 1999).

Fistulas arteriovenous are possibly caused by the rupture of anartery next to venous plexus, with spontaneous anastomosis. The patient can tell

buzzed and pulse sensations in the face and the eyes. Its treatment consists of theselective embolisation of the vases that feed the fistula. The aseptic necrosis is

established due to an interruption of the vascularization, being able to bedevastator for the patient and the professional, a time that is very difficult to reachthe rehabilitation (ALMEIDA-JNIOR; CAVALCANTE, 2004).

The occurrence of the bad positioning to maxilla has a biggerfrequency for being a technical order problem. Carrying through an adjusted

planning, with splints without distortions and a correct surgery of models, thiscomplication can be minimized (ARAJO, 1999).

The trans-operatory hemorrhage is one of the most frequentcomplications told in the Le Fort I osteotomy, being the most common cause ofassociated hemorrhage to the orthognatics surgery. It consists of the lack of trans-operatory hemostasy and, in most of cases, it occurres due to an imperfection of

the surgeon about fully knowing the anatomy of the area where he is working.


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However, the bone anatomy, vascular anatomy or modified soft tissues canpresent problems even to the most experiencedsurgeons (LANIGAN, 1997).

The vases more common associated with arterial hemorrhages arethe terminals branches of the maxillary artery, especially the descending palatine

artery and the esphenopalatine, even though the proper maxillary artery and theinternal carotid can also be involved. The anastomosis between the branches ofthe arteries carotid internal and external or between the other side corresponding

branches of the external carotid can perpetuate the bleed, although the surgical tieof the main vase. The maxillary artery and its branches are more vulnerable to theinjuries during the pterigomaxillary disjunction or still during the inferior

breaking of the maxilla. The descending palatine artery is the most vulnerablevase during these surgical moments, due to the relationship between thedescending palatines vases and the Le Fort I posterior and medial osteotomies.Therefore, the majority of the studies related to the posterior region of the maxillasays about the standard of the maxilla pterygoid separation process during the

osteotomy (RENICK; SYMINGTON,1991 e LANIGAN; GUEST, 1993).The venous bleed after the Le Fort I osteotomies involves mainly

venous plexus, which corresponds to a venous net juxtaposed to the pterygoidmuscles. It is important to point out that this plexus communicates with thecavernous sinus, of intracranial localization, draining the blood saturated incarbon dioxide from meninges through the oval foramen. To this plexusconverges the draining of the veins that correspond to the branches of the twoforebodies maxillary arteries, the medium meninge, the palatine biggest, theesphenopalatine, the buccal, the alveolar e the inferior ophthalmic (GERHARDTDE OLIVEIRA, 1998).

A Le Fort I case is presented where when is carried through thedesimpaction of the maxilla, occurred the disruption of vases becoming necessaryto bind the carotidal external and internal arteries (NEWHOUSE; SCHOW;KRAUT et al., 1982).

The bleed can vary from light to intense, being able to arrive untilthe hypovolemic shocked, thus it is very important in the daily pay-operatory to

be taken some prevention writs in relation to the hemorrhage, as adjustedsanguineous suppliment attainment for an eventual transfusion and, also, the

possibility to carry through the surgery in induced and controlled hypotension(LANINGAM; HEY; WEST, 1991). The German school does not praise to bindor to cauterize the sanguine vases, aiming at a minor fibrosis and tecidual

reaction, therefore the sanguineous losses can be diminished through the reducedand controlled hypotension, thus providing better operatory field visualization anddiminishing the surgical time (GRANDO; PURICELLI; CHIAO et al., 1990).

The controlled hypotension was induced and had a great impulsewhen the Sodium Nitroprussiate was introduced (MORACA, 1962). Thismodality in the general anesthesia is based on the position of the patient and thevasodilatation causing alterations of the daily pay-load and the after-load. Thecardiac debit and the systemical vascular resistance are the variable manipulatedwithout real alterations of the volemy, making possible the accomplishment of thesurgery with diminished levels of cardiac frequency, preventing bigger bleeds. Itis important to emphasize that the surgeon promotes a correct vascular tie,

contrary to it, when reestablishing the pressure and the normal cardiac frequency,


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can occur bleeds in the postoperative (GRANDO; PURICELLI; CHIAO et al.,1990).

By occurring septum shunting line, it can have very ackwardfunctional and aesthetic problems, in the postoperative one. It can occur by the

insufficient removal of the septal crest of the maxilla and septum gristly duringthe trans-operatory, or even during the cannulas placement and/or during the nasalcavity aspiration, or still during the extubation. Some shunting lines offer the

possibility of reduction, however, it has those that can need a posteriorseptumplastia (ARAJO, 1999).

Studies show that signals and symptoms in the postoperative onecan occur as posterior nasal secretions, nasal congestion, fever and headaches.Aiming at to prevent these facts, if the patient presents some disease in the daily

pay-operatory must be used nasal laxatives to promote the fast exit of the blood ofthe maxillary sinus in the postoperative one (YOUNG; EPKER, 1972).

The occurrence of the maxillary sinusitis is a rarer complication in

the use of this technique, however in occurring it, it must be managedtherapeutical medication with the use of nasal laxatives, antibiotics andantihistaminic (ARAJO, 1999).

Amongst the ophthalmic injuries, the xerophthalmia, blindnesswith the injury of II cranial pair, oculomotor with the III cranial pair, beyondinjury of the abducent nerves with the VI cranial pair. Corneal xerosis orxerophthalmia consists of a disease of the ocular globe, promoting disappearanceof lachrymal secretion and, in such a way, the ocular globe becomes dry, rough,without brightness and, with parchment aspect (NEWLANDS; DIXON;ALTMANM, 2004).

DISCUSSION

Literature is unanimous in saying that the orthognatic surgerysupplies to the patient face harmony, beyond reestablishing the function and, thus

bringing a psychosocial improvement, coming to provide a better quality of life(CUNNINGHAM; HUNT; FEINMANN; 1995 e HUNT; CUNNINGHAM,1997 and PETERSON, 2000).

The orthodontics can decide the problem in some situations,providing to the patients even a camouflage, however, when there is a discrepancyin the base bone, the orthodontic treatment cannot supply, having necessity of the

surgical intervention. Remembering that the surgery always must be preceded ofnon-compensatory orthodontic treatment, as some authors agree (PROFFIT,1991 and TOLEDO-FILHO; MARZOLA; TOLEDO-NETO, 1998).

MIRANDA (1996)and CORTEZZI (1996)agree when affirmingthat the patients with maxillary alterations, can present, concomitantly, nasalalterations or even though temporomandibular dysfunction.

Many are the indications for the execution of the technique of thetotal osteotomy of the maxilla with diverse stories in literature agreeing to suchindications as the extreme exposition of the previous incisors, the horizontalexcess, the anteroposterior excess, the vertical excess, the crossbite unilateral or

bilateral and the maxillary hypoplasia (BELL; ALESSANDRA; CANDIT,

1968; EPKER, 1981; EPKER; STELLA; FISH, 1995 and PETERSON,2000).


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The deep anatomical knowledge of the maxillary region, beyond itsdevelopment, has basic importance for the success of the surgeon and the surgicalmaneuver (WIKKELING, KOPPENDRAAIER, 1973; WASHBURN;SCHENDEL; EPKER, 1982; MELSEN, 1987 and HERFORD;

THARANON; FINN, 2001).Some authors agree that Le Fort I osteotomy carried through inchild can be complicated by the development of the molar beyond the growth ofthe maxillary complex, being able to intervene with the future bone development(WIKKELING, KOPPENDRAAIER, 1973 and HERFORD; THARANON;FINN, 2001). However, there is a discord of authors, affirming that, after studiesin 16 patients between 10 and 16 years, had not been evidenced alterations in theface development (WASHBURN; SCHENDEL; EPKER, 1982).

Amongst the bones and involved anatomical structures directly inthe execution of the techniques cited in the present work authors affirm as main,

beyond the maxilla, the maxillary sinus, the hard/soft palate, the Vmer bones,

Ethmoide, sphenoid (CASTRO, 1976 and SICHER; TANDLER, 1981).FVERO (1986)affirms having a great interest to the surgeon the

division to maxillary of the triplets that covers pterigopalatine cavity, infra-orbitalcanal and face being these the terminal branches. However the branches of thetriplet nerve are vastly cited in literature because they are all directly joined to thediverse techniques and possible manipulations to be carried through in themaxillary bone complex (SICHER; TANDLER, 1981).

It is possible to meets in literature the first technique of maxillas total osteotomy described (VON LANGENBECH, 1859) and, until then themaxilla was not separate of the pterygoid plateaus, what started to occur from thedecade of 30 with AXHAUSEN, using it to correct breakings maxilla and, also,for WASSMUND, carrying through the osteotomy of canine pillars, being theauthors revised unanimous when affirming such pioneering (AXHAUSEN, 1934;FVERO, 1986; ARAJO, 1999 and MENUCI-NETO; POLIDO;MAZZOLENI et al., 2004).

Initially osteotomy was realized in two surgical times (KOLE,1959), however, with the evolution of the technique, it is possible to finddescribed the same procedure realized in only one surgical time (MOHNAC,1967 and PAUL, 1969), situation followed by great part of authors of the presenttime.

After all studies elucidating the maxillary revascularization

(BELL, 1969), many authors from literature affirm that Le Fort I osteotomycomes to be widely used for the fact of provide an enormous variety of movementThus, advances, increase /reduction of vertical dimension are cited, having stillthe possibility of accomplishment of a segmentation of the maxilla, promotingstill bigger movements (GRAZIANI, 1986 and S JNIOR, 2001).

OBWEGESSER (1969) described the technique of Lequadrangular Fort I osteotomy, indicating for patients with horizontal deficiencyand, to zygomaticmaxillary with an exacerbated nasal projection.

The technique of the high osteotomy is very defended also using asargument the fact of the zygomatic bone to be dense, bringing a higher stabilityand setting (KUFNER, 1971). Although to occur a great stability, it is possible to

meet in literature, until the current days, few and restricted cases with thisindication.


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Traditional osteotomy (BELL, 1975), today is used for themajority of the authors, due to its indication for diverse types of cases. Throughthis technique is possible to reduce the face height, the exposition of incisive teethand inter-labial space and, thus, to put into motion the maxilla for a class I

occlusion (PEDERSEN, 1972; KRUGER, 1984; BARROS; MANGANELLO-SOUZA, 1998 and S-JNIOR 2001).For patients with agreed horizontal and anteroposterior

deficiencies, the osteotomy in slope can be applied, getting an advance to themaxillary and at the same time a descenso (REYNEKE; MOSUREIK, 1985).However great part of the authors uses the traditional technique of BELL, makingdescenso after to carry through the straight line osteotomy, with the argument toget greater exactness in the carried through movement (PEDERSEN, 1972;KRUGER, 1984; MANGANELLO-SOUZA, 1998 and S-JUNIOR, 2001).

Studies affirm that the maxilla during the mobilization processsuffers great deficit from sanguine suppliment, however this transitory ischemia

does not cause damages to the region, therefore has a fast revascularization afterthe stabilization. This fact suggests that if there is the necessity of being carriedthrough the tie of the descending palatines arteries, will not have problems withthe heal (BELL, 1975). However, it has discords because authors affirm to havegreat risk of necrosis occurrence to lacking blood vessels of the maxilla in casethat it has the tie, recommending that the descending palatine vases must be

preserved, what would increase the security of the Le Fort I osteotomy(LANIGAN; HEY; WEST, 1990). However they agree when affirming that themaintenance of the muscular insertions is basic to diminish the necrosis risk tolacking blood vessels of the maxilla (BELL; FONSECA, KENNEDY et al.,1975 and LANIGAN; HEY; WEST, 1990).

Authors agree when saying that the orthodontists have shown abigger interest in providing to the patients a better picture of the harmony and facefunction, increasing the surgical indications, when they are (BLOOM, 1961 ePASTORI; MARZOLA; MENDES et al., 2005).

Many works had been carried through aiming at to foresee thealterations of soft tissues in relation to the bone movements, however the authorsaffirm to occur great variations in the results (BELL; PROFFIT; WHITE,1980). Disagreeing with the above-mentioned authors, some of them affirm thatthe orthognatics surgery is a total previsible procedure in relation to the alterationsof face soft tissues (JACOBSON; SARVER, 2002).

Amongst the searched authors for accomplishment of the presentwork, all agree, when they are mentioned to the minimum of six months so thatthey are gotten resulted more necessary in the alterations of soft tissues(BLOOM, 1961; DANN; FONSECA; BELL, 1976; SCHENDEL;EISENFELD; BELL et al., 1976; BELL; PROFFIT; WHITE, 1980 andMANSOUR; BURSTONE; LEGAN,1983).

In studies on the movement of soft tissues with hard tissues afterthe osteotomies of the maxilla in lateral telerradiografies they had evidenced to be

possible, in the daily pay-operatory, to foresee the changes that will occur in softtissues(DANN; FONSECA; BELL, 1976).

Analyzing lateral telerradiografies in the postoperative and daily

pay the authors are vast affirming that the structures that had suffered to greatersmovements after osteotomy had been the superior lip and the nasal apex, reducing


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the vermillion of the superior lip to a large extent of the cases (PEDERSEN,1972;DANN; FONSECA; BELL 1976; SCHENDEL; EISENFELD; BELL et

al., 1976 and MANSOUR; BURSTONE; LEGAN,1983).All the authors tell the hemorrhage as being the most common

complication to occur to the carried through the osteotomy, related to themaxillary bone artery, in its terminal branches and, more specifically thedescending palatine artery and the esphenopalatine artery (NEWHOUSE;SCHOW; KRAUT et al.,1982; GRANDO; PURICELLI; CHIAO et al., 1990;RENICK; SYMINGTON, 1991; LANIGAN; GUEST, 1993; LANIGAN, 1997and ARAJO, 1999).

They agree when they affirm to have other serious complications asthe ophthalmic, the xerophthalmia, the blindness, injury of the oculomotor nerveand abducent injuries, being able to occur with a higher frequency and, with lesseroccurrence the maxillary sinusitis, fistulas arteriovenous oroantrals andnasoantrals, the shunting lines of septum, pseudo-arthrosis, the velopharynx

incompetence, beyond damage to the nervous system and ischemic necrosis(YOUNG; EPKER, 1972; ARAJO, 1999 and NEWLANDS; DIXON;ALTMANM, 2004).

CONCLUSIONS

Based in literature review, since the beginning of the use of Le FortI total osteotomy of the maxilla technique, it can be concluded that:

1. Orthognatic surgery is a positive treatment when it aims toreestablish the facial aesthetic, dental harmony and psychosocial improves.

2. The possibilities for the accomplishment of the Le Fort Iosteotomy are vast, with basic importance for the correct indication for each case,therefore the techniques developed until today search to take care of to the diverseoccurrences of dentofacial deformities.

3. A minute knowledge of the anatomy of the maxillary region isnecessary, thus preventing higher complications in the trans-surgical.

4. After studies related to the microcirculation, the execution of thetechnique can be carried through with bigger security for the surgeons, a time thatthe revascularization is total gotten.

5. The soft tissues that suffer to greater alterations because of theexecution of this surgical technique are the superior lip and the nasal apex.

6. The hemorrhage is the main complication, mainly happenedfrom the maxillary artery and its terminal branches, especially the descendingpalatine artery and esphenopalatine.

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_____________________________* In accordance with the ABNT norms.


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