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MAXILLARY OSTEOTOMIES
JOHN P. KELLY, D.M.D., M.D.
MAXILLARY OSTEOTOMIES 75
TOTAL MAXILLARY OSTEOTOMY (LE usually donate two units of blood for potential au-
FORT I) tologous transfusion.
General anesthesia with the use of nasotracheal
Since 1974, when the downfracture technique of intubation is required; attention must be paid to
total maxillary osteotomy was introduced, this pro- securing the endotracheal tube without distortion of
cedure has been a standard part of the surgical the nose and upper lip. The patient is then positioned
armamentarium. Prior to that time, surgical ap- with the head and back elevated slightly to decrease
proaches to the total osteotomy of the upper jaw the venous tone at the surgical site. The maxillary
were quite limited, enabling the surgeon to perform buccal and labial sulcus is infiltrated with a solution
little more than a simple anterior repositioning of the of 1:100,000 epinephrine prior to initiating the sur-
maxilla. Posterior movements were generally accom- gery as an aid to hemostasis.
plished only by means of segmental osteotomies of
the premaxilla; superior repositioning of the posterior
maxilla by segmental osteotomy was difficult and Technique
frequently unsuccessful; lenghtening or inferior re-
positioning of the upper dental arch was essentially A full thickness mucoperiosteal incision is made in
the maxillary buccal sulcus, starting at the zygomatic
impossible.
buttress on one side and continuing horizontally
Total maxillary osteotomy is now indicated for any
around to the corresponding point on the opposite
deformity of the upper jaw in any of the three planes
side (Fig. 7-1). Firm retraction of the buccal sulcus
of space. Where necessary, the maxilla can be seg- with the surgeon's index finger will facilitate avoid-
mented to effect differential movements of its various ance of the buccal fat. The incision should be placed 1
components. The procedure is frequently combined cm superior to the mucogingival junction whenever
with other osteotomies performed simultaneously to possible to leave a convenient flap of mucosa for later
correct associated deformities of the mandible or wound closure.
nose. Even in the absence of simultaneous surgical
procedures, the maxillary osteotomy produces notable
changes in both the mandible (the principle of
autorotation) and the nose that must be considered in
the treatment planning of the surgery.
Although there are no absolute contraindications to
the total maxillary osteotomy, special care must be
taken in those patients who have had previous
surgery in the same area, including particularly those
patients with previous cleft palate repair or rhino-
plasty. For these patients there are several modifi-
cations of the surgical approach (these are well de-
scribed in the standard texts on orthognathic surgery
and are not discussed here).
Preparation
Preparation for the total maxillary osteotomy is
similar to that for any orthognathic procedure. Pre-
surgical orthodontic therapy to eliminate dental com-
pensations, align and level the dental arch, and
coordinate the upper arch with the postsurgical po-
sition of the lower dentition is critical. Cephalometric
prediction tracings and carefully performed model
surgery, often requiring facebow-mounted articulated
casts, enable the surgeon to proceed. Any necessary
occlusal templates or splints may be prepared after
the model surgery has been completed. The patient
who is to undergo this procedure, alone or in
combination with a mandibular procedure, will Figure 7-1
76 MAXILLARY OSTEOTOMIES
With a cobra retractor placed posteriorly in the If preoperative planning indicates the need for any
subperiosteal tunnel, a malleable ribbon retractor superior repositioning of the maxilla, the desired
placed subperiosteally in the inferior portion of the amount of ostectomy can now be measured on the
lateral nasal wall, and a broad periosteal elevator lateral wall of the maxilla, and the second cut is made
retracting tissue superiorly in the cheek, excellent with the saw.
visualization of the lateral maxillary wall is obtained At the anterior extent of the osteotomy incision, the
(Fig. 7-3). Reference marks can then be drawn or reciprocating saw is extended through the lateral
scored on the bone; the most inferior and lateral maxillary wall to cut the lateral nasal wall at its
point of the pyriform rim is usually taken as the junction with the nasal floor. The ribbon retractor is in
initial point of reference. In most cases, with the place to protect the nasal mucosa and the endo-
exceptions to be discussed later, the initial osteotomy is tracheal tube.
made in the lateral wall of the maxilla in a plane Upon completion of these cuts, the lateral maxillary
horizontal to the occlusal plane from the pyriform rim area is packed with a moist gauze while attention is
to the posterior extent of the zygomatic buttress; directed to the opposite side, where the identical
posterior to the buttress the cut is directed more procedure is performed.
inferiorly to end low in the pterygoid fissure. A thin- The nasal attachments to the maxilla are now
bladed reciprocating saw is most effective for making separated (Fig. 7-4). First the septum and vomer are
this initial cut. separated from the nasal floor by use of a septal chisel
placed carefully in the subperiosteal plane. Next,
guarded osteotomes are advanced along the lateral
nasal walls until the strong buttress of bone at the
posterior extent of the nasal cavity and the maxillary
sinus is separated from the pterygoid plates; care
should be taken to keep the osteotomes as low in the
nasal wall as possible.
78 MAXILLARY OSTEOTOMIES
Where the orthodontic preparation is such that preservation of the integrity of the palatal soft tissue
segmental surgery is necessary in the maxilla, trans- is of critical importance for maintaining the vitality
verse or longitudinal osteotomies may now be carried of the dentoalveolar structures. Completion of seg-
out (Fig. 7-8). An oscillating saw is most useful for mental osteotomies interdentally is accomplished with
making transverse cuts across the nasal and antral absolutely minimal detachment of mucoperios-teum;
floors, whereas the reciprocating saw is used for a thin osteotome can be malleted through the alveolar
making longitudinal cuts through the nasal floor on bone or the basal bone can be levered with a larger
one or both sides. In either case, great care must be osteotome to create a greenstick fracture of the
taken that the cut is made only through the bone; alveolus.
MAXILLARY OSTEOTOMIES 81
Figure 7-9
The acrylic template prepared at the time of the of the superior surfaces of the maxilla is carried out
model surgery is now secured to the upper teeth to until passive repositioning can be achieved. Particular
maintain the mobilized segments in position, restoring attention must be paid to any tendency to deflect the
the maxilla to a single unit for manipulation. nasal septum as the maxilla is raised; a groove or
The maxilla is now positioned into the desired channel must be made in the nasal floor to
location, utilizing the previously made reference accommodate the septum, or the lower portion of the
marks or an interocclusal splint for orientation (Fig. 7- septum itself may be trimmed. Where there has been
9). With the maxilla temporarily fixed to the man- planned intrusion of the anterior maxilla, trimming of
dibular dental arch, the maxillomandibular complex is the bone anteriorly at the nasal sill may be required to
rotated, carefully maintaining the physiologic position avoid encroachment on the nasal airway, if this bone
of the condyles, until the maxilla is firmly, but has not already been removed in the initial horizontal
passively, repositioned. Additional careful trimming bone cuts.
82 MAXILLARY OSTEOTOMIES
Fixation of the maxilla in the desired position is niques. Although some surgeons have in the past used
achieved either with direct interosseous wires or with suspension wires alone as the means of fixation, such
titanium mini plates (Fig. 7-10). The wires or plates indirect techniques offer no advantages and pose the
are placed at the pyriform rims and the zygomatic distinct disadvantage of being very imprecise.
buttresses bilaterally. The choice between the use of Once the fixation has been applied, it is critical to
wires or mini plates is a function of the surgeon's recheck the midline position of the maxillary incisors
preference, the quality of the bone, the anatomic relative to the philtrum of the upper lip. The attach-
shape of the lateral maxillary wall, and the nature of ments to the mandibular arch must also be released at
the osteotomy movement. this point to check for passive return of the mandible
For the inferiorly repositioned maxilla, the use of to the desired occlusion with the maxilla in its new
mini plates to span the gap created in the lateral position. The fixation of the maxilla must be adjusted
maxilla is mandatory; autologous bone grafts are or replaced until the correct position and relationship
trimmed and wedged into the gaps. Where a stepped with the mandible can be confirmed.
relationship between the upper and lower sides of the The incision is closed in running fashion with a
osteotomy has been created at the sites of fixation, single mucosal resorbable suture. Simple closure is
whether the result of maxillary advancement or adequate for most patients, but attention must be paid
widening, mini plates are also advantageous in main- to any tendency to inversion of the vermilion of the
taining the desired position more easily than is pos- upper lip, in which case V-Y closure of the mucosa
sible with interosseous wires. may be employed.
Suspension wires from the infraorbital rim, the If a mandibular osteotomy is being performed
pyriform rim, or the zygomatic buttress have often during the same surgery, this procedure is now
been described as supplements to the direct wiring, completed. When the pharyngeal pack has been
but they have little value with present fixation tech- removed at the conclusion of the procedure, an 18-
gauge nasogastric tube is passed to empty the stomach
prior to anesthetic emergence and extubation.
A brief period of elastic intermaxillary fixation is
usually used, lasting for 5 to 7 days. Upon release of
intermaxillary fixation, guiding elastics between the
upper and lower arch bars are frequently used for 2 or
more weeks.
Postoperatively, the patients are maintained on
antibiotics and nasal decongestants for 5 to 7 days.
The patient's diet is restricted to liquids and soft
solids for 2 to 3 weeks, with a gradual return to a full
diet after that.
Figure 7-10
MAXILLARY OSTEOTOMIES 83
II
84 MAXILLARY OSTEOTOMIES
Figure 7-13
The buccal cortex of bone is cut with an oscillating planned position, it is stabilized with a previously
saw or a fissure bur, first vertically distal to the cuspid prepared orthodontic wire or an acrylic occlusal splint
and then horizontally to the pyriform rim above the secured to the segment and the posterior teeth. The
tooth apex. This osteotomy is completed bilaterally. incisions are then closed with interrupted resorbable
A transverse palatal incision is made, and the palatal sutures.
tissues are reflected posteriorly to enable the surgeon
to complete the transverse palatal osteotomy.
A short vertical incision is made directly over the Posterior Segmental Maxillary
anterior nasal spine. Minimal dissection of the soft Osteotomy
tissues is performed to allow placement of an osteo-
tome to separate the premaxilla from the nasal septum. Isolated mobilization of the posterior maxillary
The premaxillary segment can now be rotated segments enjoyed widespread use prior to the intro-
superiorly on its soft tisue pedicle, enabling the duction of the total maxillary osteotomy. None of the
surgeon to have direct access to the osteotomy sites for described approaches provided adequate access to the
any necessary trimming. medial and posterior areas of the maxilla. Con-
When the segment can be placed into its pre- sequently, these procedures have generally been
abandoned in favor of the total maxillary osteotomy
to provide safer and more reliable surgery.
86 MAXILLARY OSTEOTOMIES