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H. Matras, A. Perneczky
K. Schuchardt: Fortschritte der Kiefer- u. Gesichtschirurgie, Bd. XX. Thieme, Stuttgart (in press) Schmid, E.: Die aufbauende Kieferkammplastik. Ust. Z. Stomat. 51 (1954) 582 Terry, B.: Die Knochentransplantation zur Korrektur des atrophierten Kieferkammes. 2nd Congress European Association for Maxillo-Facial Surgery, 16.-21. September 1974, Zfirich
Priv.-Doz. Franz Hiirle, M.D., D. M. D., Department of Maxillo-Facial Surgery, 78 Freiburg i. Br., Hugstelterslrafle 55

Hofer, 0., H. Mehnert: Neue Methoden zur Rekonstruktion des Alveolarkammes. Dtsch. Zahn-, Mundu. Kieferheilk. 41 (1964) 313 Neuner, 0.: Sekundfire Korrekturm6glichkeiten bei Lippen-Kiefer-Gaumenspaltenpatienten. Ust. Z. Stomat. 62 (1965) 268 Obwegeser, H. L.: Die totale Mundbodenplastik. Schweiz. Mschr. Zahnheilk. 73 (1963) 565 Obwegeser, H. L.: Weitere Erfahrungen der aufbauenden Kammplastik. Schweiz. Mschr. Zahnheilk. 77 (1967) 1002 Schettler, D.: Sandwich-Technik mit Knorpeltransplantat zur Alveolarkammerh6hung im Unterkiefer. In:

J. max.-fac. Surg. 3 (1975) 260-262 Georg Thieme Verlag, Stuttgart

Topographical Anatomy of the Total Osteotomy of the Midface

Helene Matras, Axel Perneczky
Dept. of Maxillo-Facial Surgery (Head: Prof. S. Wunderer, M.D., D.M.D.) and NeurosurgicaI Dept. (Head: Prof. H. Kraus, M.D.) of the University of Vienna, Austria

Summary
In this study, the operating conditions for total osteotom.y of the middle part of the face have been simulated in a cadaver and the topography of the organs at risk has been examined. The area of the maxillary tuberosity is the region which is mainly exposed to considerable injury to vessels; here an uncontrolled fracture as compared with a systematic osteotomy is the safer method under the given anatomical conditions.

vidual chapters on the cranio-facial-osteotomy lines. It is our intention to study and to describe the topography of the arterial and venous system and nerves involved in osteotomies of the facial skeleton as described b y Tessier.

Material and Methods

The external carotid artery was injected with Latex in 4 human skulls fixed with formalin. Osteotomy and mobilization of the middle part of the face was carried out under simulated operating conditions. The osteotomy lines created were then exposed and the parts especially endangered examined.

Key-Words: Osteotomy of the mid face; Cranio-faciaI

dysostoses; Maxillary artery.

Introduction
Total osteotomy of ~he midface is a surgical method for treatment of facial deformities occurring in cases of cranio-facial dysostoses (Crouzon's disease, A p e r t ' s syndrome) or other facial deformities (of post-traumatic aetiology). This treatment was carried out for the first time by Gillies in 1949. In his papers (1971a and b) Tessier, who developed this method into a stand a r d operation, points out the dangerous stages in a total disjunction of the middle part of the face (principally this osteotomy corresponds to an artificially created fracture of the Le Fort I I I type). These dangers are described in the indi-

Findings
I. Infrabasal osteotomy
The infrabasal osteotomy separates the cerebral cranium from the facial skeleton at the level of, or slightly below the fronto-nasal suture, its definite location depends on the plane of the cribriform lamina. Furthermore, infrabasal osteotomy facilitates the exposure and transsection of the medial walls of the orbit and osteotomy of the
vomer.

Topographical Anatomy of the Total Osteotomy of the Midface

261

J
Fig. 1 Keel-shaped midline osteotomy and its relation to the cribriform lamina and to the olfactory ilia. A: Cribriform lamina, B: olfactory ilia, C: olfactory bulb.

............

Fig. 2 Osteotomy of the orbita walls, a: Inferior orbital fissure, b: posterior lacrimal crista, c: infraorbital sulcus, d: inferior oblique muscle, e: anterior ethmoidal artery.

This infrabasal transsection should be carried almost as far as the anterior ethmoidal foramen and from there downward. By performing the osteotomy in such a way, the lacrimal organs remain untouched, and the anterior ethmoidal artery, which partly supplies the dura of the anterior cranial fossa, can be preserved. In the midline the osteotomy is keel-shaped; the vomer is cut through in such a way that the posterior end of the incision lies approximately in the region of the nasal crista of the palatal bone. By employing this type of osteotomy (Fig. 1) the cribriform lamina is not likely to be perforated, and also the olfactory fila wilt not be injured. II. Osteotomy o1 the lateral rim and the lateral wall of the orbit On the lateral rim of the orbit the osteotomy is started at the level of the zygomatico-frontal suture and may be extended in various ways as an os.teotomy of the anterior part of the zygomatic bone. In a purely subperiostal approach the branches of the facial nerve are not injured. But the zygomatico-facial nerve and the zygomaticotemporal nerve, which pass through the zygomatic bone, cannot be preserved. The osteotomy of the lateral wall of the orbit is carried downward as in the case of the medial wall. At the same time the deep temporal artery and vein, which

Fig. 3 Relation between artery and bone on the maxillary tuberosity before (A) and after (B) uncontrolled fracture,

supply the temporal muscle, and the temporal nerve can be preserved by retracting the temporal muscle. III. Osteotomy of the floor of the orbit The osteotomy of the floor of the orbit connects the osteotomy lines on the medial and lateral walls. While approaching the orbital floor the insertion of the inferior oblique muscle situated adjacent to the posterior lacrimal crista may be preserved only if the osteotomy of the medial wall of the orbit had been extended far enough downward (Fig. 2). The osteotomy of the floor of the orbit crosses the infraorbital neuro-vascular bundle; the shape of the infraorbital canal varies from case to case.

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H. Matras, A. Perneczhy: Topographical Anatomy of the Total Osteotomy of the Midface

at the level of the osteotomy; if it lies in a canal, however, its preservation may be problematic. 4. The posterior wall of the tuberosity is the most exposed osteo'tomy region with respect to the topography of the vessels. Here the posterior superior alveolar artery divides into several branches, which meander on the surface of the bone over a distance of about 1 cm before perforating it. This topography (Fig. 3) implies that on sharp dissection of the maxillary tuberosity the vessels must of necessity be damaged. An uncontrolled fracture, by contrast, will leave them intact and - just because of their topography - enough excess length will be available on ~he surface of the bone to safely span the fracture site. Uncontrolled fracture of the maxillary tuberosity is carried out in the course of the mobilization of the middle part of the face following osteotomy. Similarly, the pterygoid plexus is primarily threatened on sharp dissection of the bone.
Conclusion

IV. Osteotomy of the pterygo-maxillary

connexion
The connexion between the maxillary tuberosity and the pterygoid process is sectioned via the mouth. After this the cranial part of the posterior wall of the tuberosity is the only osseous bridge preserved. The posterior wall of the tuberosity is covered by the posterior superior alveolar artery, which has a wide lumen and a tortuous course, as well as by the pterygoid plexus.
Discussion

Our anatomical studies documented the following important topographical conditions. 1. The main vascular organ of the medial wall of the orbit, i.e. the anterior ethmoidal artery, has to be exposed and, if necessary, clamped, since an uncontrolled rupture of the vessel causes undesirable intra-orbital haematomas. 2. Small hyp-aesthetic skin areas on the zygomatic bone and on the temporal bone, respectively, occur if the zygomatico-facial nerve and the zygomatico-temporal nerve are severed. 3. The infraorbital neuro-vascular bundle can easily be preserved, if it is situated in a groove
References

Although the findings reported were observed in normal skulls, they also apply to facial stenoses, since relative sizes are not a decisive factor in this paper. This study shows that uncontrolled fracture of the maxillary tuberosity is less traumatic to the vascular system than sharp dissection.

Gillies, H., S. H. Harrison: Operative correction by

osteotomy of recessed malar maxillary compound in a case of oxycephaly. Brit. J. plast. Surg. 2 (1950) 123

the severe facial deformities of eraniofaciaI dy sostosis. Plast. reeonstr. Surg. 48 (1971) 419
Univ.-Doz. Dr. Helene Matras, Klinih fiir Kieferchirurgle, Alserstrasse 4, A-1090 Wien Ass.-Arzt Dr. Axel Perneczky, Neurochirurgische Klinih, Alserstrasse 4, A-I090 Wien

Tessier, P.: Traitement des dysmorphies facialis propres

aux dysostoses cranio-faciales Maladies de Crouzon et d'Apert. Neuro-Chirurgie 17 (1971) 295

Tessier, P.: The definitive plastic surgical treatment of