7

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

Subperiosteal dissection is then carried out supe-

riorly to expose the lateral maxillary walls bilaterally
(the infraorbital foramen can be visualized at this time
so that its exiting contents can be protected) (Fig. 7-
2). Dissection inferiorly, in the direction of the
maxillary occlusal plane, is to be avoided to preserve
collateral blood flow. The subperiosteal dissection is
carried posteriorly from the zygomatic buttress to the
pterygomaxillary fissure, creating a subperiosteal
tunnel lying parallel to the occlusal plane. A moist
sponge is packed into each tunnel while the remainder
of the soft tissue dissection is carried out. With the
upper lip firmly retracted superiorly and the pynform
rim thus exposed to view, careful subperiosteal
dissection of the floor of the nose and the lateral nasal
wall up to the inferior turbinate can be accomplished;
a Joseph elevator functions very well for this purpose.
Sharp dissection is occasionally required to separate
the attachments at the anterior nasal spine.
Figure 7-2

With a cobra retractor placed posteriorly in the
subperiosteal tunnel, a malleable ribbon retractor
placed subperiosteally in the inferior portion of the
lateral nasal wall, and a broad periosteal elevator
retracting tissue superiorly in the cheek, excellent
visualization of the lateral maxillary wall is obtained
(Fig. 7-3). Reference marks can then be drawn or
scored on the bone; the most inferior and lateral
point of the pyriform rim is usually taken as the
initial point of reference. In most cases, with the
exceptions to be discussed later, the initial osteotomy is
made in the lateral wall of the maxilla in a plane
horizontal to the occlusal plane from the pyriform rim
to the posterior extent of the zygomatic buttress;
posterior to the buttress the cut is directed more
inferiorly to end low in the pterygoid fissure. A thin-
bladed reciprocating saw is most effective for making
this initial cut.
MAXILLARY OSTEOTOMIES 77
If preoperative planning indicates the need for any
superior repositioning of the maxilla, the desired
amount of ostectomy can now be measured on the
lateral wall of the maxilla, and the second cut is made
with the saw.
At the anterior extent of the osteotomy incision, the
reciprocating saw is extended through the lateral
maxillary wall to cut the lateral nasal wall at its
junction with the nasal floor. The ribbon retractor is in
place to protect the nasal mucosa and the endo-
tracheal tube.
Upon completion of these cuts, the lateral maxillary
area is packed with a moist gauze while attention is
directed to the opposite side, where the identical
procedure is performed.
The nasal attachments to the maxilla are now
separated (Fig. 7-4). First the septum and vomer are
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

In many patients it will now be possible to rotate

the maxilla downward with digital pressure anteriorly,
creating a greenstick fracture in the posterior wall of
the maxillary sinus (Fig. 7-5). Where this is not
possible, curved osteotomes are placed into the
pterygomaxillary fissure behind the tuberosity and
advanced inferiorly and medially to complete the
separation of the maxilla from the midfacial skeleton.
The maxilla can now be rotated inferiorly (downfrac-
tured) to give exposure to the antral and nasal floors
from above. Any remaining soft tissue attachments to
the nasal floor can be dissected under direct vision.
Should there be notable bleeding from the posterior
maxilla, usually the result of injury to the greater
palatine artery, a gauze sponge is placed for tampon-
ade of one side while the surgeon addresses the other
side (Fig. 7-6). The maxilla is held in the
downfractured position with a bone hook placed on
the anterior maxilla; the cobra retractor is placed
laterally and posteriorly. The bleeding vessel is ex- pedicle, which provides the blood supply for the
posed with the use of bone rongeurs and pituitary mobilized jaw (Fig. 7-7). Any necessary trimming of
rongeurs to remove the posterior wall of the maxilla; bone can be readily achieved, utilizing rongeurs or a
control of hemorrhage is then achieved wih electro- large round bur, while protecting the soft tissues with
cautery or, preferably, vascular clips. The first side is the cobra retractor laterally and posteriorly and a
then packed, and any bleeding on the opposite side Langenbeck retractor medially. For trimming and
can then be controlled in an identical fashion. adjusting bony projections in the midline of the nasal
Complete access to the maxilla is now achieved floor, an Obwegeser channel retractor placed over the
with a dry field and with protection of the soft tissue posterior nasal spine provides excellent access and
protection.
MAXILLARY OSTEOTOMIES 79
80 MAXILLARY OSTEOTOMIES
Where the orthodontic preparation is such that
segmental surgery is necessary in the maxilla, trans-
verse or longitudinal osteotomies may now be carried
out (Fig. 7-8). An oscillating saw is most useful for
making transverse cuts across the nasal and antral
floors, whereas the reciprocating saw is used for
making longitudinal cuts through the nasal floor on
one or both sides. In either case, great care must be
taken that the cut is made only through the bone;
preservation of the integrity of the palatal soft tissue
is of critical importance for maintaining the vitality
of the dentoalveolar structures. Completion of seg-
mental osteotomies interdentally is accomplished with
absolutely minimal detachment of mucoperios-teum;
a thin osteotome can be malleted through the alveolar
bone or the basal bone can be levered with a larger
osteotome to create a greenstick fracture of the
alveolus.

Figure 7-9
The acrylic template prepared at the time of the
model surgery is now secured to the upper teeth to
maintain the mobilized segments in position, restoring
the maxilla to a single unit for manipulation.
The maxilla is now positioned into the desired
location, utilizing the previously made reference
marks or an interocclusal splint for orientation (Fig. 7-
9). With the maxilla temporarily fixed to the man-
dibular dental arch, the maxillomandibular complex is
rotated, carefully maintaining the physiologic position
of the condyles, until the maxilla is firmly, but
passively, repositioned. Additional careful trimming
MAXILLARY OSTEOTOMIES 81
of the superior surfaces of the maxilla is carried out
until passive repositioning can be achieved. Particular
attention must be paid to any tendency to deflect the
nasal septum as the maxilla is raised; a groove or
channel must be made in the nasal floor to
accommodate the septum, or the lower portion of the
septum itself may be trimmed. Where there has been
planned intrusion of the anterior maxilla, trimming of
the bone anteriorly at the nasal sill may be required to
avoid encroachment on the nasal airway, if this bone
has not already been removed in the initial horizontal
bone cuts.
82 MAXILLARY OSTEOTOMIES
Fixation of the maxilla in the desired position is
achieved either with direct interosseous wires or with
titanium mini plates (Fig. 7-10). The wires or plates
are placed at the pyriform rims and the zygomatic
buttresses bilaterally. The choice between the use of
wires or mini plates is a function of the surgeon's
preference, the quality of the bone, the anatomic
shape of the lateral maxillary wall, and the nature of
the osteotomy movement.
For the inferiorly repositioned maxilla, the use of
mini plates to span the gap created in the lateral
maxilla is mandatory; autologous bone grafts are
trimmed and wedged into the gaps. Where a stepped
relationship between the upper and lower sides of the
osteotomy has been created at the sites of fixation,
whether the result of maxillary advancement or
widening, mini plates are also advantageous in main-
taining the desired position more easily than is pos-
sible with interosseous wires.
Suspension wires from the infraorbital rim, the
pyriform rim, or the zygomatic buttress have often
been described as supplements to the direct wiring,
but they have little value with present fixation tech-
Figure 7-10
niques. Although some surgeons have in the past used
suspension wires alone as the means of fixation, such
indirect techniques offer no advantages and pose the
distinct disadvantage of being very imprecise.
Once the fixation has been applied, it is critical to
recheck the midline position of the maxillary incisors
relative to the philtrum of the upper lip. The attach-
ments to the mandibular arch must also be released at
this point to check for passive return of the mandible
to the desired occlusion with the maxilla in its new
position. The fixation of the maxilla must be adjusted
or replaced until the correct position and relationship
with the mandible can be confirmed.
The incision is closed in running fashion with a
single mucosal resorbable suture. Simple closure is
adequate for most patients, but attention must be paid
to any tendency to inversion of the vermilion of the
upper lip, in which case V-Y closure of the mucosa
may be employed.
If a mandibular osteotomy is being performed
during the same surgery, this procedure is now
completed. When the pharyngeal pack has been
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.
 MAXILLARY OSTEOTOMIES 83

MODIFICATIONS OF THE BASIC

TECHNIQUE
The horizontal osteotomy of the lateral maxillary
wall (described previously) is applicable in the ma-
jority of cases and can produce a stable result. Mul-
tiple modifications of the basic osteotomy design
have been described and are useful in special cases.
In patients with nasomaxillary deficiency, the lateral
maxillary osteotomy can be performed high on the
lateral wall, passing from the pyriform aperture to
the zygoma just beneath the infraorbital foramen
(Fig. 7-11). At the zygoma the osteotomy is continued
in a vertical direction to the level of the antral floor,
where it is again turned horizontally and posteriorly
to the pterygoid fissure. When the maxilla is
advanced, the gap that results at the vertical portion
of the osteotomy may be grafted with autologous
bone or occluded with struts of hydroxyapatite; in
many cases, the gap may be left unfilled and the
mobilized maxilla may be fixed rigidly with bone
plates.

II
84 MAXILLARY OSTEOTOMIES
Patients requiring pure vertical lengthening of the
maxilla or just anterior repositioning will be well
treated with the conventional horizontal osteotomy
(Fig. 7-12). However, patients needing simultaneous
advancement and lengthening will benefit from the
use of a sloped lateral maxillary osteotomy. The angle of
the slope in the portion of the osteotomy extending
posteriorly from the pyriform rim is determined by
scribing a triangle on the lateral maxilla: the base of
the triangle is the distance desired for anterior re-
positioning; the height of the right side of the triangle
equals the amount of lengthening planned; the os-
teotomy is performed horizontal to the hypotenuse of
the triangle. The posterior extent of the slope is
determined by the position of the infraorbital foramen
and the zygoma. At the zygoma, the osteotomy is
turned inferiorly and posteriorly to extend to the
pterygomaxillary fissure in the conventional fashion.
Upon completion of the total maxillary osteotomy, the
maxilla slides along the inclined plane of the lateral
maxillary wall until the desired position is achieved.
Rigid fixation with plates is necessary. The posterior
gap created by the advancement does not always
require placement of a bone graft; the sliding
osteotomy usually eliminates the need for a graft to
stabilize the downward movement.
PARTIAL MAXILLARY
OSTEOTOMIES
Anterior Segmented Maxillary
Osteotomy
Mobilization of the premaxilla alone has been a
popular surgical procedure for many years. It re-
mains applicable in patients with Class II malocclu-
sion and premaxillary excess. More rarely, the pro-
cedure may be used for isolated intrusion or extrusion
of the anterior dentoalveolar segment.
The approach described by Wunderer is most com-
monly used. The labial soft tissue attachments are
carefully preserved to maintain vitality to the seg-
ment while excellent access to the osteotomy sites is
achieved with vertical labial incisions and a trans-
verse palatal incision.
Following infiltration of the tissues of the labial
vestibule with a solution of 1:100,000 epinephrine, a
vertical mucoperiosteal incision is made in the bicuspid
area bilaterally (Fig. 7-13). A subperiosteal tunnel is
dissected forward to the pyriform rim approxi-
mately 5 mm above the level of the cuspid tooth
apex.

Figure 7-13
The buccal cortex of bone is cut with an oscillating
saw or a fissure bur, first vertically distal to the cuspid
and then horizontally to the pyriform rim above the
tooth apex. This osteotomy is completed bilaterally.
A transverse palatal incision is made, and the palatal
tissues are reflected posteriorly to enable the surgeon
to complete the transverse palatal osteotomy.
A short vertical incision is made directly over the
anterior nasal spine. Minimal dissection of the soft
tissues is performed to allow placement of an osteo-
tome to separate the premaxilla from the nasal septum.
The premaxillary segment can now be rotated
superiorly on its soft tisue pedicle, enabling the
surgeon to have direct access to the osteotomy sites for
any necessary trimming.
When the segment can be placed into its pre-
MAXILLARY OSTEOTOMIES 85
planned position, it is stabilized with a previously
prepared orthodontic wire or an acrylic occlusal splint
secured to the segment and the posterior teeth. The
incisions are then closed with interrupted resorbable
sutures.
Posterior Segmental Maxillary
Osteotomy
Isolated mobilization of the posterior maxillary
segments enjoyed widespread use prior to the intro-
duction of the total maxillary osteotomy. None of the
described approaches provided adequate access to the
medial and posterior areas of the maxilla. Con-
sequently, these procedures have generally been
abandoned in favor of the total maxillary osteotomy
to provide safer and more reliable surgery.
86 MAXILLARY OSTEOTOMIES

Surgically Assisted Rapid

Palatal Expansion
Although small amounts of transverse maxillary
deficiency can be corrected by longitudinal osteotomy
of the nasal floor at the time of total maxillary
osteotomy, larger amounts of correction or expansion,
which are necessary to relieve maxillary dental
crowding, are more readily achieved by the ortho-
dontist with the use of a rapid palatal expansion
(RPE) appliance. For younger patients, the appliance
alone is effective at accomplishing the increase in
width of the maxilla. In adults, resistance to expan-
sion is encountered at the zygomatic buttresses as the
appliance is activated, making surgical assistance
necessary.
Some surgeons have advocated a complete maxil-
lary osteotomy at the Le Fort I level together with a
midline osteotomy at the time of insertion of the RPE
appliance; such extensive surgery is not necessary
(Fig. 7-14). An alternative approach has been to
combine lateral maxillary oseotomies with a midline sinus to a point just anterior to the pterygomaxillary
split. The need for the midpalatal separation has been fissure. The incision is closed with a single layer of
questioned, based on experience with expansion of continuous resorbable suture.
cleft palate patients and on laboratory studies. The appliance is activated by two quarter turns at
Consequently, a relatively simple lateral maxillary the conclusion of the procedure; the patient is in-
osteotomy, performed with local anesthesia in the structed to advance one quarter turn each morning
outpatient setting, has been found to be most effective. and evening until the desired amount of expansion is
The RPE appliance is cemented in place preoper- achieved. Postoperative analgesics, antibiotics, and
atively. Following infiltration of the maxillary buccal sinus decongestants are provided.
sulcus with a solution of 1:100,000 epinephrine in 2%
xylocaine, a mucoperiosteal incision is made high in KEY REFERENCES
the sulcus. The periosteum is reflected to expose the
lateral maxillary wall. A fissure bur or a reciprocating Epker, B N , Fish, L C Dentofacial Deformities Integrated Or-
saw is then used to make a horizontal osteotomy in thodontic and Surgical Correction St Louis, C V Mosby Co
1986
that wall from the anterior extent of the maxillary Bell, W H , Proffit, W R , White, R P Surgical Correction of
Dentofacial Deformities Philadelphia, W.B Saunders Co., 1980