477
CLINICS IN
The Approach to Dentofacial
Skeletal Deformities Using
a Multisegmentation Technique
Karl-Erik Kahnberg, DDS, PhD, Dr Odonta,*,
Catharina Hagberg, DDS, PhD, Dr Odontb
- Orthodontic planning
- Surgical technique
- Postoperative orthodontic management
Today repositioning the maxilla to correct various
midfacial dentofacial skeletal deformities has be-
come a routine procedure. A single-piece maxilla
can be repositioned in the sagittal plane, impacted
or lengthened in the vertical plane, and rotated,
depending on the clinical situation. When patients
present with an anterior open bite, cross-bite, asym-
metry, or more complex deformities of the jaws,
however, the ability to multisegment the maxilla
can be an invaluable technique for the maxillofacial
surgeon. Although surgically assisted rapid palatal
expansion can correct transpalatal constriction, it
is limited in correcting the dental arch deformity in
a single transverse plane and requires a second surgi-
cal procedure to correct the deformity when it
coexists in other planes. Today the authors
preference is a multisegmentation approach that
corrects the dentofacial deformity in multiple
planes: transverse maxillary expansion and lowering
of the segmented palate while simultaneously cor-
recting the sagittal and vertical maxillarymandibu-
lar relationship (Figs. 1 and 2) [1].
At the Institute of Odontology at the Sahlgren-
ska Academy, University of Goteborg, multisegmen-
a
Department of Oral and Maxillofacial Surgery, Institute of Odontology, The Sahlgrenska Academy, Univer-
sity of Goteborg, Sweden
b
Department of Orthodontics and Jaw Orthopedics, Institute of Odontology, The Sahlgrenska Academy,
University of Goteborg, Sweden
* Corresponding author.
E-mail address: k-e_kahnberg@odontologi.gu.se (K-E. Kahnberg).
0094-1298/07/$ see front matter 2007 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 477484
- Complications
- Summary
- References
tation of the maxilla is well established and is ac-
cepted by the authors orthodontic colleagues
when presurgical orthodontic expansion is replaced
by surgical expansion at the time of the formal or-
thognathic procedure in most of patients. This ap-
proach, however, requires precise handling of oral,
gingival, and palatal mucosa to maintain an ade-
quate blood supply to the multiple segments follow-
ing manipulation and to ensure that each of the
dental arch segments remains adherent to the under-
lying periosteum. The most critical part of the proce-
dure is executing the interdental osteotomies. The
authors have found that it is technically easier to
make interdental osteotomies when the space be-
tween the teeth is narrow but large enough to allow
a thin osteotome to fit between the adjacent teeth.
Orthodontic planning
As with all orthognathic surgical procedures, the pa-
tients are managed by an experienced orthodontic-
surgical team. A successful outcome requires an
understanding of the limitations in what can be
achieved during the orthodontic presurgical
doi:10.1016/j.cps.2007.05.003
478 Kahnberg & Hagberg
treatment as well as the limitations for surgical pro-
cedures by each of the member of the team. Risks
for postsurgical relapse caused by factors such as oc-
clusal instability, changes in muscular function, and
tongue thrust should be considered in advance and
managed appropriately. Although the treatment
plan for each patient is unique, general guidelines
concerning presurgical orthodontics and maxillary
osteotomy with multisegmentation have evolved
based on the authors long-term experience. When
there is a transverse discrepancy between the maxil-
lary and mandibular dental arches, orthodontic ex-
pansion of the maxilla should be avoided when
surgery is planned. Otherwise, the authors have
found, the transverse width frequently is insuffi-
cient for orthodontic management alone. In many
instances segmentation is needed at the time of
Fig. 1. (AC) The patient
presented with a severely
constricted maxilla with
a high arched palatal vault.
Presurgical orthodontics in-
volved extraction of 1st pre-
molars to relieve crowding,
alignment, and leveling.
(D) No attempt was made
to correct the constricted
transverse width orthodon-
tically. (E) The occlusion and
(F) postoperative appear-
ance after multisegmental
maxillary surgery.
the surgery to coordinate the dental arches ideally.
Although other centers may prefer to diverge the
dental roots to facilitate interdental osteotomies,
the orthodontists at the authors center do not rou-
tinely diverge the roots, because the authors usually
feel comfortable performing the interdental osteot-
omies without that procedure. When space at the
dental level must be closed surgically, however, it
is important to have sufficient space between the
roots to execute this closure at the time of the surgi-
cal procedure.
In cases with an anterior open bite, the presurgi-
cal orthodontics should be planned to close the
open bite with the surgical procedure, and no at-
tempt should be made to close the bite with
orthodontic mechanics. Thus it is important to
assess overbite and overjet continuously during

the presurgical treatment phase with serial photo-
graphs, radiographs, and dental models. To
perform necessary tooth movement (eg, to align
the teeth or close spaces after extraction), many or-
thodontists prefer to use segmented arch wires.
When a nonsegmented wire technique is used, ver-
tical steps or sweep is necessary to maintain the
open bite vertically. When the open bite has been
reduced orthodontically, it is essential that a sec-
tional wire be used in the maxilla in the last 2 to
3 months before surgery to avoid relapse. Section-
ing the arch wire allows the open bite to become ev-
ident before surgery. This precaution is essential to
avoid postsurgical relapse. The arch wire must be
passive and not cause any undesired tooth move-
ment at the time of the final surgical planning [2].
When the patient comes to surgery, the final arch
The Approach to Dentofacial Skeletal Deformities 479
Fig. 2. The patient pre-
sented with (A) a long-face
syndrome, (B) an anterior
open bite deformity, and
(C) a constricted maxilla.
(DF) The postoperative re-
sult after a multisegmented
maxilla with simultaneous
mandibular surgery.
wire should be a rectangular stainless steel arch
wire, typically 0.019  0.025, sectioned accord-
ing to the treatment plan with surgical hooks
placed in as many interdental spaces as possible
within each of the sections. Another source of er-
ror is bonding brackets in the region of the
lower incisors too close to the incisal edge. These
brackets need to be repositioned to achieve an
appropriate overbite at the time of surgery to
avoid interference with the bracket placement.
Additionally, the second molars must be banded
in both the upper and lower jaw. In the upper
jaw care must to be taken not to extrude or tip
the molars buccally; otherwise, the palatal cusp
will result in interference when the surgical oc-
clusion is achieved. Serial dental casts should
be used to follow the progress of the
480 Kahnberg & Hagberg
orthodontic treatment and for the timing of
surgery. Model surgery with segmentation should
be performed to simulate the surgery and to
ensure coordination of the dental arches (Fig. 3).
Surgical technique
Maxillary osteotomy according to the LeFort I
method is made in a routine fashion after
Obwegeser. An oral mucosal vestibular incision is
made above the attached gingiva. The maxilla and
nasal piriform are exposed in the subperiosteal
plane. An osteotomy of the maxilla is made section-
ing the medial, anterior, and posterior lateral walls.
The septum is separated from the vomer. The
Fig. 3. Model surgery: The maxillary dental cast is seg-
mented to improve the arch form and coordinated
with the mandibular dental arch. An occlusal splint
is fabricated and used in the operative procedure to
replicate the model surgery.
vertical interdental osteotomies then are made. De-
pending on the surgical orthodontic plan, these os-
teotomies can be between the canine and the first
premolar, between the lateral incisor and the ca-
nine, or between the central incisors. The osteoto-
my is not completed fully but covers about two
thirds of the distance. The vertical interdental os-
teotomy is initially done with a fine Lindemann
burr and then is completed with a very thin osteo-
tome. The pterygoid process then is separated
from the palatine bone. The maxilla is downfrac-
tured and then fully mobilized maximally to gain
access to the hard palate. In a four-piece maxilla, os-
teotomies are made on both sides of the midline,
one on each side parallel to the residual septum re-
sulting (Fig. 4); and in six-piece maxilla, two osteot-
omies are made on each side of septum (Fig. 5) [1].
When needed, it also is possible to make an osteot-
omy between the central upper incisors to widen
the arch between the cuspids. This procedure results
in a seven-piece maxilla (Fig. 6). An occlusal wafer
is placed, as determined in the model surgery, and
the patient is placed in maxillary-mandibular fixa-
tion. The bone segments then are fixed with tita-
nium plates and screws. Iliac bone graft is placed
in the vertical gaps when the osteotomy gap exceeds
2 to 3 mm. Bone graft from the iliac crest normally
is used when the maxilla is sagitally and/or verti-
cally repositioned with a discrepancy between max-
illa and midface of more than 3 to 4 mm.
Otherwise, the authors fill small postoperative in-
terdental spaces with bone fragments from the pos-
terior sinus wall.
With due care to avoid injury to the periosteum
and maintenance of the vascular supply through-
out the procedure, these osteotomies allow the sur-
geon to correct the maxillary deformity in multiple
planes simultaneously with the transverse expan-
sion of the maxilla and vertical corrections be-
tween the anterior and posterior segments of the
maxilla. With this approach it is possible to correct
various open-bite deformities and transverse dis-
crepancies at the time of the surgical procedure,
avoiding multiple staged surgical procedures and
increased orthodontic treatment time. This ap-
proach, however, requires intraoperative precision
and attention to the vascular supply of the multi-
ple segments.
Postoperative orthodontic management
As soon as the intermaxillary fixation and the oc-
clusal wafer have been removed by the surgeon,
typically at 8 weeks, the orthodontist sees the
patient. The sectioned wire in the upper jaw
then is changed to a continuous (nonsectioned)

Fig. 4. Osteotomies are made on both sides of the palate resulting in a four-piece maxilla.
passive rectangular steel wire to maintain stability
when the patient returns to normal oral-motor
functioning.
The occlusion can be guided by using light elas-
tics or rectangular boxes in a class II or III direction
depending on the original sagittal relationship be-
tween the jaws. When the authors believe there is
an increased risk for relapse in open-bite defor-
mities, they prefer using light dental elastics at the
anterior segment during the night. After an initial
phase of changeable elastics for guidance of the oc-
clusion, the final orthodontic adjustments can be
performed to maximize coordination of the dental
arches. As with single-segment maxillary cases, the
orthodontic treatment is completed approximately
6 months after surgery. The patients are followed
with serial radiographs including periapical films
to assess the dentition adjacent to the interdental
osteotomy sites.
The orthodontic retention principles are the
same as those in nonsurgical orthodontic cases.
Normally retention is maintained by the use of
bonded lingual retainers in both the upper and
lower anterior dental segments between the ca-
nines. Retention plates are used to preserve the
transverse expansion of the maxilla. Because of
the significant change in the muscular function in
their chewing, swallowing, and breathing patterns,
these patients should be followed more frequently
and for a longer period of time once they are in
the retention period. Close follow-up can result in
earlier detection of relapse that may be related to
The Approach to Dentofacial Skeletal Deformities 481
function, and functional orthodontic appliances
can be used to minimize relapse.
Complications
The authors have had nearly 30 years experience in
multisegmenting the maxilla. Their studies focusing
on the complication rate and tendency for relapse
have confirmed the stability of the surgical ap-
proach and the paucity of complications [3]. Today
321 maxillas have been segmented; complications
have occurred in less than 3% of these cases. The
stability of transverse widening has been examined
in a follow-up study using both clinical assessment
and study cast models. Although a small degree of
relapse does occur in the transverse direction, it is
thought to be within the acceptable limits of ortho-
dontic stability [4].
In a recent publication the first author and col-
leagues [3] analyzed the frequency of complications
associated with segmentalization of the maxilla.
Eighty-two consecutive patients who underwent
dentofacial correction by segmented maxillary os-
teotomy alone or in combination with simulta-
neous mandibular surgery between 1992 and
1998 were followed for up to 30 months postoper-
atively. A total of 158 interdental osteotomies were
performed, involving a total of 316 teeth. In this se-
ries the investigators found only a small number of
complications, which included osteolytic processes,
marginal bone destruction, root resorption, or
482 Kahnberg & Hagberg

Fig. 5. (A) Additional parallel palatal osteotomies can be made resulting in a six-segment maxilla. (B) The addi-
tional parallel palatal osteotomies in the six-piece maxilla allow greater expansion and flexibility of the dental
segments and simultaneously lower a high-vaulted palate. Care is taken to not strip off the palatal mucosa.

Fig. 6. An additional osteotomy between the central incisors allows expansion of the anterior segment to correct
the canine width.
 The Approach to Dentofacial Skeletal Deformities 483

Fig. 7. (A, B) No adverse affects are seen in the periapical radiographs at 30 months after interdental osteotomies
distal to the canines on both sides. In contrast, in another case, there is a small loss of approximately 3 mm of
marginal bone distal to the canine between the (C) preoperative and the (D) postoperative periapical at 30
months. (E) A periapical radiograph of iatrogenic damage 30 months postoperatively; however, there is no ev-
idence of osteolysis or resorption around either the remaining root or the root fragment.

mechanical injuries to the teeth (Fig. 7). They

found root resorption after surgery in eight teeth,
four of which were in a single patient. This finding
should be considered in the context of the 31 teeth
that were observed to have root resorption before
the surgery. Three teeth were injured directly by sur-
gical trauma, but all three were healthy at 30
months despite the root transection. The reader
can find further details in the investigators report
[3].
Summary
This article describes the authors approach to cor-
recting dentofacial skeletal deformities requiring
multisegmentation of the maxilla. Achieving opti-
mal results requires a close collaboration within
the orthodontic-surgical team. The importance of
attention to detail in the course of the surgical pro-
cedure cannot be overemphasized, because compli-
cations of avascular necrosis cannot be corrected
484 Kahnberg & Hagberg
easily. The multisegmental maxilla is a valuable
technique and adds to the versatility of the LeFort
I in the treatment of open bite and transverse dis-
crepancies in dentoalveolar deformities.
References
[1] Krekmanov L, Kahnberg KE. Transverse surgical
correction of the maxilla. J Craniomaxillofac
Surg 1990;18:3324.
[2] Proffit WR, White RP Jr. Combined surgical-ortho-
dontic treatment: who does what, when? In: Sur-
gical orthodontic treatment. Mosby-Year book,
Inc; 1990. p. 192224.
[3] Kahnberg KE, Vannas-Lofqvist L, Zellin G. Com-
plications associated with segmentation of the
maxilla: a retrospective radiographic follow-up
of 82 patients. Int J Oral Maxillofac Surg 2005;
34:8405.
[4] Kahnberg KE. Transverse expansion of the maxilla
using a multisegmentation technique. Scand J
Plast Reconstr Surg Hand Surg, in press.