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Orthognatic Surgery

Maxillary surgery
1. Segmental osteotomy of the maxilla
2. Total maxillary osteotomy

Mandibular surgery
1.Ramus osteotomy
2. Body osteotomy of mandible
3. Subapical body osteotomy
4. Genioplasty

The elements of the facial skeleton can be repositioned, redefining the face
through a variety of well-established osteotomies, including Le Fort I-type
osteotomy, Le Fort II-type osteotomy, Le Fort III-type osteotomy, maxillary
segmental osteotomies, sagittal split osteotomy of the mandibular ramus, vertical
ramal osteotomy, inverted L and C osteotomies, mandibular body segmental
osteotomies, and mandibular symphysis osteotomies.
Most maxillofacial deformities can be managed with 3 basic osteotomies:
the mid face with the Le Fort I-type osteotomy, the lower face with the sagittal
split ramal osteotomy of the mandible, and the horizontal osteotomy of the
symphysis of the chin.

Mid face
Various osteotomies are used to correct midfacial deformities, and the
choice of procedure depends on the specific deformity. The Le Fort osteotomies
are named after the 3 classic lines of weakness of the facial skeleton described by
Rene Le Fort in 1901. Complete craniofacial dysjunction by the Le Fort III
osteotomy allows the surgeon to alter the orbital position and volume, zygomatic
projection, position of the nasal root, frontonasal angle, and position of the
maxilla and to lengthen the nose. The Le Fort II osteotomy allows the surgeon to
alter the nasomaxillary projection without altering the orbital volume and
zygomatic projection. The Le Fort I osteotomy allows for correction primarily at
the occlusal level affecting the upper lip position, nasal tip and alar base region,
and the columella labial angle without altering the orbitozygomatic region.
Nevertheless, remember that these standard Le Fort osteotomies frequently
must be modified to address the specific clinical situation. For example, modify
the standard Le Fort I osteotomy to include a portion of the body of the zygoma
when the lower maxillary deficiency is accompanied by inadequate zygomatic
projection but the orbit does not require alteration as it does in a Le Fort III. A
modified, high Le Fort I osteotomy is often used when performing midfacial
advancement for patients with cleft lip and palate. In addition to providing more
malar projection, a downward sloping osteotomy elongates the nasolabial region,
which is frequently short in the patient with a cleft. The Le Fort II and III
osteotomies generally are part of the treatment plan in the major craniofacial

dysotosis syndromes and are described elsewhere. For most midfacial


maxillofacial deformities, the Le Fort I osteotomy and its variations are adequate.

Lower face
For the lower face, various osteotomies are used to correct mandibular
deformities, and the choice depends on the particular deformity. Currently, the
sagittal split ramal osteotomy is the primary choice for correcting most cases of
mandibular retrognathism and prognathism. In extreme cases of mandibular
prognathism, some surgeons prefer the intraoral vertical osteotomy or the inverted
L osteotomy. In situations of mandibular advancement in which the mandibular
rami is hypoplastic and cannot be sagittally split, the inverted L and the C
osteotomy with bone grafts are preferred. Deformities of the chin can exist
independently of mandibular deformities, and the chin can be abnormally
proportioned without occlusal involvement.
While alloplastic chin implants are used most commonly for correction of
minimal sagittal chin deficiencies, the horizontal osteotomy of the symphysis
(osseous genioplasty) is a far more versatile procedure. The chin can be
repositioned in multiple planes, allowing for correction of significant sagittal and
vertical deformities of deficiency (microgenia) or excess (macrogenia) and
asymmetric conditions.

REFERENCES

Patel, P.K.; Gassman, A.; Morris, D.E.; Zhao, L. 2012. Orthognathic Surgery
Treatment

&

Management.

Available

http://emedicine.medscape.com/article/1279747-treatment#a1128

at:
(accessed

February 2012).

Balaji., S.M. 2007. Textbook of Oral and Maxillofacial Surgery. India. Elsevier
India.