Maxillary Orthognathic Surgery: Richard E. Bauer III,, Mark W. Ochs

Ma x illar y O rthog n at hic
Surgery
Richard E. Bauer III, DMD, MD*, Mark W. Ochs, DMD, MD
KEYWORDS
LeFort Osteotomy Maxilla Orthognathic surgery Dentofacial deformity
KEY POINTS
Maxillary manipulation for a skeletal malocclusion is a common surgical procedure with many var-
iations that can optimize outcomes.
When combined with perioperative orthodontic treatment, planning maxillary surgery can be an
effective way to maximize aesthetics and function.
Landmark studies have showed the safety of maxillary surgery and now new technologies are tak-
ing effectiveness and efficiency to a new level.
BACKGROUND phenomenon and osseous healing after total

maxillary osteotomy.
A German von Langenbeck is credited with
the first maxillary osteotomy performed in
SEGMENTAL MAXILLARY SURGERY
1859 to access the nasopharynx.1
Surgically Assisted Rapid Palatal Expansion
Wassmund performed the first maxillary
osteotomy for orthognathic purposes in Indications for Surgically Assisted Rapid Palatal
1927.2 Expansion (Fig. 1)
Schuchardt separated the pterygomaxillary Transverse deficiency with high palatal vault
junction for complete mobilization of the Arch length discrepancy especially where
maxilla and adequate anterior repositioning.3 arch length is needed in the anterior
Obwegeser popularized the maxillary LeFort No other vertical or anteroposterior
osteotomy in the 1960s4; however, anesthetic abnormalities
techniques, specifically hypotensive anes- Teeth completely blocked out of the arch
thesia, had not been modernized and the Advantages
risk of bleeding with down-fracturing of the Good stability
maxilla was great.5 Can be done in an outpatient setting
Bell provided the first scientific basis for the Le Disadvantages
Fort I down-fracture. Microangiographic evi- Need for palatal expander preoperatively
dence suggested that bilateral severance of (Fig. 2)
the descending palatine vessels does not Patient compliance is a necessity
compromise the blood supply to the mobi- Unaesthetic transitional period during consol-
lized maxilla.6 Subsequently, Bell and col- idation (Figs. 3 and 4)
oralmaxsurgery.theclinics.com
leagues7 demonstrated the revascularization Second surgery likely
Department of Oral and Maxillofacial Surgery, University of Pittsburgh Medical Center, Eye and Ear Institute,
203 Lothrop Street, Suite 214, Pittsburgh, PA 15213, USA
* Corresponding author.
E-mail address: bauerre@upmc.edu
Oral Maxillofacial Surg Clin N Am 26 (2014) 523–537

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524 Bauer III & Ochs
Fig. 1. Anterior and posterior transverse discrepancy with significant crowding.
Fig. 2. Orthodontic appliances and palatal expander.
Fig. 3. Consolidation phase.
Fig. 4. Post orthodontic leveling and aligning.
Maxillary Orthognathic Surgery 525
Procedure Pearls
Standard LeFort osteotomy soft tissue
approach and dissection
High and flat osteotomies to prevent vertical
changes with expansion (Fig. 5)
- May need to relieve lateral buttresses to
prevent interference with expansion (see

Fig. 5, arrows)
Paramedian segmental osteotomy: Thinner
palatal bone with thicker soft tissue Fig. 6. Dual plane of occlusion.
Pterygomaxillary and nasal septum separa-
tion for mobility and symmetric widening
Segmental LeFort Osteotomy

Indications for Segmental LeFort Osteotomies
Transverse deficiency primarily in the
posterior
Combined transverse discrepancy with ante-
roposterior and/or vertical abnormalities
Dual plane of occlusion (Fig. 6)
Advantages
Good stability with preoperative planning and
orthodontic–surgical coordination
- May need intraoperative placement of a
maxillary splint or composite bonding of

Fig. 7. Maxillary splint with palatal strap.
brackets at interdental osteotomy sites
(Figs. 7 and 8)
- May need postoperative transpalatal arch
wire or auxiliary arch wire (Figs. 9 and 10)

Single surgery
Disadvantages
Need for good orthodontic–surgical postop-
erative coordination for stability
Potential need for occlusal splint
postoperatively
Need for grafting maxillary widening defects
(Fig. 11)
Fig. 8. Composite resin cured over segmented arch
May need to consider repositioning orthodon-
wire. Arrows indicate composite resin placed intrao-
tic brackets postoperatively if segmental me- peratively after fixation and closure.
chanics were used preoperatively
Procedure Pearls
Standard LeFort osteotomy soft tissue
approach and dissection
Fig. 5. Intraoperative osteotomies. Arrows indicate

areas of extra reduction. Fig. 9. Postoperative transpalatal arch wire.
Fig. 12. Horseshoe palatal osteotomy.
ANTERIOR OPENBITE CLOSURE

Differential Impaction
Fig. 10. Postoperative auxiliary arch wire.
Ideal for single occlusal plane in the maxillary
arch (Fig. 15)
- Extend soft tissue dissection to the level of
Advantages
designed interdental osteotomies
Single piece Lefort osteotomy
Complete interdental osteotomies before
Not as technically demanding as multipiece
downfracture
surgery
Paramedian segmental osteotomy for 2-piece
Multipiece complications are not a factor
Lefort osteotomies
Shorter operative time
- Thinner palatal bone with thicker palatal
No need for postoperative splint or special or-
soft tissue
thodontic considerations
- Good for small expansions only
Disadvantages
Palatal horse shoe osteotomies for larger
Less control of the occlusal plane
transverse corrections (Fig. 12)
May have increased relapse potential from an
- Divides tension and vectors over several
orthodontic standpoint owing to preoperative
sites
leveling and aligning into a single arch form
- Thinner palatal bone with thicker palatal
Significant rotational changes at the anterior
soft tissue
nasal spine may result in poor aesthetic
- Fully mobilize the maxillary segments and
outcome
undermine the palatal tissues (Fig. 13)
Secure maxillary segments into maxillary
Multipiece Lefort Osteotomies
splint
- Passive fit into splint is imperative to mini- Ideal for dual or multiple occlusal planes in the
mize torqueing cusps into the splint and maxillary arch (Fig. 16)
to minimize relapse potential Advantages
- Ensure there are no bracket–splint Complete control of postoperative occlusal
interferences plane
Consolidate maxillary segments with rigid Provides the orthodontist preoperative
fixation and graft expansion defects before freedom to align arch segments without risk-
establishing vertical positioning by reducing ing relapse by forcing into a single arch form
bony interferences and rigidly fixating Control of bony segments to prevent un-
(Fig. 14) wanted aesthetic changes
Fig. 11. (A, B) Cadaveric graft in place at expansion defects. Arrows indicate cadaveric grafts in situ.
Fig. 13. (A, B) Mobilization of segments and undermining of palatal tissues.
Disadvantages
Longer operative time and technically more
demanding surgery
Need for postoperative stabilization of seg-
ments (splint, transpalatal arch wire, etc; see
Figs. 7–10)
Procedure Pearls
Accurate bite registration is paramount when
combining with mandibular surgery; ensure
that first contact occlusion is captured as
many of these patients have centric relation–
centric occlusion shifts due to best fit occlu-
sions (Fig. 17)
External skeletal reference for measurement
of vertical position intraoperatively (Fig. 18)
Plan on reducing heavily at maxillary crest and
Fig. 14. Consolidate maxillary segments before estab- junction of palatine bones medially (Fig. 19)
lishing the vertical position. Arrows indicate rigid fix- Cauterize the descending palatine vessels in a
ation joining maxillary segments. controlled fashion especially with significant
Fig. 15. Single maxillary occlusal plane. Fig. 16. Dual maxillary occlusal plane.
Fig. 17. (A, B) Bite registration for anterior open bites.
posterior impaction or large multipiece move- Procedure Pearls

ments (Fig. 20) Perform horizontal osteotomies at a level that
When checking for bony interferences, apply allows for bony reduction and adequate room
pressure only at the gonial angles to prevent for fixation above tooth roots
distracting the condyles from the fossa Perform inferior turbinectomies with maxillary
Consider larger/stouter rigid fixation plates impactions (Fig. 24)
Must consider vertical reduction of the nasal
TREATING VERTICAL MAXILLARY EXCESS floor (prevents nasal septum deviation) and
anterior nasal spine
Considerations Lip anatomy may require modification of
Carefully evaluate closure (ie, V-Y closure, mucosal resection
- Vertical excess—measure the incisor show
to prevent thinning of the lip, etc)
at rest and full smile
- Lip animation—the upper lip may “un-
drape” the maxilla and thin upon full smile

(Fig. 21)
- Zone of attached gingiva—the presence of
gingival hyperplasia may lead to an erro-

neous diagnosis of maxillary excess
Base the surgical plan on the rest position of
the upper lip
Even though the maxilla is in excess, these
patients tend to have constricted nasal
airways
Vertical impaction may position the incision
such that closure will cause thinning of the up-
per lip; modification by resection of excess
mucosa to “even” incision margins will pre-
vent stretching the upper lip inward (Figs. 22 Fig. 19. Adequate bony reduction to eliminate
and 23) interferences.
Fig. 18. External skeletal reference for maxillary verti- Fig. 20. Cauterization of the palatine vessels. Arrow
cal changes/reference. indicates greater palatine vessels.
Fig. 21. “Undrape” of the maxilla on full smile.
Fig. 22. Upper lip distortion with vertical impaction. Small arrow indicates movement of labial mucosa to close
incision following maxillary impaction. Large arrow indicates unwanted flattening and rolling of vermillion.
The right side of the image is the unwanted aesthetic outcome.
Fig. 23. (A, B) Mucosal resection to prevent lip distortion.
Fig. 24. (A, B) Inferior turbinectomies and mucosal closure.
Fig. 25. (A–C) Gingival recontouring after maxillary surgery.
Fig. 26. (A–C) Miter block grafts to fit tightly to increase stability.
Fig. 27. Right and left maxilla with autogenous iliac crest bone graft and fixation.
Fig. 28. (A). Cadaveric autogenous iliac crest bone graft. (B). Cadaveric autogenous iliac crest bone graft with
bone morphogenetic protein on absorbable collagen sponge.
Gingival resection/reductions should be Maxillary downgrafts

done as a second stage surgery once the - Autogenous anterior iliac crest for interpo-
swelling from the maxillary surgery has sitional blocking grafts (Fig. 27)
resolved to maximize aesthetic outcomes - Cadaveric iliac crest allografts for interposi-
(Fig. 25) tional blocking grafts (with or without re-

combinant human bone morphogenetic
BONE GRAFTING AT THE TIME OF protein-2; Fig. 28)
MAXILLARY SURGERY INFUSE (Medtronic, Minneapolis, MN,
USA) use in this case would be consid-
Indications ered extended clinical use and is an off-
Segmental maxillary surgery with expansion label procedure
defects - For both autogenous grafting and cadaveric
Maxillary downgrafting grafting, it is important to miter the block

Maxillary clefts graft into a well-fitting interpositional graft
Considerations that can be incorporated into the rigid fixa-
Maxillary expansion defects tion for maximum stability (see Figs. 26–28)
- Graft with cortical cadaveric iliac crest Maxillary clefts
“matchsticks”; modify size and shape to - With surgical movement, treatment plan as
maximize stability (Fig. 26) you would any other case
Fig. 29. Excess maxillary arch length.
Fig. 30. Maxillary anterior protrusion with class III

relationship molars.
Fig. 31. Maxillary vertical excess.
Fig. 32. (A, B) Resection of excess arch length.
Fig. 33. Cut then rasp the resected ends.
Is there vertical maxillary excess that requires

the maxilla to move up and back to correct the
deformity (Fig. 31)?
Is there a single plane or dual plane of
occlusion?
Procedure Pearls
Treating excess arch length
Consolidate dentition and maintain space
at the desired location in the arch preoper-
atively (see Fig. 29)
Multipiece maxillary surgery except that the
plan is to resect the excess space at the
time of surgery (Fig. 32)
Cut then remove and rasp the area of
resection (Fig. 33)
Splint design is of utmost importance; be
sure to allow 1 mm of interdental space at
the area of resection to allow easier fit of
Fig. 34. Splint design with 1 mm of excess space at the segments into the splint (Fig. 34).
site of resection. Good rigid fixation and postoperative
maxillary splint for stability (Fig. 35)
Treating Maxillary Protrusion
- Fully mobilize maxilla and treat as a Extract first maxillary premolars at time of
segmental maxillary surgery surgery
- Bone graft expansion defects as well as Multipiece maxillary surgery except that the
cleft site as mentioned plan is to resect the residual socket site and
- Rigid fixation and strongly consider a close the space at the time of surgery (see
maxillary postoperative splint Fig. 32)
Cut then remove and rasp the residual
TREATING ARCH LENGTH INCOMPATIBILITY socket site (see Fig. 33)
AND MAXILLARY PROTRUSION Splint design same as mentioned in excess
arch length (see Fig. 34)
Evaluate true nature of deformity Reduce and sculpt piriform rims for aes-
Is there excess arch length (Fig. 29)? thetics (see Fig. 34; Figs. 36 and 37)
Is there protrusion of the anterior maxilla Good rigid fixation and postoperative
(Fig. 30)? maxillary splint for stability (see Fig. 36)
Fig. 35. Rigid fixation and immediate postoperative film showing maxillary splint wired to maxillary arch wire.
Fig. 36. Rigid fixation and postoperative maxillary splint.
Moving the Maxilla Up and Back Reduce the piriform rim and anterior nasal
If present, leave the maxillary third molars floor vertically 60% to 80% of the total
and plan on removing at the time of surgery planned movement
because this will eliminate a significant Reduce and miter carefully; bone contact is
amount of surgical bone reduction intrao- key for stability
peratively (see Fig. 31) Adapt zygomatic buttress L-plates as far
Need to reduce posterior edge of maxilla, posterior as possible and/or consider posi-
anterior pterygoid plates and clip or tional screws (Fig. 38)
cauterize the greater palatine vessels (see
Figs. 19 and 20) COMPUTER-ASSISTED PLANNING AND
Evaluate the arc of closure in maxilloman- SPLINT FABRICATION
dibular fixation to get to desired vertical
and appropriate reduction Imaging allows improved understanding of
Fully mobilize the maxilla deformities in multiple dimensions
Fig. 37. Preoperative and postoperative occlusion after premolar extraction and closure of space surgically.
Fig. 38. (A, B) Maxillary fixation with plates and/or positional screws.
Fig. 39. (A, B) Anatomic relationships clearly understood before surgery. Red circles indicate areas of overlap
(posterior) and expansion (anterior).
Fig. 40. (A, B) Intraoperative splints for maxillomandibular fixation. Splints may also be used for postoperative
stability.
Fig. 41. (A–C) Interdental osteotomy guide.
Fig. 42. (A–C) Interdental osteotomy guide technique.
Virtual planning is developing into the stan- 2. Wassmund M. Frakturen und Lurationen des Ge-
dard for treatment of complex dental and sichtsschadels. Berlin: 1927.
facial reconstructions 3. Schuchardt D. Ein Beitrag zur chirurgeschen Kiefer-
Virtual planning provides insight to anticipated orthopadie unter Berucksichtigung ihrer Bedertung
anatomic relationships at osteotomies before fur die Behandlung angeborener und erworbener
surgery, allowing for efficient and detailed Kieferdeformitaten bei Soldaten. Deutsch Zahn
preoperative plans (Fig. 39) Mund Kieferheilkd 1942;9:73.
Laboratory time can be eliminated with accu- 4. Obwegeser HL. Eingriffe an Oberkiefer zur Korrektur
rate splints fabricated for intraoperative des progenen. Zahnheilk 1965;75:356.
maxillomandibular fixation; splints can be 5. Fonseca RJ, Marciani RD, Turvey TA. 2nd edition.
fabricated to individual specifications (ie, Oral and maxillofacial surgery, vol. 3. St Louis
sandwich splints for multipiece double jaw (MO): Saunders; 2009. p. 171.
surgery or addition of a palatal strap for maxil- 6. Bell WH. Revascularization and bone healing after
lary widening; Fig. 40) anterior maxillary osteotomy: a study using adult
Accurate and efficient interdental osteotomy rhesus monkeys. J Oral Surg 1969;27:249.
guides can be fabricated from the patient 7. Bell WH, Fonseca RJ, Kennedy JW, et al. Bone heal-
data to prevent root damage (Figs. 41 and 42) ing and revascularization after total maxillary osteot-
omy. J Oral Surg 1975;33:253.
REFERENCES
RECOMMENDED READING
1. von Langenbeck BV. Beitrage zur Osteoplastik-Die
osteoplastische Resektion des Oberkiefers. In: Fonseca RJ, Marciani RD, Turvey TA. 2nd edition. Oral
Goschen A, editor. Deutsche Klinik. Berlin: Reimer; and maxillofacial surgery, vol. 3. St Louis (MO): Sa-
1859. unders; 2009. Chapters 7 and 8.

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Ma x illar y O rthog n at hic

BACKGROUND phenomenon and osseous healing after total

leagues7 demonstrated the revascularization  Second surgery likely

Oral Maxillofacial Surg Clin N Am 26 (2014) 523–537

Fig. 1. Anterior and posterior transverse discrepancy with significant crowding.

Fig. 2. Orthodontic appliances and palatal expander.

Fig. 3. Consolidation phase.

Fig. 4. Post orthodontic leveling and aligning.

prevent interference with expansion (see

Segmental LeFort Osteotomy

maxillary splint or composite bonding of

wire or auxiliary arch wire (Figs. 9 and 10)

Fig. 5. Intraoperative osteotomies. Arrows indicate

Fig. 12. Horseshoe palatal osteotomy.

ANTERIOR OPENBITE CLOSURE

Fig. 13. (A, B) Mobilization of segments and undermining of palatal tissues.

Fig. 17. (A, B) Bite registration for anterior open bites.

posterior impaction or large multipiece move- Procedure Pearls

drape” the maxilla and thin upon full smile

gingival hyperplasia may lead to an erro-

Fig. 21. “Undrape” of the maxilla on full smile.

Fig. 23. (A, B) Mucosal resection to prevent lip distortion.

Fig. 24. (A, B) Inferior turbinectomies and mucosal closure.

Fig. 25. (A–C) Gingival recontouring after maxillary surgery.

 Gingival resection/reductions should be  Maxillary downgrafts

(Fig. 25) tional blocking grafts (with or without re-

 Maxillary downgrafting grafting, it is important to miter the block

maximize stability (Fig. 26) you would any other case

Fig. 29. Excess maxillary arch length.

Fig. 30. Maxillary anterior protrusion with class III

Fig. 31. Maxillary vertical excess.

Fig. 32. (A, B) Resection of excess arch length.

Fig. 33. Cut then rasp the resected ends.

 Is there vertical maxillary excess that requires

Fig. 36. Rigid fixation and postoperative maxillary splint.

Fig. 41. (A–C) Interdental osteotomy guide.

Fig. 42. (A–C) Interdental osteotomy guide technique.

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Is there vertical maxillary excess that requires