**3. Le Fort I osteotomy**

The maxillary discrepancies and the midface abnormalities can easily be corrected by Le Fort I level osteotomy with variable surgical modifications. In 1927, Wassmund performed the first Le Fort I osteotomy for an open-bite deformity [11]. The advancement of maxilla was performed by Axhausen [12], and Bell was the first to show the vascular supply and safety of the procedure at this osteotomy level [13]. The quadrangular Le Fort I was first described by Obwegeser in 1969 [14].

#### **3.1. Technique**

**Figure 4.** The sagittal mini plate has been bended and passively adopted to proximal and distal segments with

**Figure 3.** (a) Osteotomy line starting from medial surface of ramus down to ascending ramus to he external oblique linea inferiorly with ultrasonic surgery; (b) thin osteotome is placed for separation of outer cortex of the inferior

monocortical mini self-drive screws and let mandible for early functioning.

border.

116 Current Approaches in Orthodontics

The patient is intubated via nasotracheal preformed intubation tube (RAE tube) to avoid nasal deformation during the surgery. Prior the incision a circular infiltrative local anesthesia is administrated with vasoconstrictor agent. A mucosal incision at the vestibular fornix region from one premolar to another is initiated with Colorado Needle electrocautery (**Figure 5a**). To avoid repetitive coagulation, layer-by-layer single application is essential for deeper soft tissue structures down to the periosteum. A mucoperiosteal flap is raised both on sagittal and vertical plans. Laceration of the periosteum would result in discomfortable bleeding and herniation of Bichat fad pad. Depending of the level of the osteotomy, the reflection of the flap may extend up to the infraorbital region. A curved periosteal elevator would be essential for the elevation of the nasal mucosa on the medial sinus wall and midpalatal suture for each side (**Figure 5b**). If a collective fashion of haemorrhagia occurs, a fine rat tail tamponade with tranexamic acid solution will control it. Using piezoelectric ultrasonic surgery device, osteotomy will be initiated at the apertura priformis back to the crista zygomaticus and through the tuberosity of the posterior maxilla. Also via the piezosurgery tip, the medial antral wall osteotomy may be completed. Thanks to its selective cutting effect with cavitation phenomenon, also the palatine bone can be cut via piezosurgery. Even in some cases, from anterior nasal spine to posterior nasal spine, septal separation from midpalatal suture can be performed via piezoelectric surgery (**Figure 5c**). For each maneuver special piezo cutting tips can be preferred even for the pterygomaxillary junction region (**Figure 5d**). When all the

running inside of it. If the surgeon is inexperienced, it is so easy to face an aggressive hemorrhage from the palatine artery. It can be controlled easily by direct packing with a immediate down fracture procedure to isolate the bleeding source. The septal cartilage and midpalatal bone would be separated using nasal septal osteotome. The assisting hand's point finger should be placed posterior-to-posterior nasal spine to feel the tip of the septal osteotome at the end (**Figure 7**). After the down fracture, Tessier mobilizers or Rowe forceps are used to mobilize the maxilla freely. At this point the lacerations on the nasal mucosa is sutured, and posterior reflection of the soft tissues was completed (**Figure 8a**, **b**). If the maxilla is going to be impacted, the septal cartilage would be trimmed as required to avoid deviation of the septum. If the anterior nasal spine is problematic for columella or nasal shape, it can also be removed till the desired level. If the magnitude of the advancement, impaction, or rotation is quite much, surgeon will face resistance; then decompression of the palatal artery and removal of the palatal bone around are necessary. These risky maneuvers can easily be done via piezoelectric surgery without bleeding. As an alternative, a round diamond rotatary burr can be preferred. Surgical saws may lead to hemorrhage. The maxilla will be repositioned with a surgical prefabricated splint followed by intermaxillary fixation. The bone edges are controlled, and interference of excessive bones is removed. When maxilla and mandible act as one unit due to intermaxillary fixation, rotation is completed by gentle force application on both sides of the mandibular premasseteric notches, and rigid fixation is performed (**Figure 9**). If regular micro- or miniplates are going to be used for rigid fixation; I suggest to use two plates on each side in inferior repositioning and advancement surgeries. If the maxilla is impacted, one four-hole L-shaped plate is adequate on each side. For the first time in the literature in 2008, I have published stress distribution both on plates (single- or double-plate fixation on each side) and facial skeleton after rigid fixation in Le Fort I osteotomies for all scenarios, and since 10 years, I clinically follow the guidelines of my publications to choose the number of the plates for each case [15–17].Also as an alternative, I

**Figure 6.** Pterygoid osteotome placed at the pterygomaxillary junction, and the assisting point finger is positioned on the

Current Approaches in Orthognathic Surgery http://dx.doi.org/10.5772/intechopen.83547 119

hamulus pterygoideus to feel the disjunction and the tip.

**Figure 5.** (a) Nasotracheal intubation via RAE tube, Colorado Needle for soft tissue incision, and the at very deepest sulcus, the incision is initiated between premolar regions; (b) soft tissue flaps created by subperiosteal tunneling; (c) anterior nasal spine to posterior nasal spine and also septal separation from mid palatal suture can be performed via piezo electric surgery; and (d) piezo cutting tips can be preferred even for the pterygomaxillary junction region.

osteotomies are performed via piezoelectric surgery, a bi-digital mild pressure on the anterior incisors is applied by the surgeon in vertical and sagittal directions for down fracture of the maxilla. In cases that osteotomies are performed by rotary handpieces or saws, the osteotomy lines are quite similar to piezosurgery, but care must be taken while malleating curved pterygoid osteotome to separate the pterygomaxillary junction. The surgeons' eye should follow the upper occlusion, and the osteotome should be parallel to this line to avoid directing it cranially. One should place the point finger of the assisting hand to the pterygoid hamulus intraorally to feel the tip of the pterygoid osteotome (**Figure 6**). If such malpositioning occurs, there is the risk of laceration of maxillary artery close to the posterior region. Also during medial antral wall osteotomy, care must be taken not to go so far posteriorly due to laceration risk for descending palatinal artery. Because around 3.5 cm posteriorly, the sound will change and a resistance will occur during chiseling. This means that one has reached to the perpendicular lamina of the palatine bone that descending palatine artery is

**Figure 6.** Pterygoid osteotome placed at the pterygomaxillary junction, and the assisting point finger is positioned on the hamulus pterygoideus to feel the disjunction and the tip.

running inside of it. If the surgeon is inexperienced, it is so easy to face an aggressive hemorrhage from the palatine artery. It can be controlled easily by direct packing with a immediate down fracture procedure to isolate the bleeding source. The septal cartilage and midpalatal bone would be separated using nasal septal osteotome. The assisting hand's point finger should be placed posterior-to-posterior nasal spine to feel the tip of the septal osteotome at the end (**Figure 7**). After the down fracture, Tessier mobilizers or Rowe forceps are used to mobilize the maxilla freely. At this point the lacerations on the nasal mucosa is sutured, and posterior reflection of the soft tissues was completed (**Figure 8a**, **b**). If the maxilla is going to be impacted, the septal cartilage would be trimmed as required to avoid deviation of the septum. If the anterior nasal spine is problematic for columella or nasal shape, it can also be removed till the desired level. If the magnitude of the advancement, impaction, or rotation is quite much, surgeon will face resistance; then decompression of the palatal artery and removal of the palatal bone around are necessary. These risky maneuvers can easily be done via piezoelectric surgery without bleeding. As an alternative, a round diamond rotatary burr can be preferred. Surgical saws may lead to hemorrhage. The maxilla will be repositioned with a surgical prefabricated splint followed by intermaxillary fixation. The bone edges are controlled, and interference of excessive bones is removed. When maxilla and mandible act as one unit due to intermaxillary fixation, rotation is completed by gentle force application on both sides of the mandibular premasseteric notches, and rigid fixation is performed (**Figure 9**). If regular micro- or miniplates are going to be used for rigid fixation; I suggest to use two plates on each side in inferior repositioning and advancement surgeries. If the maxilla is impacted, one four-hole L-shaped plate is adequate on each side. For the first time in the literature in 2008, I have published stress distribution both on plates (single- or double-plate fixation on each side) and facial skeleton after rigid fixation in Le Fort I osteotomies for all scenarios, and since 10 years, I clinically follow the guidelines of my publications to choose the number of the plates for each case [15–17].Also as an alternative, I

osteotomies are performed via piezoelectric surgery, a bi-digital mild pressure on the anterior incisors is applied by the surgeon in vertical and sagittal directions for down fracture of the maxilla. In cases that osteotomies are performed by rotary handpieces or saws, the osteotomy lines are quite similar to piezosurgery, but care must be taken while malleating curved pterygoid osteotome to separate the pterygomaxillary junction. The surgeons' eye should follow the upper occlusion, and the osteotome should be parallel to this line to avoid directing it cranially. One should place the point finger of the assisting hand to the pterygoid hamulus intraorally to feel the tip of the pterygoid osteotome (**Figure 6**). If such malpositioning occurs, there is the risk of laceration of maxillary artery close to the posterior region. Also during medial antral wall osteotomy, care must be taken not to go so far posteriorly due to laceration risk for descending palatinal artery. Because around 3.5 cm posteriorly, the sound will change and a resistance will occur during chiseling. This means that one has reached to the perpendicular lamina of the palatine bone that descending palatine artery is

**Figure 5.** (a) Nasotracheal intubation via RAE tube, Colorado Needle for soft tissue incision, and the at very deepest sulcus, the incision is initiated between premolar regions; (b) soft tissue flaps created by subperiosteal tunneling; (c) anterior nasal spine to posterior nasal spine and also septal separation from mid palatal suture can be performed via piezo electric surgery; and (d) piezo cutting tips can be preferred even for the pterygomaxillary junction region.

118 Current Approaches in Orthodontics

**Figure 7.** Nasal osteotome is placed on the midline just below the septum to separate the septal cartilage and the midpalatal bone junction. Assisting point finger placed on to the posterior nasal spine.

**Figure 9.** Intermaxillary fixation with a surgical splint, and superior repositioning of the complex with gentle pressure

Current Approaches in Orthognathic Surgery http://dx.doi.org/10.5772/intechopen.83547 121

**Figure 10.** Preformed Le Fort miniplates and self-drive screws used for rigid [18] fixation. This special form supplies

enough rigidity with just one plate and there is no need to place posterior plates around zygomatic buttress.

that has been applied bilaterally on both premasseteric notches.

**Figure 8.** (a) Rowe forceps placed bilaterally on the down fractured maxilla to complete the disjunction, (b) suturing the nasal mucosa ruptures.

suggest to use preformed Le Fort microplates that are currently available on the market with different shoulder sizes (**Figure 10**). Another current advancement in rigid fixation materials is the patient-specific titanium miniplates that are manufactured via 3D printers. The use

**Figure 9.** Intermaxillary fixation with a surgical splint, and superior repositioning of the complex with gentle pressure that has been applied bilaterally on both premasseteric notches.

**Figure 10.** Preformed Le Fort miniplates and self-drive screws used for rigid [18] fixation. This special form supplies enough rigidity with just one plate and there is no need to place posterior plates around zygomatic buttress.

suggest to use preformed Le Fort microplates that are currently available on the market with different shoulder sizes (**Figure 10**). Another current advancement in rigid fixation materials is the patient-specific titanium miniplates that are manufactured via 3D printers. The use

**Figure 8.** (a) Rowe forceps placed bilaterally on the down fractured maxilla to complete the disjunction, (b) suturing the

**Figure 7.** Nasal osteotome is placed on the midline just below the septum to separate the septal cartilage and the mid-

palatal bone junction. Assisting point finger placed on to the posterior nasal spine.

nasal mucosa ruptures.

120 Current Approaches in Orthodontics

**5. Conclusion and the future**

surgery will take place within a couple of years.

I declare that there is no conflict of interest.

Address all correspondence to: msatac@gmail.com

Zahn MundKieferheilkunde. 1942;**9**:73

Pathology, Oral Radiology. 1957;**10**:677-689

**Conflict of interest**

**Author details**

Mustafa Sancar Atac

**References**

As I have briefly explained the basic techniques that are commonly used in orthognathic surgery, for 5 years we are already beyond the future. The current advancements are tomographic evaluation including 3D reformatted frames integrated to advanced software programs with facial scanning to analyze the facial proportions rather than 2D cephalometric radiographs and 3D scanning of the teeth integrated with tomography that let to us perform operation in virtual environment and print out 3D splints. Besides other advancements are; 3D printing of the individual titanium plate screw fixation systems will avoid producing surgical splints, as well as using piezoelectric surgery rather than burs and saws supplies for bloodless and neuro-sensorial deficit-free operations, finally last but not the least, a totally robotic guided

Current Approaches in Orthognathic Surgery http://dx.doi.org/10.5772/intechopen.83547 123

Faculty of Dentistry, Gazi University, Department of Oral and Maxillofacial Surgery, Ankara, Turkey

[1] Schuchardt G. BeitragzurchirurgischenKieferorthopadieunterBerucksichtigungihrer fur tdieBehandlungangeborener und erworbener Kiefer deformitatenbeiSoltaten. Dtsch

[2] Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surgery, Oral Medicine, Oral

[3] Dal PG. Retromolar osteotomy for the correction of prognathism. Journal of Oral

[4] Hunsuck EE. A modified intraoral sagittal splitting technic for correction of mandibular

Surgery, Anesthesia, and Hospital Dental Service. 1961;**19**:42-47

prognathism. Journal of Oral Surgery. 1968;**26**:250-253

**Figure 11.** 3D evaluation and planning of a hemimandibular hyperplasia case using DICOM data with a surgical software, published in Journal of Cranio-Maxillofacial Surgery in 2009.

of 3D surgical planning in orthognathic surgery cases is on the market more than 10 years. Meanwhile we also published a paper with 3D tomographic DICOM data transferred to software and completed the operation virtually in 2009 (**Figure 11**) [18]. Depending on surgeons and orthodontist's choice, currently there are many alternatives to each other starting from conventional cast model articulating and model set up on casts, to 3D analyze and 3D printing of surgical splints and titanium fixation plates. On the other hand, higher technology for planning and manufacturing with 3D printers increases the financial expenses. After rigid fixation of the maxilla, the alar wings, nasal tip, and nostril symmetry and projection of the upper lips and the gums should all be evaluated. If the maxilla has been impacted, the nostrils and the nasal soft base will be wider, and alar chinch suture is essential to control the width. Also, a V–Y closure will help to improve the philtrum projection.
