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    Manejo ortodóntico y técnicas de cirugía ortognática en el paciente adulto

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    Manejo ortodóntico y técnicas de cirugía ortognática en el paciente adulto

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    Adult Orthodontics and Orthognathic Surgery

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    IvethGallardo
    Manejo ortodóntico y técnicas de cirugía ortognática en el paciente adulto

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    THE INTERNATIONAL JOURNAL OF ADULT ORTHODONTICS AND ORTHOGNATHIC SURGERY Art and science of the Le Fort I downfracture William H. Bell, DDS ‘Chawket Mannal. DDS lo Mortalena Villa Toki-Eder Biddaray France Hane G. Luhr, DMD, MD Department of Maxillotects! Surgery University Hospital of Goettingen 3400 Goettingen Federal Republic of Germany 1-1988 Art and science of the Le Fort I downfracture reports are presented which illusirate the use of Le Fort | osteotomy and other adjunctive surgical procedures in treating patients with dentofacial deformities and mandibular dysfunction. Introduction Today there is a clinical” func- tlonal,*? and blologica* foundation for surgical repositioning of the maxilla in many adult and adolescent patients. Restoration of normal jaw function or im- Proved function, optimal facial esthetics, and long-term dental and skeletal sta- bility are essential for successful ortho- gnathic surgery. The key to achieving these objectives Is to analyze facial pro- portions, and then establish and imple- ment esthetic priorities through the use of cephalometric planning and occlusal studies.> A large proportion of individuals with dentofacial deformities manifest man- dibular dysfunction and a variety of Problems ranging from painless clicking in the temporomandibulor joints to se- mal function after surgical repositioning of the jaws. To reach these objectives, orthognathic surgery techniques com- bining maxillary, mandibular, and chin surgery with efficient orthodontic treat- ment and systematic neuromuscular re- habilitation have been developed. The combined surgical-orthodontic vided by the Le Fort | downtracture tech- nique affords the surgeon great latitude and safety in comecting mandiilary defor- mities.” in addition, the abillly to repo- sition the mondiia In all three dimensions of space dramatically increases effi- ciency of treatment by the surgeon and orthodontist. Anatomical basis for osteotomy design Superior, anterior, or posterior maxil- lary repositioning may result in poor bony interfaces and few abutment 23 ‘William H. Bell, DDS Department of Surgery Division of Oral and ‘The University of Texas Southwestern Medical Center 5323 Harry Hines Boulevard Dallas, Texas: 75235 ‘Chawket Mannal, DDS cio Mortalena Villa Toki-Eder Biddaray France Hans G. Luhr, DMD, MD of Maxillofacial Surgery University Hospital of Goettingen 3400 Goettingen Federal Republic of Germany The International Journal of Adult Orthodontics and Orthognathic Surgery 1/88 24 The International Journal of Adult Orthodontics and Orthognathic Surgery 1/88 bone of the lateral antral wall may be thin and friable. areas because bone of the lateral max- Mary walls is frequently thin and friable and may not support the use of rigid skeletal fixation (Fig 1). When osteotomies are made in the superior aspect of the lateral manila, where bony walls are an- gular, the margins of the proximal and distal segments may not be juxtaposed. This may cause telescoping of the pos- terior manila into the antrum and long- Exposure of osteotomy site ‘Successful transposition of the maxil- dento-osseous segments by A horizontal incision is made in ‘the manillary vestibule superior to the mu- cogingival junction, extending from the fist molar region of one side fo a similar area on the contralateral side. At the zy- where the sof tissue is relatively thick and ‘extensible. Anteriorly, the incision is made more inferiorly, 3 or 4 mm above the mucogingival line, to minimize dis- tuption of some of the muscles of facial expression attached fo the upper lip. To maintain maximum circulation to the maxillary bone and teeth, the inferior mucoperiosteal tissues are elevated just ‘enough to allow visualization and pal- pation of the bone encasing the apices of the teeth and to facilitate interdental osteotomies (Fig 4). Therefore, a maxi- mum. buccolabial and palatal pedicle to the mobilized segments is maintained. € Figs 2a and 2b When osteotomies are made in the superior aspect of the lateral maxilla, where bony walls are angular, he marpin fhe proxi ‘be juxtaposed, allow- ‘The International Journal of Adult Orthodontics and Orthognathic Surgery Vol. 3: Fig 3a Anatomical basis for osteotomy design. Lateral maxillary osteotomy design is inaividual- ized. Improved stability and control and use of rigid skeletal fixation is facilitated by lateral maxillary os teotomy coursing from the piriform aperture pos- teriory into the denser bone of the zygomnatic-max- itary buttress or the root of the zygoma. jon show- Fig3e Cross-sectional view of molar regi ing planned lines of sectioning through roots of the zygomnas, nasal walls, and nasal septum. The margins of the superior flap are faised to expose the infraorbital nerve and the maxilla immediately lateral and medial to the nerve (Fig 4). Dissection is carried anteriorly to facilitate reflection of the nasal mucoperiosteum from the lateral and inferior aspects of the piri- form rim and anterior nasal floor, The mucoperiosteum is detached from the nasal floor, the base of the nasal septum, ‘and the lateral nasal walls. By tunneling subperiosteally to the pterygomaxillary junction, the posterolateral portion of the manilia is visualized. With the tip of a curved right-angle retractor positioned cat the junction, the mucoperiosteal re- flection is extended over the inferior as- pect of the zygoma. After the masseter muscle is released to gain access and Fig 3b Plan of surgery: Two-segment Le Fort |os- teotomy to superiorly reposition the maxilla. Cross- hatched area indicates planned ostectomies. Fig 3d The zygomaticomaxilary buttress, root of the zygoma, and inferior and lateral piriform rims where the lateral and medial walls of the maxila become confluent to form a relatively thick buttress of bone provide stable anchorage for small bone plates and screws anteriorly and posteriorly and a buttress for the predictable placernent of iniaid sta- bilizing bone gratts. The repositioned maxilla is sta- bilized with small bone plates and screws, 25 Fig. 4 The margins of the supe- fior flap are raised to expose the infraorbital nerve and the maxilla immediately lateral and medial 1o the neve, root of the zygoma, inferior aspect of the zygoma, anterior nasal floor, piriform ap- erture, and pterygomaxillary junc tion. Anterior and posterior verti- cal reference lines and planned lateral maxilary osteotomies are etched into the lateral maxilla at the desired level with a No. 701 fissure bur. 26 The International Journal of Adult Orthodontics and Orthognathic Surgery 1/88 Fig 5 (Left) The major portion of the lateral maxilla is sectioned ‘from the contralateral side with a reciprocating saw blade. Fig 6 (Right) Vertical through- ‘andthrough osteotomy is made with a reciprocating saw blade to the inferior and deep aspect of the zygoma. Fig 7 (Left) Bone is sectioned with a sharp, curved osteotome which is directed inferiorly and medially at a 45° angle to the pter- ygomaxilary junction. Fig 8 (Right) Midportion of the ‘medial antral wall is sectioned with a finely tapered osteotome. Sectioning of the medial antral wall is terminated at least 1 cm short of the perpendicular plate of the palatine bone to avoid tran- secting the descending palatine vessels, exposure to the inferior-medial aspect of the zygoma, a cotfonoid pack is placed to retract the inferior contents of the Infratemporal fossa away from the osteotomy sites. Osteotorny design Vertical reference lines are inscribed into the lateral aspect of the piriform ap- etture and at the zygomatic-maxillary buttress perpendicular to the occlusal plane. Based upon millimetric measure- ments made from the cephalometric prediction studies transferredtothe bone with calipers, the proposed osteotomies are inscribed into the lateral maxilla with a fissure bur (Fig 4). The inferior bone cut is positioned at a safe level above the apex of the maxillary canine, which can ‘usually be visualized with minimal retrac- tion of the Inferior mucosal margin. Position and angulation of the oste- cotomies is based upon a correlated clinical examination, cephalometric planning studies, and model surgery. Ac- curate transfer of cephalometric infor- mation is facilitated by the geometric design of the osteotomy made through the lateral maxilla and root of the zy- goma {Fig 3}. Osteotomies are designed ‘and positioned to improve stability of the proximal and distal segments by maxi- mum interfacing of the bony margins. Anteriorty, the osteotomy is designed so that the largest possible bony interface can be created while the bone cut is positioned at a safe distance above the tooth apices in the thicker part of the maxilla. The lateral maxillary osteotomy courses from the piriform aperture pos- terlorly info the denser bone of the root of the zygomna 5 mm or more above the inferior aspect of the zygoma (Fig 4). The ‘osteotomy design must also be consis- tent with the esthetic objectives of the planned surgery. When osteotomies or ostectomies are made in the thick root of the zygomas, the margins of the proximal and distal segments are consistently juxtaposed af- ter surgery (Fig 3). The posterior portion of the maxilla is sectioned with a fissure bur to sequentially determine the relo- tive thickness of the zygomatic maxillary buttress and to provide a stable index and referrent for subsequent sectioning ofthe lateral maxilla. The degree of pen- The International Journal of Adult Orthodontics and Orthognathic Surgery Vol. 327 etration of the root of the zygoma and posterior extension of the lateral maxil- lary osteotomy will vary according to the degree of pneumatization of the antrum and position of the posterior wall of the antrum. When trial sectioning of the maxilla and zygomatic-mmaxillary buttress reveals relatively thick bone, the maxil- lary step osteotomy may be used and is technically easier? if the posterior por- tion of the lateral maxilla and the zy- gomatic-maxillary buttress are very thin, great care and meticulous technique are exercised to avoid fracturing the root of the zygoma. Even if this should occur, 98 It has in fwo patients, the fractured free segment can be repositioned as planned and stobllized to the distal seg- ment with an interosseous wire, cir- cumzygomatic wire, or bone plate. Sectioning the maxilla The mojer portion of the lateral maxilla Is sectioned from the contralateral side with a reciprocating saw blade; the os- teotomy is then extended anteriorly to the lateral piriform rim. With a periosteal elevator or small malleable retractor Passed subperiosteally medial to the lat eral nasal wall to protect the nasal mu- ‘coperiosteum, the anterior aspect of the lateral nasal wall is sectioned with the reciprocating saw blade (Fig 5). The harizontal osteotomy is extended posteriorly into the dense root of the zy- goma to a point 5 or 6 mm above the inferior aspect of the body of the zy- goma and 4 to 6 mm distal to the zy- gomaticomanxillary suture line“ Then a vertical through-and-through osteotomy is made with a reciprocating or oscillat- ing saw blade to the inferior and deep ‘aspect of the zygoma (Fig 6). With the ‘contents of the infratemporal fossa re- flected, the osteotomy is directed infe- rorly and medially at a 45° angle to the pterygomaxillary junction (Fig 7). Be- ‘cause the bone in this area is generally relatively thin, the osteotomy can usually be made with a finely tapered, curved osteotome. When the bone is thick, how- ever, the posterior vertical osteotomies are made with an oscillating or recip- rocating saw blade. Finally, the maxilla is separated from the pterygoid process by malleting an osteotome directed me- dially and anteriorly into the pterygo- maxillary suture (Fig 7). The midportion of the medial antral wall is sequentially sectioned with a fis- sure bur and finely tapered osteoctome Positioned between the margins of the lateral maxillary ostectomy. Sectioning of the medial antral wall is terminated at least 1.cm short of the perpendicular plate of the palatine bone to avoid franssecting the descending palatine vessels (Fig 8). The thin antral wall con- tiguous to the vessels generally fractures when the maxilla is downfractured. A nasal septal osteotome positioned parallel to the hard palate is malieted toward a finger positioned on the pos- terior nasal spine to separate the base of the posterior bony nasal septum from the maxilla, Gradually increasing inferior Pressure on the anterior aspect of the maxilla facilitates visualization of the no- sal surface of the maxilla and lateral na- sal walls. While the midface structures are stabilized by the assistant, the sur- geon uses both hands to hinge the max- illa inferiorly and posteriorly. The assistant simuttaneously detaches the remaining mucoperiosteum from the nasal floor and horizontal plate of the palatine bone to facilitate downfracturing. The posterior part of the maxilla is sep- ‘arated from its remaining bony attach- ments by forward pressure of a perios- teal elevator or similar instrument against the thick and strong posterior aspect of the horizontal plate of the palatine bone Fig 9. The mobilized maxila has been hinged inferiorly on an axis posterior part ofthe maxilais sep- arated from its remaining bony at- bby forward pressure of 2 periosteal elevator or similar in- strument against the thick poste- flor aspect of the horizontal plate of the palatine bone to achieve mobility 28 The International Journal of Adult Orthodontics and Orthognathic Surgery 1/88 aston Ran ne me downfractured, the vertical di- posite lars is carefully reduced with a prominence lies lateral to the descending pal- aline vessel Fig 11 (Right) With the lage ved: retractors to achieve mobility and movement of the maxilla fo the contralateral side (Fig 9). A similar procedure is accom- plished on the opposite side. With the manilia in the downfractured Position, bone interferences in any area can be readily Kientified and removed under direct visualization. Reduction of the height of the lateral nasal walls is ‘accomplished with ronguers. Meticulous and sequential reduction of the poste- rlor aspect of the lateral nasal wall and alveolopalatal junction in the area op- Posite the second and third molars is ac- complished with ronguers and burs. Fi- nally, osteotomes, burs, and/or Kerrison forceps may be used to carefully expose the descending palatine vessels (Fig 10). After the overlying bone has been ex- ised, an effort is made to preserve the integrity of these vessels whenever fea- sible. When the planned posterior and superior movements are problematic, the vessels can be sharply transected or cauterized after vascular clips have been placed. With large retractors po- sitioned, the posterior maxillary tuber- ‘sity can be removed to facilitate pos- terior maxillary repositioning (Fig 11). The height of the vomer is reduced an amount proportional to the planned su- perior movement of the maxilia. A mid- sagittal groove is made in the superior aspect of the maxilla fo accommodate ‘the nasal septum and to prevent its lat- eral displacement. Submucous resec- tion of the cartilagenous nasal septum is accomplished to facilitate superior movement of the repositioned maxilia ‘and to prevent buckling of the sep- tum. The mucoperichondrium envelop- ing the inferior aspect of the cartlagen- ‘ous septum is incised and detached bilaterally from the inferior-lateral aspect of the septum. The height of the carti- lage is reduced an amount proportional tothe superior movernent of the maxilla. The maxilla can now be rotated upward info the planned relationship without bucking the septum. The mucosal mar- gins are then closed with catgut sutures. After the maxilla is completely mobi- lized, the interocclusal splint is precisely ligated to: the maxilla. The mandibular teeth are indexed into the splint, and maxillomandibular fixation is accom: plished with wire ligatures between the vertical lugs attached fo the arch wire. The monillary-mandibular complex is Moved as a unit through the mandibular arc of rotation so that the areas of bone contact can be visualized as the maxilla is positioned upward and forward. Bone |s removed from the posterior margins until the mobilized segment can be pas- sively seated in the desired vertical po- sition and the margins of the lateral max- illory osteotomies are juxtaposed. With the condyles held upward and forward against the posterior slopes of the artic- ular eminences, the maxilary-mandib- ular complex is repeatedly rotated closed to the desired vertical postion (Fig 12). Finally, the maxilla is stabilized in the planned position by appropriate bone piate osteosynthesis. Stabilization of manilla with rigid skeletal fixation Today, through the use of many dif- ferent combinations of biocompatible The International Journal of Adult Orthodontics and Orthognathic Surgery Vol. 3 29 and corrosion-resistant bone plates and screws, the Le Fort | downfracture is even more versatile than previously used methods””** The drastic shortening of the period of maxillomandibular fixation from 6 to 12 weeks to only a few days, ‘Of, More commonly, the total elimination of maxillomandibular fixation, Is one of the principal advantages of the mini bone plate technique. Therefore, it is possible to open the mouth in the always potentially critical period after extuba- tion without the danger of displacing the segments. Because airway problems are avoided, there is, generally speaking, no need for keeping the patient in an in- tensive care unit for the first postopera- five night. The opening of the mouth, moreover, facilitates oral hygiene, pre- vents temporomandibular joint hypo- mobility, and minimizes the progression of preexisting periodontal disease which might occur during prolonged maxillo- mandibular fixation. Rigid fixation short- ens the hospital stay and indeed the entire period of morbidity following Le Fort | osteotornies. Further, the ability to open the mouth after surgery has a profound comforting psychologic effect ‘on the patient. ‘Whenever feasible, four plates are placed anteriorly and posteriorly where relatively thick cortical bone is present. With the application of rigid fixation in Le Fort | osteotomies, the need for bone grafting has decreased.” This is another advantage of mini plate fixation. Despite improved stability with these techniques, however, bone grafting across the os- teotomy sites and bone gaps may be essential fo facilitate bone healing. For instance, bone grafting is generally nec- essary in selected cases when the ver- tical dimension of the maxilla and mid- face Is to be increased and in cleft palate patients with severe atrophy on the affected side. The main disadvantage of bone plates Is the inability to adjust the appii- ance once it has been placed. Also, the method may take longer than wire os- teosynthesis when the surgeon is not fa- miliar with this technique. However, once the individual has gained some experi- ence and routinely works with exper! enced assistants, there is little time dif- ference between the two methods. This 's particularly true in cases of major max- iilary advancements, of inferior reposi- tioning of the maxilla, and segmenta- fion of the maxilla, where interosseous wire fixation is difficult, Interosseous wires are effective when tension forces can be applied—ie, in one direction only— whereas plates can stabilize segments in all three dimensions. Small Vitallium® (Howmedica Corp) bone plates are available in different designs and varying lengths. The two ec- centric holes on either side of the bony gaps on the straight, curved, or “T” plates are designed to provide compres- sion This mechanism is rarely indi- cated in the clinical practice of orthog- nathic surgery. Therefore, the mini plates ate applied in a noncompressive mode (Figs 13 and 14). A bone plate of proper length and shape should routinely pro- vide two holes for screws in the stable segment and two holes for fixing the re- Positioned segment. Because of their small size and thinness, Vitallium mini Plates are versatile and may be adapted to almost any variety of con- toured bone surfaces. The specific ap- plication and configuration of the small bone plates will depend on the bone contour and varieties of bony steps which result from segmenting the max- lila, Usually the plate requires some amount of bending and trial fitting to Passively adapt to the underlying bone. Selection of the appropriate length ‘and contouring of the plate for implan- tation is facilitated by the use of very thin and malleable tin templates. A template Fig 12 Alter the interocciusal splint (bive) is precisely ligated to the maxilla, the mandibular teeth are indexed into the splint; max- illomandibular foxation is accom- plished with wire ligatures be- tween vertical lugs attached tothe arch wire. With the condyles: held upward and forward against the Posterior slopes of the articular th tical position. The maxilla is sta- bilized with small bone plates and screws. 30 The International Journal of Adult Orthodontics and Orthognathic Surgery 1/88 Fig 13 (Let) Application of a minicompression plate in a non- third screw is inserted in the out- ermost hole of the kong leg to pre- vent any axial compression of the two segments, Fig 14. (Right) The last screw is inserted in the large portion of the eccentric hole. is custom fitted and adapted to the in- dividual contour of the maxilla across the ©steotomy site with light digital pressure. similar type and size bone plate is then formed with bending forceps so that it will duplicate the shape and configu- ation of the template [Fig 15). Now the late is formed with the bending insiru- ™menis until itlies passively across the os- tectomy site and is flat against the bone surfaces. If the plate does not contact the underlying bone, the movable, re- Positioned dentoalveolar segment of the maxilla will be displaced when the screws tightened. The resuttant torquing may create a malocclusion. Once contoured to lay passively against all bone surfaces, the plate is held in position with a plate-holding for- eps and secured to both the distal ‘and proximal segments with two vital- lium screws (Fig. 16a). To prevent any Compression, the screws are first placed in the outermost centric holes of the Plate, which prevents advancement of ‘the bone segments. Only then is the last screw inserted within the large diameter of the eccentric hole (so-called non- compressive position) (Fig 14) The use of self-tapping screws with milled grooves facilitates and simplifies surgical technique. Optimal fitting of screw heads to plate holes maintains the surface of implants very fiat without in- terfering with soft tissue contour. Because Vitallium alloy is biocompatible and re- sistant to corrosion, it is unnecessary to remove the bone plates and screws. The use of the low-profile Philips-head screw in conjunction with a plate of only 0,7 mm in thickness virtually eliminates the Patients ability to detect the implant. The bone is prediilled with a drill bit of 4.5-mm diameter (Fig 160). It is important fo maintain a speed lower than 1,000 pm and to irrigate the drill to minimize thermal damage to the bone. Besides bone necrosis, high-speed driling will cause an undesirable enlargement of the drill hole {the drill bit is tumed off Fig 15a Five-hole, curved, thin, maleable tin template custom-fitted and adapted to the individual contour of zygomaticomiaxit lary step osteotomy. template, Fig 15b_ Similar type and size bone plate formed with bending forceps so that it du- plicates the shape and configuration of the Fig 15¢ Bone plate passively adapted and fixed to underlying bone with 2.mm selt-tap- ing screws, ial Journal of Adult Orthodontics and Orthognathic Surgery Vol. 331 Fig 16a (Lett) Curved bone plate held in position with plate-holding forceps as bone |s predriled with a 1.5-mm dril bit Fig 16b (Right) A 2.mm diameter selt- tapping screw held in place with a screw- holding clamp and tightened snugly with a Phillips screwdriver. Proximal and distal segments are stabilized with four screws. Fig 16c (Lett) There are many alternative methods of stabilizing posterior proximal and distal segments; the choice is based upon individual anatomical and positional considerations. Shown here is a posterior T-shaped plate stabilized with 8-mm-long screws, Fig 160. (Right) Two-hote straight plate with ‘S:mm-long screws in proximal and distal segments. Stabilization of these plates is readily accomplished Fig 16e Posterior ditect interosseous wite Fig 16 _Four-hole posterior bone plate and. combined with anterior 90° L-plate. anterior infraorbital rim suspension wire ne- cessitated by inadequate lateral piriformrim plates. thickness. center by centrifugal forces). Only a pre- cise 1.5.mm diameter drill hole will pro- vide maximum holding power of the self- tapping screw. Because screw pull-out strength is directly related to bone thick- ness and screw size, bone screws are more stable when placed in the thickest available bone, A 2-mm diameter self- tapping screw 6, 8, or 10 mm in length is inserted with a screw-holding clamp and tightened snugly (Fig 16b). Adap- tation of the plate to the movable por- tion of the maxilla is confirmed. If nec- essary, the screw can be loosened somewhat and the plate rotated to achieve the desired location and ad- aptation to the underlying bone. To fix the maxilla in the desired position, a sec- ‘ond screw is inserted into the outermost centric hole of the stable proximal por- tion of the 2ygoma and tightened. Should inadvertent sipping of the standard 2-mm screw occur, the need for drilling another hole in the bone may be avoided by using a larger “emer- gency” screw 2.4 mm in diameter, After the standard-size screw Is removed with a screw forceps, the emergency screw, identified by its highly polished head, is inserted into the same hole and tight- ened snugly. Osteosynthesis is completed when the third and fourth screws are sequentially placed in the large portion of the two innermost eccentric holes adjacent to the osteotomy site. Fig 169 _Interpositional bone graft stabi: lized by anterior L- and posterior T-shaped 36 The International Journal of Adult Orthodontics and Ortho; Fig 200 Finally, a spatula osteotome is malieted into the interseptal area between the lateral incisors and canines to fracture the crestal alveolar bone. be orthodontically repositioned into an alveolar graft site after surgery. In such cases autogenous particulate marrow is routinely used. Vertical interdental osteotomies in the: lateral incisor-canine interspaces are: connected by a U-shaped transpalatal osteotomy distal to the incisive canal (Figs 20b and 20c). This improved oste- cotomy design provides a broader soft tissue pedicle to the anterior dento- osseous segment. The maxilia can be sectioned parasagittally to increase or decrease the intermolar width and im- Prove interdigitation of the teeth. The is elevated to expose the interdental bone at the site of the proposed vertical osteotomy: it is usually retracted so that the crestal alveolor bone in the osteotomy site and the bony Prominences overlying the canines and lateral incisors can be identified. The mucoperiosteum is minimally detached from the incisor segment fo maximize its soft tissue pedicle. It can be elevated more from the larger posterior segment because the vascular pedicie from the contiguous bone and attached muco- hie Surgery 1/88 periosteum is broader. The margins of the mucosa are retracted with skin hooks to allow visualization of the labial oste- otomy site and prevent injury of the at- fached gingiva. Vertical interdental osteotomies are made with a fissure bur and extended from the anterior aspect of the nasal ficor inferiorty to the level of the attached gingiva 3 to 4 mm above the level of the alveolar crestal bone. Superiorty, they are deepened into the spongiosa and extended fo intersect with the planned palatal osteotomies. More in- feriony, they are made through the cor- tical alveolar bone only. When there is minimal bone between closely spaced teeth the inferior labial cortex is sec- tioned with a sharp spatula osteotome only. The surgeon's finger is positioned on the palatal mucosa, and a fissure bur is used to Connect the vertical Interden- tal osteotomies on the two sides. The in- teqrity of the palatal mucosa along the entire course of the planned osteot- omy Is preserved by carefully malieting the osteolome against the finger. A finely tapered spatula osteotome is mal- leted interproximally to fracture first the thicker, incompletely sectioned palate (Fig 20c). The interradicular sectioning proceeds sequentially superiorly/inferi- ony in a stepwise fashion, one half chisel at a time, until the osteotome transects the palatal and alveolar bone and its tip makes contact with the parasagittal osteotomy. Finally, a tapered ostectome is di- fected into the thin interseptal area be- tween the lateral incisors and canines to fracture the crestal alveolar bone (Fig 20d). A finger pressed on the mu- cosa detects when the ostectome has transected the palatal cortex. The prox- imal and distal segments must be freely movable with light digital pressure. Sec- fioning the bone in this manner mini- mizes detachment of the labial or pal- atal soft tissue and the removal of crestal alveolar bone. By widening the maxilla with para- sagittal osteotomies, much of the relax- ation needed for expansion can be achieved, while a safe soft tissue pedicle 32 The International Journal of Adult Orthodontics and Orthognathic 5 Fig 17a System consists of 44 assorted Vitalium mini plates, matching templates, and selt-tapping screws 2.0-mm in diameter. Figs 17 and 17c Dual action of pliers facilitates contouring of mini plates up to 90° Next, the appropriate bone plate is positioned and stabilized to the opposite: zygoma, The method of stabilizing the bone plates isbased upon individual an- atomical and planned positional con- siderations. Numerous and varied meth- ‘ods are utilized (Figs 16c to 16g). Final stabilization of the repositioned maxilla is achieved with two additional bone plates, tridlfitted passively and secured to the piriform rim areas. Depending on the individual anatomical situation, four- hole, slightly curved, T- or L-shaped plates are utlized. By subperiosteal tunneling at the lat- eral and inferior aspects of the piriform aperture, and careful retraction and vi- sualization, the surgeon can assess the ‘anatomy of the inferior and lateral piri- form rim areas. Here the lateral and me- dial walls of the maxilla become con- fluent to form a relatively thick and discemible buttress of bone (Fig 3). Placement of bone screws through both cortices of this thickened bone usually provides a means of stabilizing a bone plate in the anterior part of the maxilla. The relatively thick inferior aspect of the piriform rim of the repositioned segment consistently provides stable anchorage gery 1/88 for bone screws. Placement of 90° or 440° bone pilates is usually feasible, even in patients with vertical maxillary de- ficiency, who manifest relatively litie bone between the nasal floor and the apices of the anterior teeth. The new mini fixation system As a further development of the Vitallium® Mini Compression Plates, the new Mini Fixation System (Howmedica Corp) has been introduced (Fig 7a). De- signed primarily for orthognathic surgery purposes, it is based on ten years’ ex- Perience with rigid fixation in the mid- facial skeleton? Maintaining the strength of the original plates where the plate crosses the osteotomy site, the new plates (L-, T-, and double T-type plates} have smaller connecting bars between the outermost holes to facilitate bend- ing. In orthognathic surgery it is of par- ‘omount importance that the plates are passively fitted to the bone contour ‘when the screws are inserted. As previ- ‘ously mentioned, this is essential to pre- vent the dislocation of tooth-bearing segments and subsequent occlusal dis- turbances. Because of the smalier con- ‘The International Journal of Adult Orthodontics and Orthe Fig 17 necting bars, the new plates are easier to bend and thereby fulfil the need of Passive adaptation to the individual bone contour. A special newly designed angle-bending pliers facilitates con- touring of miniplates up to 90° (Figs 175 ‘and 7c}. In Le Fort | osteotomies, particularly when the maxilla must be segmented in multiple parts, there may not be ideal bony contact in every part of the oste- otomy site. These gaps should be main- tained by bridging them with plates. Therefore, the application of axial compression (with close impaction of the bone segments) is generally con- traindicated in orthognathic surgery. Because axial compression is rarely indicated in orthognathic surgery, the new fixation system has no eccentric Fig 17d Plates of the Mini Fixation System. The range consists of straight and slightly curved plates (however, without the eecen- tric holes of the Mini-Compression plates), T-, double T- and L-shaped plates. A con- tinuous plate of 6 or 9 cm length was de- signed for special purposes in midface skel- etal surgery. It may be cut to the desired length using a wire cutter pathic Surgery Vol. 3 33 Fig 17@¢ The L-shaped plates are fre- quently used to stabilize Le Fort | osteoto- mies. The plates are slightly tapered at the junction of the long and short leg of the Land T-shaped types, allowing them to be easily bent and passively adapted to the in- dividual bone contour. The plates can be bent aiso in the horizontal plane, ie, the po- sition of the plate holes can be changed as Gesired (see Fig 19). compression holes; this further facilitates plate fixation by the surgeon. Figure 18 demonstrates the application of the mini Plates in Le Fort | osteotomies. Because of the special design of the plates, the small, paralle! connection bars. be- tween the outermost holes, the L-, T-, and double T-type plates not only can be contoured easily to nearly every angle but also may be bent in the horizontal plane (Fig 19). The possibility of changing the position of the outermost holes ac- cording to the individual's anatomic re- quirements increases the versatility of the system Finally, maxillomandibular fixation is released and the stability of the maxilla is confirmed. With superior digital pres- sure in the angles of the mandible fo maintain the proper condyle-fossa Figs 188 and 18 Rigid fixation of a Le Fort | osteotomy by L-shaped mini plates: Fig 18a shows right maxilla; Fib 18 shows left maxilla. Note that the position of the outermost hole of the plate at the zygomatic buttress has been changed by bending the small connecting bar (short Jeg of the L-plate) in the horizontal plane to avoid serew insertion into the osteotomy gap. Fig 18¢ Three-dimensional rigid fixation of Le Fort | osteotomy and combined orbital- zygomatic osteotomy (type Wassmund II) by mini plates. 34 The International Journal of Adult Orthodontics and Orthognathic Surgery 1/88 fig 19a (Left) The plug of the special bending pliers is inserted into the plate hole while the con- necting bar is bent. Fig 19b (Right) The schematic drawing demonstrates how the position of the outermost hole can be changed by bending the piate in the horizontal plane. relationship, the mandible is rotated closed into the occlusal splint. The man- dible should index passively and pre- cisely into the splint without interferences or condylar shifts. In selected patients, when the maxilla has not been seg- mented and a stable occlusion has been achieved, the occlusal splint may be removed and the patient allowed to function immediately. The failure to remove adequate bene from the posterior and medial aspects of the repositioned maxilla is probably the single most important cause of ap- parent “relapse” and anterior “open bite” after surgery. If premature con- tacts and open bite exist after release ‘of max

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