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ANATOMICAL STUDY AND CONSIDERATIONS ABOUT THE DISJUNCTION
TECHNIQUE IN ORTHOGNATHIC SURGERY

PTERYGOMAXILLARY REGION IN SKULLS -

ANATOMICAL STUDY AND CONSIDERATIONS
ABOUT THE DISJUNCTION TECHNIQUE
IN THE ORTHOGNATHIC SURGERY

REGIÃO PTERIGOMAXILAR EM CRÂNIOS –

ESTUDO ANATÔMICO E CONSIDERAÇÕES
SOBRE A TÉCNICA DE DISJUNÇÃO
NA CIRURGIA ORTOGNÁTICA

Gabriel Ramalho FERREIRA *

João Lopes TOLEDO-FILHO **
Clóvis MARZOLA **
Gustavo Lopes TOLEDO**
Cláudio Maldonado PASTORI**
Marcos Maurício CAPELARI **
Leonardo Perez FAVERANI ***
Marília GERHARDT DE OLIVEIRA****

_____________________________________________
* Resident in Oral and Maxillofacial Surgery of the Hospital Association of Bauru - Base Hospital
and Brazilian College of Oral and maxillofacial Surgery.
** Professors of Oral and Maxillofacial Surgery in Hospital Association of Bauru - Base Hospital and
Brazilian College of Oral and Maxillofacial Surgery.
*** Resident in Oral and Maxillofacial Surgery of the Hospital Association of Bauru - Base Hospital
and Brazilian College of Oral and maxillofacial Surgery.
**** Professor Doctor in Oral and Maxillofacial Surgery of the Pontific Catholic University – Rio
Grande do Sul.
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ABSTRACT

The pterygomaxillary disjunction is one important surgical step of Le

Fort I osteotomy in orthognathic surgery. Several techniques have been described
for the pterygomaxillary disjunction, in view of the large number of surgical
complications in this procedure, especially the neurovascular complications. The
main factors of these injuries are the poor positioning of chisels and the lack of
knowledge of regional anatomy. Therefore, this paper aim to describe a more
predictable surgical technique, and this research was conducted establishing
measures of pterygomaxillary region. The distance from the lower point of
pterygomaxillary suture to the uppermost portion (A-B) was on average of 11.55
mm. The distance from the outermost edge of the pillar zygomatic suture
pterygomaxillary (D ⊥ AB) was 24.51 mm. The measurement between the lowest
portions of the pterygomaxillary suture the orbital apex (A-E) was 32.54 mm, and the
base of the skull (A-F) was on average 34.59 mm. With these values, we can
conclude that the detailed knowledge of anatomical landmarks, as well as surgical
techniques, are major factors for the realization of orthognathic surgery, with less
chance of complications.

RESUMO

A disjunção da sutura pterigomaxilar é um passo cirúrgico importante

da osteotomia Le Fort I nas cirurgias ortognáticas. Diversas técnicas foram descritas
para a disjunção pterigomaxilar, tendo em vista a presença de inúmeras complicações
cirúrgicas envolvendo este procedimento, principalmente as complicações
neurovasculares. Dentre as causas destas lesões, estão como principais fatores, o
mau posicionamento dos cinzéis e o desconhecimento da anatomia regional. Para
tanto, com a proposta de tornar a técnica cirúrgica mais previsível, esta pesquisa foi
realizada, por meio de uma análise mensurativa dos principais reparos anatômicos da
região pterigomaxilar. A distância mais inferior da sutura pterigomaxilar à porção
mais superior (A-B) foi em média de 11,55 mm. A largura da sutura pterigomaxilar
(A-C) foi de 10,29 mm em média. A distância da porção mais externa do pilar
zigomático à sutura pterigomaxilar (D A-B) foi de 24,51 mm. A mensuração entre a
porção mais inferior da sutura pterigomaxilar ao ápice orbitário (A-E) foi 32,54 mm
e, à base do crânio (A-F) foi em média, 34,59 mm. Com estes valores, pode-se
concluir que o conhecimento minucioso das referências anatômicas, assim como das
técnicas cirúrgicas, são fatores primordiais para a realização das cirurgias
ortognáticas, com menor chance de complicações.

Uniterms: Le Fort I; Osteotomy; Pterygomaxillary Disjunction; Fracture.

Unitermos: Osteotomia Le Fort I; Disjunção pterigomaxilar; Fratura.

INTRODUCTION

The Le Fort I osteotomy is a very accomplished and relatively safe

procedure in orthognathic surgery. It was first described for the treatment of nasal
polyps in the nasopharynx (VON LANGENBECK, 1859). Later, in a situation of
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recurrent epistaxis in a patient with nasal polyps, maxillary osteotomy was necessary
to stop the bleeding (CHEEVER, 1867). To correct dentofacial deformities,
anteroposterior maxillary deficiency, were performed only in the following
(WASSMUND, 1927).
The delineation of the bone cut associated with the mobilization of the
maxilla was, and remains, the most promising method to overcome the resistance of
the soft tissues of the face. Furthermore, it provides the maxillary repositioning in
the desired position by surgeon. However, the biological bases and the main aspects
related to the particularities of surgical technique have been established through
studies of revascularization by angiographic and microscopic analysis. These
observations have given ground to state that the palate mucosa associated with
vestibular gingiva showed an adequate nutrient pedicle for the osteotomized and
mobilized maxilla (BELL; FONSECA; KENNEDY, 1975). Increasing the
confidence and safety of the professionals in indicate this procedure.
Since that, the Le Fort I osteotomy has been performed routinely in
the movements of the maxilla. However, some complications, especially trans-
operative are reported with regard to lesions of vascular and nervous structures of the
pterygomaxillary region. The presence of several vessels and nerves in this region
(maxillary artery, maxillary vein, pterygoid plexus and pterygopalatine ganglion)
aware that surgeon must be very careful in respect to surgical technique, especially in
the osteotomy with chisels in posterior wall of maxilla, as well as in the separation of
the pterygoid process of sphenoid bone of the maxillary tuberosity (O `REGAN;
BHARADWAJ, 2005).
A few studies have been conducted to investigate the anatomical
relationships around pterygomaxillary suture (TURVEY; FONSECA; HILL, 1980;
NAVARRO; ZORZETTO; TOLEDO-FILHO, 1982 and APINHASMIT;
CHOMPOOPONG; METHATHRATHIP et al., 2005). Consequently, there is a
lack of credible information concerning the measurements of these anatomical
landmarks, especially about the correct positioning of chisels in relation to the
relevant structures.
Therefore, the idealization of this research by describing the
relationship of the main anatomic marks in pterygomaxillary region through a study
that measured skulls, are justified. The proposal was to guide the oral and
maxillofacial surgeons to develop a technique that respects the limits imposed by the
vascular and nervous structures during the osteotomy in this region with chisels and
to prevent complications during the surgery and postoperatively.

LITERATURE REVIEW
The pterygomaxillary disjunction is one of the most important step of
the Le Fort I. The surgeon must know the anatomy of the region and the main
complications of this peculiar step of orthognathic surgery that associated with
down-fracture of the maxilla are the moments of greatest potential for accidents and
complications.
Aware of this, in order to make reading more enjoyable, the literature
review was divided into topics. The first one will review anatomical structures in the
region, and the second the main papers on anatomical measurements and finally, the
available techniques for pterygomaxillary disjunction and complications associated
with them.
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ANATOMICAL STRUCTURE OF
PTERYGOMAXILLARY REGION

Maxila

The maxilla is the second largest bone of the face, and connect to the
other maxilla to form the entire upper arch, most of the oral cavity roof, nasal cavity
floor and wall orbital floors, part of infratemporal and pterygopalatine fosse. It also
contains the inferior orbital fissure and pterigomaxilar fissure (GRAY, 1995). The
maxilla has four processes, the frontal, zygomatic, alveolar and palatine. The body
of the maxilla is hollow and communicates with the nasal cavity via the maxillary
ostium in the middle nasal meatus. The bone has reinforced areas, known as pillars
when vertical (pterygomaxillary, zygomatic and nasomaxillary) and arches when
they are horizontal (supraorbital, infraorbital, maxillary and zygomatic) (FREITAS,
2006).

Sphenoid

The sphenoid bone is located at the base of the skull, anterior to the
temporal and occipital bone. It consists of a central portion or body, two greater
wings and two lesser wings, and two pterygoid plates that are directed inferiorly
from the body and wings (GRAY, 1973). In the greater wing are founded round,
oval and spinosum foramen, and spine of the sphenoid ridge and the Eustachian tube.
The lesser wing is crossed by the optical channel and contains the anterior clinoid
process (SPALTEHOLZ, 1988). The pterygoid processes of sphenoid bone has two
plates: lateral and medial. The first is short and wide (for the lateral pterygoid
muscle) and the other is long and narrow. Both are united, above, to form the
pterygopalatine groove, and then diverge to form the deep pterygoid fosse (for the
medial pterygoid muscle). A notch between the two plates is filled by the pyramidal
process of palatine bone. The medial plate of pterygoid runs inferiorly to the
pterygoid hamulus, whose lateral face is carved in the shape of the groove, the
groove of pterygoid hamulus (for the tendon of the tensor veli palatini)
(SPALTEHOLZ, 1988). The superior orbital fissure is enclosed by greater and
lesser sphenoid wing and contains the following structures: superior ophthalmic vein,
oculomotor nerve, trochlear nerve, abducens nerve, frontal nerve, lacrimal nerve,
nasociliary nerve (GRAY, 1995).

Palatine

The palatine bones are located posterior to maxilla and anterior to the
processes of the sphenoid bone. Participate in dividing of oral, nasal and orbital
cavity. Its horizontal blade shows nasal surface smooth and slightly excavated and
palatine face creased. Forms transverse palatine suture with the palatine process of
the maxilla, and with the contralateral palatine bone forms midpalatal suture
(SPALTEHOLZ, 1988). From the posterior margin of the angle formed by two
blades, horizontal and perpendicular, protrudes the pyramidal process, which
articulates with pterygoid processes. In the perpendicular plate, should be mentioned
the following structures and anatomical marks sphenopalatine notch, greater palatine
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groove, lesser palatine canals, nasal concha ridge, orbital process and sphenoid
process (SPALTEHOLZ, 1988).

Pterygopalatine fosse
The pterygopalatine fosse is a small pyramidal space below the apex
orbit, it communicates with the infratemporal fosse through the fissure
pterygomaxillary with the nasal cavity by the sphenopalatine foramen and with the
orbit by the inferior orbital fissure. The round foramen has its opening in the
posterior wall of the same being crossed by the maxillary nerve, which follows a
anterolateral course (GRAY, 1973).

NEUROVASCULAR STRUCTURES OF THE

PTERYGOMAXILLARY REGION

Maxillary Artery
The maxillary artery is the larger of the terminal branches of the
external carotid artery, arising in the parotid gland behind medially the neck of the
mandible. There is a varying relation between the artery and lateral pterygoid
muscle. In more than 50% of persons, the artery is lateral to the muscle, passing
between the mandible and sphenomandibular ligament. In the remaining, the artery
passes medial to the lateral pterygoid muscle. It has many branches: deep auricular
artery, anterior tympanic artery, middle meningeal artery, inferior alveolar artery,
anterior and posterior deep temporal artery, masseteric artery, internal and external
pterygoid artery, buccal artery; posterior superior alveolar artery, infraorbital artery,
descending palatine artery, pterygoid canal artery, sphenopalatine artery
(FONSECA; WALKER, 1991).
In resume, the maxillary artery, the main branch of the external
carotid, distributes branches to maxilla, mandible, muscles of mastication, palate,
nasal cavity walls and part of the dura mater (SPALTEHOLZ, 1988).

Pterygoid Plexus

The pterygoid plexus is around the maxillary artery in the

infratemporal fosse. Is tributary of retromandibular vein below and medial to the
neck of the mandibular condyle. Many of the deep veins of face drains into this
plexus and this is one potential area of significant bleeding during mobilization of
fractures of Le Fort I type. Considering that these fractures can occur at the
pterygomaxillary junction or through the pterygoid plates. Because this is a region
that is not seen during the treatment of most fractures, compression and local
measures are the only available means of hemostasis (FONSECA; WALKER,
1991).

Maxillary Nerve (V2)

Essentially sensitive, follows the lateral wall of the cavernous sinus,

traverses the foramen rotundum of the sphenoid and reaches the pterygopalatine
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fosse (SPALTEHOLZ, 1988). In fosse is divided into three main branches:

pterygopalatine, infra-orbital and zygomatic nerve (FONSECA; WALKER, 1991).

Pterygopalatine Ganglion
The pterygopalatine ganglion was usually described with the
maxillary nerve to be in the path of this nerve, however, it is a parasympathetic nerve
ganglion intermediate process in which the synapses of neurons pre-and post-
ganglionic visceral efferent pathways general. For this reason it is described in the
intermediate nerve (SPALTEHOLZ, 1988). The motor fibers of facial-intermediate
(V2) has different real origins, all of which are nuclei of the bridge: 1. Nucleus of the
facial nerve to the muscle mimic, stylohyoid muscle and posterior belly of digastrics
muscle. 2. Nucleus tears, to the tear nasal and palatine glands. 3. Salivary rostral
nucleus, are distributed to the submandibular and sublingual glands.

Anatomical Measurements

In an attempt to determine the relationship of the internal maxillary

artery in the pterygopalatine fosse, 16 cadavers were dissected for the
individualization of the external carotid artery. From these specimens were taken
from the mandibular branch and the condyle, for further dissection of the terminal
branches of the internal maxillary artery in pterygomaxillary fosse. The average
distance from the lower point of pterygomaxillary suture to internal maxillary artery
was 25 mm. The average height of pterygomaxillary suture was 14.6 mm and the
diameter of the artery was 2.63 mm (TURVEY; FONSECA; HILL, 1980).
In a study of casts of the pterygopalatine fosse to locate the round
foramen, pterygoid and sphenopalatine foramen, the authors concluded that the first
presented always above and lateral to the second. And the sphenopalatine always
presented at the junction of the posterior fosse with its roof (NAVARRO;
ZORZETTO; TOLEDO-FILHO, 1982).
Given the high incidence of injuries to the descending palatine artery
during osteotomy of the maxilla in orthognathic surgery, a survey of 30 human skulls
was performed. The authors obtained the internal maxillary artery enters the
pterygopalatine fosse in a level of about 16.6 mm above the nasal floor, branching in
this region to form the descending palatine artery. This goes a short distance within
the pterygopalatine fosse and enters the greater palatine canal. They also concluded
that to avoid damage to the descending palatine artery, during a chisel osteotomy in
lateral wall of the nasal cavity, it must not extend more than 30 mm from the
piriform aperture in a posterior direction in females, and 35 mm in men. In addition,
stated that the pterygomaxillary separation should be pursued through the adaptation
of a curved osteotome in pterygomaxillary suture, or a saw with a right angle to
avoid excessive anterior angulations. Affirmed that the upper sharp portion of
curved chisel or saw to be less than 10mm above the nasal floor (LI; WEAR;
ALEXANDER, 1996).
With the proposal to delineate the maxillary artery and its branches
and develop a classification of them, 15 adult Korean cadavers were dissected in the
pterygopalatine region, totaling 30 sides. In 20 heads were carried out CT scans.
From pterygomaxillary suture to the pterygopalatine fosse maxillary artery was
divided into 5 branches in the following order: posterior superior alveolar artery,
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infraorbital artery, pterygoid canal artery, descending palatine artery and

sphenopalatine artery. The average distance from the lowest point of
pterygomaxillary suture to the posterior superior alveolar artery, infraorbital artery
and descending palatine artery were, respectively, 15.22 mm, 32.2 mm and 24.8 mm.
Concluding with these results, that the pterygomaxillary disjunction can be
conducted safely without damaging the maxillary artery and its branches (CHOI,
PARK, 2003).
To avoid damage to the descending palatine artery during Le Fort I
osteotomy, the posterior maxilla was evaluated through direct inspection and
computerized imaging (CT) and CT scans of the films. Fifty-five Thais skulls were
used, 38 males and 17 females. On inspection, 27.28% of the sutures
pterygomaxillary presented themselves as synostosis. The average height of
pterygomaxillary suture, the posterior maxilla and maxillary tuberosity were 15.14 +
/ -2.46 mm, 22.51 + / -3.5 mm, and 7.45 + / -2.76 mm, respectively. The average
length of the medial wall of the maxillary sinus measured from the piriform aperture
to the descending palatine canal in Le Fort I level was 34.4 + / -2.96 mm
(APINHASMIT; CHOMPOOPONG; METHATHRATHIP et al., 2005).
Many complications occur from unfavorable disjunction between the
posterior maxilla and pterygoid plates, including excessive bleeding, cranial nerve
injuries and damage to the carotid artery. The separation of maxilla from the skull in
the Le Fort I osteotomy with an osteotome, does not always induce an exact
separation on the pterygomaxillary suture at the posterior nasal spine. It is often used
a curved osteotome with a blind approach to fissure pterygomaxillary, but other
approaches using modified osteotome like swan-neck and shark-fin osteotome, and
ultrasonic bone curettes increased the safety of this procedure. Given this, 37
Japanese patients with mandibular pragmatism and asymmetry were examined
postoperatively by computed tomography. They were submitted to the Le Fort I
osteotomy without a pterygoid osteotome, with an ultrasonic curette used to remove
interference at the pterygomaxillary region after the down fracture. This work aimed
to examine the pterygomaxillary separation at the posterior nasal spine level after Le
Fort I osteotomy. They conclude that the Le Fort I osteotomy without a
pterygomaxillary osteotome does not always induced an accurate pterygomaxillary
separation, at the level of the posterior nasal spine (24%). However, the ultrasonic
bone curette could remove more safely interference between the posterior maxillary
regions from pterygoid plates (UEKI; HASHIBA; MARUKAWA et al., 2009).

AVAILABLE TECHNIQUES FOR

PTERYGOMAXILLARY SEPARATION

The available techniques for pterygomaxillary separation found in the

literature were osteotomy with curved Obwegeser’s osteotome, swan's neck
osteotome, "shark-fin" osteotome, osteotomy using a micro-oscillating saw, leverage
alone without an use of pterygoid chisel, osteotomy of the tuberosity and the use of
ultrasonic curette (OBWEGESER, 1969; WIKKELING; TACOMA , 1975;
CHENG, ROBINSON, 1993; LANIGAN; GUEST, 1993; LANIGAN; LOEWY,
1995, LASTER; ARDEKIAN; RACHMIEL et al., 2002; O `REGAN,
BHARADWAJ, 2005 and UEKI, HASHIBA; MARUKAWAI et al., 2009).
Osteotomy of pterygomaxillary region with a curved Obwegeser
chisel is done by a blind approach to achieve the separation of the maxilla from skull
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(OBWEGESER, 1969 e O `REGAN, BHARADWAJ, 2005). An important aspect

of this technique is the angle given by surgeon to chisel. The chisel should remain in
all time under the periosteum, with its tip in the pterygomaxillary suture, angled from
lateral to medial and top to bottom. Surgeon's index finger should palpate the palatal
region of the tuberosity and pterygoid hamulus to feel their separation (Figure 1)
(TURVEY, FONSECA, HILL, 1980 and REYNEKE, 2005).

Figure 1 –Curved osteotome positioned to pterygomaxillary disjunction.

Source - Photo taken from the gallery skulls of the Department of anatomy of FOB-USP.

The pterygomaxillary separation using "swan neck" chisel allows the

chisel to be directed from posterolateral to anteromedial one, while the curved handle
of the instrument accommodates the cheek (WIKKELING; TACOMA, 1975).
In a study to evaluate the performance of this instrument in 12 fresh cadavers (24
sides), pterygoid plates were fractured in 9 of 24 sides, in five sides and there were
multiple fractures. But all fractures occurred at level of Le Fort I (Figure 2)
(ROBINSON, 1993).

Figure 2 –Swan neck osteotome to pterygomaxillary separation. The curved handle accommodates
the cheek.
Source - Figure taken from the article: CHENG, H. H. ROBINSON, P. Evaluation of a swan's neck
osteotome for pterygomaxillary dysjunction in the Le Fort I osteotomy. Brit. J. oral Surg.,
v. 31, p. 52-3, 1993.

The “shark-fin” osteotome was developed to achieve a clearer

separation of the pterygomaxillary region. In a study of 10 patients undergoing Le
Fort I osteotomy, in one side was used the curved Obwegeser osteotome, while the
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other was used “shark-fin” osteotome. In the results evaluation by computed

tomography the authors obtained, a complete or almost complete separation was
obtained, whereas the use of the Obwegeser osteotome resulted in five sites with
fractures of the maxillary tuberosity and three with high-level fractures of the
pterygoid plates (Figure 3) (OBWEGESER, 1969 and LASTER; ARDEKIAN;
RACHMIEL et al., 2002).

Figure 3 - The “shark-fin” osteotome for a more precise pterygomaxillary separation.

Source - Photo taken from the article: LASTER, Z.; ARDEKIAN, L.; RACHMIEL, A. et al., Use of
the 'shark-fin' osteotome in separation of the pterygomaxillary junction in Le Fort I
osteotomy: a clinical and computerized tomography study. Int. J. oral Maxillofac. Surg., v.
31, p.100-3, 2002.

Other authors presented the use of micro-oscillating saw for

pterygomaxillary disjunction and found an ideal separation in 70% of cases, and
when there were fractures of the pterygoid plates, none were higher, near the skull
base (Figure 4) (JUNIPER; STAJCIC, 1991 and LANIGAN; GUEST, 1993).

Figure 4 - Micro-oscillating saw to pterygomaxillary disjunction.

Source - Image taken from the article: LANIGAN, D.T.; GUEST, P. Alternative approaches to
pterygomaxillary separation. J. oral Maxillofac. Surg., v. 22, p. 131-8, 1993.

Pterygomaxillary separation without an osteotome is also an option in

Le Fort I osteotomy, by means of a leverage (PRECIOUS; MORRISON,
RICARD, 1991). Other authors’ preconized the use of the thin, sharp, 8-mm,
straight osteotome distal to the second molar, approximately 0.5 to 1 cm from the
crest of the maxillary tuberosity, separating the maxilla from the skull. In the study,
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the chisel was used trough the soft tissues of the maxillary tuberosity, before the
other osteotomies of Le Fort I osteotomy (LANIGAN; GUEST, 1993). More
recently with the development of ultrasonic curettes, the pterygomaxillary suture
separation proved, according to the authors, to be efficient, with greater safety for the
descending palatine artery showing highly predictable results (UEKI;
NAKAGAWA; MARUKAWA, 2004).

COMPLICATIONS ASSOCIATED WITH

PTERYGOMAXILLARY DISJUNCTION
The complications associated with Le Fort I osteotomy in consulted
literature were: malposiotioning of the maxilla, intraoperative hemorrhage,
postoperative arteriovenous fistula, asseptic necrosis, oro or nasal fistula, maxillary
sinusitis, maxilla pseudoarthrosis, nasal septum deviation, velopharyngeal
incompetence, dysfunction of the Eustachian tube, ophthalmic complications,
damage to nasolacrimal system, undesirable fractures between palatine bone and
maxilla and unfavorable fractures through the pterygoid plates (PARNES;
BECKER, 1972; SHER, 1980; BELL; THRASH; ZYSSET, 1986; LANIGAN;
TUBMAN, 1987; WITZEL, 1989; LANIGAN; HEY; WEST, 1990, VAN
SICKELS; TUCKER, 1990, PETERSON, 1991; LANIGAN; GUEST, 1993;
LANIGAN; ROMANCHUK, OLSON, 1993; SHOSHANI; SAMET ;
ARDEKIAN et al., 1994; MENENDEZ; BIEDLINGMAIER; TILGHMAN,
1996; ARAUJO, 1999; APINHASMIT; CHOMPOOPONG;
METHATHRATHIP et al., 2005; MARZOLA, 2005; O `REGAN,
BHARADWAJ, 2005; REYNEKE, 2005 and UEKI, HASHIBA ;
MARUKAWAI et al., 2009). Among the complications related to the Le Fort I will
be detached those that are related to pterygomaxillary disjunction.

DYSFUNCTION OF
EUSTACHIAN TUBE

Excessive pression over pterygoid hamulus may result in fracture of

the same and predispose the patient to a dysfunction of the Eustachian tube. This is a
channel that connects the middle ear to the pharynx and with the function of
maintaining the air balance between the two surfaces of the tympanic membrane. As
a result, promotes the equalization of pressure between the external and middle ear.
In situations where there is a loss of this balance, the main complication associated is
propensity to otitis media (REYNEKE, 2005).

OPHTHALMIC
COMPLICATIONS

Ophthalmic lesions appear to be mediated through untoward fractures

that extend to the pterygopalatine fosse, base of the skull, and orbit can occur in
association with the pterygomaxillary dysjunction and maxillary downfracture
(LANIGAN; ROMANCHUK, OLSON, 1993). In general the complications can
be grouped into four categories: loss of function of the lacrimal gland, damage to
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cranial nerves, injury to internal carotid artery and blindness (CRUZ, SANTOS,
2006).

INTRAOPERATIVE OR
POSTOPERATIVE HEMORRHAGE

The descending palatine artery is the most commonly injured in Le

Fort I osteotomy, during the osteotomy of the lateral or medial maxillary sinus,
pterygomaxillary disjunction or the downfracture of maxilla. However, after the
downfracture, the bleeding is easily controlled, after visualization and cauterization
of artery (LI; WEAR, ALEXANDER, 1996). On the other hand, the initial
treatment of postoperative bleeding is the anterior nose packing and, with no
resolution, a more invasive approach is required, by means of embolization of the
internal maxillary artery, or even ligature of the external carotid artery (LANIGAN;
WEST, 1984). At the end of the surgical procedure, in wich was noted excessive
bleeding, proven by the quantitative values postoperative hemoglobin (Hb) and
hematocrit (Ht), the replacement is necessary. In the first instance we use the
infusion of crystalloids (saline 0.9% or Ringer's lactate), which have similar
composition to plasma, or colloids (dextran, gelatin, albumin) that are plasma
expanders. However, if hypovolemia is severe with clinical signs of cardiac output
depression, represented by tachycardia, hypotension, tachypnea, decreased level of
consciousness and vascular collapse, blood transfusion is mandatory (WALT, 1982
and DAVID, 2004).

ARTERIOVENOUS
FISTULA
During orthognathic surgery, when occur the lesion of an artery near a
venous plexus, with spontaneous anastomosis is called arteriovenous fistula. The
most revealing sign of this complication is buzzing and permanent pulsation in face
in the postoperative period. Despite the low incidence in the literature, it is essential
that the surgeon diagnose that condition. The treatment consists of selective
embolization of the vessels near the fistula (HABAL, 1986 and LANIGAN; HEY,
WEST, 1991).

FRACTURES IN THE EFFECTS

PTERYGOMAXILLARY

In the maxillary Le Fort I osteotomy during orthognathic surgery,

some unfavorable fractures have been reported, mainly in the moment of
pterygomaxillary disjunction, associated with damage to the descending palatine
artery.
In a study, was performed Le Fort I osteotomy in 37 patients without a
pterygoid osteotome, with an ultrasonic curette used to remove interference at the
pterygomaxillary region. Evaluating 74 pterygomaxillary disjunctions, only 18 of
these (24%) showed a correct separation. In 29 (39.2%) of the 74 disjunctions, was
not observed complete separation between the maxilla and the lateral pterygoid
plates and / or the medial pterygoid plates, but in all cases there was a separation of
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pterygoid plates in a lower level (Figure 5) (UEKI, HASHIBA; MARUKAWA et

al., 2009).

Figure 5 - Classification scheme of types of separation of the region pterigomaxilar. The black dot
shows the greater palatine canal.
Source: Image taken from the article: UEKI, K.; HASHIBA, Y.; MARUKAWA, K. et al.,
Assessment of pterigomaxilar separation in Le Fort I osteotomy in class III patients. J. oral
Maxillofac. Surg., v. 67, p. 833-9, 2009.
MATERIAL AND METHODS
This research project was referred to the Ethics committee in
research with human subjects at the Faculty of Dentistry of Santa Fé do Sul -
FUNEC, which obtained authorization for its execution by means nº. 0000028.
Were objects of these study 30 dry, dentated skulls, from the
Department of Anatomy, Faculty of Dentistry of Bauru, São Paulo University -
USP. The pterygomaxillary suture was measured bilaterally.
Therefore, a chart was created for the purpose of recording the data
obtained by measuring between points named by means of letters of the alphabet in
order to elucidate the main anatomical landmarks to be carefully observed in
orthognathic surgery (Table 1).
These measurements were taken by a researcher trained for this
urpose, being held on two occasions with an interval of fifteen days, to compare data
and check if there was an error noteworthy. For the measurements realization, we
used a 150 mm digital caliper (Starret ®) and a needle point compass at the defined
points by the distances to be analyzed, crashed to the bar and the digital caliper
obtained in the desired measures. The studied points correspond to the following
distances (Figures 6, 7, 8, 9 e 10).
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Table 1 - File created for recording the points measured.

SKULLS Nº 30
SKULL SIDE(R) A–B A–C A-B A-E A-F
RIGHT
(L)LEFT

01 R
L
02 R
L
03 R
L
04 R
L
05 R
L
06 R
L
07 R
L
08 R
L
09 R
L
10 R
L
11 R
L
12 R
L
13 R
L
14 R
L
15 R
L
16 R
L
17 R
L
18 R
L
19 R
L
20 R
L
21 R
L
22 R
L
23 R
L
24 R
L
25 R
L
26 R
L
27 R
L
28 R
L
29 R
L
30 R
L

Source - Data gathered from Service of the Oral and Maxillofacial Surgery.
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PTERYGOMAXILLARY REGION IN SKULLS –
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Figure 6 - A-B - The lowest point of the suture (A) to the most superior point pterygomaxillary suture
(B).
Source - Photo taken from the gallery skulls of the Department of anatomy of FOB-USP.

Figure 7 – A-C - The lowest point of the pterygomaxillary suture (A) and contralateral side of the
palate (C).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP.

Figure 8 – D AB (distance from the outermost point of the zygomatic pillar (D) the pterygomaxillary
suture (A-B).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP.
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PTERYGOMAXILLARY REGION IN SKULLS –
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Figure 9 - A-E (from the lowest point of the pterygomaxillary suture (A) to the orbital apex (E).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP

Figure 10 – A-F (from the lowest point of pterygomaxillary suture to skull base (F).
Source - Photo taken from the skulls of the Department of anatomy of FOB-USP.

RESULTS

The height of the pterygomaxillary suture measured between two

points (A-B), lower and upper, presented an average of 11.55 mm, with a minimum
of 6.88 mm and a maximum of 18.15 mm, with no statistically significant difference
between right and left sides of the skulls, but with differing measures when
compared with each other.
With regard to the width of the pterygomaxillary suture (A-C), the
mean score was 10.29 mm, with values between 6, 81 and 13 mm, 74 mm. The
measurement of the outermost point of the zygomatic pillar to pterygomaxillary
suture (D AB), presented as minimum measure 19.22 mm and a maximum of 29.70
mm, with an average of 24.51 mm.
Concerning to the distance between the lowest portions of the
pterigomaxilar suture to the orbital apex (A-E), the average was 32.54 mm, with
values varying from 25.56 mm to 42.68 mm. Relating to the average distance
between the lowest points of the pterigomaxilar suture to the skull base (A-F), was
obtained a mean value of 34.59 mm that ranged between 25.95 mm and 42.85 mm.
These results could be viewed in the tables and prepared the following chart (Tables
2 e 3 and Chart 1).
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PTERYGOMAXILLARY REGION IN SKULLS –
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Table 2 - Data obtained from measures in the pterygomaxillary suture and their anatomical relations.

SKULLS Nº 30 A–B A–C D A-B A-E A-F

SKULL SIDE
(R)Right
(L)Left
01 R 10,57 9,66 25,06 31,22 34,32
L 11,10 9,78 24,00 31,44 33,27
02 R 10,57 10,47 26,87 31,23 34,56
L 11,30 10,79 23,47 31,12 32,62
03 R 10,47 10,87 29,31 32,18 36,56
L 10,65 8,77 28,33 31,15 34,30
04 R 14,27 8,97 25,64 36,58 40,28
L 12,10 9,10 27,39 36,52 40,46
05 R 7,07 11,53 25,33 30,39 32,83
L 13,18 10,01 25,25 32,01 36,81
06 R 9,75 9,15 21,29 30,39 32,71
L 9,78 9,30 21,21 28,90 31,93
07 R 13,16 11,06 25,73 25,56 30,98
L 9,40 9,35 23,83 30,02 31,56
08 R 8,04 10,07 19,52 31,67 29,13
L 6,88 9,32 19,22 35,10 34,36
09 R 12,55 10,72 25,08 27,70 30,79
L 11,42 10,24 25,91 33,02 33,08
10 R 13,12 10,71 22,79 33,13 36,06
L 13,49 10,78 24,65 32,52 33,34
11 R 17,02 11,03 25,20 36,88 38,43
L 18,15 11,72 24,77 38,33 40,46
12 R 8,70 10,41 25,04 29,34 31,80
L 7,64 11,24 24,52 32,11 34,22
13 R 11,82 12,16 22,88 34,63 35,06
L 11,73 11,97 25,09 35,10 36,75
14 R 15,78 11,11 25,37 32,19 37,07
L 15,41 10,83 24,43 33,66 35,05
15 R 10,83 20,96 21,02 32,39 32,45
L 10,21 9,72 22,93 36,98 35,47
16 R 9,17 6,81 29,70 33,15 32,18
L 9,61 7,91 28,48 36,46 36,99
17 R 11,13 9,20 22,38 31,97 33,87
L 11,30 10,50 20,92 28,49 32,51
18 R 13,10 9,45 23,87 32,74 37,53
L 9,47 10,47 23,07 35,31 38,44
19 R 8,87 8,66 25,03 30,93 33,59
L 11,49 9,20 25,64 30,74 34,07
20 R 13,95 8,72 26,03 33,74 35,40
L 12,84 10,39 26,55 37,20 38,97
21 R 14,32 10,34 26,53 32,82 37,64
L 15,30 10,31 25,25 32,80 37,85
22 R 10,51 12,03 26,02 31,19 30,64
L 8,00 11,16 25,72 33,69 33,80
23 R 15,00 9,88 28,16 36,09 41,90
L 14,05 10,77 28,26 36,60 42,05
24 R 9,04 11,32 21,29 30,80 31,59
L 10,07 11,00 21,70 33,19 33,67
25 R 10,89 13,74 26,94 36,93 37,96
L 10,27 11,60 29,39 42,68 42,85
26 R 12,06 9,89 21,99 26,14 25,95
L 10,52 10,01 22,47 28,51 27,90
27 R 9,98 9,75 22,68 27,27 28,55
L 9,48 10,28 22,51 30,52 32,82
28 R 15,60 8,73 23,86 32,26 33,86
L 14,97 9,05 24,77 33,95 36,82
29 R 11,86 11,82 22,50 31,41 34,84
L 11,61 13,57 22,85 30,41 34,26
30 R 11,17 9,90 22,96 28,82 28,48
L 10,85 9,01 22,16 31,99 31,44

Source - Results taken from Service of the Oral and Maxillofacial Surgery.
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PTERYGOMAXILLARY REGION IN SKULLS –
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TECHNIQUE IN ORTHOGNATHIC SURGERY

The results were recorded and transferred to the software program

Statistica version 5.1, from StatSoft Inc. USA. They were tabulated and described by
the mean values and standard deviation of minimum and maximum, by paired t test.

Table 3 – Mean values, standard deviation, minimum and maximum value of the measures evaluated.

Measusre Mean Dp Minimum Maximum

A-B 11,55 2,45 6,88 18,15

A-C 10,29 1,24 6,81 13,74

D A-B 24,51 2,42 19,22 29,70

A-E 32,54 3,14 25,56 42,68

A-F 34,59 3,56 25,95 42,85

Source: Results taken from Service of the Oral and Maxillofacial Surgery.

Graphic 1 - Mean, standard deviation, minimum and maximum measurements.

Distância (mm)
45

40

35

30

25

20

15

10

0
A-B A-C Perp. A-B A-E A-F
Source: Results taken from Service of the Oral and Maxillofacial
Medidas Surgery.
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PTERYGOMAXILLARY REGION IN SKULLS –
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Comparing the left and right sides of the skulls, only in the
measurements A-E and A-F there was a statistically significant difference, p<0.05.

Table 4 - Comparison between the right and left sides by paired t test.

Right Left

Measure t P

Mean dp Mean dp

A-B 11,68 2,46 11,41 2,47 0,807 0,426 ns

A-C 10,30 1,34 10,27 1,14 0,172 0,865 ns

D A-B 24,54 2,46 24,48 2,42 0,241 0,811 ns

A-E 31,72 2,89 33,35 3,23 -4,094 <0,001 *

A-F 33,90 3,65 35,27 3,40 -3,247 0,003 *

* - Statistically significant difference (p <0.05)

ns - Not statistically significant
Source: Results taken from Service of the Oral and Maxillofacial Surgery.

DISCUSSION
The literature is limited in studies that correlates surgical techniques
and anatomical basis of pterygomaxillary region in orthognathic surgery. The
knowledge of this anatomic region for correct disjunction of pterygomaxillary suture
is essential. The vascular and nervous structures (maxillary artery, maxillary vein,
pterygoid plexus and ganglion pterigoplalatine) at this region are important
parameters for placement of the instruments used for pterygomaxillary disjunction
(GRAY, 1973; SPALTEHOLZ, 1988; FONSECA; WALKER, 1991 and GRAY,
1995). There is consensus among the authors, including of the present paper that this
statement is true, which justifies studies designed to measures specific anatomic
landmarks of this region to increase the knowledge of this region.
The height of the pterygomaxillary suture (A-B) observed in the skulls
measured in this study, was in average 11.55 mm, without statistically significant
differences between the right and left sides of the skulls. In contrast, other studies
showed that the height of the pterygomaxillary suture was in average 14.6 mm
(TURVEY; FONSECA, HILL, 1980), 15.22 mm (CHOI, PARK, 2003) or 15.14
mm (APINHASMIT; CHOMPOOPONG; METHATHRATHIP et al., 2005).
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Probably because this researches were conducted in different countries, with

different facial biotypes. Therefore we can say that with these measures, the chisels
used in this region may have a width from 8 to 10 mm, to avoid damage to adjacent
structures.
The width of the pterygomaxillary suture were in average 7, 45 mm
(APINHASMIT; CHOMPOOPONG; METHATHRATHIP et al., 2005), which
is not congruent with the results of this study, which showed average width of
pterygomaxillary suture (A-C) average of 10.29 mm. This disagreement can also be
explained because of distinct demographic regions were evaluated. Or even due to
these measures were carried out in a distinct way by the authors of this paper in
relation to Thailand authors. The values of this research guide surgeons not to
introduce the curved osteotome more than 10mm in pterygomaxillary separation.
This research assessed the distance from the outermost point of the
zygomatic pillar pterygomaxillary suture (D A-B), and was noted absence of this
measurement in the reviewed papers. The measure was in average 24.51 mm. The
present authors are in agreement that a clinical parameter is essential in surgical
technique adopted in our Institute that uses a chisel to osteotomize lateral wall of
maxilla. It should be noted that during the taps with hammer, the sound will remain
unchanged until the osteotome has been stabilized in the pterygoid plate. The chisel
should start from the zygomatic pillar in a posterior and slightly lower direction,
osteotomizing lateral wall of maxilla until it reaches the pterygoid process. During
this traject, half to one third of its active tip remains out of the lateral wall of maxilla.
Given the appearance of some reports of ophthalmic complications
due to fractures directed to the orbit or skull base. Neurovascular injuries are
observed as a result of tension, compression or countercoup, which may cause
ophthalmoplegia, lacrimal system damage or even blindness (LANIGAN;
ROMANCHUK, OLSON, 1993). Therefore, because there is no craniometric
studies in this regard, in the consulted literature, this paper showed the distances of
the lowest portion of pterygomaxillary suture to orbital apex (A-E), and skull base
(A-F), with averages of 32.54 mm and 34 59 mm, respectively. Assuming that these
complications are disastrous to the patient, the surgeon must be careful about the
positioning of the osteotomes, and the surgical movements of maxilla. The
impaction of maxilla must be careful with regard to passivity when determining the
height of the upper incisors to posterior fixation.
Comparing the data of the measurements of A-E and A-F, there was
both a statistically significant when evaluated right and left sides (p <0.05).
Probably due to the fact that some skulls were measured in subjects with facial
asymmetry, with a superior growth of the posterior facial height in one of the sides.
Among the techniques described for pterygomaxillary disjunction, the
most common techniques are the ones that use a curved chisel (OBWEGESER,
1969), shark-fin osteotome (LASTER; ARDEKIAN; RACHMIEl et al., 2002),
swan’s neck osteotome (WIKKELING; TACOMA, 1975), use of micro-oscillating
saw (JUNIPER; STAJCIC, 1991 and LANIGAN; GUEST, 1993), downfracture
without pterygomaxillary osteotomy, only by a leverage (PRECIOUS;
MORRISON, RICARD, 1991), using an straight chisel trough the soft tissues of the
maxillary tuberosity (LANIGAN; GUEST, 1993) and by means of ultrasonic
curettes (UEKI, NAKAGAWA, MARUKAWA, 2004). The philosophy of the
researchers of this study corroborates with the technique that uses curved chisel,
believing that the domain of technique by surgeons results in the security of the
 783
PTERYGOMAXILLARY REGION IN SKULLS –
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same. This technique is certainly the most used and older, which suggests that the
number of complications in front of the universe of all operated patients is small.
What justifies further studies with the other techniques, to obtain data with greater
reliability, in terms of statistical significance.

CONCLUSIONS
Considering the results obtained from this research and literature
review, we can conclude that:
1. The anatomical knowledge of the pterygomaxillary region is of
fundamental importance in pterygomaxillary disjunction.
2. Most complications during the Le Fort I osteotomy is related to the
pterygomaxillary disjunction.
3. The craniometric measurements used help the professional in the
execution of the maxillary osteotomy.
4. The safety of disjunction with the use of curved chisel is directly
proportional to the domain of this technic.
5. The chisels used to pterygomaxillary disjunction may have a width
from 8 to 10 mm,
6. Surgeons must not introduce the curved osteotome more than
10mm in pterygomaxillary separation.

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