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On the feasibility of intraoral maxillo-malar osteotomy
110
J. Cranio-Max.-Fac.Surg. 17 (1989)
J. Cranio-Max.-Fac. Surg. 17 (1989) 110-115 © Georg Thieme Verlag Stuttgart • New York
On the Feasibility of Intraoral Maxillo-Malar Osteotomy Roberto Brusati, Enrico Sesenna*, Mirco Raffaini Dept. of Maxillo-FacialSurgery(Head:Prof. R. BrusatiM.D,, DMD.), Universityand Hospitalof Parma,Italy * AssociateProfessorof Maxillo-FacialSurgery,Universityof Chieti,Italy Submitted 12.5.88; accepted 20.7.88
Introduction The maxillo-malar osteotomy, also called modified Le Fort III, and intermediate or butterfly osteotomy, should be considered for treating those patients with anteroposterior hypoplasia of the upper jaw combined with a flattened paranasal area, retrusion of the lower orbital rim and malar deficiency together with a normal nasal projection. In these patients a facial advancement of the Le Fort III type would result in excessive nasal prominence and a simple maxillary advancement using Le Fort I osteotomy would only partially correct the deformity leaving the zygomatic defect untreated. A maxillo-malar advancement will specifically correct the deformity, simultaneously improving both the occlusal defect and the malar retrusion. This procedure, as employed first by Obwegeser (1969) (Fig. 1), was characterized by the mobilization of the upper jaw together with the entire zygomatic complex, including the frontal apophysis, the lower orbital rim, a part of the orbital floor and the frontal process of the maxilla up to the level of the nasolacrimal groove. During the 1970's, many surgeons used this method, sometimes with slight personal variations (Rehrmann, 1971; Kufner, 1971; Souyris et al., 1973; Popescu, 1974; Epker and Wolford, 1975, 1979; Champy et al., 1979; Steinhauser, 1980). They all utilized a double access: intraoral and extraoral either subciliary or endoconjunctival. Recently Ferronato (1983) for the extraoral access has proposed a minute incision located in a cutaneous fold of the lateral half of the lower eyelid, just below the tarsal plate. Even though the cutaneous and endoconjunctival incisions are generally without cosmetic or functional consequences, we believe it is worthwhile reporting the possibility of using, without difficulty, an exclusively intraoral route in performing a maxillo-malar osteotomy. Recently, Keller and Sather (1987) reported seven cases of maxillo-malar osteotomy (named quadrangular Le Fort II osteotomy), as described by Kufner (1971), utilizing only a transoral approach. We therefore present extensively here our technique previously exposed in a preliminary report (Brusati et al., 1987).
Summary The maxillo-malar osteotomy is one of the osteotomies developed over the years to correct the deformities of the midface without modifying the nasal projection. After having for many years approached the osteotomy through the classic double access, intraoral and subciliary, we verified the feasibility of this osteotomy via an intraoral route only. For this purpose we modified slightly the classic osteotomy lines, however still including in the mobilized fragment the most prominent and therefore the most aesthetically important portion of the zygoma. At the lower orbital rim the medial osteotomy cut is performed with a fissure bur, the lateral one with an oscillating saw. Both the osteotomies are extended posteriorly in the orbital floor with a fine osteotome. Then, after having performed all other osteotomy cuts, the maxillo-malar complex is down-fractured. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are broken during a careful downfracture, avoiding fracture between the maxilla and zygoma. The complex is advanced and stabilized with intermaxillary fixation, osteosynthesis and bone grafts. A bone graft to the orbital floor is unnecessary. Key words Maxillo-malar osteotomy - Intraoral approach Maxillo-malar deficiency - Down-fracture
Surgical Technique Access is obtained via the classic intraoral vestibular incision from tuberosity to tuberosity. Then the periosteum is dissected from the piriforrn rim, from the anterior and lateral walls of the maxilla, from the inferior orbital rim, and from the anterior orbital floor. Care is taken to avoid transection of the periorbita, which would cause herniation of the periorbital fat. The most anterior insertion of the masseter muscle should be dissected from the zygoma in order to expose fully the body of the zygoma up to the level of the arch and the zygomatic groove which is locat-
Fig.1
Obwegeser's rnaxillo-malar osteotomy procedure,
On the Feasibility of Intraoral Maxillo-Malar Osteotomy
!
/
,..=_
"q,~,/.//
Osteotomy lines employed by us: a) dotted line including orbital floor and most of the infraorbital rim; b) continuous line including the orbital floor but remaining lateral to the infraorbital foramen; c) dashed line avoiding the orbital floor (for explanation see text). Fib.2
ed just below it. Using a fissure bur, an osteotomy is performed, extending from the orbital rim to the base of the piriform aperture. This osteotomy is characterized by a vertical cut, medial or lateral to the infraorbital foramen, and by a horizontal one to reach the lateral rim of the piriform aperture (Figs. 2 a and b line). Then, using the angular blade of a reciprocating saw, a malar osteotomy is performed from the infero-lateral corner of the orbital rim, downwards and posteriorly directed to the anterior insertion site of the masseter. Both osteotomies, lateral and medial, of the orbital rim are extended posteriorly in the orbital floor to a depth of 10-15 mm. This is done with a fine osteotome directed towards the anterior part of the inferior orbital fissure in order to complete the osteotomy or to reduce the nonosteotomized bone area of the orbital floor to only a few ram. Instead of performing the osteotomies of the infraorbital rim, it is possible to trace an osteotomy line slightly inferiorly to the orbital rim, therefore completely avoiding the orbital floor (Fig. 2 c). Then, after having dissected the mucoperiosteum from the lateral nasal walls and floor, these are osteotomized with a thin osteotome. The base of the nasal septum is separated from the maxilla and then the pterygomaxillary disjunction is performed with a curved osteotome in the usual way. The same osteotomies are performed on the contralateral side. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are: a) a thin, limited portion of the orbital floor; b) the postero-medial and posterior maxillary wall; c) some small portions of the postero-lateral wall of the maxilla, extending from the inferior orbital fissure to the inferior part of the pterygo-palatine fissure which cannot be reached by the osteotome or the reciprocating saw. These bony bridges, particularly difficult to reach and to section, but very thin, can be easily broken during the down-fracture. The down-fracture is performed with thinned Tessier mobilization forceps which are placed in the osteotomy line at the piriform aperture.
J. Cranio-Max.-Fac. Surg. 17 (1989)
111
The mobilization must be done initially with caution, carefully controlling both orbito-malar areas to ensure symmetrical one-piece fracturing. Osteotomes are also inserted bilaterally in the zygomatic osteotomies. When rotated, they aid in strengthening the downwards movement of the osteotomized sector. Any fracturing between the zygomatic and maxillary area can be prevented by alternating these movements together with those exerted by the Tessier forceps. The fracture of the orbital floor can extend posteriorly to the inferior orbital fissure, or be localized in a particularly fragile anterior area. After completion of the downfracture it is necessary to advance the maxillo-malar complex as usual in order to free it completely from all the fibroligamentous attachments. When the maxillo-malar complex is freely (Fig. 3) movable for advancement, the intermaxillary fixation in the correct occlusion is applied. Autogenous cortico-cancellous bone grafts, obtained from the ilium and appropriately contoured, are inlayed. They are inserted in the gaps which are present in the zygomatic osteotomy line and between the pterygoid process and the maxillary tuberosity. If the medial osteotomy of the orbital rim is lateral to the infraorbital foramen, additional grafts in the paranasal area (around the infraorbital nerve) may be necessary (Figs. 4 and 5). No attempt is made to bridge by grafting the resulting defect in the orbital floor, because the periorbita should retain its integrity. If any laceration of the periorbita has resulted, this can be detected and repaired immediately after the downfracture when access and feasibility is optimal (Fig. 6). Any required grafting on the orbital floor should be done at this time before superiorly repositioning the osteotomized fragment. Osteosyntheses are performed on the malar body, wiring the bone grafts, and the piriform rims. The incisions are sutured and the intermaxillary fixation is maintained for four weeks. Clinical Cases
Case I (Fig. 7). B. S. aged 20, female, exhibits a class III appearance due to hyperplasia of the mandible and a sagittal maxillary deficiency associated with zygomatic, infraorbital rim and paranasal retrusion. From the occlusal point of view, a class III malocclusion with an 8 ram. dental reverse overjet and bilateral crossbite is present. The maxillo-malar osteotomy was performed by the method described, using a type b osteotomy tracing, for an advancement of 6 ram. The mandible was then retropositioned in I class occlusion by bilateral sagittal osteotomies of the rami. After 2 years, the postoperative results show a correct facial morphology with adequate zygomatic prominence together with a normalization of the inferior third of the face and with a correct occlusion. Case 2 (Fig. 8). P.E. aged 20, male, presents a complex facial deformity associated with characteristic naso-maxillary dysplasia (Binder's syndrome) together with a normal positioned nasal bridge, a bilateral zygomatic hypoplasia, a maxilla anteroposteriorly underdeveloped, and a large mandible overdeveloped anteroposteriorly. During a first surgical procedure, a maxillo-malar osteoto-
112
J. Cranio-Max.-Fac. Surg. 17 (1989)
Fig.3 Intraoperative view of the down-fractured maxillo-malar
R. Brusati et al.
Fig. 4
Intraoperative view of the bone grafts in the paranasal area.
complex mobilized via the exclusively intraoral approach.
Fig.5 Axial CT of facial skeleton after maxillo-malar osteotomy shows the bone grafts in the zygomatic osteotomy gaps and the paranasal area appositional bone grafts.
Fig.6 Intraoperative view demonstrating the integrity of the periorbita and the relatively large access, if necessary, for its repair.
my advancement was performed (8 mm.), using the technique advocated (osteotomy tracing type b), and bilateral sagittal osteotomies of the mandible to obtain an 8 mm. retrusion. Three months later a second operation was carried out to correct the nasal anomaly by a nasal septum advancement (Holmstr6rn, 1986) and by an osteochondral graft to the nasal spine and columella. A reduction genioplasty was performed vertically and transversely. Both a satisfactory aesthetic result and a stable, normal occlusion have been achieved.
and zygomatic hypoplasia associated with a normal nasal prominence. This osteotomy method focusses on improving the defect without compromising the surrounding areas which 'exhibit a correct morphology. It also offers a limited relapse risk, especially at the zygoma. The zygomatic advancement obtained by this method certainly appears more natural and more stable than when onlay bone grafts or alloplastic augmentation are applied. However, this advantageous surgical procedure is more complex than the classic Le Fort I maxillary osteotomy. The simultaneous mobilization of maxilla and zygoma requires accurate control of the osteotomized sites to ensure that a fracture at the maxillo-malar conjunction does not occur during the down-fracture, which would compromise the fixation of the zygoma in the correct position. With classic osteotomy tracing, subciliary or endoconjunc-
Discussion
Maxillo-malar osteotomies are very successful when performed on selected cases exhibiting maxillary retrusion
On the Feasibility of Intraoral Maxillo-Malar Osteotomy
J. Cranio-Max.-Fac. Surg. 17 (19 8 9)
113
Fig.7a
Fig.7c
Fig.7e
Fig.7b
Fig.7d
Fig, 7f
Fig.7a and b Facial appearance from frontal view before and after surgery.
Fig.7c and d Facial appearance from profile view before and after surgery.
Fig.7e and f after surgery.
Teleradiography before and
Fig. 7 g and h surgery,
Occlusion before and after
Fig.7g
Fig.7h
Fig.7
Retromaxillism, case 1.
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R. Brusati et al.
Fig.8a
Fig.8c
Fig.8e
Fig.8b
Fig.8d
Fig. 8f
Fig.8a and b Facial appearance from frontal view before and after surgery.
Fig.So and d Facial appearance from profile view before and after surgery.
Fig.8e and f after surgery.
Teleradiography before and
Fig.8g and h surgery.
Occlusion before and after
Fig. 8 g
Fig. 8 h
Fig.8 Retromaxillism and macrogenia, case 2.
On the Feasibility of lntraoral Maxillo-Malar Osteotomy
J. Cranio-Max.-Fac. Surg. 17 (1989)
115
It is also possible to avoid the orbital floor during the fracturing by moving the osteotomy line to just below the orbital rim, instead of including it completely. This, however, does not eliminate the possibility of zygomatic advancement. Because of these advantages we believe the above described intraoral method to be particularly useful since it permits optimal visibility during all phases of the maxillo-malar osteotomy without any excessive difficulties. References
Fig.8i Intraoperative view after septum advancement procedure: the septum is fixed to the nasal spine in the correct anterior position. tival incisions are necessary. The subciliary incision permits an extended view of the orbital area but sometimes results in unaesthetic scarring. The endoconjunctival approach (Tessier, 1973) does not cause external scarring, but it allows a limited access to the orbital area and occasionally causes an entropion of the lower lid. The cutaneous access proposed by Ferronato (1983), even if it is small and causes only limited scarring, may not be welcome to the patient. The method we use permits us to avoid any cutaneous or endoconjunctival access without complicating the surgical procedure. The site of the malar osteotomy is located more anteriorly than is the case when using the traditional techniques but not so anteriorly as in Kufner's (197l) modification. In this way only the most prominent, and therefore the most aesthetically important portion of the zygoma, is included in the maxillo-malar mobilized complex. The medial side of the osteotomy may be carried out in two different locations: lateral to the nerve, when paranasal morphology is adequate and only small onlay bone grafts are necessary, or medial to the nerve, if the paranasal region or the remaining midfacial skeleton exhibit a serious deficiency. Neither the fracturing nor the subsequent mobilization of the orbital floor causes ocular problems. When this procedure is correctly performed, the periorbita remains intact, and the limited bone defect of the orbital floor resulting from the advancement of the orbital rim does not need bone grafting.
Brusati, R., E. Sesenna, M. Raffaini: L'osteotomia maxillo-malare solo per via endorale nella correzione delle dismorfosi del terzo medio della faccia. Atti del 36 ° Congresso della Societ~ Italiana di Chirurgia Plastica, Ricostruttiva ed Estetica. Torino 16-19 settembre 1987. Monduzzi Editore, Bologna (1987) 863 Cbampy, M., ]. P. Lodde, A. Wilk: Apropos de 30 cas d'ost~otomies transfacciales interm~diaires. Ann. Chir. Hast. 24 (1979) 351 Epker, B.N., L.M. Wolford: Middle-third facial osteotomies: their use in the correction of acquired and developmental dento-facial and cranial deformities. J. Oral Surg. 33 (1975) 491-514 Epker, B.N., L.M. Wolford: Middle-third advancement: treatment considerations in atypical cases. J. Oral Surg. 37 (1979) 31-41 Ferronato, G.: Le vie di aggressione chirurgica extra ed endorali per la correzione delle disgnazie con grave iposviluppo del terzo medio della faccia. Min. Stomatol. 32 (1983) 851-867 Holmstr6m, H.: Surgical correction of the nose and midface in maxillo-nasal dysplasia (Binder's Syndrome). Hast. Recostr. Surg. 78 (1986) 568-580 Keller, E.E., A.H. Sather: Intraoral quadrangular Le Fort II osteotomy. J. Oral Maxillofac. Surg. 45 (1987) 223-232 Kufner, J.: Four-year experience with major maxillary osteotomy for retrusion. J. Oral Surg. 29 (1971) 549-553 Obwegeser, H.L: Surgical correction of small or retrodisplaced maxillae. The "dish-face" deformity. Hast. Reconstr. Surg. 43 (1969) 351-365 Popescu, V. C.: Advancement of the middle third of the face without bone grafting in a case of Crouzon's Disease. J. Maxillofac. Surg. 2 (1974) 219-223 Rehrmann, A.: Orthop~idische Chirurgie der Kiefer. In: Ausgew/ihlte Kapitel aus dem Gebiet der Plastischen Chirurgie. TherapieWoche, G. Braun Verlag, Karlsruhe (1971) 50-54 Souyris, F., J.B. Caravel, J.P. Reynaud: Ost6otomies "interm~diaires" de l'&age moyen de la face. Ann. Chir. Hast. 18 (1973) 149-154 Steinhauser, E.W.: Variations of Le Fort II osteotomies for correction of midfacial deformities. J. Maxillofac. Surg. 8 (1980) 258-263 Tessier, P.: The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J. Maxillofac. Surg. 1 (1973) 3-8
Prof. R. Brusati, M.D., D.M.D. Cattedra e Divisione di Chirurgia Maxillo-Facciale Universit~ e Ospedale di Parma Via Gramsci 14 1-43100 Parma Italy
J. Cranio-Max.-Fac.Surg. 17 (1989)
J. Cranio-Max.-Fac. Surg. 17 (1989) 110-115 © Georg Thieme Verlag Stuttgart • New York
On the Feasibility of Intraoral Maxillo-Malar Osteotomy Roberto Brusati, Enrico Sesenna*, Mirco Raffaini Dept. of Maxillo-FacialSurgery(Head:Prof. R. BrusatiM.D,, DMD.), Universityand Hospitalof Parma,Italy * AssociateProfessorof Maxillo-FacialSurgery,Universityof Chieti,Italy Submitted 12.5.88; accepted 20.7.88
Introduction The maxillo-malar osteotomy, also called modified Le Fort III, and intermediate or butterfly osteotomy, should be considered for treating those patients with anteroposterior hypoplasia of the upper jaw combined with a flattened paranasal area, retrusion of the lower orbital rim and malar deficiency together with a normal nasal projection. In these patients a facial advancement of the Le Fort III type would result in excessive nasal prominence and a simple maxillary advancement using Le Fort I osteotomy would only partially correct the deformity leaving the zygomatic defect untreated. A maxillo-malar advancement will specifically correct the deformity, simultaneously improving both the occlusal defect and the malar retrusion. This procedure, as employed first by Obwegeser (1969) (Fig. 1), was characterized by the mobilization of the upper jaw together with the entire zygomatic complex, including the frontal apophysis, the lower orbital rim, a part of the orbital floor and the frontal process of the maxilla up to the level of the nasolacrimal groove. During the 1970's, many surgeons used this method, sometimes with slight personal variations (Rehrmann, 1971; Kufner, 1971; Souyris et al., 1973; Popescu, 1974; Epker and Wolford, 1975, 1979; Champy et al., 1979; Steinhauser, 1980). They all utilized a double access: intraoral and extraoral either subciliary or endoconjunctival. Recently Ferronato (1983) for the extraoral access has proposed a minute incision located in a cutaneous fold of the lateral half of the lower eyelid, just below the tarsal plate. Even though the cutaneous and endoconjunctival incisions are generally without cosmetic or functional consequences, we believe it is worthwhile reporting the possibility of using, without difficulty, an exclusively intraoral route in performing a maxillo-malar osteotomy. Recently, Keller and Sather (1987) reported seven cases of maxillo-malar osteotomy (named quadrangular Le Fort II osteotomy), as described by Kufner (1971), utilizing only a transoral approach. We therefore present extensively here our technique previously exposed in a preliminary report (Brusati et al., 1987).
Summary The maxillo-malar osteotomy is one of the osteotomies developed over the years to correct the deformities of the midface without modifying the nasal projection. After having for many years approached the osteotomy through the classic double access, intraoral and subciliary, we verified the feasibility of this osteotomy via an intraoral route only. For this purpose we modified slightly the classic osteotomy lines, however still including in the mobilized fragment the most prominent and therefore the most aesthetically important portion of the zygoma. At the lower orbital rim the medial osteotomy cut is performed with a fissure bur, the lateral one with an oscillating saw. Both the osteotomies are extended posteriorly in the orbital floor with a fine osteotome. Then, after having performed all other osteotomy cuts, the maxillo-malar complex is down-fractured. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are broken during a careful downfracture, avoiding fracture between the maxilla and zygoma. The complex is advanced and stabilized with intermaxillary fixation, osteosynthesis and bone grafts. A bone graft to the orbital floor is unnecessary. Key words Maxillo-malar osteotomy - Intraoral approach Maxillo-malar deficiency - Down-fracture
Surgical Technique Access is obtained via the classic intraoral vestibular incision from tuberosity to tuberosity. Then the periosteum is dissected from the piriforrn rim, from the anterior and lateral walls of the maxilla, from the inferior orbital rim, and from the anterior orbital floor. Care is taken to avoid transection of the periorbita, which would cause herniation of the periorbital fat. The most anterior insertion of the masseter muscle should be dissected from the zygoma in order to expose fully the body of the zygoma up to the level of the arch and the zygomatic groove which is locat-
Fig.1
Obwegeser's rnaxillo-malar osteotomy procedure,
On the Feasibility of Intraoral Maxillo-Malar Osteotomy
!
/
,..=_
"q,~,/.//
Osteotomy lines employed by us: a) dotted line including orbital floor and most of the infraorbital rim; b) continuous line including the orbital floor but remaining lateral to the infraorbital foramen; c) dashed line avoiding the orbital floor (for explanation see text). Fib.2
ed just below it. Using a fissure bur, an osteotomy is performed, extending from the orbital rim to the base of the piriform aperture. This osteotomy is characterized by a vertical cut, medial or lateral to the infraorbital foramen, and by a horizontal one to reach the lateral rim of the piriform aperture (Figs. 2 a and b line). Then, using the angular blade of a reciprocating saw, a malar osteotomy is performed from the infero-lateral corner of the orbital rim, downwards and posteriorly directed to the anterior insertion site of the masseter. Both osteotomies, lateral and medial, of the orbital rim are extended posteriorly in the orbital floor to a depth of 10-15 mm. This is done with a fine osteotome directed towards the anterior part of the inferior orbital fissure in order to complete the osteotomy or to reduce the nonosteotomized bone area of the orbital floor to only a few ram. Instead of performing the osteotomies of the infraorbital rim, it is possible to trace an osteotomy line slightly inferiorly to the orbital rim, therefore completely avoiding the orbital floor (Fig. 2 c). Then, after having dissected the mucoperiosteum from the lateral nasal walls and floor, these are osteotomized with a thin osteotome. The base of the nasal septum is separated from the maxilla and then the pterygomaxillary disjunction is performed with a curved osteotome in the usual way. The same osteotomies are performed on the contralateral side. The residual thin bone structures which connect the maxillo-malar complex to the cranio-facial skeleton are: a) a thin, limited portion of the orbital floor; b) the postero-medial and posterior maxillary wall; c) some small portions of the postero-lateral wall of the maxilla, extending from the inferior orbital fissure to the inferior part of the pterygo-palatine fissure which cannot be reached by the osteotome or the reciprocating saw. These bony bridges, particularly difficult to reach and to section, but very thin, can be easily broken during the down-fracture. The down-fracture is performed with thinned Tessier mobilization forceps which are placed in the osteotomy line at the piriform aperture.
J. Cranio-Max.-Fac. Surg. 17 (1989)
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The mobilization must be done initially with caution, carefully controlling both orbito-malar areas to ensure symmetrical one-piece fracturing. Osteotomes are also inserted bilaterally in the zygomatic osteotomies. When rotated, they aid in strengthening the downwards movement of the osteotomized sector. Any fracturing between the zygomatic and maxillary area can be prevented by alternating these movements together with those exerted by the Tessier forceps. The fracture of the orbital floor can extend posteriorly to the inferior orbital fissure, or be localized in a particularly fragile anterior area. After completion of the downfracture it is necessary to advance the maxillo-malar complex as usual in order to free it completely from all the fibroligamentous attachments. When the maxillo-malar complex is freely (Fig. 3) movable for advancement, the intermaxillary fixation in the correct occlusion is applied. Autogenous cortico-cancellous bone grafts, obtained from the ilium and appropriately contoured, are inlayed. They are inserted in the gaps which are present in the zygomatic osteotomy line and between the pterygoid process and the maxillary tuberosity. If the medial osteotomy of the orbital rim is lateral to the infraorbital foramen, additional grafts in the paranasal area (around the infraorbital nerve) may be necessary (Figs. 4 and 5). No attempt is made to bridge by grafting the resulting defect in the orbital floor, because the periorbita should retain its integrity. If any laceration of the periorbita has resulted, this can be detected and repaired immediately after the downfracture when access and feasibility is optimal (Fig. 6). Any required grafting on the orbital floor should be done at this time before superiorly repositioning the osteotomized fragment. Osteosyntheses are performed on the malar body, wiring the bone grafts, and the piriform rims. The incisions are sutured and the intermaxillary fixation is maintained for four weeks. Clinical Cases
Case I (Fig. 7). B. S. aged 20, female, exhibits a class III appearance due to hyperplasia of the mandible and a sagittal maxillary deficiency associated with zygomatic, infraorbital rim and paranasal retrusion. From the occlusal point of view, a class III malocclusion with an 8 ram. dental reverse overjet and bilateral crossbite is present. The maxillo-malar osteotomy was performed by the method described, using a type b osteotomy tracing, for an advancement of 6 ram. The mandible was then retropositioned in I class occlusion by bilateral sagittal osteotomies of the rami. After 2 years, the postoperative results show a correct facial morphology with adequate zygomatic prominence together with a normalization of the inferior third of the face and with a correct occlusion. Case 2 (Fig. 8). P.E. aged 20, male, presents a complex facial deformity associated with characteristic naso-maxillary dysplasia (Binder's syndrome) together with a normal positioned nasal bridge, a bilateral zygomatic hypoplasia, a maxilla anteroposteriorly underdeveloped, and a large mandible overdeveloped anteroposteriorly. During a first surgical procedure, a maxillo-malar osteoto-
112
J. Cranio-Max.-Fac. Surg. 17 (1989)
Fig.3 Intraoperative view of the down-fractured maxillo-malar
R. Brusati et al.
Fig. 4
Intraoperative view of the bone grafts in the paranasal area.
complex mobilized via the exclusively intraoral approach.
Fig.5 Axial CT of facial skeleton after maxillo-malar osteotomy shows the bone grafts in the zygomatic osteotomy gaps and the paranasal area appositional bone grafts.
Fig.6 Intraoperative view demonstrating the integrity of the periorbita and the relatively large access, if necessary, for its repair.
my advancement was performed (8 mm.), using the technique advocated (osteotomy tracing type b), and bilateral sagittal osteotomies of the mandible to obtain an 8 mm. retrusion. Three months later a second operation was carried out to correct the nasal anomaly by a nasal septum advancement (Holmstr6rn, 1986) and by an osteochondral graft to the nasal spine and columella. A reduction genioplasty was performed vertically and transversely. Both a satisfactory aesthetic result and a stable, normal occlusion have been achieved.
and zygomatic hypoplasia associated with a normal nasal prominence. This osteotomy method focusses on improving the defect without compromising the surrounding areas which 'exhibit a correct morphology. It also offers a limited relapse risk, especially at the zygoma. The zygomatic advancement obtained by this method certainly appears more natural and more stable than when onlay bone grafts or alloplastic augmentation are applied. However, this advantageous surgical procedure is more complex than the classic Le Fort I maxillary osteotomy. The simultaneous mobilization of maxilla and zygoma requires accurate control of the osteotomized sites to ensure that a fracture at the maxillo-malar conjunction does not occur during the down-fracture, which would compromise the fixation of the zygoma in the correct position. With classic osteotomy tracing, subciliary or endoconjunc-
Discussion
Maxillo-malar osteotomies are very successful when performed on selected cases exhibiting maxillary retrusion
On the Feasibility of Intraoral Maxillo-Malar Osteotomy
J. Cranio-Max.-Fac. Surg. 17 (19 8 9)
113
Fig.7a
Fig.7c
Fig.7e
Fig.7b
Fig.7d
Fig, 7f
Fig.7a and b Facial appearance from frontal view before and after surgery.
Fig.7c and d Facial appearance from profile view before and after surgery.
Fig.7e and f after surgery.
Teleradiography before and
Fig. 7 g and h surgery,
Occlusion before and after
Fig.7g
Fig.7h
Fig.7
Retromaxillism, case 1.
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R. Brusati et al.
Fig.8a
Fig.8c
Fig.8e
Fig.8b
Fig.8d
Fig. 8f
Fig.8a and b Facial appearance from frontal view before and after surgery.
Fig.So and d Facial appearance from profile view before and after surgery.
Fig.8e and f after surgery.
Teleradiography before and
Fig.8g and h surgery.
Occlusion before and after
Fig. 8 g
Fig. 8 h
Fig.8 Retromaxillism and macrogenia, case 2.
On the Feasibility of lntraoral Maxillo-Malar Osteotomy
J. Cranio-Max.-Fac. Surg. 17 (1989)
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It is also possible to avoid the orbital floor during the fracturing by moving the osteotomy line to just below the orbital rim, instead of including it completely. This, however, does not eliminate the possibility of zygomatic advancement. Because of these advantages we believe the above described intraoral method to be particularly useful since it permits optimal visibility during all phases of the maxillo-malar osteotomy without any excessive difficulties. References
Fig.8i Intraoperative view after septum advancement procedure: the septum is fixed to the nasal spine in the correct anterior position. tival incisions are necessary. The subciliary incision permits an extended view of the orbital area but sometimes results in unaesthetic scarring. The endoconjunctival approach (Tessier, 1973) does not cause external scarring, but it allows a limited access to the orbital area and occasionally causes an entropion of the lower lid. The cutaneous access proposed by Ferronato (1983), even if it is small and causes only limited scarring, may not be welcome to the patient. The method we use permits us to avoid any cutaneous or endoconjunctival access without complicating the surgical procedure. The site of the malar osteotomy is located more anteriorly than is the case when using the traditional techniques but not so anteriorly as in Kufner's (197l) modification. In this way only the most prominent, and therefore the most aesthetically important portion of the zygoma, is included in the maxillo-malar mobilized complex. The medial side of the osteotomy may be carried out in two different locations: lateral to the nerve, when paranasal morphology is adequate and only small onlay bone grafts are necessary, or medial to the nerve, if the paranasal region or the remaining midfacial skeleton exhibit a serious deficiency. Neither the fracturing nor the subsequent mobilization of the orbital floor causes ocular problems. When this procedure is correctly performed, the periorbita remains intact, and the limited bone defect of the orbital floor resulting from the advancement of the orbital rim does not need bone grafting.
Brusati, R., E. Sesenna, M. Raffaini: L'osteotomia maxillo-malare solo per via endorale nella correzione delle dismorfosi del terzo medio della faccia. Atti del 36 ° Congresso della Societ~ Italiana di Chirurgia Plastica, Ricostruttiva ed Estetica. Torino 16-19 settembre 1987. Monduzzi Editore, Bologna (1987) 863 Cbampy, M., ]. P. Lodde, A. Wilk: Apropos de 30 cas d'ost~otomies transfacciales interm~diaires. Ann. Chir. Hast. 24 (1979) 351 Epker, B.N., L.M. Wolford: Middle-third facial osteotomies: their use in the correction of acquired and developmental dento-facial and cranial deformities. J. Oral Surg. 33 (1975) 491-514 Epker, B.N., L.M. Wolford: Middle-third advancement: treatment considerations in atypical cases. J. Oral Surg. 37 (1979) 31-41 Ferronato, G.: Le vie di aggressione chirurgica extra ed endorali per la correzione delle disgnazie con grave iposviluppo del terzo medio della faccia. Min. Stomatol. 32 (1983) 851-867 Holmstr6m, H.: Surgical correction of the nose and midface in maxillo-nasal dysplasia (Binder's Syndrome). Hast. Recostr. Surg. 78 (1986) 568-580 Keller, E.E., A.H. Sather: Intraoral quadrangular Le Fort II osteotomy. J. Oral Maxillofac. Surg. 45 (1987) 223-232 Kufner, J.: Four-year experience with major maxillary osteotomy for retrusion. J. Oral Surg. 29 (1971) 549-553 Obwegeser, H.L: Surgical correction of small or retrodisplaced maxillae. The "dish-face" deformity. Hast. Reconstr. Surg. 43 (1969) 351-365 Popescu, V. C.: Advancement of the middle third of the face without bone grafting in a case of Crouzon's Disease. J. Maxillofac. Surg. 2 (1974) 219-223 Rehrmann, A.: Orthop~idische Chirurgie der Kiefer. In: Ausgew/ihlte Kapitel aus dem Gebiet der Plastischen Chirurgie. TherapieWoche, G. Braun Verlag, Karlsruhe (1971) 50-54 Souyris, F., J.B. Caravel, J.P. Reynaud: Ost6otomies "interm~diaires" de l'&age moyen de la face. Ann. Chir. Hast. 18 (1973) 149-154 Steinhauser, E.W.: Variations of Le Fort II osteotomies for correction of midfacial deformities. J. Maxillofac. Surg. 8 (1980) 258-263 Tessier, P.: The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J. Maxillofac. Surg. 1 (1973) 3-8
Prof. R. Brusati, M.D., D.M.D. Cattedra e Divisione di Chirurgia Maxillo-Facciale Universit~ e Ospedale di Parma Via Gramsci 14 1-43100 Parma Italy