SMS

Segmental Maxillary Surgery

Segmental surgery is utilized in order to facilitate narrowing or widening of the maxillary dental
arch, close interdental spaces or surgical levelling of the occlusal plane.

Interdental Osteotomy

Tips
• Ensure that there is sufficient space between the roots of the teeth at the proposed interdental
osteotomy site. For vertical movements of the segments the roots should be at least parallel
while if closure of an interdental space is contemplated the roots should be divergent.
• Initiate the interdental osteotomy before the maxilla is down fractured. This has two distinct
advantages:
(i) if the maxilla is stable it makes the initial bur cut and tapping with the interdental
osteotome easier.
(ii) stretching of the vital soft tissue pedicle of the maxilla is prevented by the fact that the
osteotome is tapped while the maxilla is stable.
• Reflect the mucoperiosteum minimally to expose the interdental bone (fig 1).
• Use a small fissure bur (701) and penetrate only the cortical bone between the roots of the
adjacent teeth (fig 2).
• Use a thin spatula osteotome to complete the interdental osteotomy.
• Place a finger on the palate to palpate the osteotome as it perforates the palatal bone (fig 3).
• The surgeon should hold the osteotome in one hand while placing a finger of the other hand in
the palate. The assistant taps the osteotome carefully. As the osteotome passes through the
alveolar bone and then thick palatal bone, the resistance to tapping helps the surgeon visualize
the position of the osteotome tip.
• Be careful not to damage the periodontal tissue at the alveolar crest.
• The segment is only mobilized once the maxilla is down fractured. This is achieved by
completion of the palatal osteotomy through the nasal floor.
• Mobilize the segments with finger pressure or rotation of a flat instrument placed into the line of
the interdental osteotomy (fig 3).

The LeFort I
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Segmental Maxillary Surgery

Traps and Complications

• An attempt to perform an interdental osteotomy with insufficient space between tooth roots may
damage the teeth leading to root resorption and periodontal trauma.
• Excessive mucoperiosteum reflection may jeopardizes blood supply to dento-alveolar segments.
• Initiating the osteotomy by drilling through the cortical bone too deeply could damage tooth
roots.
• Incorrect direction of the osteotomy may damage tooth roots.
• Performing the interdental osteotomy after downfracture of the maxilla will make the interdental
osteotomy cumbersome.
(i) difficult to tap the osteotome while the maxilla is mobile.
(ii) may damage soft tissue pedicle.
(iii) more difficult to establish the direction of the roots once the maxilla is mobilized.

Figure 1 Figure 2

Figure 3 Figure 4
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Nasal Floor (Palatal) Osteotomy

Tips
• The palatal osteotomy in the nasal floor is done once the maxilla is downfractured.
• Support the maxilla while the osteotomies are performed to protect the mucoperiosteal
pedicles.
• Paramidline sagittal osteotomies are performed if any transverse changes are contemplated
(fig 1).
• The palatal osteotomy is done lateral to the nasal septum where the bone is thin and the
palatal mucosa slightly thicker than in the midline of the palate.
• Use a small bur (701) and drill through the bone lateral to the nasal septum without
perforating the palatal periosteum while monitoring the cut with finger pressure in the
palate (fig 2).
• Connect the palatal osteotomy with the interdental osteotomy and complete the osteotomy
with a thin osteotome.
• Be very careful not to tear the palatal mucosa, especially transversely.
• The segments are mobilized with finger pressure or using a small flat instrument placed in
the interdental osteotomy cut and rotating it (fig 3).
• For palatal expansion of 3mm or less a single osteotomy is sufficient.
• Expansion of more than 3mm will require bilateral osteotomies of the nasal floor. For large
expansion it may be desirable to graft the defect. When placing bonegrafts in the nasal
floor make sure that the nasal and palatal mucosa are intact.
• Large palatal expansion may result in tension in the palatal soft tissue. Tension may be
released by further lateral mucoperiosteal dissection or incising the periosteum in an area
not overlaying the osteotomy in an antero-posterior direction. Ensure that the nasal
mucosa is intact and never incise or tear the palatal mucosa transversely.

Traps and Complications

• Failure to support the mobile maxilla while completing the osteotomies may stretch (or tear)
the mucoperiosteal pedicles and jeopardize the blood supply to the maxilla.
• Placement of the palatal osteotomy too far lateral may lead to damage to the greater
palatine neurovascular bundle.
• Placement of the palatal osteotomy in the centre of the palate may tear the palatal mucosa,
as the bone in this area is thick while the mucosa thin.
• A transverse tear of the palatal mucosa will jeopardize the blood supply to the segments,
which may cause necrosis of mucoperiosteum and, or bone.

The LeFort I
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Nasal Floor (Palatal) Osteotomy

Figure 1 Figure 2

Figure 3
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Fixation and Stabilization After Segmental Osteotomies

Tips
• It is wise to use a prefabricated acrylic splint made according to the model surgery to
establish the planned occlusion.
• Place a 2-hole boneplate across the interdental osteotomy, one screw on either side, to
secure the segments (fig 1).
• Place an interdental wire around the teeth adjacent to the osteotomy (fig 1).
• Boneplates must be bent accurately to conform to the bony contour and secured with two
screws on either side of the LeFort I osteotomy. Each segment should be secured with a
boneplate (fig 2).
• Bone defects may be grafted to promote more rapid healing of bone at the osteotomy sites.
Be careful, however, not to force bone into the defects which may displace the segments.
• Bone defects larger than 3mm in the palate should be grafted to promote bone healing and
enhance stability of the result.
• Bonegrafts at the piriform rim and zygomatic buttress areas should be stabilized with wire
or screw fixation.
• Be careful not to leave unsupported bonegrafts in the area. The bone may be dislodged
into the maxillary sinus leading to infection.

The LeFort I
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Segmental Maxillary Surgery

Traps and Complications

• Inadequate fixation will lead to malocclusion, non-union and malunion.
• A poorly fitting splint will make surgery cumbersome and difficult and may lead to malocclusion.
• A dislodged bonegraft in the maxillary sinus will eventually sequestrate and will have to be
removed.
• A displaced graft may lead to instability of the maxillary segments and result in an unfavorable
occlusion.

Figure 1

Figure 2