Access osteotomies in oral

and maxillofacial surgery




 The craniofacial skeleton can be regarded as an osteoplastic

structure as its excellent blood supply allows the
mobilisation and replacement of bone fragments,either
pedicled on their soft tissues or as free bone segments

 Von langenbeck in 1859 performed a horizontal osteotomy

at the level of fracture line
 Later in 1901, it was described as the lefort 1 position to

access the pathology in the nasopharynx
 Kocher modified vonlangenbeck’s technique by dividing the

maxilla in the midline to approach the pituitary fossa

Concept of modular osteotomies .

Various osteotomies to access various areas Infratemporal fossa :zygomatic arch osteotomy with or without lateral orbital rim or Inverted L zygomatic bone osteotomy with or without involvement of lateral orbital rim Lesions involving parapharyngeal. lateral pharyngeal and deep spaces of neck. retromaxillary and tonsillar fossa can be accessed by mandibular osteotomies . posterior oral floor.

For increased exposure of the parapharyngeal space. Skull base can be approached anteriorly and laterally---bitemporal craniotomy with frontonasalorbital osteotomy Middle cranial base approaches include Le Fort I maxillary osteotomy. sometimes combined with mandibulotomy and frontonasoorbital osteotomy .a second horizontal osteotomy of the mandibular ramus above the lingula. infratemporal fossa and pterygomaxillary region upto the skull base --.

Pedicled osteotomy of maxilla/hard palate & zygoma .




Maxillary osteotomy Provides wide exposure of soft palate and nasopharynx .


Nasal osteotomy Primarily for the resection of any pathology within nasal cavity.ethmoid and sphenoid sinuses .



maxillary nasal osteotomy .Modification -.

1986a. Sailer described the use of the Le Fort I osteotomy as a surgical approach for the removal of pathological conditions within the maxilla. pterygomaxillary region.Lefort 1 osteotomy  In 1986. 1986)  Different approaches for removal of tumours in the midface. 1997). skull base and nasopharynx have been described. . giving access to the facial skeleton in order to perform osteotomies or en bloc resections (Shah and Galicich. Altemir.(Sailer and Makek. 1977. Most of these use the Ferguson Weber incision or modifications thereof. Brusati. Salins. 1991.

5-4. posterior wall of sphenoid sinus. greater wing of sphenoid bone .5 cm for the posterior nasal spine.  Inferior extent: C1 (possibly C2)  Lateral extent: pterygoid and temporalis muscle  Posterior extent: Clivus.5 cm inferiorly compared with the 11. Anatomic boundaries/surgical exposure  The LeFort I downfracture creates a funnel-like opening with a 3:1 ratio of anterior to posterior displacement of the inferior maxilla. The anterior nasal spine travels 3.  Superior extent: sella turcica. cribiform plate.

Accessible areas .

View after lefort 1 down fracture .

Exposure from posterior ethmoidal cells to craniocervical junction .

Advantages  No visible scar  The aesthetic aspect of this approach is not only relevant in younger patients. It allows excellent access to mobilize and fix the buccal fat pad to the medial aspect of the defect following partial maxillary resection in order to cover the nasal aspect of bone grafts in resections involving the whole maxillary sinus floor(Egyedi. 1977. . 1986). but is even more important in patients undergoing radiotherapy  Facilitation of the ensuing reconstructive procedures. Sailer and Makek.

clivectomy and dural opening (van Loveren et al. Indications : for the tumours situated in or extending into the maxillary order to perform neurosurgical procedures following pharyngotomy. maxillary sinuses & nasopharynx  The Le Fort I osteotomy was even described as a single access for exposing the medial compartment of the inferior skull base from the tuberculum sellae to the foramen magnum. the sphenoid sinus or the nasopharynx  Accessible areas: nasal cavity. 1981) in which a maxillary osteotomy was used for removing a tumour from the nasopharyngeal area.. . 1994).  The LeFort I osteotomy for approaching diseases in the cranial base was first described by Cheever (Moloney and Worthington.

. The possible factors could be rupture of the descending palatine artery (DPA) during surgery (Sasaki et al. 2010). 1997).  Avascular necrosis of maxilla in 1% of cases (Lanigan.. perforation of the palatal mucosa that impairs blood supply to the maxillary segment (Pereira et al. Limitations: vascular supply to mobilised maxilla  Restriction of lateral access due to pterygoid plates  The incidence of other minor intra-operative and peri- operative complications are considered low (Kramer et al. 1990).. . 2004). post-operative vascular thrombosis.

Complications Rare complications with this procedure includes subcutaneous emphysema (Stringer et al..1990). ...2010) and  Blindness(Cruz and dos Santos..2008)  Aseptic necrosis of the maxilla (Lanigan et al. 1984).  Upper lip hypoesthesia (Ueki et al. 2006). 1979) Unilateral abducens nerve palsy (Watts. Fatal arteriovenous fistula (Laetitia Goffinet et al.

submandibular region and neck .Lip split /mandibular split – mandibular swing approach An incision to divide the lower lip and chin Division of the mandible anterior to mental foramen Dissection of tissues in the floor of mouth.

Access areas : floor of mouth Tongue. tonsillar fossa. soft palate.supraglottic larynx and the pterygomandibular region . oropharynx including the posterior pharyngeal wall.





Various osteotomies for tumors of parapharyngeal space The rigid bony walls of the mandible direct tumour growth medially to the parapharyngeal space Bulge of soft palate is the diagnostic sign .


Double mandibular osteotomy with coronoidectomy for tumours in the parapharyngeal space British Journal of Oral and Maxillofacial Surgery (2003) 41. 142–146 .

Vertical ramus osteotomy .


Osteotomy in the vertical ramus outside the mandibular foramen for tumours in the parapharyngeal space Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e29.e32 .




Mandible osteotomies .

Inverted L or C osteotomy .

Inverted L or C osteotomy .

Lateral zygomatic osteotomy .


inaccessible tumors of the head and neck. Various approaches have been devised for their better exposure and it is our expertise as maxillofacial surgeons to provide surgical access by various approaches. .Conclusion Tumors occurring in the inaccessible regions present a surgical challenge and access osteotomies of the facial skeleton is the answer to access these deeply situated.