Access osteotomies in oral

and maxillofacial surgery

PRESENTER
DR.REHANA SULTANA
POST GRADUATE STUDENT

CONTENTS
INTRODUCTION
HISTORY
CONCEPT OF MODULAR OSTEOTOMIES
VARIOUS OSTEOTOMIES
MAXILLARY OSTEOTOMIES
MANDIBULAR OSTEOTOMIES
MODIFICATIONS
CONCLUSION
REFERENCES

Introduction

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

History
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 vonlangenbecks 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, posterior oral floor,

retromaxillary and tonsillar fossa can be accessed by
mandibular osteotomies

For increased exposure of the parapharyngeal space,

infratemporal fossa and pterygomaxillary region

upto the skull base --- a second horizontal osteotomy
of the mandibular ramus above the lingula.
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

Pedicled osteotomy of maxilla/hard palate & zygoma

Maxillary osteotomy
Provides wide exposure of soft palate and

nasopharynx

IF INFRAORBITAL NERVE
HAS TO BE LIGATED

IF INFRAORBITAL NERVE
HAS TO BE SACRIFICED

Nasal osteotomy

Primarily for the resection of any pathology within

nasal cavity,ethmoid and sphenoid sinuses

Modification -- maxillary nasal osteotomy

Lefort 1 osteotomy
In 1986, Sailer described the use of the Le Fort I osteotomy as a

surgical approach for the removal of pathological conditions within the

maxilla.(Sailer and Makek, 1986)
Different approaches for removal of tumours in the midface,

pterygomaxillary region, skull base and nasopharynx have been

described. Most of these use the Ferguson Weber incision or
modifications thereof, giving access to the facial skeleton in order to
perform osteotomies or en bloc resections (Shah and Galicich, 1977;
Altemir, 1986a; Brusati, 1991; Salins, 1997).

 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 3.5-4.5 cm inferiorly compared with the 11.5 cm for the posterior nasal spine.
Superior extent: sella turcica, cribiform plate.
Inferior extent: C1 (possibly C2)
Lateral extent: pterygoid and temporalis muscle
Posterior extent: Clivus, posterior wall of sphenoid sinus,

greater wing of sphenoid bone

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, but is even more important in patients undergoing

radiotherapy
Facilitation of the ensuing reconstructive procedures. 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; Sailer and Makek, 1986).

 Indications : for the tumours situated in or extending into the maxillary

sinus, the sphenoid sinus or the nasopharynx

Accessible areas: nasal cavity, 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,in order to perform neurosurgical
procedures following pharyngotomy, clivectomy and dural opening (van
Loveren et al., 1994).
The LeFort I osteotomy for approaching diseases in the cranial base was
first described by Cheever (Moloney and Worthington, 1981) in which a
maxillary osteotomy was used for removing a tumour from the
nasopharyngeal area.

 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.,

2004).
Avascular necrosis of maxilla in 1% of cases (Lanigan,
1997). The possible factors could be rupture of the
descending palatine artery (DPA) during surgery (Sasaki et
al., 1990), post-operative vascular thrombosis, perforation
of the palatal mucosa that impairs blood supply to the
maxillary segment (Pereira et al., 2010).

Complications
Rare complications with this procedure includes

subcutaneous emphysema (Stringer et al., 1979)

Unilateral abducens nerve palsy (Watts, 1984),
Upper lip hypoesthesia (Ueki et al.,2008)
Aseptic necrosis of the maxilla (Lanigan et al.,1990),
Fatal arteriovenous fistula (Laetitia Goffinet et
al.,2010) and
Blindness(Cruz and dos Santos, 2006).

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,

submandibular region and neck

Access areas : floor of mouth

Tongue, tonsillar fossa, soft palate, oropharynx

including the posterior pharyngeal wall,supraglottic

larynx and the pterygomandibular region

MANDIBULAR SWING OSTEOTOMY

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, 142146

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

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, 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.