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Archive for the ‘orthognathic surgery’ Category

OR Snapshots – Premaxillary Osteotomy

Thursday, October 20th, 2016


Orthognathic surgery is a well known type of bone procedures that move the upper and lower jaws to improve one’s bite (occlusion) as well as improve jaw relationships to the face. It is done on the upper and lower jaws with the mainstay procedures of a LeFort I osteotomy (upper jaw) and sagittal split ramus osteotomies. (lower jaw)

The LeFort I osteotomy moves the upper jaw and is done by a horizontal bone cut above the level of the upper tooth roots across the maxilla and nose. This allows the entire dentoalveolar unit of the maxilla to be moved horizontally forward or vertically up or down. When seen intraoperatively it is a dramatic procedure when one sees the whole upper jaw brought down to peer into the maxillary sinuses and the nose.

premaxillary-osteotomy-intraop-dr-barry-eppley-indianapolisA much less known maxillary bone procedure is that of the premaxillary osteotomy. As the name suggests it is just a part, the front part to be specific, of a LeFort I osteotomy. This is the anterior maxillary segment that contains the six front teeth from canine to canine. It is unique from the Lefort I osteotomy because it requires a vertical bone cut between the canine and premolar teeth as well as a bone cut across the palate to get the bone segment to move.

The indications for a premaxillary osteotomy are very limited. The picture in this blog is from an older patient who wanted his front upper teeth moved up and back to correct a lifelong tongue thrusting problem. This was able to be done for him because he was already missing his first premolar tooth on the right side and had a decayed second premolar tooth on the opposite side which could be removed. This provide a safe space to make the vertical bone cuts.

Case Study – Non-Orthodontic LeFort 1 Advancement

Friday, February 19th, 2016


Background: Treatment of a midface deficiency is most commonly done by moving the upper jaw forward. Done by making a horizontal bone cut just above the roots of the teeth, the upper jaw is brought forward into a new horizontal position. This well known facial bone procedure is the LeFort I osteotomy and has been the backbone of everyday orthognathic surgery for the past fifty years.

LeFort I OsteotomyCommon facial osteotomy procedures, such as the Lefort I, fall under the generic category of orthognathic surgery. As implied in its name, this involves the jaw bones and how the teeth meet or interdigitate. One of the essential aspects of this type of surgery is the need for before and after surgery orthodontics. Getting the teeth prepared so that they will meet perfectly once the facial bones are moved into their new position is not only of functional significance but often the definitive measure of the success of the procedure.

But not every patient who is in need of a Lefort I osteotomy, or any form of orthognathic surgery, is always a good candidate for orthodontic therapy. Due to compliance issues or the inability to tolerate the intraoral manipulations of orthodontic appliances, consideration can be given to doing the surgery ‘braces free’. This is done with the understanding that the goal of an ideal occlusal interdigitation is not achievable.

Case Study: This 15 year-old teenage female had a severe midface deficiency and upper airway obstruction due to a limited nasal airway. Due to a developmental delay, the application of orthodontic appliances and therapy was not possible.

LeFort 1 Advancecment Dr Barry Eppley IndianapolisLeFort 1 Advancement oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, a one-piece LeFort 1 advancement was performed with an advancement of 11mms. The goal was to get the anterior maxillary incisor teeth to sit in front of the mandibular incisor teeth in terms of degree of advancement. It was accepted that the premolar and molar occlusion would be far from ideal. Rigid 1.5mm plate and screw fixation was applied. No after surgery jaw wiring or intermaxillary fixation was used. She was allowed to have full jaw motion after surgery with a diet restricted only by her comfort.

While any form of orthognathic surgery (maxillomandibular osteotomies) is ultimately judged by a specific measurable outcome (the occlusion), there are other facial benefits that can supercede how the teeth interdigitate…particularly when they do to fit that well initially anyway.


1) A maxillary advancement (LeFort I osteotomy) can be done in rare circumstances without the need for presurgical orthodontics.

2) A LeFort I osteotomy produces well known midface aesthetic benefits including profile enhancement and improved nasal airway breathing.

3) A non-orthodontic LeFort I advancement is a skeletal improvement procedure, not a dental one.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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