15
Sequencing of Orthognathic
Procedures: Step-by-Step Approach
JEFFREY C. POSNICK, DMD, MD
• Description and Sequencing of Orthognathic
and Other Frequent Simultaneous
Procedures: Step-by-Step Approach
• Conclusions
Maxillofacial surgeons and orthodontists are the primary
clinicians who care for individuals who present with jaw
deformities, malocclusions, and the associated facial dys-
morphologies. When an orthognathic approach is indi-
cated, there are a limited number of basic surgical techniques
that are used to facilitate the three-dimensional reposition-
ing of the skeletal units (i.e., the maxilla, the mandible, and
the chin region) to achieve desired improvements in head
and neck function and to enhance facial aesthetics. By and
large, these options include the Le Fort I (Type) osteotomy,
with or without segmentation of the down-fractured
maxilla; sagittal split ramus osteotomies of the mandible;
and an oblique osteotomy of the chin. Each of these three
basic osteotomies and its associated fixation techniques has
evolved gradually to its current usage (see Chapter 2).1-6
This chapter provides the surgeon with a step-by-step
technical description for the safe execution of Le Fort I
osteotomy of the maxilla, sagittal split ramus osteotomies
of the mandible, osseous genioplasty, and other frequent
simultaneously performed procedures (e.g., septoplasty,
reduction of inferior turbinates, recontouring of the nasal
floor, removal of wisdom teeth, neck region soft-tissue reju-
venation) as I routinely carry them out ( Video 6 and 7).
The approach is described as it is typically executed for
the patient who is undergoing all of these procedures simul-
taneously. An individual’s unique anatomy and clinical pre-
sentation may require variations in surgical approaches and
sequencing of treatment.
Description and Sequencing of
Orthognathic and Other Frequent
Simultaneous Procedures:
Step-by-Step Approach
Preparation and Draping
Step 1. The patient is placed supine on the operating
room table with the head in a Mayfield (horse-
shoe) headrest in the neutral neck position.
Step 2. A nasotracheal cuffed (Ring-Adair-Elwyn [RAE])
tube is inserted by the anesthesiologist and then
secured by the surgeon to the cartilaginous septum
with suture (#0 Ethibond). An additional suture
(#0 Ethibond) is placed in the midline anterior
hair-bearing scalp and then around the endotra-
cheal tube extension over the top of the head to
further secure it and to limit tension on the nose
(Fig. 15-1).
Step 3. Ophthalmic antibiotic ointment and protective
corneal shields are placed beneath the eyelids (or
temporary tarsorrhaphies are performed, if pre-
ferred) to prevent corneal injury during the opera-
tion (Fig. 15-2, A through C).
Step 4. The anesthesiologist places monitoring equipment
for the safe delivery of deliberate hypotensive
anesthesia (i.e., arterial line, Foley catheter, large-
bore venous lines, pulse oximeter, carbon dioxide
monitor, and temperature probe). The bed is then
positioned at approximately 15 degrees reverse
Trendelenburg (see Chapter 11).
Step 5. Antibiotics (e.g., Cefazo­lin (Ancef ); 15 to 20 mg/
kg and up to 1 g) and steroids (e.g., Dexameth­
asone 0.5 mg/kg/dose, max: 8 mg) are adminis-
tered intravenously by the anesthesiologist.
Step 6. The head and neck are prepped with povidone–
iodine (Betadine) solution. Avoid using soap or
alcohol solutions that could irritate the cornea and
the mucous membranes. Draping should provide
for adequate exposure of the forehead, the eyes,
441
442 S E C T I O N 2 Planning, Surgical Technique, & Complications
Septal cartilage
Secure ET tube to nasal septum
• Figure 15-1 Step 2.
the external ears, the face, and the neck. Staples
are used to secure the drapes (Fig. 15-3).
Step 7. The mouth and pharynx are suctioned, and a
moistened gauze with a radiopaque marker is
inserted as a throat pack. The teeth and dorsum
of the tongue are cleansed with a sterile tooth-
brush (1.5% hydrogen peroxide or 0.12%
chlorhexidine). The mouth is irrigated with
normal saline solution and suctioned.
Step 8. Steroid cream (e.g., betamethasone 0.5%) is
applied to the lips to limit edema that could
otherwise result from contusion during surgery.
Step 9. Lidocaine solution (Xylocaine 1% with 1 : 100,000
epinephrine) is infiltrated into the lateral vesti-
bules of the mandible, the facial vestibule of the
chin, and the labial vestibules of the maxilla.
Cortical Cuts for Sagittal Split Ramus
Osteotomies ( Video 6:2 and 7:2)
Step 10. A medium rubber mouth prop is placed between
the maxillary and mandibular molars on one side
to maintain mouth opening. Attention is turned
to the lateral vestibule of the contralateral
mandible.
Step 11. A. Incision Option One: No erupted wisdom
tooth for extraction. If there is no erupted
wisdom tooth to extract (i.e., if the wisdom
tooth is fully impacted, absent, or erupted and
is to remain in place), an incision is made with
a Bovie electrocautery device or a knife (no.
15 blade) in the depth of the vestibule adja-
cent to the second molar (Fig. 15-4, A). The
incision extends both anteriorly and posteri-
orly for a total length of 4 cm. The incision is
carried down to bone. A sufficient cuff of
mucosa is maintained adjacent to the gingiva
of the molar teeth for relaxed wound closure.
B and C. Incision Option Two: Erupted or par-
tially erupted wisdom tooth for extraction. If
there is a partially erupted (Fig. 15-4, B) or
fully erupted (Fig. 15-4, C) wisdom tooth to
be removed, the incision starts 1 cm distal and
lateral to the wisdom tooth and extends to the
distobuccal line angle of the tooth. The inci-
sion continues anteriorly along the cervical
gingival margin of the tooth within the sulcus
and then anterior and lateral into the depth
of the vestibule. The incision is carried down
to bone. A sufficient cuff of mucosa, including
part of the papilla, is maintained adjacent to
the gingiva of the second molar for relaxed
wound closure.
Step 12. The subperiosteal dissection exposes the anterior
aspect of the lateral ramus and the posterior body
of the mandible down to the inferior border (Fig.
15-5, A). The extent of the dissection anterior to
the gonial angle depends on the planned buccal
extension of the proximal segment. The dissection
exposes the anterior superior aspect of the ramus
up toward the coronoid process, with stripping of
the temporalis muscle tendon (Fig. 15-5, B C ).
The dissection exposes the medial aspect of the
ramus superior toward the sigmoid notch and
inferior toward the mandibular canal (Fig. 15-6,
A). (I do not dissect below the inferior alveolar
neurovascular bundle or circumferentially around
it, because I believe this may cause additional
contusion and paresthesia.)
Step 13. Retraction of the soft tissues is performed with a
curved Kocher clamp on the coronoid process
(superior exposure); a channel retractor superior
to the neurovascular bundle (medial ramus
exposure); an inferior border retractor placed
anterior to the gonial angle (anterior expo­
sure); and a tongue retractor (lingual exposure)
(Fig. 15-6).
Step 14. With a sterile pencil, the osteotomy lines are
marked out for the sagittal splitting of the ramus
of the mandible. A reciprocating saw (i.e., with
a short, straight blade) completes the cortical
osteotomies.
A. The first cut is made horizontally through the
medial cortex of the ramus. This is judged to
be just superior to the occlusal plane of the
mandibular molars and well inferior to the
region of the anterior aspect of the ramus,
where the medial and lateral cortices join and
no longer maintain a medullary cavity. The
medial osteotomy need not extend more than
2 cm posterior (Hunsuck modification) (see
insert of Fig. 15-6, A). By keeping the medial
cut “low” (i.e., close to the mandibular molar
occlusal surface) and “short” (i.e., only 2 cm
back), the incidence of a “bad” split (i.e., with
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 443

Placement of
ophthalmic
ointment

Placement of
corneal shield

Temporary tarsorraphy option

• Figure 15-2 Step 3.

444 S E C T I O N 2 Planning, Surgical Technique, & Complications

• Figure 15-3 Step 6.

• Figure 15-4 Step 11, A, B, and C.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 445

A B C

• Figure 15-5 Step 12.

B C

• Figure 15-6 Step 14, A, B, and C.

446 S E C T I O N 2 Planning, Surgical Technique, & Complications
the condyle as a third segment) is greatly
reduced.
B. The osteotomy then extends anteriorly and
just lateral (buccal) to the molars. It is impor-
tant that the saw blade penetrate the cortex
and enter the medullary cavity in all locations.
If the wisdom tooth is impacted, the saw
blade will bounce off the wisdom tooth just
after penetrating the superior paper-thin
cortex (Fig. 15-6, B); this will be just lateral
to the second molar. The blade will penetrate
back into the medullary cavity as the osteot-
omy progresses anterior past the impacted
tooth.
C. The reciprocating saw is then repositioned to
complete the vertical cortical osteotomy. The
osteotomy location will depend on the
planned buccal extension of the proximal
segment (i.e., the Dal Point modification.)
The vertical osteotomy begins at the inferior
border of the mandible, where the inferior
alveolar nerve is close to the cortex and prone
to laceration (Fig. 15-6, C). The osteotomy
then continues superiorly to join the cortical
osteotomy, which was previously completed
lateral to the molars.
COMMENT: When later “splitting” the ramus (see
Steps 53 through 58), as the inferior alveolar nerve
enters the mandibular foramen, it may remain within
either the proximal segment or the distal segment (see
Fig. 15-6, A inset). Traditional thinking is that the medial
osteotomy must remain above the mandibular foramen
as it extends posterior. I believe that it is more important
to keep the medial osteotomy low and short; this is a
reliable way to achieve a favorable split with limited risk
of the condylar component inadvertently remaining part
of the distal segment. After the low and short split is
completed, I do not favor the automatic need to
completely remove all aspects of the inferior alveolar
nerve that may remain within the proximal segment.
This is especially true at the mandibular foramen
location. I do not drill out or curette the inferior alveolar
nerve from the proximal segment unless it would
otherwise be under tension after repositioning the distal
segment. In my experience, however, this is not usually
the case.
Step 15. If the wisdom tooth is erupted and is to be
removed, then the extraction is completed now or
just before the cortical osteotomies; doing so
before the actual split will limit a fracture of the
lingual plate that may otherwise occur during
dental extraction. A rotary drill with a tapered
fissure bur may be used to judiciously remove
bone adjacent to the tooth and to section the
tooth to facilitate an atraumatic extraction.
Step 16. The wound is irrigated and suctioned. The retrac-
tors are removed, and two 1 inch × 3 inch cot-
tonoids are placed for packing (i.e., hemostasis).
One is placed along the medial ramus, and the
other is placed along the lateral body of the
mandible.
Step 17. Attention is turned to the contralateral ramus of
the mandible, and identical procedures to those
described in Steps 10 through 16 are carried out.
Maxillary (Le Fort I) Osteotomy
( Video 6:3 and 7:3)
Step 18. With the use of a Tessier caliper, the vertical dis-
tance (height) between the medial canthus and
the mid-maxillary incisor crown is measured on
the left and right sides and recorded; this generally
measures between 55 mm and 70 mm (Fig. 15-7).
This is a reproducible relative measure of the ante-
rior vertical maxillary height (see Chapter 12).
NOTE: If 70 mm is the baseline measurement and
3 mm of vertical intrusion at the incisors is a surgical
objective, then, after maxillary repositioning, 67 mm
should be the new measurement before the placement
of fixation across the Le Fort I osteotomy.
Step 19. Attention is turned to the vestibule of the maxilla
on one side. Two medium “toed-in” retractors are
used to retract the lip and cheek and thus expose
the vestibule. A circumvestibular incision is initi-
ated from the zygomatic buttress region anteriorly
toward the midline (Fig. 15-8). It is useful to
remain deep in the vestibule and to leave a full
cuff of mucosa adjacent to the attached gingiva of
the teeth. The most posterior aspect of the inci-
sion remains just anterior to and on the dental
(vestibular side) of the visualized parotid duct.
The incision is made with a Bovie electrocautery
device or a knife (#15 blade). Once the incision
is made through the mucosa the knife is directed
toward the dentoalveolar region and down to
bone. This will avoid injury to the infraorbital
nerve and limit the exposure of the buccal fat pad.
Step 20. Straight and curved elevators are used for the
subperiosteal dissection of the anterior maxilla
extending to and on either side of the infraorbital
nerve; extending medially to expose the pyriform
rim, the floor of the nose, and the anterior
nasal spine; and extending posterior to the ptery-
gomaxillary junction. A long “toed-out” retractor
is placed subperiosteally in the pterygomaxillary
space (Fig. 15-9).
CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 447

• Figure 15-7 Step 18.

Incision away from attached gingiva

Circumvestibular incision

• Figure 15-8 Step 19.

• Figure 15-9 Step 20.

448 S E C T I O N 2 Planning, Surgical Technique, & Complications
Step 21. The two medium toed-in retractors are shifted to
the contralateral side of the maxilla, and the iden-
tical incision, dissection, and exposure are accom-
plished as described in Steps 19 and 20.
Step 22. Straight and curved elevators are used to further
separate the nasal mucosa from each lateral nasal
wall; the anterior nasal spine from the cartilagi-
nous septum; and the nasal mucosa from the floor
of the nose (Fig. 15-10).
Step 23. With four medium toed-in retractors (one on
either side of the infraorbital nerve on each side
of the maxilla) and two long toed-out retractors
(one in each pterygomaxillary junction) in place,
the anterior maxilla is fully visualized. A sterile
pencil is used to mark the location for the
horizontal Le Fort I osteotomy (Fig. 15-11). If
• Figure 15-10
• Figure 15-11
significant maxillary intrusion is planned, a second
parallel osteotomy line is marked out. The lower
marking (i.e., the osteotomy site) is placed to be
within the sinus, above the roots of the teeth, into
each lateral nasal aperture, and below each zygo-
matic buttress. If an ostectomy is to be preformed,
the upper marking is made superior and parallel
to the lower marking and below the infraorbital
nerves (Fig. 15-11).
Segmentation of the Maxilla
Step 24. If segmentation of the maxilla is to be completed,
the interdental osteotomies are initiated before
down-fracture. This provides a stable “workbench”
for the initiation of each interdental osteotomy.
Step 22.
Step 23.
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
The interdental osteotomies are typically made
either between the lateral incisor and the canine
on each side (Fig. 15-12, A) or between the
central incisors (Fig. 15-12, B). The subperiosteal
dissection of the gingival cuff provides adequate
exposure of each interdental osteotomy location
without the need for direct mucosa incisions.
Each interdental osteotomy site is marked with a
sterile pencil. The osteotomy is then initiated with
an oscillating saw (i.e., a short fan blade on a long
shaft) and later deepened after down-fracture with
the oscillating saw (i.e., a longer fan blade on a
long shaft).
NOTE: The lateral incisor and canine roots—and, to
a lesser extent, the two central incisor roots—are
naturally divergent. Therefore, there is no advantage or
need for the orthodontist to create a gap for the
interdental osteotomy. Perforation into the periodontal
ligament space with injury to the dental roots when
completing these interdental osteotomies should be an
uncommon occurrence.
B
• Figure 15-12
449
Maxillary (Le Fort I) Osteotomy: Continued
Step 25. With a reciprocating saw (i.e., a long straight
blade), the Le Fort I horizontal osteotomy is com-
pleted through the lateral, anterior, and medial
maxillary walls on each side (Fig. 15-13, A through
C). Before the medial maxillary osteotomy is com-
pleted, the lateral nasal mucosa is protected with
a small malleable retractor placed between the
lateral nasal wall and the nasal mucosa. Before the
lateral maxillary osteotomy is completed, the pter-
ygoid fossa soft tissues are protected with a long,
toed-out retractor.
Step 26. With a specialized guarded chisel and mallet, the
septum of the nose (i.e., cartilage and bone) is
separated from the maxilla. Care is taken to avoid
penetration past the septum into the nasopharynx
(Fig. 15-14).
Step 27. With a specialized curved chisel and mallet, the
pterygomaxillary suture is separated on each side
(Fig. 15-15). Care is taken to avoid injury to the
internal maxillary artery or to the pterygoid plexus
and to avoid perforation through the palatal
mucosa. For a patient with extreme maxillary
hypoplasia (e.g., Treacher Collins syndrome), the
Step 24.
450 S E C T I O N 2 Planning, Surgical Technique, & Complications

• Figure 15-13 Step 25.

• Figure 15-14 Step 26.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
• Figure 15-15
chisel may be within millimeters of the optic
foramen and the optic nerve.
Step 28. With a Tessier (blunt) zygomatic hook placed on
the ledge of the nasal sill, force is applied to
“down-fracture” the Le Fort I osteotomy unit.
While down-fracturing, a Frazier suction tip and
a periosteal elevator are used by the assistant to
further separate and to limit the tearing of the
nasal mucosa (Fig. 15-16).
Step 29. After down-fracture, the maxillary sinus mucosa
is generally stripped off of its bony surfaces with
a Frazier suction tip and a hemostat (Fig. 15-17).
This is done to remove chronic inflammatory
tissue (polyps) from the sinus and to reduce
hemorrhage.
Step 30. Placing the Tessier (blunt) hook behind the maxil-
lary tuberosity and applying anterior and contra-
lateral directed force to one side at a time assists
with the disimpaction of the maxilla (Fig. 15-18).
The advantage of the Tessier hook is that it assists
with the mobilization of the maxilla without con-
tusion of the palatal mucosa, which may occur
with standard (Rowe) nasomaxillary disimpaction
forceps. When disimpacting with the Tessier hook
behind the tuberosity, the surgeon’s other hand is
used to grip the anterior maxilla (rather than the
teeth) and to apply simultaneous anterior and
contralateral force. This is helpful to prevent the
fracturing of the tuberosity by the Tessier hook.
This is repeated on each side two times to achieve
maximum disimpaction. During this process, the
assistant to the surgeon stabilizes the patient’s
head with one hand over each ear. For a maxillary
disimpaction that requires more extensive
advancement, the Rowe forceps may be required.
451
Step 27.
Septoplasty and the Reduction of
the Inferior Turbinates ( Video 6:4 and 7:4)
Step 31. When indicated on the basis of the patient’s
history and clinical examination, attention is
turned to the removal of the deviated portions of
the septum of the nose that are causing blockage
of the airway.
A. With an elevator, the submucosal dissection
of the cartilaginous septum (i.e., the quadran-
gular cartilage) and the bony septum (i.e., the
vomer and the perpendicular plate of the
ethmoid) is carried out (Fig. 15-19, A).
B. The deviated and thickened aspects of the car-
tilaginous septum and the bony septum are
resected with a rongeur (Fig. 15-19, B). The
more anterior components of the cartilagi-
nous septum that provides needed support to
the nasal dorsum and the tip are not dis-
turbed. This includes at least 1 cm of the
dorsal and caudal cartilage. When a maxillary
intrusion (i.e., for impaction) is planned, even
if septoplasty is not required to correct chronic
nasal obstruction, the inferior aspect of the
septum (i.e., the bone and cartilage) is removed
to prevent buckling.
Step 32. When indicated by the patient’s history and phys-
ical examination, attention is turned to reducing
each hypertrophic inferior turbinate that is causing
blockage of the airway. An incision is made
through the nasal mucosa just below and parallel
to each turbinate (Fig. 15-20, A). If the nasal
mucosa was torn during down-fracture, the
laceration is used and may be extended for
improved turbinate exposure. Each enlarged
452 S E C T I O N 2 Planning, Surgical Technique, & Complications

Down-fracture of maxilla with intact nasal mucosa

• Figure 15-16 Step 28.

inferior turbinate is visualized (Fig. 15-20, B), and

the inferior aspect of each is resected with a
straight Mayo scissors (Fig. 15-20, C). Hemostasis
is obtained along the cut edge of each turbinate
with the Bovie electrocautery device (Fig. 15-20,
D). The nasal mucosa is reapproximated with
interrupted sutures (3-0 Vicryl [polyglactin 910])
to create a closure that is as watertight as possible
(Fig. 15-20, E).

NOTE: To prevent a fire in the operative field, if

there are any air leaks around the nasotracheal tube,
then the electrocautery device is not used.

Removal of the Maxillary Wisdom Teeth

( Video 6:5)
• Figure 15-17 Step 29. Impacted Wisdom Teeth
Step 33. A. If indicated, each bony impacted maxillary
wisdom tooth is removed through the sinus
floor (Fig. 15-21). A rotary drill with a small
watermelon bur is used to remove bone from
the sinus floor that is directly over the impacted
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 453

Behind maxillary tuberosity

• Figure 15-18 Step 30.

Deviated septum

Nasal mucosa covering

inferior turbinates

• Figure 15-19 Step 31, A and B.

454 S E C T I O N 2 Planning, Surgical Technique, & Complications

B C

Inferior turbinate exposed after

elevation of nasal mucosal flaps

• Figure 15-20 Step 32.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
• Figure 15-21
tooth. Next, using a rotary drill with a tapered
fissure bur, bone is removed adjacent to the
impacted tooth. Depending on the extent of
tooth development, the impacted wisdom
teeth may also be sectioned to assist with
removal. A dental elevator is used to remove
the tooth. Perforation through the palatal
mucosa is an uncommon occurrence.
Erupted Wisdom Teeth
B. If indicated, each erupted maxillary wisdom
tooth is removed before down-fracture. This
provides a stable “workbench” at the time of
extraction. To preserve maximum circulation
to the down-fractured maxilla, it is important
to minimize the disruption of the adjacent
palatal and labial mucosa at the time of
extraction.
Segmentation of the Maxilla: Continued
If segmentation of the maxilla is to be carried out, the
interdental cuts that were initiated previously are completed
during this stage.
Three Segments
Step 34. A. Description of a three-piece Le Fort I oste-
otomy with interdental cuts between the
lateral incisor and the canine on each side
connected to parasagittal osteotomies through
the hard palate:
(1) The parasagittal maxillary osteotomy is
completed through the down-fracture
using a reciprocating saw with a short,
straight blade. The osteotomy is from
455
Step 33.
the posterior edge of the hard palate ante-
riorly to the pre maxillary region (Fig.
15-22, A-1).
(2) If the planned posterior arch-width
expansion is significant, then a second
parasagittal osteotomy is also completed
on the contralateral side (Fig. 15-22,
A-2). The two parallel parasagittal oste-
otomies allow for a more tension-free
expansion than a single osteotomy.
(3) The previously initiated interdental oste-
otomies are deepened using an oscillating
saw with a longer, fan blade on a long
shaft (Fig. 15-22, A-3).
(4) The oscillating saw with a longer, fan
blade on a long shaft is also used to
connect each interdental osteotomy to
the parasagittal osteotomy along the floor
of the nose at the level of the incisal
foramen (Fig. 15-22, A-4).
(5) A fine chisel (i.e., 5 mm or 7 mm in
width) is placed into the interdental oste-
otomy on the same side as the parasagittal
osteotomy, and an elevator is placed into
the parasagittal palatal osteotomy (Fig.
15-22, A-5). Twisting the elevator and
chisel simultaneously assists with the
splitting of the maxilla into segments.
(6) The fine chisel (i.e., 5 mm or 7 mm) is
then placed into the other interdental
osteotomy site, and an elevator is placed
in the nasal floor osteotomy site. With a
twisting motion, separation is completed
(Fig. 15-22, A-6). Perforation through
the palatal mucosa (when completing
456 S E C T I O N 2 Planning, Surgical Technique, & Complications

A1

A2 A3

Osteotomy across hard palate to

A4 separate premaxillary segment

• Figure 15-22 A, Step 34, A, Part 1 through Part 4.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 457

A5

A6

• Figure 15-22A, cont’d Step 34, A, part 5, 6. B,

Continued
458 S E C T I O N 2 Planning, Surgical Technique, & Complications
B1
B2
• Figure 15-22B, cont’d
the parasagittal palatal osteotomy) with a
reciprocating saw may occur. The creation
of a permanent palatonasal fistula or the
compromise of the circulation to the
maxillary segments should be an uncom-
mon occurrence (see Chapter 16).
Two Segments
B. Description of a two-piece Le Fort I osteot-
omy with an interdental cut between the
central incisors connected to parasagittal oste-
otomies through the hard palate:
(1) The parasagittal palatal osteotomy is com-
pleted through the down-fracture using a
reciprocating saw with a short, straight
blade from the posterior edge of the hard
palate anteriorly to the level of the incisive
foramen (Fig. 15-22, B-1). If the planned
posterior arch-width expansion is signifi-
cant, then a second parasagittal osteot-
omy is also completed on the contralateral
side.
(2) The previously initiated interdental oste-
otomy is deepened using an oscillating
B3
Step 34, B, Part 1 through Part 3.
saw with a longer, fan blade on a long
shaft (Fig. 15-22, B-2).
(3) A fine chisel (i.e., 5 mm or 7 mm in
width) is placed into the interdental oste-
otomy, and an elevator is placed into the
parasagittal osteotomy. Twisting both
simultaneously assists with the splitting of
the maxilla into the two segments (Fig.
15-22, B-3). Perforation through the
palatal mucosa when completing the
parasagittal palatal osteotomy may occur.
The creation of a permanent palatonasal
fistula or the compromise of the circula-
tion to the maxillary segments should be
an uncommon occurrence.
Maxillary Le Fort I Osteotomy: Continued
( Video 6: 6-10 and 7: 5-9)
Step 35. The maxillary segments are next secured into the
prefabricated acrylic intermediate occlusal splint
with the use of 26-gauge wire placed through
interdental drill holes in the splint and around the
orthodontic arch wire (Fig. 15-23).
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
Step 36. The maxillary segments are secured to the man-
dible in the occlusion established by the “interme-
diate” splint with the use of 26-gauge wire loops
passed around hooks located on the orthodontic
arch wires (Fig. 15-24).
Step 37. With the condyles seated in the terminal hinge
position (i.e., the same position that they were in
when capturing centric relation in the office
setting), the maxillomandibular com­plex is
rotated to achieve the vertical dimen­sion that
was preoperatively determined (Fig. 15-25, A).
A. If vertical shortening (impaction) of the
maxilla is planned, this will require the
removal of bone interferences with rongeurs
or u s i n g a rotary drill w i t h a water­
melon bur.
• Figure 15-23
Intermediate splint
• Figure 15-24
459
B. The Tessier caliper is used to measure the ante-
rior vertical dimension (i.e., the anterior facial
height) of the midface (i.e., the medial canthus
to the mid-maxillary incisor on each side) to
confirm that the desired vertical height is
achieved (Fig. 15-25, B).
Step 38. With the condyles remaining in the terminal
hinge position (i.e., the same position that they
were in when capturing centric relation in the
office setting) and with the maxilla in the pre-
ferred vertical location, appropriately sized and
individually contoured L-shaped titanium plates
(one by one) are most frequently placed across
each zygomatic buttress and at each lateral nasal
rim and secured with titanium screws (1.7 mm in
diameter and 4 mm in length) (Fig. 15-26).
Step 35.
Step 36.
460 S E C T I O N 2 Planning, Surgical Technique, & Complications

• Figure 15-25 Step 37, A and B.

• Figure 15-26 Step 38.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
Step 39. A. The jaws are unwired (Fig. 15-27, A).
B. With the condyles seated in the terminal
hinge position, the mandible is rotated verti-
cally (up and down) to check
the occlusion. The occlusion must be found
to be even within the intermediate splint
(Fig. 15-27, B).
Step 40. A. After the occlusion is determined to be even,
the intermediate splint is removed.
B. The “final” splint is placed on the maxillary
teeth and secured to the orthodontic wire
(Fig. 15-28, A). This is accomplished with the
use of 26-gauge wires passed through the
interdental drill holes in the “final” splint
and around the orthodontic arch wire
(Fig. 15-28, B).
• Figure 15-27
461
Step 41. When the extent of horizontal advancement and
vertical lengthening of the maxilla are judged to
be significant, then an interpositional bone graft
may be beneficial for the achievement of reliable
healing (Fig. 15-29, A). In these circumstances, I
prefer to use autogenous or allogenic iliac bone
graft. A bloc of corticocancellous bone is crafted
and tightly wedged into the gap on each side.
Each graft is inset in between the pyriform rim
and the zygomatic buttress titanium plates (Fig.
15-29, B). An additional plate is then contoured
to extend from the anterior maxilla above, across
the graft, and then onto the alveolar process of
the anterior maxilla. Titanium screws (1.2 mm
in diameter and 3 mm in length). then secure the
plate to the bone (Fig. 15-29, C).
Step 39, A and B.
462 S E C T I O N 2 Planning, Surgical Technique, & Complications
Remove
intermediate
splint
A B
• Figure 15-28
Pyriform Rim, Nasal Floor, and Anterior Nasal
Spine Recontouring ( Video 6:9 and 7:7)
Step 42. The nasal aperture, the floor of the nose, and the
anterior nasal spine are inspected. Refinement and
recontouring of these structures using a rotary
drill with a watermelon bur are frequently benefi-
cial (Fig. 15-30). For example, in the patient with
vertical maxillary excess (i.e., long face growth
pattern), the deepening and recontouring of the
nasal floor, the pyriform rims, and the anterior
nasal spine will generally improve nasal airflow
(i.e., the correction of a tight nasal inlet and an
elevated nasal floor) and also enhance nasal aes-
thetics (i.e., limit unwanted alar base widening
and tip elevation).
Chin Osteotomy ( Video 6:11 and 7:10)
Step 43. Attention is next turned to the facial vestibule of
the chin. The lower lip is stretched outward to
allow for exposure of the vestibule and the visual-
ization of the mental nerve through the mucosa
on each side. In the depth of the vestibule, an
incision is made with the use of a Bovie electro-
cautery device or a knife (#15 blade) through the
mucosa from cuspid region to cuspid region, stop-
ping just short of the visualized mental nerve on
each side (Fig. 15-31). The center two thirds of
the incision are next extended down to bone. A
full cuff of mucosa and muscle is maintained adja-
cent to the attached gingiva of the anterior teeth.
This should allow for adequate layered wound
closure (i.e., involving muscle and mucosa)
without resulting periodontal sequelae.
Step 44. Dissection with an elevator exposes the anterior
surface of the chin (not completely to the inferior
border of the central chin). The dissection contin-
ues laterally and remains inferior to the mental
Place
final
splint
Step 40, A and B.
nerve, with lateral exposure to the inferior border
of the mandible. There is no need to dissect above
the mental nerve on either side. If a 360-degree
dissection around the nerve is completed, it is
more likely that the nerve will be excessively
stretched or avulsed.
Step 45. A small S-shaped Tessier chin retractor is placed
on each side inferior to the mental nerve and later-
ally to the inferior border. A sterile pencil is used
to mark the location of the oblique osteotomy
(Fig. 15-32); this should be planned sufficiently
below the dental roots and the mental foramen
on each side. The exact location of the osteotomy
will depend on the presenting chin morphology
and the planned reconstruction (i.e., vertical
reduction or lengthening and extent of horizontal
advancement).
Step 46. Using an oscillating saw with a short fan blade on
a long shaft, a vertical groove is made in the
midline across and perpendicular to the proposed
horizontal osteotomy (Fig. 15-33, A). This will
help to maintain vertical orientation after the
osteotomy and before fixation.
Step 47. A drill hole is placed in the midline within the
distal chin (Fig. 15-33, B). Later, a screw (1.7 mm
in diameter and 8 mm in length) will be partially
inserted. The screw is not placed in the distal chin
until the osteotomy is completed. It will then be
held with a wire twister and used as a retractor
and a holder to facilitate the repositioning and
orientation of the distal chin unit.
Step 48. The oblique osteotomy of the chin is initiated in
the central portion using an oscillating saw with
a wide, fan blade on a short shaft (Fig. 15-34).
The use of this saw and blade helps to maintain
orientation and limit a cant in the osteotomy.
Step 49. The reciprocating saw with a short blade and then
with a longer blade is used to complete the lateral
aspects of the osteotomy and to go through the
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 463

Additional microplate
and screws

• Figure 15-29 Step 41.

464 S E C T I O N 2 Planning, Surgical Technique, & Complications
• Figure 15-30
• Figure 15-31 Step 43.
depth of bone on each side (Fig. 15-35). An osteo-
tome may be inserted with a twisting motion to
complete the osteotomy separation.
Step 50. When vertical shortening of the chin is planned,
there are two options.
A. If only limited shortening is required in com-
bination with horizontal advancement, it
may be preferable to use a rotary drill with a
Step 42.
watermelon bur to remove bone height at the
osteotomy line.
B. If a more significant vertical reduction is
planned, a second parallel osteotomy for
ostectomy is completed through the proximal
chin (below the dental roots) using a recipro-
cating saw with a long straight blade. Any
lateral irregularities are also removed using a
rotary drill with a watermelon bur. This is
to limit postoperative palpable or visible
step-offs.
Step 51. The distal chin is held in the desired position by
the assistant with the use of the wire twister
secured to the positioning screw. The surgeon
custom contours each titanium plate across the
osteotomy site and then secures each plate with
screws (1.7 mm in diameter and 4 mm in length).
Typically, either a three- or four-hole straight plate
is contoured with the ends placed on either side
of the osteotomy. The superior screw is usually
placed in between the lateral incisor and the
canine on each side. With the chin secured in its
new location, the positioning screw is removed
(Fig. 15-36, A and B).
Step 52. If significant vertical lengthening is carried out, an
interpositional graft (i.e., autograft, allograft, or
block hydroxyapatite) is crafted and placed in the
gap (Fig. 15-37). The graft fills the central gap in
between the fixation plates. I do not find it neces-
sary to place graft in the lateral aspect of the gaps.
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
• Figure 15-32
A1
B1
• Figure 15-33
An additional plate with screws is generally placed
vertically in the midline across the osteotomy site
directly over the graft (see Chapter 18).
Sagittal Split Ramus Osteotomies: Continued
( Video 6:12 and 7:11)
Step 53. Attention is returned to one side of the ramus of
the mandible. The previously placed packs are
removed and retractors (i.e., tongue, inferior
border at buccal extension, toed-in Langenbeck at
anterior ramus to retract the cheek, and medium
465
Step 45.
A2
B2
Steps 46 and 47.
malleable to expose the medial cut) are placed for
sufficient exposure to complete the sagittal split-
ting of the ramus of the mandible.
Step 54. Initially, fine osteotomes (i.e., 5 mm and 7 mm
in width) are used with a mallet to confirm that
all cortical cuts are complete (Fig. 15-38). When
twisting the chisels, a degree of movement should
be visualized along the vertical cut down to the
inferior border. Care is taken to avoid injury to
the inferior alveolar nerve, which is located super-
ficial to the cortex along the inferior aspect of the
buccal shelf extension.
466 S E C T I O N 2 Planning, Surgical Technique, & Complications

• Figure 15-34 Step 48.

• Figure 15-35 Step 49.

Step 55. A larger osteotome (10 mm in width) is then is sometimes desirable. A thin periosteal elevator
placed deep into the medullary cavity near the may be used to gently tease the neurovascular
second molar of the mandible. A sagittal split bundle free from the proximal segment. A rotary
spreader forceps is placed deep into the medullary drill with a watermelon bur may also be used to
cavity (i.e., more distal) in the buccal extension release the neurovascular bundle from the proxi-
region (Fig. 15-39). After both of these are in mal segment.
place, a simultaneous twisting and spreading
motion is employed to complete the separation.
During separation, the neurovascular bundle is
NOTE: It is not usually necessary to completely free
visualized, and the correct separation of the condyle
the nerve from the proximal segment. Caution is
(retained to the proximal segment) is confirmed.
warranted, because a degree of contusion to the
Step 56. With the split complete, further freeing of the
neurovascular bundle will occur when doing so.
neurovascular bundle from the proximal segment
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
• Figure 15-36
• Figure 15-37
Step 57. A curved Kocher clamp is placed on the distal
aspect of the proximal segment. The clamp is used
as a handle to apply force and to ensure the com-
plete separation and freedom of motion of the
proximal and distal segments (i.e., soft-tissue
release).
Step 58. The identical sagittal splitting of the ramus of the
mandible is completed on the contralateral side;
see Steps 51 through 57.
467
Step 51.
Step 52.
Removal of Impacted Mandibular
Wisdom Teeth ( Video 6:12)
Step 59. If present, each bony impacted mandibular
wisdom tooth located within the distal segment is
removed with a dental elevator (Fig. 15-40). It
may be helpful to use a rotary drill with a tapered
fissure bur to remove bone adjacent to the tooth.
Sectioning the tooth may be required to facilitate
468 S E C T I O N 2 Planning, Surgical Technique, & Complications
the atraumatic removal of the tooth. This will
minimize the chance for an uncontrolled fracture
of the lingual plate.
Sagittal Split Ramus Osteotomies: Continued
( Video 6: 12-15 and 7: 11-14)
Step 60. The distal mandible is placed into occlusion
through the prefabricated final splint, which has
already been secured to the maxilla. The jaws
• Figure 15-38 Step 54.
• Figure 15-39
are wired together with 26-gauge wire loops
placed around the orthodontic interdental hooks
(Fig. 15-41).
Step 61. Attention is turned to the proximal segment of
the mandible on one side. The proximal segment
is seated with the condyle in the terminal hinge
position. This is accomplished with the placement
of a fine curved hemostat to the edge of the buccal
extension. The condyle will then rest in a superior
and anterior position within the glenoid fossa
(i.e., the same position that it was in when captur-
ing centric relation in the office setting). Any
interferences that prevent sufficient passive bone
contact of the proximal and distal segments along
the osteotomy site are managed using a rotary drill
with a watermelon bur (Fig. 15-42). If the man-
dible is set back, an appropriate section of bone is
also removed from the distal aspect of the proxi-
mal segment (i.e., the buccal shelf ) to prevent
any cortex overlap. When setting the mandible
back, the removal of bone interferences from the
lingual plate of the distal segment is also generally
required. These tasks are accomplished using
either a rotary drill with a watermelon bur or a
reciprocating saw with a short, straight blade.
NOTE: The hemostat is not used to clamp the
proximal and distal segments together. Gentle superior
and posterior force is applied to seat the condyle in the
terminal hinge position.
Step 55.
 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 469

• Figure 15-40 Step 59.

• Figure 15-41 Step 60.

Step 62. A 4-mm lateral neck incision (just below inferior

border of the mandible) is made through the skin
for trocar insertion (Fig. 15-43, A through C). The
location of the incision is based on the best posi-
tion of the trocar for ideal bicortical screw place-
ment. With the use of a straight hemostat, blunt
dissection through the skin incision is accom-
plished to achieve intraoral exposure. The trocar
is then introduced, and the cheek retractor com-
ponent of the trochar is placed to improve
visualization.
Step 63. The proximal segment is seated with the condyle
in the terminal hinge position. This is accom-
plished via the placement of a fine curved hemo-
stat to the edge of the buccal extension. (Note that
the hemostat is not used to clamp the proximal
and distal segments together.) Gentle superior and
• Figure 15-42 Step 61. posterior force is applied to seat the condyle in the
470 S E C T I O N 2 Planning, Surgical Technique, & Complications

B
4-mm skin incision Insertion of trocar

C
Trocar inserted Trocar cheek retractor in place

• Figure 15-43 Step 62.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach
terminal hinge position. The condyle will then
rest in a superior and anterior position within the
glenoid fossa (i.e., the same position that it was in
when capturing centric relation in the office
setting). Three bicortical titanium screws (2.3 mm
in diameter and 14 mm to 16 mm in length) are
generally sufficient to passively secure the proxi-
mal and distal segments together (Fig. 15-44, A
through C). The bicortical screws are placed in
locations where bone contact is the best. A fourth
screw is sometimes placed. Stability is further
improved when the screws are positioned as far
from each other as possible. Plates with unicorti-
cal screws are occasionally preferred to bicortical
screw fixation.
Step 64. Attention is turned to the contralateral side, and
identical procedures are carried out; see Steps 60
through 63.
Step 65. The jaws are then unwired. With the application
of posterior and superior vectored force to the
anterior mandible, the condyles are seated in the
terminal hinge position. The mandible is then
rotated (up and down) to check that the occlu-
sion is even and passive into the splint (Fig.
15-45). If not, the bicortical fixation screws are
removed, and the process is repeated; see Steps
59 through 63.
Wound Closure ( Video 6: 16 and 7: 15)
The anesthesiologist is asked to discontinue the deliberate
hypotensive anesthesia before wound closure. This should
unmask any significant bleeding vessels.
Step 66. The maxillary, mandibular, and chin vestibular
wounds are irrigated, suctioned, and checked for
hemostasis. The wounds are then closed with
interrupted suture (3-0 Vicryl and 3-0 chromic).
A. The mandibular vestibular wounds are gener-
ally closed in one layer with interrupted suture
(3-0 Vicryl). Running and locking (3-0
chromic) suture may be substituted (Fig.
15-46, A). A watertight closure is important
to prevent dehiscence followed by increased
risk of infection.
B. The maxillary wound is generally closed with
running and locking suture (3-0 chromic)
(Fig. 15-46, B). The risk of dehiscence or
infection is low.
C. The wound of the chin is closed in two layers
(i.e., muscle and mucosa). Three to five inter-
rupted buried sutures (3-0 Vicryl) are placed
for muscle layer closure. Locking and running
sutures (3-0 chromic) are used for the closure
of the mucosa layer (Fig. 15-46, C). A two-
layer closure is essential to limit dehiscence
and to prevent chin ptosis.
471
D. The trocar (skin) wounds are closed with two
interrupted sutures (6-0 nylon).
Step 67. The mouth is irrigated and suctioned, and the
throat pack is removed. An orogastric tube is
placed to drain the stomach and then removed.
Interdental elastics are applied to secure the
occlusion.
Anterior Neck Soft-Tissue Procedures
( Video 7:16)
Step 68. If anterior neck soft-tissue management is planned,
it is carried out at this stage. This may include
cervical flap elevation, supra-platysma and sub-
platysma defatting, and vertical platysma muscle
plication (see Chapter 40). Additional prepping
with povidone–iodine (Betadine) solution is
carried out, and a sterile drape is placed over the
standard drapes that are already in place. Sterile
instruments and a fresh gown and gloves are used.
Injection with tumescent solution is completed in
the supra-platysma plane.
A. A 3-cm submental incision is made within or
just caudal to a natural submental crease.
B. Two double skin hooks are placed (i.e., one
on either side of the incision) to provide
tension on the flaps.
C. If the separation of the cervical skin from the
underlying platysma muscle is planned, it is
accomplished with a blunt-tipped scissors.
The cervical skin flap elevation off of the pla-
tysma muscle may continue laterally over the
sternocleidomastoid muscles inferiorly to the
thyroid cartilage and superiorly to the inferior
border of the mandible.
D. A cannula (no. #7 plastic curved) is used to
suction the fat above and in between the
platysma muscles.
E. Plication of the platysma muscle in the
midline (vertically) from above the thyroid
cartilage to just below the chin may also be
carried out with interrupted suture ties (3-0
Vicryl).
F. After confirming satisfactory hemostasis, the
submental skin wound is closed in two layers:
dermal (5-0 Vicryl) and skin (6-0 nylon).
G. A light pressure dressing (Jobst type) is gener-
ally applied to the neck. In general, I do not
find it necessary or useful to place a drain.
Emergence from Anesthesia
Step 69. The corneal shields or temporary tarsorrhaphies,
if used, are removed. The sutures used to secure
the endotracheal tube to the scalp and the septum
of the nose are released. When the appropriate
472 S E C T I O N 2 Planning, Surgical Technique, & Complications

Intraoral view with trocar in place

B
Power drill (2.3-mm bit) inserted through trocar

C
Screwdriver inserted through trocar 3 bicortical screws (2.3 mm in diameter and 14-16mm in length) in place

• Figure 15-44 Step 63.

 CHAPTER 15 Sequencing of Orthognathic Procedures: Step-by-Step Approach 473

physiologic parameters are met, the patient is

generally extubated in the operating room and
then taken to the recovery room breathing
spontaneously. If any airway need arises, the
interarch elastics are removed without concern
(see Chapter 11).

Conclusions
The surgical management of dentofacial deformities has
gradually evolved. By understanding the technical details
for the safe execution of the maxillary (Le Fort I), mandibu-
lar (sagittal splitting of the ramus), and chin (osseous genio-
plasty) osteotomies, each skeletal unit may be precisely and
efficiently repositioned (i.e., in three dimensions) during
one operation. Other simultaneous adjunctive procedures
(i.e., septoplasty; the reduction of the inferior turbinates;
• Figure 15-45 Step 65.

A B

• Figure 15-46 Step 66, A, B, and C.

474 S E C T I O N 2 Planning, Surgical Technique, & Complications

the recontouring of the pyriform rims, the nasal base, and
the anterior nasal spine; the removal of wisdom teeth; and
soft-tissue neck rejuvenation) are routinely performed,
when indicated, to improve head and neck function (i.e.
occlusion, chewing, speech articulation, swallowing,
breathing, and lip closure) and to enhance facial aesthetics.
Special circumstances and unusual anatomy may require
variations of the techniques described in this chapter. The
development of a consistent approach for most routine cases
limits morbidity and increases efficiency of care.

References
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2. Posnick JC, Fantuzzo JJ, Troost T:
Simultaneous intranasal procedures to improve
chronic obstructive nasal breathing in patients
undergoing maxillary (Le Fort I) osteotomy. J
Oral Maxillofac Surg 65:2273–2281, 2007.
3. Posnick JC: Le Fort I, sagittal split and
genioplasty: historical perspective and
step-by-step approach. In Posnick JC, editor:
Craniofacial and maxillofacial surgery in children
and young adults, Philadelphia, 2000, W.B.
Saunders Company, pp 1081–1102.
4. Obwegeser HL. In Trauner R, Obwegeser H,
editors: Zur operationstechnik bei der progenie
und anderen unterkieferanomalien. Dtsch
Zahn- Mund- u Kieferheilk 23:1–26, 1955.
5. Obwegeser HL: The surgical correction of
mandibular prognathism and retrognathia with
consideration of genioplasty. I. Surgical
procedures to correct mandibular prognathism
and reshaping of the chin. Oral Surg Oral Med
Oral Pathol 10:677–689, 1957.
6. Obwegeser HL: Der offene biss in chirurgischer
sicht. Schweiz Monatschr Zahnhlkd 74:668–687,
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