SURGICAL CORRECTION OF SMALL OR RETRODISPLACED MAXILLAE ‘The “Dish-face” Deformity HUGO L, OBWEGESER, MD, DMD. Zurich, Switzerland A posterior displacement of the max- ila may be present, with the maxilla cither underdeveloped or normal in size, and may be coupled with a normal occlu: sion, The term “dish-face deformity” is generally applied. ‘The displacement may also be found with an Angle Class IIT malocclusion. Here, the term pseudoprognathism is commonly used. INDICATIONS FOR SURGERY 1. Functional indication Therapy may be indicated for im- provement of mastication, speech, or breathing. Improvement of occlusion may be necessary as a therapeutic or prophylactic measure in temporoman- dibular joint disorders. 2, Esthetic indication ‘The disturbance in the patient's out- ward appearance may create a personal desire for correction. This reason, in most cases, is the main motivation for seeking therapy. In the patient's eyes, the esthetic consideration is often more important than the functional one. ‘There is a difference in this problem between male and female. Both want to have their situation corrected, when the deformity is very pronounced. However, in cases of minor retrodisplacement of the maxilla, a male may believe his con- dition emphasizes the masculinity of his face. ‘The same situation in a female may look unpleasant* or the woman may think it gives her the appearance of a ‘masculine profile. 3. Psychic indication Due to his unusual appearance the patient may develop psychological prob- Jems. Abnormalities of occlusion, masti- cation, speech, and breathing may lead to the same. Females suffer more than males. The psychological problems of the patient begin very often at the age of puberty, or even before. When successful correction of the displacement is per- formed early enough, the psychic dis- order may be fully reversible. If the displacement is not corrected before the age of 20 (0 23, the psychic disorder may be so deeply ingrained that, in spite of later successful correction of the skeletal situation, it may still remain partially irreversible. 4. Social indication Because of disturbances in both ap- pearance and function, psychic and ac- ‘companying abnormalities, these patients have to cope with a great number of dis- advantages. Reduction of the masticatory function may make one dependent on home cooking and cause digestive prob- lems. One's appearance may completely bar him from certain types of professions, From the Department for Oral and Maxillofacial Surgery of the University Dental School, University ot Zurich. *Eiit's nae. Those of us who think that beauty has many forms might not agree, or might isagres as to what we think Is “minor” or “absent” The editor, for example, would like to qo on recerd ss enthusiastically approving the physiognomy of, ay, a potential “Migs Dorothy Lamour!" te. would stay the hand which sects to “iaprove™ te sa382 ‘or may prevent him from advancing in his profession in accord with his mental and manual capabilities. ‘The resultant psychic manifestations, due to the pa- tient’s skeletal disorder alone, may be enough to hinder him. in his vocation. Perhaps worst of all for the patient, his personal and private life sutfers from these esthetic, psychological and func tional abnormalities. ANATOMICAL SITCATION Various anatomical patterns may be found, but they may be classified into two main groups. 1. Those with normal occlusion. 2. Those with Angle Class TIT malocel sion, with or without open bite Depending on the situation, surgery will have to deal either with the “dish- face deformity” alone, or also with con- comitant abnormal occlusal and inter- maxillary relationships. As there are 3 generally accepted classical profile types (A. M. Schwarz!)—the straight forward profile, the straight backward profile, and the average profile—there is no way to obtain a measurable plan ds to where and to what extent correction has ta be per formed. Therefore, it will depend on the patient's wishes and the surgeon's judg- ment and intuition to decide which part of the facial skeleton has to be corrected in which direction—and to what degree. The cephalogram and other roent genographic projections definitely aid in making up one’s mind, ‘The tracing of the cephalogram may be of more value (in this respect) than the patient's photo- graph though, in some cases, the latter can be more important. For the correc: tion of occlusion, study models are a necessity; we mount them in a special articulator (Obwegeser®), which permit us 10 move any parts of the models in any desired direction to determine the re- quired correction. Through the model PLASTIC & RECONSTRUCTIVE SURGERY, April 1969 operation, we can appraise the tooth: bearing arch. After taking accurate meas- ‘urements, we either enlarge the arch (for cases of micromaxillism) or advance the arch (for cases of retromaxillism) until normal occlusion with the mandibular teeth is obtained, All of our reconstruc- tion work in this area is based upon normal occlusion, WHICH PROCEDURE? Various types of procedures are avail- able for correction of retrodisplacement of the whole, or parts, of the maxilla. Depending on the case, one may be able to correct the whole disfigurement with one procedure only, or two or more pro: cedures, either in one operation or in different operations, may be required. ‘The decision will depend on the patient's personal wishes and the snrgeons’s judg- ment. For these reasons, rather than dis- ‘cussing the various types of deformities, the procedures will be discussed. Which procedure will be used depends upon the individual case. DENTAL PROSTHESIS Without surgery, a dental prosthesis ‘may support the upper lip and, to a cer- extent, the cheek. However, for contour restoration, the socalled cover denture is not recommended as, within a few years, it may have 2 deleterious ef fect upon the remaining teeth. MAXILLARY ONLAY Cases with normal occlusion, but flat- ness in the middle third of the face, may find remarkable improvement. through an intraoral maxillary onlay (Converse and Shapiro, Schmid,* Ragnell,* etc). The technique is generally known. For this procedure, we personally prefer bank cartilage or bone. Bone is normally used during the same operation, bone graft- ing is performed for gaining bony unionVol. 43, No. 4 / spvaNciNc THE UPPER JAW 393 Fic. 1. Correction of facial contour with a denture, after an epithelial inlay proceduse in a patient witha retodisplaced edentulous maxilla, between the moved and stable parts of the middle-third of the facial skeleton. The onlay can be placed around the pyriform aperture only, or up to (and including) the infraorbital rim. ‘The Gillies* type of buccal inlay, pri marily advocated for advancement of the nose for the luetic dish face deformity, is an extreme form of the buccal inlay technique. As the appliance isa kind of cover denture, this type of operation is recommended for edentulous cases only. There is another type of buccal inlay, which does not open the pyriform aper ture (Pichler, Obwegeser’) and still brings excellent results where indicated (Fig. 1). All types of buccal inlay techniques do have the great drawback that the surgical result may be destroyed, more or less completely, if the patient is not able 10 cooperate properly. The buccal inlay has another disadvantage in edentulous ret rodisplaced maxillas. Because of the ret rodisplaced supporting base for the den. ture, the mandibular front teeth contact the upper denture in front of the maxilla. This, after some years, leads automati ally to supplementary resorption of al veolar bone. ENLARGING THE MAXILLARY CIRCUMBER. ENCE IN EDENTULOUS MANILLAE This procedure may often be indicated in edentulous cleft palate cases, and in some other edentulous cases of micro: maxillism and retromaxillism. Bone, from cither the hip or rib, may be used to create a new alveolus and enlarge the anterior part of the maxilla (Obweg- exer"), Another ideal donor site is the inferior rim of the chin prominence (Neuner"); as it consists mainly of cor- tical bone, the risk for infectionPLASTIC & RECONSTRUCTIVE SURGERY, April 1969 ‘he, % Lransplantauion ot cin promanence ane canceuous Hone 1rom snae eet to MENA, for correction of facial contour (in a cave of edentaloue retromaxili), ie. 8. Technique for forward repositioning of anterior pare of lage alveolar segment, in 2 unit tral cleft. This segment receives its bleed supply through only the narrow pedicle of vestibular muco periosteum, Defecte are filed with bone. When the Anterior part of the other alveolar segment is in luded in the forward movement, the vesdbular pedicle becomes considerably wider amd the blood apply is more secure greater and the amount of resorption is less (Fig. 2) Subsequently, all these cases need a second operation for improvement of the vestibular area. Any of the various types of vestibuloplasty may be used (Ob- wegeser’). FORWARD REPOSITIONING OF ANTERIOR It is now a routine operation to re position the anterior part of the maxilla posteriorly for correction of maxillary protrusion (Wasmund, Wunderer"), The same type of operation may be used to advance any desired part of the maxitla anteriorly (Converse et al). As it is im- possible to stretch the palatal soft tissues enough for the necessary amount of for- ward movement, one should elevate the entire palatal soft tissue covering. ‘The mobilized anterior part of the maxilla can receive its blood supply through the vestibular mucosa, which is left attached. The bone defects produced in the ante- rior wall of the antrum, and in the al- veolus and hard palate, have to be filled with bone grafts (Fig. 8). This type of operation is very useful when only minor repositioning has to be achieved and when the occlusion in the biscupid and molar area is acceptable (Figs. 4, 5). LE FORT 1 FRACTURE-OPERATION There are definitely many cases which, according to occlusal necessities, requireVol. 43, No. 4 / apvaxciN THE UPPER JAW ie, 4 Forward repositioning of anterior unilateral cleft ip and palate a forward advancement of the whole tooth-bearing maxillary arch. This oper ation has been performed only occasion: ally. Circular detachment of the maxilla, as a Le Fort I type of fracture, was performed first by. Wassmund® in 1927 for closure of an open bite. However Axhausen" (1934) was the first to ad- vance the maxilla anteriorly in a surgical fracture of the Le Fort I type, using elastics, postoperatively, for the forward movement. Schucharde'® (1942), after he had detached the maxilla from the ptery- oid process in a second operation, used weights to effect the same movement. He mentioned that this procedure should be used more often in Angle Class III cases. He states, however, that it cannot be used in cleft palate cases. Some operators cut the boné across the hard palate (Co: verse and Shapiro, Cupar, Gillies, Rowe,'* Kale,”). We prefer to make our bone cut as high as possible, from the tuberosity area around the whole maxilla, staying just beneath the infraorbital foramen. part of large maxillary alveolar segment, in a Fic. 5. (above) Pre-operative and (Below) post: ‘operative occlusal views of patient shown in Figure a356 PLASTIC & RECONSTRUCTIVE suRGERY, April 1969 Fic. 6, High Le Fort I osteotomy for forward movement of the maxilla. 4, Path of bone cute, B, Reperitioned taxila, wich bone implant behind tuberosity to stabilize maxilla C, Postoperative anterior view. See text for bone implantation technique used in this procedure, (At first we performed this high Le Fort I type fracture by also cutting the pterygoid plates. In contrast 19 Hogeman and Vilmar,* we had some relapses. Because of this we later detached the ‘maxilla from the pterygoid plates) In the same session we open the max- illary arch by cutting the palate lateral to the mid-palatal sutures (Obwegeser?! 8, Later we fill the space between the ptery- goid process and tuberosity area by in- serting a piece of bone (Fig. 64, B). In cases of considerable forward move- ment of the maxilla, to build a bony bridge between the stable and moved parts, itis necessary to put ina bone graft from the zygomatic crest to the pyriform aperture (Fig. 6). This forward move- ‘ment has been accomplished for distances up to 20 mm. In spite of broad commu- nication to the open antrum, the cancel lous bone which bridges the gap will heal perfectly, as shown by Gillies? Bone placed along the anterior wall of the antrum also increases the contour of the face; for this reason, it may be placed as high as the infraorbital rim (Fig, 6C) Ic is not difficult to cut the Le Fort I type fracture. What may be difficult, how- ever, in such a complete mobilization, is the positioning of the maxilla withoutVol, 43, No. / apvaxcuso tue UPPER JAW f | | 357 Fic. 7. Conection of vetromaxillom in a unilateral cleft lip and palate patient, by a high Le Fore Lesteotomny, Fo, 8, Tomograms in a case similar to Figure 7, in which the maxilla has been moved forward 20 mim. Notice the bone graft in the canine fosa and the pteryee-maxillary aveas any tension into the preoperatively planned occlusion. It has been our ex: perience that it is necessary to have the maxilla so mobile that it can be repo sitioned by using only forceps. Even though both palatal arteries were prob- ably not functioning (in some cases) after the forward repositioning of the maxilla, there has always been enough blood sup- ply coming through the soft tissue cover-388 Fic, 9, Forward advancement of middlethied of face via a Le Fort IK oxteotomy: (above) pre ‘operative, and. (Below) postoperative schematics of facial bones, In the bone ents the lacrimal sac and IMetimal canal anay be excluded (@), or included (@): detects inthe orbital wall (-) may not requice bone implantation (@) 10 stabilze them and to fecare bun tno. ing of the hard palate, This occurred in spite of the fact that (in many of our cases) very little antral or nasal mucosa of the repositioned part had any connection with the mucosi of the non-mobilized area of the maxilla (Figs. 7, 8). ‘The incision line is made in the vesti- ule, from one zygomatic crest to the zygomatic crest on the other side. From this incision line, the bone cut is made circumferentially on the maxilla, at a level just beneath the infraorbital fora- men. The incision allows enough access PLASTIC & RECONSTRUCTIVE SURGERY, April 1969 to separate the maxilla from the palate, ‘As we do not have the Delbet-Tessier** “diadem” for mobilization of the max- illa, we use a very heavy elevator inserted behind the tuberosity area. LE FORT IIL FRACTURE-OPERATION Most cases can be corrected perfectly the Le Fort I type of fracture-opera- tion, occasionally utilizing supplemen- tary onlays around parts of the orbit. Others require a Le Fort III fracture: operation, ‘According to the literature, Gillics'™ seems to have been, until recently, the only one who had advanced the middle- third of the facial skeleton via a surgically performed Le Fort III fracture. He had done it only once. Not long ago, Murray and Swanson?® also published one case. However, it has not yet become a routine operation, Since Tessier, at the Fourth Interna- tional Conference on Plastic Surgery in Rome (1967) demonstrated his ingenious work on the upper-half of the facial skel- ‘eton, there is no longer any reason why this procedure should not be done rou- tinely. ‘Tessier® * demonstrated clear operating procedures for advancing the upper-half of the middlethird of the facial skeleton, for producing surgically a Le Fort III fracture, and for correction of hypertelorism (Tessier e¢ al), includ- ing removal of parts of the base of the skull. His many variations of cutting the upper-half of the facial skeleton will stimulate the modification of incision lines on the bone. In the future, surgery of this type will probably be based on the methods he has pioneered (Fig. 9). ‘The deformity requiring the surgical Le Fort 111 fracture procedure is retro- displacement of the entire middle-third of the facial skeleton, regardless of ori- gin (Figs. 10, 11).Vol. 43, No. # / apvascuso ‘THE UPPER Jaw 359 Fic, 1 Pre- and postoperative profile views of patient treated by method shown in Fig: ures COMBINED LE FORT II AND LE FORT 1 ‘OSTEOTOMY PROCEDURE In some cases an independent forward repositioning of the lower half and the upper half of the middle third of the facial skeleton must be performed. In the lower half of the middle third of the facial skeleton the degree of forward movement is determined by occlusal ne- ccessity. The degree of movement of the upperhalf is influenced mainly by es- thetics. To achieve both goals simul taneously, one can perform both a Le Fort III and a Le Fort I osteotomy pro- cedure in one operation (Fig. 12), IE the case also requires a narrowing of the upper half, this portion may be fractured in the midline and along the suture lines between the nasal bones and maxilla, ot lateral to them (Fig. 13). By doing this the nasal bridge can auto matically be raised to a certain height For simultaneous correction of a more pronounced hypertelorism, a strip of bone and tissue could also be removed (Tessier®"). And, if the occlusion de- mands it, there is no reason why one should not remove a strip of bone in the middle of the lower-half of the middle third (palate and alveolus). During a combined Le Fort IIT and Le Fort 1 osteotomy procedure, the maxillary arch can also be widened by opening it (Fig. 14), as we do when necessary in the Le Fort I procedure (Obwegeser®! ®) Bone cuts may be made, according to the individual case. The temporal proc ess of the zygomatic bone is detached from the maxillary complex (Figs. 9, 14) or is included therein (Fig. 12). In the latter case, the bone cut may follow the 2ygomatictemporal suture line. In our360 PLASTIC & RECONSTRUCTIVE suRGERY, April 1969 Tic. 11, Cephalograms of patient shown in Figure 10: preoperative, postoperative during intermaxilary fxation with ranfofacial suspension to pins in frontal bone, and after trea Fic, 12, Schematic of combined Le Fort 1 and Le Fort Il osteotomies for correcting an unequal degree of retrodisplacement of the lower and upper halves of the middlexhird of the face, Temporal process of ?ygoma included.Vol. 43, No. # / spvancina THE UPPER Jaw 361 Fic, 18. One-stage surgical conection, by combined Le Fort 1 and Le Fort IIT osteotomies, Jn a case in which the middle-hied of the face's upper and lower halves are Uneqally dis, placed backwards. In thls cae the lateral oxbital sina have been splie according 12 Teasers technique. (above, left) Bone cuts (above, right) Model operation, Belore gaps ase filed with done. (below) Technique of bone cus, including the lateral orbital rim and excluding the temporal process ofthe eygoma, Do opinion, this has the disadvantage, how- ever, that the masseter muscle will be pulled forward. In the lateral wall and floor of orbit the bone cut may run in front of che infra. orbital fissure or actoss it. To preserve the lacrimal system the bone cut may stop lateral to the lacrimal sac and lac- rrimal duct, or it may follow higher up and posterior to the sac, thus including the lacrimal canal and lacrimal sac in the section to be moved. The nasal septum is detached from the base of the skull in the Le Fort IT seas demonstate bone impiant osteotomy, and additionally from the palate in a supplementary Le Fort I pro- cedure. In performing a combined Le Fort III and Le Fort I osteotomy procedure it is best, according to our experience, to ad: vance first the whole middle-third of the face—as far forward as is necessary for esthetic reasons—and then do the Le Fort osteotomy for the required occlusal cor- rection. It is obvious that, for certainty of firm bony union, important spaces between the moved and stable parts of the facial362 PLASTIC & RECONSTRUCTIVE SURGERY, April 1969 ee, 1. (above) Pre- and postoperative views of patient corrected by method shown ia Figure 18. She sill needs @ shinoplasy. (below) Pre- and. postoperative cephalograms. skeleton must be filled with bone. Other defects can be left unfilled. Bony steps, resulting from the movement of skeletal parts, are contoured with pieces of bone. ‘There must be proper postoperative im. mobilization of the moved parts, the type being left to the surgeon. SUGGESTION OF OSTEOTOMY PROCEDURE It is no longer too difficult to repo- sition the maxilla through either a surgi- cal Le Fort I or Le Fort Il fracture. Tak- ing this into consideration, there is no reason why (although I have not done it yet mysclf) the Le Fort II type fracture should not be performed in cases where indicated. INCISION LINES ON THE SKIN ay THE MOUTH AND. Access to the bone may be gained by various types of skin incisions. For the supra-and lateral orbital rim, Tessier® *7 uses either an incision in the eyebrow, or a semicircular incision from one ear 0 the other across the top of the skull, (pulling the whole anterior half of scalp downwards). For access to the infraor- bital rim, he has used an incision in the eyelid, oF a high incision below the in: fraorbital rim in the skin lines. In the Le Fort III procedure, when the bone is cut lateral to the lacrimal canal, there is no need for a supplementary incision on the nose. However, when the Le Fort III procedure includes theVol. 43, No. 4 / spvancivo THe vePER Jaw 363 Fic, 15, Schematic of combined Le Fort IM and Le Fort 1 osteotomy, with simultaneous opening of the maxillary arch to correct an uneqtal degvee of retroisplacement of the Upper and lower hal ofthe middle third ofthe face. For diageamatie contrast the Bowe implantation along the osteotomy ste ie incomplete lacrimal sac and duct or the nasal bones, a supplementary incision on the nose is necessary. A vertical cut gives more access to the bone around the nose than a hori- zontal one. All of these cases require a vestibular incision, supplementary to the skin incisions. SUMMARY ‘There are many ways of dealing with retro. and micromaxillism. Various pro: cedures are discussed. The choice de- pends on the anatomical situation of the case. Maxillary onlay, epithelial inlay, and the various Le Fort fracture-opera- tions, and variations of them, are availa. ble. ‘Typical cases treated by the various classical procedures are demonstrated, in. cluding a combined Le Fort 1 and’ II fracture-operation for correction of un- equal retrodisplacement of the upper- half and lower-half of the middle-third of the facial skeleton, It has become almost routine to move any part of the lower-half of the facial skeleton in any desired direction (Ob- wegeser®%*), Recently, through the364 extraordinary work of Tessier, it seems possible to execute similar reposition: ings in the upper-half of the face. By em- ploying these concepts, a complete al- ‘eration of the human physiognomy now seems possible. Hugo L. Obwegeser, M.D., DMD. Zahnéiretliches Institut Universitat Ziirich Plattenstrasse 11, Postfach 8028 Ziivich, Switzerland Dr. Obwegeser is Profewsor and Head of the Department for Oral and Maxillofacial Surgery at the Dental Ineitate of the University of Zurich. ACKNOWLEDGMENT am most grateful to Dr. R. Shaye, asitant in the Department of Orthodontics (Head: Prof. Hou), Zusich ‘University Dental Institute, for his pet bp in ping his paper no prope Hal REFERENCES 1, Sehware, A. Mi Lehrgang der Gebisregulierung, Bd. 1 Urban & Schwarzenberg, Wlen-tnns. Druck, 1951. 2, Obwegeter, H. L: Der offene Biss in chirurgi chi Sich. Schweiz, Mschr, f. Zahnhellkde 742688, 1964 {8 Converse, J. ME, and Shapiro, H. Hs tn Kazane flan, V.IL, and Converse, J. Ms: The Surgical Treatment” of Facial Injuries, Williams & Wilkins Co, Maltimore, 1998 4. Schinid, Es Ueber neue Wege in der platschen Chirurgie der Nase. Bruns Belt Hin. Chir, 184: 385, 1952, 5. 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Puamo ano Reoonisonrs Soxcene al 1, Nout (Copp 6 Jou by The Wass € Wun Co, Priel nS