Detailed Report on Orthognathic Surgery for Maxillary

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Detailed Report on Orthognathic Surgery for Maxillary Prognathism (Protrusive Upper Jaw)

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1. Overview of Maxillary Prognathism

Maxillary prognathism (commonly referred to as “protrusive upper jaw” or “bimaxillary protrusion” when combined with mandibular retrusion) is a dentofacial deformity in which the maxilla grows excessively forward relative to the mandible, resulting in facial disharmony and malocclusion.

• Etiology: genetic predisposition, abnormal skeletal growth patterns, orofacial habits (thumb sucking, mouth breathing), or pathological conditions.
• Indications for surgery:
  • Skeletal-based maxillary protrusion unresponsive to orthodontic treatment alone.
  • Completed skeletal growth (females ≥16 years, males ≥18 years).
  • Severe malocclusion (open bite, crossbite, or deep bite).
  • Functional impairment in mastication, phonation, or breathing.
  • Significant facial aesthetic concerns.

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2. Preoperative Assessment and Preparation

2.1 Clinical and Diagnostic Work-up

• Clinical evaluation: facial symmetry, occlusion, temporomandibular joint (TMJ) function.
• Radiographic studies: lateral cephalometric analysis, panoramic radiograph, and cone-beam computed tomography (CBCT).
• Model analysis: dental impressions, digital scans, and virtual surgical planning (VSP).

2.2 Orthodontic Preparation

• Pre-surgical orthodontics (6–18 months): alignment and decompensation of dentition to ensure stable occlusion after repositioning of the jaws.

2.3 Systemic and Psychological Preparation

• Laboratory tests: complete blood count, coagulation profile, hepatic and renal function tests.
• Anesthesia evaluation: airway assessment, cardiopulmonary status.
• Psychological counseling: to set realistic expectations and obtain informed consent.

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3. Surgical Procedure

3.1 Anesthesia and Patient Positioning

• General anesthesia with nasotracheal intubation to allow intraoral surgical access.
• Patient positioned supine with slight head elevation.

3.2 Incision and Exposure

• Intraoral vestibular incision in the maxillary sulcus (no external scar).
• Subperiosteal dissection to expose the anterior maxillary wall, piriform aperture, and lateral maxillary buttresses.

3.3 Osteotomy (Le Fort I Osteotomy – Gold Standard Technique)

1. Horizontal osteotomy line: across the maxilla, above the apices of teeth, extending posteriorly to the pterygomaxillary junction.
2. Separation of the nasal septum and lateral nasal walls from the maxilla.
3. Down-fracture of the maxilla using controlled pressure.
4. Repositioning of the maxilla (posterior impaction, setback, rotation, or advancement) according to the surgical plan.
5. Fixation with titanium miniplates and screws for rigid stability.

3.4 Verification and Closure

• Occlusion checked using a surgical splint.
• Hemostasis achieved; closure with resorbable sutures.

Average operative time: 2–4 hours depending on complexity.

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4. Postoperative Care

• Immediate monitoring: airway, vital signs, bleeding, swelling.
• Medication: intravenous antibiotics, analgesics, corticosteroids to reduce edema.
• Dietary protocol:
  • Week 1: liquid diet.
  • Weeks 2–4: soft diet; gradual return to normal chewing.
• Oral hygiene: chlorhexidine mouth rinses, gentle brushing with soft brush.
• Elastics or intermaxillary fixation: may be required to guide occlusion.
• Follow-up: weekly during the first month, then monthly until orthodontic finishing.

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5. Potential Complications

• Early complications: hemorrhage, infection, swelling, paresthesia of infraorbital nerve.
• Late complications: relapse due to inadequate fixation, open bite, midline deviation, sinusitis, rare cases of avascular necrosis.

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6. Outcomes and Prognosis

• Aesthetic improvement: balanced facial profile, harmonious smile.
• Functional improvement: restoration of normal occlusion, mastication, speech, and airway function.
• Adjunctive orthodontics (6–12 months post-surgery): required for final occlusal finishing.
• Long-term stability is high when surgery is performed with proper planning and rigid fixation.

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7. Conclusion

Orthognathic surgery for maxillary prognathism, most commonly via Le Fort I osteotomy, is a complex but safe and effective procedure when performed in specialized maxillofacial surgery centers. It requires interdisciplinary collaboration between maxillofacial surgeons, orthodontists, and anesthesiologists. With proper case selection, preoperative planning, and postoperative management, the procedure yields significant improvements in both function and aesthetics.

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References (Authoritative Sources)

1. Bell WH, Proffit WR, White RP. Surgical Correction of Dentofacial Deformities. Philadelphia: Saunders; 1980.
2. Posnick JC. Orthognathic Surgery: Principles and Practice. Elsevier; 2014.
3. Proffit WR, White RP, Sarver DM. Contemporary Treatment of Dentofacial Deformity. St. Louis: Mosby; 2003.
4. American Association of Oral and Maxillofacial Surgeons (AAOMS). Clinical Practice Guidelines for Orthognathic Surgery. www.aaoms.org

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