專(zhuān)業(yè)英語(yǔ) Unit 27教案學(xué)習(xí)資料

UnitTwentySevenLeForteIosteotomyforcorrectionofmaxillarydeformitiesWilliamH.Bell,DDS,DallasCompletemobility,preservationofviability,andadequatefixationduringhealingisessentialtosurgicalrepositioningofthemaxillatoobtainastablerelationshipwiththemandible.LeForteIosteotomytechniqueswereusedtoconnectvariousdeformitiesofthemaxillain15adultpatients.In1927,MartinWassmundintroducedasurgicalprocedureformovingtheentiremaxilla.Theoperation,whichhassincebeencalledLeForteIosteotomyortotalmaxillaryosteotomy,wasfirstusedtocorrectananterioropenbite.Themaxillawasnotcompletelysectionedfromitsbonyattachments,andnoattemptwasmadetomobilizethemaxillaatthetimeofsurgery.Postoperatively,inermaillaryelastictractionwasusedtoclosetheopenbiteandstabilizethemaxilla.Inviewofthestateofartofanesthesiaatthetime,thelackofantibioticsandchemotherapeutics,andtheempiricalbasisformaxillarysurgery,thiswastrulyaremarkablefeat.Wassmund'sdirectapproachtothemaxillarydeformitywasclearlyyearsaheadofitstime.Thedesignofthebonyandsofttissueincisionshavebeencontinuallymodifiedtofacilitatemovementofthemaxillaandtomaintaincirculationtothemaxillaryboneandteeth.SchuchardtandKoledevisedatwo-stageproceduretopreventimpairmentofthevascularsupplytothemaxilla.Postoperatively,Schuchardtusedweightsfromanoverheadtractiondevicetorepositionthemaxillaforward.Thesecondstageofhistechniqueinvolvedseparationofthepterygoidprocessesfromthemaxillarytuberosities.Despitesuchmeasures,hebecamedisenchantedwiththeprocedureandconcludedthattheoperationshouldnotbeusedtotreatpatientswithclefts.Axhausenusedelastictractionaftersurgerytofacilitateanteriormovementandretentionofatraumaticallyretrodisplacedmaxilla.Inanapparentattempttocircumventtheseshortcomings,GilliesandConverseandShapiroadvocatedadvancingthemaxillabymeansofatransversepalatalcutofthe3unctionofthepalatineandmaxillarybone.Thesuccessofthisapproachwasnotcommentedon.Bonegraftinghasbeenadocatedtopromotebonyregenerationbetweenthebuccalbonecutsinthelateralportionsofthemaxilla.Obwegesermaintainedthatgraftingthespacebetweentheposteriormaxillaandthepterygoidplateswasessentialforstability.Inabilitytomovethemaxillathedesiredamountandrelapsewascommonfortheinnovatorsofthisoperation.Thesurgeon'sfearthatmobilizationofthemaxillawoulddevascularizeanddevitalizetheboneandteethwasthedominantreasonforsuchproblems.Thefearoftraumatizingvascularstructures,suchasthegreaterpalatineandinternalmaxillaryarteries,wasalsoamajorobjectiontothetechnique.Still,thebiologicbasisandsurgicalprinciplesformaxillaryosteotomiesremainedobscureandobviouslycontributedtopostoperativedevitalizationandlossofboneandteeth.Microangiographicandhistologicstudiesoftotalmaxillaryosteotomyperformedinadultrhesusmonkeysshowedonlytransientvascularischemia.Minimalosteonecrosis,andearlyosseousunionwhenthemaxillawaspedicledessentiallyonlytothepalatalmucosa.Preservationoftheintegrityofthegreaterpalatinearterieswasnotessentialtomaintaincirculationtothemaxilla.Figl-IncisionsofsontimeandboneforcorrectionofmaxillaryretrusionbyLeForteIosteotomytechnique.A:Typicaldental,facialandskeletalcharacteristicsofmandibularprognathismassociatedwithmaxillaryretrusion.B,C:Horizontalincisionthroughmucoperiosteuminthebuccolabialaspectofdepthofvestibule.Horizontalsupraapicalosteotomyoflabialmaxillaextendingfrompiriformrimposteriorlytopterygomaxillaryfissure.D:Separationofnasalseptumfromsuperiorpartofmaxillawithosteotome;posteriorlateralnasalwallsectionedwithosteotome.E:Separationofmaxillafrompterygoidplatewithcurvedosteotome;surgeon’sfingerispositionedbelowpalatalmucosatofeelosteotomeasittranssectsbone.F:Maxillain"downfractured"position.Mucoperiosteumhasbeendetachedandretractedawayfromentiresuperiorsurfaceofmaxillaandhorizontalplateofpalatinebone;Posteriormaxillaisseparatedfromthepterygoidplatesandperpendicularprocessofpalatinebonewithosteotomeandbur.G:Repositionedmaxillafixedtothepiriformrimsandzygomaticbuttresseswithtransosseouswires.Thecollateralcirculationwithinthemaxillaanditsenvelopingsofttissueandthenumerousvascularanastomosesintheanteriorandposteriorpartsofthemaxillapermitmanyvariationsofthetotalmaxillaryosteotomytechnique.Intraosseousandintrapulpalcirculationwasnotsignificantlyalteredbythebuccalsubapicalosteotomieswhenbonecutsweremadeawayfromtheapicesofteethandmaximalattachmentofthemucoperiosteumonthepalatalandbuccolabialgingivaofthemobilizedmaxillawaspreserved.Theseresultsgeneratedclinicalconfidenceinperformingtotalmaxillaryosteotomies.Thecurrentsurgicaltechniquewasmodifiedaftertheseanalogousinvestigationsinanimalsandpreviouslyreportedclinicaltechniques.■AnesthesiaTheoperationisperformedinthehospitalwiththepatientundergeneralanesthesiadeliveredviathenasoendotrachealroute.Successfullyadministeredhypotensiveanesthesiahasreducedbleedingandfacilitatedsurgicaldissection.Itisrarelynecessarytousetransfusions,althoughtwounitsofpackedcellsareroutinelyavailableforuseatthetimeofsurgeryiftheneedshouldarise.Reducedoperativeshocksanddecreasedpostoperativenausea,vomiting,andedemaisadditionaladvantagesofhypotensiveanesthesia.Becausesubmucosaloozingisdecreased,postoperativewoundhealingmayalsobeenhanced.Despitethesesignificantadvantages,theuseofhypotensiveanesthesiaisjustifiedonlywhenitenablesthesurgeontocarryouttheoperationbetterthanhecouldwithconventionalanesthetictechniques.Theadvantagestothepatientandsurgeonmustbeweighedagainsttheincreasedrisks.Thetechnicalskillandexperienceoftheanesthesiologistmustbeofahighorder.■SurgicalTechnique(Figl,A-G)Ahorizontalincisionismadethroughthebuccolabialmucoperiosteumabovethemucogingivaljunctionextendingfromone-secondmolarregiontotheother(Figl,B).Theincisionisplacedinthebuccolabialaspectofthedepthofthevestibule,atabouttheleveloftheapicesoftheteeth.Themarginsofthesuperiorflapareraisedtoexposetheentirelateralwallsofthemaxillazygomaticcrests,infraorbitalforamens,andthepiriformapertures.Theinferiormucoperiostealtissuesareminimallyelevatedsothattheyprovideadditionalvascularsupplytothemaxillaryboneandteeth.Goodvisualizationoftheposterolateralportionofthemaxillaisessentialandisaccomplishedbypositioningthetipofacurvedcheekretractorathepterygomaxillarysuture(Figl,B).Anothercheekretractorisplacedanteriorlytofacilitatevisualizationoftheanterolateralportionofthemaxilla.Directvisualizationandpalpationoftheboneencasingtheapicesoftheteethassessthelengthoftheteeth.Thesefindingsarecorrelatedwithmeasurementstakenfrompanoramicorlateralcephalometricradiographyorboth.Sothatahorizontallinecanbeetchedinthebone3to5mmabovetheapicesoftheteeth.Horizontalsupraapicalosteotomiesofthelateralportionsofthemaxillasaremadefromthelateralpartofthepiriformrimposteriorlyacrossthecaninefossaandthroughthezygomaticmaxillarycresttothepterygomaxillaryfissureusingafissureburinastraighthandpieceorahighspeedreciprocatingsaw.Insomecases,dependingontheexistingfacialdeformify,greateraugmentationofthemidfacialregionwillresultfromplacementoftheanteriorosteotomymoresuperiorly.Ideally,thesupraapicalbonecutsaremade3to4mmormoreabovetheapicesofthemaxillaryteeth.Themucoperiosteumiselevatedfromtheanteriorfloorofthenose,nasalseptum,andlateralwallsofthenasalcavitytofacilitateseparationofthemaxillafromthesestructures.Anasalseptalosteotomeispositionedabovetheanteriornasalspineparallelwiththehardpalateandmallettedtoseparatethenasalsepumfromthemaxilla(Figl,D).Theanteriorlaternasalwallissectionedtransantrallywithafissureburinastraighthandpiece.Theposteriorlateralnasalwallissectionedwithasharposteotomeabovethelevelofthenasalfloor.Inmanyinstances,however,thisboneismthinthatdoesnothavetobeosteotomized.Finally,sharppterygoidosteotomeismallettedintopterygomaxillarysuturetoseparatethemaxillaryfromthepterygoidplates(Figl,E).Digitalpressureonthepalatalmucosaintheregionthehamuluspermitsthesurgeontofeelosteotomeasittransectsthebonewithoutfrallmatizingtheunderlyingmucoperiosteum.Theosteotomeispositionedinferiorlytominimizedangertothevascularstructuresintheptetygomaxillaryfissure.Bymanipulationofthecurvedosteotomeandmanualpressureagainstthetuberosities,themaxillaismadepartiallymobile.Atthispoint,downwardmovementfracturesthemaxilla.Graduallyincreasingintopressureontheanteriorportionsofthemaxillafacilitatesvisualizationofthesuperiorsurfaceofthemaxillaandlateralnasalwalls(Figl,F).Themucoperiosteumiselevatedandretractedawayfromtheentiresuperiorsurfaceofthemaxilla,horizontalplateofthepalatinebone,andlateralnasalwalls.Transectionofthegreaterpalatinevesselsisofnopracticalconsequence.Digitalpressuregraduallycompletesfracturingofthemaxilla,withouttheuseofdisimpactionforceps.Thedownwardpositionofthemaxillaprovidesexcellentaccessforcompletelyseparatingthemaxillafromthepterygoidplatesandperpendicularprocessofthepalatinebone(Figl,F).Thiscanbeaccomplishedwithaburoranosteotome.Bycarefulmanipulationoftheosteotomeandforwardpressureagainstthetuberositiesandlowerpartofthemaxilla,themaxillaismadecompletelymobileandmovedintotheplannedposition.Themaxillamustbemadesomobilethatitcanbemovedwithonlylightdigitalpressureintothedesiredrelationshiptothemandible.Usingapreviouslypreparedinterocclusalsplintasanindex,themaxillaisimmobilized.forsixtoeightweekswithstainlesssteelwiresligatedbetweenpreviouslyplacedarchbarsororthodonticarchwires.Beforeplacingtheintermaxillaryfixation,anasogastrictubeisplacedinthenasalpassageoppositethesideofthenosethathasbeenintubatedinfacilitateevacuationofbloodfromthestomachandtopreventvomitingintheearlypostoperativeperiod.Thetube,whichisperiodicallyirriogated,isusuallyremovedwithin24hourswhentheaspirantofintermittentsuctionisclear.Themobilizedmaxillaisfixeddirectlytothepiriformrimsandzygomaticbuttresseswithtransosseouswireswheneverfeasible.When,however,theboneintheseareasistoothintosupportinterosseouswires,theuseofinfraorbifalrimorcircumzygomaticsuspensionwirestothemaxillaryfixationapplianceisnecessary.Inmanycasesitseemspreferabletousesuspensionwirestothemandibleforoptimumstabilization.Althoughbonegraftinghasbeenutilizedinthemajorityofpatients,itisnotroutinelyused.Indicationsfortheuseofbonegraftsaredeterminedfrompreoperativeclinicalandcephalometstudies,modelanalysis,andclinicaljudgment.Substantialadvancementorwideningofthemaxilla;augmentationofthenasolabial,molar,orinfraorbitalareas;increaseinverticalmidfacialheight;andresidualbonecleftsareindicationsforbonegrafting.Wedge-shapedcorticocancellousboneblocksareinlaidwiththecancellousbonefacingtheantrumsothattheywillnotdislodgeintotheantrumornasopharynx.Inmostcaseswheretheadvancementislessthan6mm,bonegraftsarenotusedinthepterygoid-maxillaryorlateralmaxillaryareas.Throughtheintraoralincisions,bonecanbeplacedoverthelateralandanteriormaxillainfraorbitalrim,andzygomaforrestorationofthecontouroftheseareas.Themucoperiostealincisionsareclosedwithinterruptedhorizontalmattresssutures.Ifanairwayproblemisanticipatedintheimmediatepostoperativeperiod,themobilizedmaxillamaybesuspendedbyverticallugsoreyeletspreviouslyincorporatedintotheacrylicwafersplint.Theimmediateneedforintermaxillaryfixationistherebyobviated.Themandibleisimmobilizedfourorfivedaysaftersurgerywhenthenasalpassagesarepatent.Theuseofnasopharyngealairwaysforoneortwodaysmayhelpmaintainpatencyofthenasalpassages,moldthenasalmucosaagainstthesuperiorsurfaceofthemaxilla,andobliteratedeadspacebeneaththenasalmucosa.Nasopharyngealairwaysmustbecarefullymonitored,changed,andcleanedfrequentlysothattheydonotbecomeobstructedwithbloodandmucus.Aftertheairwaysareremoved,thenasalpassagesaresprayedperiodicallywithoxymetazolinehydrochloridenasalspray.Threeorfourdaysaftersurgery,thenasalpassagesareclearedofinspissatedbloodclotsandmucuswithasmallaspiratingtip.Patientsareroutinelygivenantibioticsanddecongestantsforsevendayspostoperativelyoruntilsuch'timeasthesofttissueincisionshavehealed.Afterthemandibleismobilized,thesplintisremovedandseveralintermaxillaryelasticsarewornatnightonlyfortwoorthreeweeks.Thisregimeniscontinueduntiltherearesynchronousjawfunction,astableocclusion,andclinicalstabilityofthemaxilla.Fig2ModificationofLeforteIosteotomytechniqueforcorrectorofskeletal-typeanterioropenbiteortotalmaxillaryalveolarhyperplasia.A:Dentalandskeletalcharacteristicsofskeletaltypeanterioropenbitedeformity.Stippledareasindicateosteotomysites.B,C:Horizontalincisionthroughmucooperosteuminbuccolabialaspectofdepthofvestibule.Horizontalsupraapostecomyoflateramaxillaextendsfrompiriformrimposteriorlytopterygomaxillaryfissureamountofbonetobeecisedisdeterminefromsectionmodelsbeforesurgery.D,E:Medialantralwallsectioned3to4mmabovepalatalrootsandnasalfloorthroughbonywindowcreatedbybuccalostectomy.■ApplicationsofTechniqueWiththemaxillainthe"downfractured"position,manytechnicalmodificationsofmaxillaryosteotomiesarefeasible-themaxillaiseasilysectionedsagitally,transversely,orcircumpalatallytofacilitatesimultaneousmovementoftheanteriorandposteriormaxillarydento-alveolarsegments(Fig2-4).Simultaneousanteriorandposteriormaxillaryosteotomies,combinedwithextractionoffirstorsecondpremolars,canfrequentlyfacilitatecorrectionofsevereocclusalproblemswithassociatedbuccalorpalatalcrossbitesinasingleoperation.Theanteriorandposteriormaxillarydento-alveolarsegmentscanbemovedanteriorly,posteriorly,laterally,medially,superiorly,orinferiorlyintothedesiredposition.Severelyrotatedorcrowdedteethandlevelingofthelowerarch,however,areusuallybesttreatedbypreoperativeorpostoperativeorthodontics.Fig3A,B:Separationofnasalseptumfromsuperiorpartofmaxillawithosteotomeplacedparallelwithhardpalate.C,D:Posteriorlateralnasalwallsectionedwithosteotome.E:Separationofmaxillafromthepterygoidplatewithosteotome.Surgeen’sfingerispositionedbelowpalatalmucosatofeelosteotomeasittranssectsbone.Fig4–A:Maxillain“downfracture”position.Mucoperiosteumhasbeendetachedandrewactedawayfromsuperiorsurfaceofmaxillaandhorizaongtalplateofpalatinebone.B:Verticalostectomyinpremolarextractionsite.Digitalpressureisonpalatalmucosatofeelburwhenitsectionsthebone.C:Anteriorandposteriormaxillaryostectomiesandosteotomicsofmaxillawithdeeppalatalvault.Sagittalosteotomiesaremadethroughmaxillarysinusintooralcavityfromtuberosityanteriorlytoverticalostectomyinpremolarregion;verticalostectomiesareconnectedbytransversepalatalostectomy.Surgion’sfingerisplacedonpalatalmucosatoprotectvascularpedicleandtofeelburasittranssectspalatalbone.Horizongtalportionofpalateremainsattachedtopalatalmucosa.D:Sectioningofmaxillawithlowpalatalvault.Sagittalboneincisionsaremadeintonasalcavity;horizontalhorizontalportionofhardpalateremainspedtcledtopalatalmucosa.TableTreatmentsusedtocorrectdeformitiesofthemaxillain15patientsince1971.GatenoAgeRaceSexDentalFacialdeformityEtiologyMovementofmaxilla(mm)treatmentComplicationsFollow-up(month)116WMMRDevelopmentalAnterior,101,2,429221WFMAHDevelopmentalSuperior,713321WFMR,MPDevelopmentalAnterior,61,2,4,6,7Increasedwidthofmandibular29419WMMR,AOBCleftlipandPalateAnterior,91,2,3,4Unlateralwideningofnasalalarbase29544WMMRPosttraumaticAnterior,101,532632BFMRPosttraumaticAnterior,91,216720WFMAHDevelopmentalPosterior,41Superior,6Flatterningofupperlip5816WMMRCleftlipandPalateAnterior,12Lateral61Relapse15919BFBP,MAH,AOBDevelopmentalSuperior,101,661018WMMRCleftlipandpalateAnterior,131,281126WFMAHDevelopmentalPosterior,15Superior,71131225WFMAN,AOBDevelopmentalPosterior,41,3,4131323WFAOBIdiopathicSuperior,101,3,7Wideningofnasalalarbases;bucklingof5nasalseptum1420WMMRPosttraumaticAnterior,41,3,5,71417WFMAH,AOBDevelopmentalSuperior,61,3,4*KEY,AOB=AnterioropenbiteKey:l.TotalmaxillaryosteotomyMAH=Maxillaryalveolarhyperplasia2.BonegraftBP=Bimaxillaryprotrusion3.GenioplastyMR=Maxillaryretrusion4.OrthodonticsMP=Mandibularprognathism5.Contouraugmentationofmalateminenceandinfraorbitalrim6.Mandibularosteotomy7.Rhinoplasty■AnatomicalConsiderationsWhenanteriorandposteriormaxillarydento-alveolarsegmentsarerepositionedsimultaneously;specialattentionmustbegiventotheanatomyofthepalatalvaultandtherelativelengthofthepalatalroots.Thehighpalatalvaultassociatedwithmaxillaryalveolarhyperplasiaandskeletaltypeanterioropenbitefacilitatessectioningofthelateralportionofthemaxillathroughthemaxillarysinusintotheoralcavity(Pig4C).Theanteriorportionofthemaxillaismobilizedafterthelateralandverticalboneincisionsareconnectedbytransversepalatalostectomyorosteotomy.Theposteriormaxillarydento-alveolarsegmentscanthenbemovedanteriorly,posteriorly,laterally,orimpactedintothemaxillarysinuses.Theentiredento-alveolarportionofthemaxillacanalsoberepositionedwithoutextractionofTeeth.When,however,thepalatalvaultisshallowandthespacebetweenthepalatalrootsandthehorizontalportionofthepalateissmall,sagittalboneincisionsaremadedirectlyintothenasalcavity(Fig4D).Superiormovementoftheposteriormaxillarydentalalveolarsegmentsismadeattheexpenseofthenasalcavity.Incaseswhereexpansionofthelateralmaxillaisindicated,dualaccesstothebuccalandpalatalareasmayindeedbenecessarybecauseoftheinelasticpalatalmucosa.Sagittalorparasagittalreliefincisionsthroughthepalatalmucoperiosteumwillfacilitatelateralmovementofthemaxilla.Themarginsofsuchnapsareraisedminimallytomaximizethepalatalbone-softtissuepedicle.TheexcellentaccessibilityandvisibilityaffordedbytheLeForteI"downfracturing"techniqueforsimultaneousanteriorandposteriormaxillaryosteotomiesmustbeweighedagainstthedisadvantages.Bucklinganddisplacementofthenasalseptumarepossiblebecausethehorizontalportionofthehardpalate.Pedicledtopalatalmucosaismovableandseparatedfromthenasalseptum.Theseproblemscanbeobviatedwhenthesurgeryisexecutedfromthebuccalvestibulethroughthreeverticalincisionsandtheseptumandhorizontalpartofthepalatearemaintainedintact.Thesurgicaltreatmentplanmustbeflexible.Techniquesusingbothincisionshavebeenusedsuccessfullyandprovidethesurgeonmorelatitudeincorrectingmaxillarydeformitiesthanhasbeenpossiblewithpreviouslyreportedtechniques.■ResultsSince1971,theLeForteI"downfracturing"Techniquehasbeenusedtoadvance,retract,raise,narrow,orexpandthemaxillain15patients(Table).Complexdentofacialproblems(Fig5-7)suchasmaxillaryretrusion,skeletaltypeanterioropenbite,maxillaryasymmetry,bilateralbuccalorpalatalcrossbite,maxillarydento-alveolarprotrusion,andmaxillaryalveolarhyperplasiahavebeensuccessfullycorrected.Thesurgicalandorthodonticprinciplesusedintreatingthewdeformitiesareillustratedbythreecasereports(casenumberscorrespondwiththoseintheTable).CASEl-Figure5showshowmaxillaryretrusionassociatedwithmandibularprognathismina16year-oldboywascorrectedbymaxillaryadvancement(surgicaltechniqueillustratedinFigl)andorthodontictreatment.Awideningofthealarbasesofthenoseandadecreaseofthenasolabialangleproducedapronouncedimprovementofthepatient'soverallfacialbalance(Fig5B,D,F,G).Interocclusalharmonywaslikewiseattained(Fig5H-J).-Comment.Allobtusenasolabialangleisprobablythesinglemostimportantdiagnosticcriterionfortotalmaxillaryadvancement.Theupperlip-nosebalancecanbesignificantlyimprovedbyreductionofsuchanangle.Fig6-Case2.A,B,21-year-oldwomanwithshortupperlip,contour-deficientchin,narrownasalalarbeses,andlackofprominenceinmidfacialregionbeforetreatment(reposeposition).C,D:Improvedfacialbalance,wideningofnasalalarbases,andincreasedprominenceinzygomxaticomaxillaryandnasomaxillaryregionsaftermaxillarysurgery(techniqueshewninpartG).E:Preoperativecephalometrictracingshowinghighmandibularplane,7mmoverjet,andskeletal-typeClassⅡmalocclusionandunilateralpalatalcrossbite.G:Diagrammaticplanofmaxillarysurgery.Simultaneousanteriorandposteriormaxillaryosteotomiesinrepositionmaxillasuperiorlyandfacilitatemaxillomandibulararchalignment.H:Postoperativeocclusion.I:Compositecephalometrictracingsbefore(solidline-21year,3months)andthreemonthsaftersurgery(brokenline-21years,6months)showingautorotationofmandible,reductionofanteriorfacialheight,restorationofchincontour,improvedupperlipline-inciserrelationship,andfunctionaloverbiteandoverjet.Maxillaissuperimposedoveranteriorportionofmaxilla;mandibleissuperimprovedovermandible.(Dr.CraigWilliams,residentinoralsurgery,ParktandMemorialHospital,Dallas,wasresponsiblefortheprimarycareofthispatient.)CASE2-A21-year-oldwomansoughttreatmenttodecreasethe"prominence"ofhermaxillaryteethandtoimprovethecontourofherface(Fig6A-B).Clinicalandcephalometricanalysesdisclosedahighmandibularplaneangle,totalmaxillaryalveolarhyperplasia,ahighpalatalvault,shortupperlip,contour-deficientchin,andlackofprominenceinthemidfacialregion(Fig6A,B,E).HerClassnmalocclusionwasassociatedwithaunilateralpalatalcrossbite,constrictedmaxillarycanines,anda7mmoverjet(Fig6F).ThesurgicaltechniqueshowninFigures24wasusedtorepositionthemaxilliasuperiorly.Theanteriorportionofthemaxillawasraised7mmandtheposteriorportionwasraised9mmtoimprovetheupperlip-incisorrelationship,tofacilitateautorotationofthemandible,andtocorrecttheoverjet(Fig6G).Verticalostectomiesweremadeinthesecondpremolarregionstofacilitatecorrectionoftheunilateralcrossbiteandalignmentofthedentalarches.Bymovingtheposteriormaxillarydento-alveolarsegmentsforward6mm,theextractionspaceswereclosedwithoutretractionoftheanteriorpartofthemaxilla.Theanteriormaxillarysegmentwassectionedbetweenthecentralincisorstoincreasetheintercaninewidthandtoimprovethefirstpremolarrelationship.Facialharmonyandocclussalbalancewereattainedafterthreemonthsoftreatment(Fig6C,D,H,I).Arhinoplastyisplannedforthefuturetoreducethenasaldorsumandwidthofthealarbasesandtoraisethetipofthenose.-Comment.Inpatientswhodisplayanexcessiveamountofgingivaandteethinapositionofreposeorwhensmiling,eitherbecauseofashortupperlipormaxillaryalveolarhyperplasia,orboth,theentiremaxillaordento-alveolarportionofthemaxillacanberepositionedsuperiorlytoimprovetheupperlipline-to-incisorrelationship.Theconsequentautorotationofthemandibleisaneffectivemeansofincreasingchinprominence.Tofacilitatesuperiormovementofthemaxilla,themaxillarybasalspineisreducedunderdirectvision.Theanteriornasalfloorcanbegroovedtoaccommodatethecartilaginousseptum.Submucosalresectionofthecartilaginousseptumortubinectomy,orboth,mayindeedbenecessarywhenthemaxillaissuperiorlyrepositionedinexcessof10mm.CASE3-Figure7showshowmandibularprognathismassociatedwithretromaxillismina21-year-oldwomanwascorrectedbymaxillaryadvancement,mandibularbodyostectomies,andorthodontics.Abroadnose,hypoplastic-appearingmidfacialregion,andprominentchinwerethedominantfacialfeaturesofthepatient(Fig7A-B).Cephalometricstudiesshowedretroinclinationofthemaxillaryandmandibularanteriorteeth(Fig7E).ExaminationofherocclusiondisclosedaClassmmolarrelationshipwithposteriorteethillcompletecrossbite.Themaxillarylateralincisors,secondandthirdmolars,andmandibularfirstmolarswerecongenitallymissing.Theloweranteriordentitionwaspositionedapproximately12mmanteriortothemaxillarydentition.Therewere7mmspacesbetweentherightandleftmandibularfirstandsecondpremolars.Afterthemaxillaryandmandibularteethwerealignedandtherotationscorrectedwithedge-wiseorthodonticappliances,themaxillawasadvanced6mmandthemandiblewasretracted7mmsimultaneously.Overallfacialbalance(Fig7C-D)wasachievedfivemonthslaterbyrhinoplasty(nasalsurgerywasperformedbyDr.JackP.Gunter,Dallas).Fig7-Case3.A,B