A COMPREHENSIVE GUIDE TO ORTHOFACIAL SURGERY
PLANNING AND OPERATIVE TECHNIQUES
Maurice Y. Mommaerts
I have known Maurice Mommaerts for a long time. Our backgrounds and careers in some
ways were like mirror images of each other: he was well grounded in hard tissue maxillofacial techniques from his training with Hugo Obwegeser in Zurich, and came across
the Atlantic to learn from Ralph Millard, the master of plastic surgery of soft tissues. I had
travelled in the other direction after my training with Millard, to learn about hard tissues
from Paul Tessier, Olympic champion of orbitocranial surgery, with frequent visits to Hugo
Obwegeser and Jacques Dautrey to learn about surgery of the tooth-bearing structures.
I recall a visit to Miami years ago by my good friend Emil Steinhauser, Obwegeser’s first
trainee and then Chief of the Maxillofacial Service in Erlangen, who I had visited there
several times. Emil came to my operating room, and was watching over my shoulder as I did
some fairly extensive orbital alterations through a coronal approach, coupled with a facelift,
all for purely aesthetic goals. Emil said “You know Tony, I could never do that in Germany.”
This type of work — coupling major skeletal alterations with concomitant soft tissue alterations — can be called interface surgery, and is now carried out on both sides of the Atlantic
by plastic surgeons with training in craniofacial surgery, and maxillofacial surgeons with
training in soft tissue alterations. Both sides have learned from each other, and can agree
that adequate training is the one essential.
Paul Tessier was not altogether pleased with the commonly used descriptor of “Craniofacial
Surgery” for the surgical specialty that he had created, and even less happy with the term
“Craniomaxillofacial Surgery,” that some read as an attempt to extend the lebensraum of
a specialty. He liked the term orbitocranial, used above, and also orthomorphic. Orthoproposomorphic, while correct in the use of Greek roots, was just too much of a mouthful,
as Maurice points out.
In the picture shown below, taken at Dr. Tessier’s 70th birthday celebration in the Club de
Chasse in Paris, Dr. Tessier is shown holding a framed object. Next to him is Madame
Delegue, his pediatric anesthesist, then myself, then Hugo Obwegeser.
In the frame was a copy of a frontispiece
of a 1828 book by J. Delpech entitled
“L’Orthomorphie” which I had found in The New
York Academy of Medicine. Dr. Tessier was
delighted to find that the term had been around
for 150 years.
Dr. Mommaerts has chosen to call his book “A Comprehensive Guide to Orthofacial Surgery”,
providing one more attempt to find a proper term for interface surgery. He meticulously
documents his work in both the hard tissue and soft tissue areas.
For a plastic surgeon, the sections on use of the simulation lab and splint fabrication,
surgical simulation from 3-D CT images, as well as orthognathic surgery, will be useful to
read. For the maxillofacial surgeon, the descriptions of aesthetic procedures such as rhinoplasty, facelifting, Botox, fat injections and other fillers, and even hair transplants,
will be of interest. All of the chapters are well referenced from the respective literatures.
The surgical procedures are copiously documented with operative photographs, albeit
somewhat small in size. There were some drawings, and I felt myself looking for more.
Dr. Mommaerts has decided to separate his material in a new way: the description of the
techniques, and their indications comes in the first half, and the presentation of results
comes in a second half, entitled “Showcase,” with nicely documented results in larger
I will certainly want to have a copy of this book in my library, and I would expect that
many involved in both plastic and maxillofacial surgery will as well. Both specialties have
contributed to interface surgery, and both will continue to learn from each other.
S. Anthony Wolfe, M.D., F.A.C.S., F.A.A.P.
Chief, Division of Plastic Surgery
Miami Children’s Hospital
Miami, Florida, USA
Over a decade ago, I published my first textbook, Comprehensive Facial Rejuvenation, that
endeavored to cover the full gamut of facial cosmetic work as it relates to the aging face.
After reading Dr. Mommaerts’ magnum opus, I see how far more impressively he has
achieved his titular objective with seminal prowess. Unifying the fields of facial plastic
surgery and ortho-maxillo-facial surgery under the rubric “Orthofacial Surgery” in a single
edition by a single author is a paramount achievement that I believe will be instructive to
both the neophyte and the seasoned surgeon interested in the discipline.
Having met Maurice in my clinic 5 years ago, I never imagined that this humble, soft-spoken
man held the stature and renown that the rest of the world clearly acknowledges. My ignorance, which I hope he has since forgiven, stemmed from my limited acquaintance with the
pantheon of CMFS giants to which he undoubtedly belongs. During his visit to Dallas, he mentioned that he would invite me to Bruges the following year to speak. It was not until I arrived
in his lovely hometown to witness the grandeur of the EACMFS spectacle, which he helmed
as President, that I finally fell on the epiphany of his esteemed position. Holding this hefty
tome in my hands only further cements my profound respect for my friend and colleague.
Orthofacial surgery, or any cosmetic intervention for that matter, must be the product
of both artistry and technical delivery. This book compels the reader to understand the
primacy of both, without which aesthetic outcomes will fall far short of the intended mark.
The facial cosmetic and reconstructive surgeon must thoughtfully and passionately embrace the social, psychosocial, and cultural ramifications of his work, as the author rightfully exhorts. Viewing every patient in this comprehensive light should inform the diligent
surgeon’s strategy so as to engender life-changing and fulfilling transformations that can
beautifully touch the lives of both the surgeon and the patient.
As the author extols the mastery of art and science as the requisite underpinning of cosmetic surgery, no other organization represents this magical union better than Apple, Inc.
Its erstwhile visionary, Steve Jobs, concluded his affecting oratory to Stanford University in
2005 with this impassioned appeal, “You’ve got to find what you love. Your work is going
to fill a large part of your life, and the only way to be truly satisfied is to do great work.
And the only way to do great work is to love what you do. If you haven’t found it yet, keep
looking. Don’t settle.” This book is an arduous labor of love and a testament to a lifetime of
dedicated and passionate pursuit of excellence for his craft. Bravo, Maurice.
Sam Lam, MD, FACS
Facial Plastic Surgeon
Dallas, Texas, USA
AbbreviAtions for LidocAine AdministrAtion
XA3D: Lidocaine 3% with adrenaline (via short dental needle)
XA1W: Lidocaine 1% with adrenaline (via Whitacre spinal needle)
Lidocaine 2% without adrenaline (via short dental needle of 0.3 mm diameter)
Endoscopic transpalatal distraction
Why this book?
Surgical facial beauty
The Le Fort I osteotomy
The social psychology of
Sagittal split osteotomy
Endoscopic bilateral sagittal split
The work-up consultation for
Unilateral sagittal split
Planning of skeletal surgery —
cornerstones and principles
The power of rotation
Mandibular midline split for
posterior widening or narrowing
Flowchart planning for skeletal
Malar valgization osteotomy
Prediction of the facial profile
Determination of the centre of
Jaw angle reduction
Photoshopping the face
Nasal frame osteotomy
Simulation surgery and transfer
Further bony augmentation with
Simulation software in evolution
Transpalatal distraction — open sky
Rhinoplasty and Le Fort I osteotomy —
nasal to oral intubation
Botulinum toxin for frown lines and
On the use of injectable fillers
Upper lip augmentation with
Dealing with postoperative
discomfort and complications
Lower lip reduction
Materials, medical aspects, and
Face and neck lift
Anesthesia for facial surgeons
Posture and working
Prepping and draping,
Body dysmorphic disorder
The negative vector eye
Cosmetic lateral canthoplasty
Quality of life before and after
Brow lift, temporal lift, and forehead lift
Management of the
related to surgery
Earlobe reduction and reconstruction
Keying the occlusion
Injectable calcium phosphate
Hair restoration in and about the face
AcknoWLeDgments | 11
To my former coworkers in Bruges, I extend my deepest gratitude, with special thanks to
Walter Jacobs, in Herentals, and to the fine circle of referring physicians and orthodontists
who so readily entrust me with their patients.
Many thanks are likewise owed to all of the surgeon trainees with whom I have had the
privilege and pleasure of collaborating during the past 22 years. Teaching does not end
with mere instruction. Above all, it is a forum where relationships are forged; and in the
course of these relationships, I was steadfastly driven to uphold the very principles for
myself that I had laid out for others.
Much appreciation also goes to the European Association for Cranio-Maxillo-Facial Surgery, and to the many Fellows of this organization who frequented Bruges and Brussels,
contributing immeasurably to my understanding of managing facial deformity. I shall be
forever indebted to all of them (too numerous to name here) for their poignant scientific
challenges and their welcomed camaraderie.
My professional growth has always been graciously nurtured by my wife, Greetje, whose
kind understanding enabled many uninterrupted weeks at my desk, foregoing snowy
slopes or sunny beaches with my family. Warm hugs are likewise conveyed to my three
boys at home—Paul, Maurits and Karel—and my charming daughter, Anna, as a tribute to
their infinite patience and expressions of love.
Last but not least, by any means, I humbly offer my deepest praise to the countless
patients with various facial deformities and deficiencies who have sought my care. It has
been my honor to treat them over the past two decades, and it is to them that I dedicate
12 | Why this book?
WHY THIS BOOK?
Veni etinam, nolens volens.
[To this I came, keen or not.]
My interest in facial plastic surgery developed during my third year of dental school, when
I was 20 years old. As is common at the university, a student may be inspired by a charismatic teacher to enter a particular field. For me, it was the docent in head and neck cancer
surgery who influenced my pursuit of medical school. Permission was needed from both
camps (the Dean of the Medical Faculty and the Director of the Dental School) in order to
matriculate, but neither side felt that I should combine these studies. I persisted, nonetheless, and in retrospect, I am gratified by the path I chose, despite a considerable increment
(11½ years) in university training.
The very same docent, Eric Fossion, later on amazed me with his dexterity in the handling
of soft tissues, as did Hugo Obwegeser (my second mentor) with his command of craniomaxillo-facial skeletal surgery. Although my next mentor, Ralph Millard, Jr, may aptly be
described as a man of few words, he was quite clear on the matter of achieving perfection
in aesthetics. His Principilization of Plastic Surgery had a profound impact on my surgical
technique, and I continue to instill his spirit in my trainees and fellows.
Visits to plastic craniofacial surgeons Paul Tessier and Daniel Marchac, and to the facial
plastic surgeon Rudolph Meyer, were a must in the days of postspecialty preceptorships,
but these renowned surgeons failed to impress me. Perhaps I was at a point beyond blind
admiration. However, I must confess that recent visits with Sam Lam and Daniel Labbé did
succeed in resurrecting the “Aha!” feeling of my first day of training in Zurich. It was there
that I assisted the esteemed Milivoj “Vojo” Perko with a unilateral cleft lip repair.
After my 1990 appointment as staff maxillo-facial surgeon in Bruges, I was able to focus
on facial deformity and congenital craniofacial malformations. For 10 years, I combined
this forte with cancer surgery and engaged in other outlets for maxillo-facial surgery, such
as traumatic injuries, joint disorders, bone atrophy, cysts, and infections. Gradually, with
the appointment of new staff members, I was free to revisit my foremost passion of facial
corrective surgery—developmental, congenital, and age-related.
Ultimately, all of my efforts with surgical innovations, publications, and various workshops
(notably, the renowned “Lobster” course), including presiding over and organizing the
2010 Meeting of the European Association for Cranio-Maxillo-Facial Surgery in Bruges,
led me to the University of Brussels as Chair of the European Face Centre.
Why this book? | 13
Many surgeon trainees and fellows have expressed interest in a solid reference book for
orthognathic surgery. From my perspective, there are but a few on skeletal facial surgery
to recommend, although a plethora exists for soft tissue remodeling. This book is intended
for both areas, combining orthognathic and plastic maxillo-facial procedures. As early as
1996, I contemplated its writing, but I remained undecided on the vantage point—for the
author or for the reader? While Ralph Millard’s career was centered on his prolific writing,
Hugo Obwegeser released his first book in retirement. I have obviously chosen the seasoned route, allowing my skills and experience to appreciably mature.
In describing corrective surgery of the skull and the face, Paul Tessier favored the term
“orthoproposomorphic.” It literally means “making the shape of the face right” and while
difficult to pronounce, the word says it all.
Surgical corrections of the face typically are under siege, unless dignified by organic,
functional rationales. Interestingly, facial enhancements abound in all “primitive” cultures,
as social custom—for example scarifications, tattooing, skull deformations, neck lengthenings, and earlobe or lip extensions. Our Western culture has made arbitrary, mindboggling distinctions in this regard: piercing of the earlobe is normal, but tongue-piercing
smacks of rebellion; eyeliner, brow, and lip tattooing are reasonable, but small, artful
tattoos of the face are “just not done”; mandibular advancements, blepharoplasties, and
rhinoplasties are socially acceptable, but lip augmentations, face-lifts, and hair transplantations are shrouded in secrecy.
The media do play a part. Television programs, such as TLC’s “Ten Years Younger,” Fox’s
“The Swan,” and ABC’s “Extreme Makeover,” unquestionably have softened the stigma
and fear of facial surgery. When the German Society of Aesthetic Plastic Surgery boycotted a regional production of “Extreme Makeover,” the motivation very likely was self-interest, rather than public concern. I am convinced that none of the members would decline a
sound makeover request.
"Everything is in the face"
During my tenure as president of the European Association for Cranio-Maxillo-Facial Surgery, I helped found a Fellowship in Cosmetic and Plastic Facial Surgery program, thereby
promoting easier access to comprehensive specialty training and accredited orthofacial
programs for young physicians. I sincerely hope that this book will also be helpful to the
next generation of surgeons passionate about facial reconstruction.
DETERMINATION OF THE CENTRE OF MANDIBULAR AUTOROTATION | 93
D E T E R M I N AT I O N O F T H E C E N T R E O F M A N D I B U L A R AU T O RO TAT I O N
Le Fort I osteotomy with maxillary impaction—whether done posteriorly to effect closure
of an anterior dental open bite, or anteriorly and posteriorly to correct a gingival smile and
lip incompetence—inherently leads to autorotation of the mandible as the teeth seek to
make contact. This maneuver elevates the lower lip, augments chin projection, reduces
anterior facial height, and confers a horizontal mandibular plane. All of these changes
are usually positive, sometimes obviating the need for other surgery, such as mandibular
osteotomy, genioplasty, or submental liposuction.
By definition, mandibular autorotation involves changes in the vertical and horizontal
direction, and of the occlusal plane. If vertical repositioning of the maxilla dictates the
extent of autorotation, the mandible then dictates horizontal maxillary repositioning to
achieve proper occlusion. The surgeon must know beforehand whether the maxilla will
be set back or advanced, and gauge the magnitude of the change. Excessive setback can
result in a concave profile and necessitate bimaxillary surgery.
The center of autorotation (CAR) is not in the center of the condyle, per se, or even found in the
joint region. I hypothesized that mouth opening and overclosure would have the same center
of rotation, and Nasser Nadjmi conducted a study of this hypothesis as part of his training
program. CAR can be precisely ascertained using two profile cephalograms or a single dynamic
cone beam computed tomography examination. If the mandibular dental midline is off-center, a
unilateral or bilateral sagittal split of the mandible is needed and the CAR loses its significance.
TECHNIQUE (WITH CEPHALOGRAMS)
Two lateral cephalograms are taken preoperatively. One is for analysis of centricity and
uses a thin acrylic wafer (Unifast) fabricated on the spot for stabilization (Ceph 1).
1. Acrylic wafer fashioned “in
vivo,” after separating occlusal
interface with Vaseline; this
ensures correct dorsal condylar
positioning (centric relationship).
2. Second wafer constructed “in
vivo” over tongue spatulas; pressure at corners of mouth forces
dorsal positioning of condyles.
94 | DETERMINATION OF THE CENTRE OF MANDIBULAR AUTOROTATION
The lateral cephalogram is obtained at a jaw opening of 10 mm, stabilized by layering an
acrylic bite block (Unifast) over wooden tongue spatulas. The mandible is manipulated
into its most retruded position (Ceph 2).
The thin wafer and bite block are both fashioned with the patient relaxed, lying in a recumbent (horizontal) position. The patient is asked to curl the tip of the tongue into the
oropharynx while the surgeon or an assistant exerts gentle dorsal pressure on the mandible. The transversely placed tongue blades retract the corners of the mouth, forcing dorsal
positioning of the mandible.
CAR determination is done in four consecutive steps. Initially (step 1), the lower incisal
edge (Il1) and Gonion (Go1) are established as landmarks on Ceph 1.
3. Il1 and Go1 landmarks on Ceph 1.
4. Il2 and Go2 determined by
Il2 and Go2 are subsequently transferred from Ceph 2 to Ceph 1, aligning cranial base
outlines of the superimposed images (step 3).
5. Transfer of Il2 and Go2 to
Ceph 1 (cranial base outlines
Thus, four landmarks are delineated on Ceph 1: lower incisal edge and gonion, before and
after opening the jaw.
DETERMINATION OF THE CENTRE OF MANDIBULAR AUTOROTATION | 95
The CAR is ultimately mapped on Ceph 1 using the method of Rouleaux (step 4). Perpendicular bisectors are first determined by conventional means (with a compass). Points Ia
and Ib define the Il1/Il2 bisector (i.e., the line perpendicular to and bisecting the distance
from Il1 to Il2). Similarly, points Ga and Gb determine the Go1/Go2 bisector. The intersection of these bisectors (Il1/Il2 and Go1/Go2) is the CAR.
6. Rouleaux method: CAR at
intersection of bisectors (lines
connecting Ia to Ib and Ga to Gb).
The CAR usually is situated posterior and
cephalad to the condyle. Positioning the
CAR further anterior and caudad should be
reserved for a Sunday (dual) bite position
with the mouth closed. Because this has
skewed past results, we take the cephalogram for analysis of centricity with an
REFERENCES TO LITERATURE
Nadjmi N, Mommaerts MY, Abeloos JVS, De Clercq CAS. Prediction of mandibular autorotation.
J Craniomaxillofac Surg. 1998;56:1241-1247
Malar valgization osteotoMy | 223
M a l a r va l g i z at i o n o s t e o t o M y
European patients commonly present with long faces, exhibiting maxillary vertical excess with paranasal, infraorbital, and
malar hypoplasia. Such patients are good candidates for a malar
valgization osteotomy, in combination with surgical impaction
of the maxilla, and sometimes with rhinoplasty for functional
and/or aesthetic reasons. When lecturing in Asia and South
America, I have noticed that opposite features are often the impetus for facial contouring, namely broad faces with deep bite
and overly prominent malar and jaw angles. Many of my Dubai
and Gulf-Arab patients prefer Caucasian-style malars.
For centuries, high “Slavic” cheekbones, situated 1.5 cm below the lateral canthus, have
been a sign of beauty in Europe and North America. Malar hypoplasia is readily recognized by placing an index finger obliquely on this particular landmark.
1. “Index finger sign” of hypoplasia,
amenable to malar valgization
Female cheekbones extend to the level of the nasal base
(sometimes lower) and are more rounded than the chiseled,
higher cheekbones of males.
A malar valgization osteotomy will not address medial infraorbital hypoplasia, but this may be augmented using hydroxyapatite/fibrin glue cement during the same surgical session
(see Further Bony Augmentation, p. 239).
In 1992, I described a malar “sandwich” osteotomy with rotational augmentation (valgization) and for years I used a block of hydroxyapatite or calcium carbonate as the “filling.”
However, this was costly and carried a risk of sinus inflammation, so I substituted simple
titanium plate osteosynthesis, since relapse is not an issue. Like after a Le Fort I advancement osteotomy, the gap left will eventually also be bridged by bone generated from tented
periosteum. The plates usually have four holes, contain three screws, and must be positioned
obliquely, from a laterocranial medialcaudal location, to prevent sagging of the malar body.
It was surprising to hear that an experienced surgeon such as Federico Hernandez-Alfaro cited
relapse as the chief reason for switching to synthetic implants, because no study has conclusively proven this to be the case. However, many studies have shown initial asymmetry and
late displacement with synthetic implants, resulting in inflammation and eventual extrusion.
224 | Malar valgization osteotoMy
When not used in combination with a Le Fort I osteotomy, a separate 2.5 cm incision is made
in the upper buccal sulcus, running horizontally from the level of the alar base. Typically, malar
valgization osteotomy addresses a specific inaesthetic feature of a more complex midface
problem and the overall approach is already dictated by a Le Fort I osteotomy incision.
2. Cone beam computed tomography 6 years postoperatively:
no relapse after 5 mm valgization of zygoma in 45-year-old
female; no ossification of
vertical osteotomy but semihorizontal lines have ossified;
concurrent jaw angle augmentation (hydroxyapatite/fibrin
glue) perfectly maintained.
3. Elevation lateral to Le Fort I
osteosynthesis plate (medial to
4. Index finger at infraorbital
rim checks extent of vertical
The mucoperiosteum is elevated vertically
from the most medial part of the zygomatic buttress, staying lateral to the infraorbital foramen and ascending to the infraorbital rim. This maneuver is controlled by the
index finger of the opposing hand.
Dissection stops a few millimeters short of the rim, leaving the orbital septum intact to
prevent eyelid and conjunctival ecchymosis. An osteotomy done higher and semi-horizontally risks entry further back at the orbital floor and may cause fracture of the orbital rim.
Periosteal elevation continues, using a curved Freer in the innominate groove, typically
found between the infraorbital rim and malar body. Dissection is again guided by the index finger of the opposing hand, which is placed at the temporofrontal process transition.
(This notch was the entry point of a zygomatic suspension awl when zygoma suspension
was applied.) Although the zygomaticofacial nerve is regularly severed, no patients have
ever complained of numbness.
The third tunnel is made on the posterior wall of the maxilla, at the level of the anterior
vertical tunnel, aiming for but not reaching the infraorbital fissure.
Malar valgization osteotoMy | 225
5. Lateral elevation, aiming for
the transition between the
temporal and frontal process of
the zygomatic bone.
6. Subperiosteal dissection,
posterior to the zygomatic buttress.
A small Obwegeser-Sailer retractor is placed at the infraorbital rim and the curved Freer is
moved behind the zygoma. A reciprocal saw upwardly cuts both sinus walls. At this point,
the chief surgeon should check for proper osteotomy height.
The Obwegeser-Sailer is kept in place while the curved Freer is hooked behind the notch,
tenting the cheek tissues. The reciprocal saw is used here with caution, keeping it very
deep so that periosteum above it is protected. The saw first cuts the thick bone of the
posterior malar body before cutting the posterior and anterior walls medially.
7. Saw osteotomy.
8. Semi-horizontal cut with Freer
protection of cheek tissues.
If in doubt, saw height at the posterior wall can be gauged with another curved Freer. The
osteotomy is finished with an 8 mm sharp Obwegeser osteotome.
Mobilization of the zygoma can be done by rotating an 8 or 12 mm osteotome in the
vertical osteotomy or with Marchac bone-spreading forceps. I find that rotating an 8 mm
osteotome anteriorly in a semi-horizontal osteotomy works best.
9. Greenstick fracture at the
with a Marchac bone spreader.
10. Preferred method: downward
luxation with 8 mm osteotome
in semi-horizontal osteotomy.
226 | Malar valgization osteotoMy
With the first two options, infracture of the canine fossa is possible, and with the third,
outfracturing of the infraorbital rim is a risk. The latter complication should not occur,
given manual control of the rim; but if it does happen, it will heal without a defect.
This downward mobilization at the temporozygomatic suture is achieved in a more controlled way than with an outfracturing. The intent is to create a greenstick fracture in the
suture, which in older patients may well be full-blown. However, the periosteal envelope
is kept intact, so fracture-luxation will not happen. On the other hand, if the posterior osteotomy stops well in front of the notch, the malar bone may fracture too far to the front,
creating a cheek depression similar to that seen after traumatic fractures.
After the bony suture gives way, the osteotome is placed in the vertical gaps and the
malar body is pushed outward, with counterpressure by the opposite hand on the cheek.
Typical outward movement is 5-10 mm.
Due to pivoting at the suture, the malar bone is also repositioned anteriorly, achieving the
desired projection below the lateral canthus. The degree to which the projection is augmented is a matter of artistry. Simulation software has yet to provide previews. Slotplates (Mommaerts, 2002) may be used for testing the ideal position, keeping the malar body rotated
with an osteotome, after which the soft tissues are redraped and the eyes are uncovered.
A four hole meshplate is bent double.
11. When mobilized at temporozygomatic suture line, 8 mm
osteotome pushes malar body
outward (after repositioning
and plating of maxilla, to avoid
strain on the maxilla).
12. Quick bending of mesh plate
with set of pliers, creating two
A hole is made medial to the osteotomy, at a height at which soft tissue support is feasible. The plate is fixed loosely with a screw. Thereafter, the malar body is moved in proper
valgus position, and the hole lateral to the gap is drilled and screwed. The initial screw is
tightened. The plate should be positioned with two screws in the laterocranial direction to
resist masseter pull on the mobilized zygoma.
I usually opt for a plate accepting two medial bone screws. This prohibits rotation even
when the plate is in laterocaudal direction.
Malar valgization osteotoMy | 227
13. Two-screw fixation of meshplate (possible displacement
of malar body downward due
to masseter muscle).
14. Use of three screws (preferred); lateral screw prevents
palpable and visible prominence.
The sinus is carefully rinsed with saline solution. Closure done is with 4-0 Vicryl Rapide in
a single running layer.
Whether combined with a rhinoplasty or lateral osteotomies, execution of this procedure
does not differ. In conjunction with a Le Fort I osteotomy, the lateral plate of the maxillary osteosynthesis is shifted medially, but must still attach to bone that can take screws.
Mobilization of the zygoma is done very delicately, avoiding any pressure to medial bone.
If hydroxyapatite paste is applied infraorbitally, the gap is protected by a collagen fleece
(e.g., TissuDura), stabilized with a few drops of fibrin glue (Tissucol/Tisseel). The same
fleece protects the gap of the maxillary osteotomy.
RefeRences to pRoducts and mateRials
Meshplates and slotplates: surgi-tec and titamed
Marchac bone-spreading forceps: stryker-leibinger
obwegeser 8 mm osteotome: stryker-leibinger
tissuDura, tissucol/tisseel: Baxter Biosurgery
RefeRences to liteRatuRe
Mommaerts My. a novel osteosynthesis plate design for routine corrective facial surgery. J Craniofac Surg.
Mommaerts My, abeloos Jvs, De Clercq Cas, neyt lF. the “sandwich” zygomatic osteotomy: technique,
indications and results. J Craniomaxillofac Surg. 1995;23:12-19.
Bettens r, Mommaerts My, sykes J. aesthetic malar recontouring: the zygomatic sandwich osteotomy. Facial
Plast Surg Clin North Am. 2002;10:265-277.
JAw AngLE rEDuCtiOn | 233
J Aw A n g L E r E D u C t i O n
Prominence of the jaw angle is attributable to hypertrophy of the
masseter muscle, bony hypertrophy, or a combination of both. The
prominence is usually a consequence of bruxism (jaw clenching). The face appears square
in frontal view, whereas in lateral view, the gonial angle is hyperacute and dorsocaudally
developed. The condition is often asymmetric.
Correction of one or both factors may be achieved surgically. Muscle reduction is subject
to either surgical excision or injection of botulimum toxin type A. Bony reduction is accomplished by lateral corticotomy or posterior/inferior ostectomy (alone or in combination).
Surgical reduction of masseter hypertrophy
The technique was developed by Hugo Obwegeser and is described by Hermann Beckers
(1976). An incision is made over the external oblique line and is extended high into the
oral vestibule to expose the anterior belly of the masseter muscle.
1. Exposed anterior segment of
right masseter muscle.
2. Clamping of medial muscle
3. Artist’s impression, with
section at the insertion site.
234 | JAw AngLE rEDuCtiOn
One-half or two-thirds of the muscle’s inner aspect is separated with a blunt Freer elevator,
reserving the outer one-half or one-third to protect the facial nerve. The muscle is split
all the way to the posterior edge, from origin to insertion. The latter is clamped with long,
curved clamps and cut using the Colorado-tip cautery knife to sever clamped muscle fibers.
4. After resection: dry, empty
pocket with residual muscle
(one-third) overlying lateral
Fibrin glue is sprayed into the cavity and a
firm-compression head bandage is applied.
Lateral decortication of the mandible
Incision is similar to that used for a sagittal split, but dissection is limited to the lateral
surface. Two Obwegeser retractors for bilateral sagittal split osteotomy are inserted in
the same cavity, with handles crossed—one horizontally positioned, anchored behind the
posterior border; the other vertically oriented to constrain the inferior edge.
With a long Lindemann bur, monocortical cuts are made in a radial pattern approximately
1 cm apart. The upper ends of the cuts are joined for a sagittal corticotomy. Chisels are used
to separate outer from inner cortex and care is taken to remove spurs at the inferior border.
5.-7. Lateral decortication,
in drawing and in live!
Angle bicortical ostectomy
The approach is similar to that of lateral decortication, as above. An oscillating saw is
used to trim the posterior border, but a reciprocating saw is used inferiorly. One can
JAw AngLE rEDuCtiOn | 235
expect tedious tendon attachments. Subperiosteal dissection is difficult to complete, even
with an Obwegeser mandibular border raspatory at hand. Maintaining symmetry is also
difficult, but a three-dimensional (3D) fluoroscope (3D Pulsera) helps in this respect.
After marking the area, botulinum toxin type A (Botox 50-80 IU, 6 injections per site)
is delivered in a cross-hatched pattern. The treatment is repeated every 2 months until
results are pleasing. These injections of muscle are full-thickness. Patients usually return
after 1 year because the bruxism persists.
8.-10. Markings for botulimum
injections. The right side will
receive more than the left.
EMLA cream is applied.
RefeRences to pRoducts and mateRials
3D Pulsera: Philips Healthcare
Colorado needle tip cautery: Stryker
Freer elevator: Stryker-Leibinger
Obwegeser mandibular border raspatory: Stryker-Leibinger
RefeRences to liteRatuRe
Beckers H. Erfahrungen mit der Masseterreduktion von oral. Fortschr Kiefer Gesichtschir. 1976;21:66-69.
PrEPPInG AnD DrAPInG, no CLIPPInG | 443
PREPPING AND DRAPING, NO CLIPPING
By definition, surgical site infections (SSIs) are those where infection occurs within 30
days after a procedure. SSIs are classified by nature of incision (superficial or deep) or by
organ/space. A stitch abscess does not qualify as an SSI.
Pathogens responsible for SSIs are seeded by the skin and mucous membranes, so efforts
to create a sterile surgical field are mandatory and common-sense. However, a sterile field
may be unattainable with certain routes of surgical access (transoral and transnasal).
When access is purely transcutaneous, gram-positive cocci (e.g., staphylococci, streptococci) are frequently implicated in the SSIs that occur, whereas streptococci and bacteriodes (anaerobes) are characteristic of SSIs following orthofacial procedures (Spaey et
al, 2005). Pathogens refractory to antimicrobial treatment, namely methicillin-resistant
Staphylococcus aureus or Candida albicans, are increasing proportionately. Candida, especially, should not be overlooked in susceptible individuals (e.g., a patient with diabetes
Shaving of hair from operative sites is not truly necessary unless it is done to facilitate
surgery. Razor blades invariably inflict microscopic nicks and cuts of the skin, promoting
bacterial contamination. If hair is removed for any reason, the appropriate time is immediately before surgery, and it is preferably done with electric clippers, leaving a 1-2 mm
stubble (Jepsen and Bruttomesso, 1993; Nichols, 2001).
Although method and time of application may vary, both aqueous- and alcohol-based
preps are available that meet Food and Drug Administration criteria for surgery. Iodophors (e.g., povidone-iodine 7.5-10.0%), alcohol in solution (caution: flammable!), and
chlorhexidine gluconate (0.05-4.0%) are the most commonly used agents. Iodophors
and chlorhexidine gluconate have broad-spectrum antimicrobial activity (Mayhal, 1993),
but there have been no controlled studies in a surgical setting to adequately compare the
efficacies of these preparations.
The Association of periOperative Registered Nurses (AORN, 2012) and European Medical Devices Directive 93/42/EEC currently endorse both reusable cotton and nonwoven
disposable surgical drapes and gowns. Nevertheless, cost-effective disposables are the
444 | PrEPPInG AnD DrAPInG, no CLIPPInG
rule in healthcare today. The drawback is that these fabrics release particulate fibers
(lint) into the surgical environment as airborne contaminants. Lint settling on nonsterile
surfaces may ultimately be deposited on instruments or tissue, corrupting the surgical
field (notably, with Aspergillus fumigatus). Maintenance of ventilation systems in operative areas must therefore be fastidious, because the filters used, however expensive, are
quickly overcome by lint.
Drape penetration by fluids, known as “strikethrough,” also allows organisms access to the
surgical site. Multiple layers are preferred in the draping process for this reason.
Because skin cannot be completely sterilized, deployment of a transparent incise drape
encourages a sterile surface. Even so, such drapes are less effective and may unnecessarily complicate the procedure when dealing with orifices (mouth, ear, nose, and navel) or
regions of skin (such as scalp) where they do not adhere.
On the other hand, the adhesive on some drapes performs so well that upon removal,
cutaneous layers are unavoidably stripped away, exposing the patient to microbes; and
removal of drapes is done frequently (up to five times per surgery) to monitor results.
Hence, surgical patients are often self-infected (with staphylococci) and not surprisingly,
suffer forehead or facial folliculitis. Some even experience hypersensitivity and develop
eczema postoperatively. The adhesive has a particular affinity for intubation lines.
It is of utmost importance that the eyes of patients are protected from irritants, such as
alcohol, which is used in dilute solution during keratotomy for epithelial debridement.
When the eyes are not the object of surgery, they should be lubricated and covered with
an adhesive pad. An oval cut from a disposable laminate drape (this being superior to
transparent polyurethane material) provides a reasonable mechanical barrier to errant
objects (e.g., a falling scalpel).
1.-3. Creating sterile eye covers
from disposable laminate drape.
Disinfection prior to surgery requires an aqueous solution. Povidone-iodine inactivates
fibrin glue and is itself inactivated by contact with blood and serum proteins (Mayhall,
1993). It is also incompatible with chlorhexidine. Given that alcohol-based disinfectants
PrEPPInG AnD DrAPInG, no CLIPPInG | 445
are noxious to the eyes, nose, and mouth, 0.05% aqueous chlorhexidine is the first choice
to prep for orthofacial surgery. A chlorhexidine-type (hexetidine) mouth rinse may be
used for oral disinfection. Hours spent over a malodorous oral cavity may otherwise be
When surgery is limited to hair or skin, and fibrin glue is not needed, povidone-iodine
7.5% shampoo and 10% solution are satisfactory disinfectants. Likewise, a 5-10% hydroalcoholic solution (iso-Betadine) is an acceptable prep for the abdomen and extremities,
with due caution when using cautery. Of note, light-colored clothing is easily stained by
TECHNIQUE OF PREPPING AND DRAPING
Surgery under general anesthesia
4. Face is disinfected twice and
5. 3M adhesive drape covering
body up to clavicles.
6. Head drape placed deep under
neck with assistance from
A drape is placed deep under the neck while the anesthesiologist elevates the patient’s head.
7. Endotracheal tube clamped
to disposable drape, providing
lift that relieves pressure on
8. One laminate drape covers
headrest; another tightly wraps
endotracheal tube and foam
support (at forehead-level).
9. and 10. Split-sheet laminate
drape covering ear (not neck);
drape does not adhere to oral
intubation line, enabling free
A split-sheet laminate drape covers the ear, but not the neck.
446 | PrEPPInG AnD DrAPInG, no CLIPPInG
11. Face is dried and oval “eyes”
(cut from laminate drape) are
placed for protection.
12. Small-sized laminate drape
(with side adhesive) covers
tube or forehead as needed.
13. 3M XL adhesive drape applied
to body (left side) with enclosure of anesthesia station.
14. Connecting cables and tubes
for coagulation (mono- and
bipolar), “cold light” operating
lamp, and suction.
Surgery under local anesthesia, with or without IV sedation
For limited surgeries performed under local anesthesia, the patient may remain dressed.
The body (trunk and extremities) is covered with a surgical gown or a laminate drape.
15. Draping for limited facial
surgery: Op-Tape barrier (two
halves) secures laminate drape
to lateral face.
The head is also wrapped, covering the ears and shoulders
laterally. The laminate sheet is secured with two halves of
adhesive Op-Tape barrier. This manner of taping prevents blood
from trickling into the hair and ears, but it should not distort
RefeRences to pRoducts and mateRials
3M XL adhesive drape, 150 × 175 cm: Mölnlycke (reference no. 777400)
3M adhesive drape, 175 × 300 cm: Mölnlycke (reference no. 778200)
Head drape 104 × 128 with turban wrap: Mölnlycke (reference no. 826900)
Hexitidine solution: Hextril, Pfizer Pharma
Split-sheet 146 × 196, split 76 cm: Mölnlycke (reference no. 206)
PrEPPInG AnD DrAPInG, no CLIPPInG | 447
A prepared set for head and neck surgery may contain the following items:
- Surgical gown
- 1 table cover 150 × 190 cm: Mölnlycke (reference no. 808000)
- 25 standard gauze abdominal swab 30 × 45 cm: Mölnlycke (reference no. 175260)
- 10 Gauze swab 5 × 5 cm: vernon Carus (reference no. 48735)
- 1 syringe bulb, 50 ml, 3 parts: tyco Healthcare (reference no. 1100-56500)
- 1 syringe, 5 ml, 3 parts l/l conc: Becton-Dickinson (reference no. 309603)
- 1 skin marker regular green with ruler: tyco Healthcare (reference no. 3114592)
- Adhesive op-tape Barrier 9 × 49 cm: Mölnlycke (reference no. 381030)
- Adhesive towel Barrier 75 × 75 cm: Mölnlycke (reference no. 706500)
- 1 syringe, 20 ml, 3 parts l/l conc: Bekton-Dickinson (reference no. 300629)
- 1 needle, green hypodermic, 21G × 50 mm: B. Braun Medical (reference no. 4665503)
- 3 blade scalpel no. 15: Swann-Morton (reference no. 205)
- 2 kidney bowls 700 ml: Deroyal Europe (reference no. 395-0700)
- 2 adhesive towels, 75 × 75 cm: Mölnlycke (reference no. 706500)
- 1 suction tube, PvC, 30 ch, 300 cm: Dahlhausen (reference no. 99.068.30.3)
- 1 suction catheter, soft PvC, 8 ch, 52 cm: B. Braun Medical (reference no. 4302087)
RefeRences to liteRatuRe
Conner r, Blanchard J, Burliname B, Denholm B, Giarrizzo S, ogg M, van Wicklin SA. Perioperative Standards
and Recommened Practices. Aornstandards.org; 2012.
Jepsen oB, Bruttomesso kA. the effectiveness of preoperative skin preparations: an integrative review of the
literature. AORN J. 1993;58:477-484.
Manz E, Gardner D, Millard M. Clipping, Prepping and Draping for Surgical Procedures; 2007
Mayhall CG. Surgical infections including burns. In: Wenzel rP, ed. Prevention and Control of Nosocomial Infections.
2nd ed. Baltimore: Williams & Wilkins; 1993:614-664.
nichols rL. Preventing Surgical Site Infections: A Surgeon’s Perspective. Emerg Infect Disease. 2001;7:220-224.
Pasqualotto AC, Denning DW. Postoperative aspergillosis. Clin Microbiol Infect. 2006;12:1060-1076.
Spaey YJE, Bettens rMA, Mommaerts MY, Adriaens J, van Landuyt Hv, Abeloos JvS, De Clercq CAS, Lamoral
PrB, neyt LF. A prospective study of infectious complications in orthognathic surgery. J Craniomaxillofac Surg.
Mangram AJ, Horan tC, Pearson ML, Silver LC, Jarvis Wr, the Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:247-278. (http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf)
nagy k, Mommaerts MY, Ignác Semmelweis, the rescuer of mothers. AJCS. 2008;25:73-77.
Keying the occlusion | 459
KEYING THE OCCLUSION
The art of applying proper intermaxillary fixation (IMF) may have spawned the specialties of maxillofacial and plastic surgery. Charles Auguste Valadier, a United States citizen
of French descent, aided British troops in France during World War I. Using a Rolls-Royce
equipped as a mobile dental laboratory, Valadier was able to repair the broken jaws of
soldiers through IMF.
Harold Delf Gillies of New Zealand, an ENT surgeon lauded as the father of European
plastic surgery, was appointed to Valadier’s hospital in Wimereux. While there, Gillies
immersed himself in the repair of facial injuries and was determined to become a facial
plastic surgeon (McAuley, 1974).
Varaztad Kazanjian, initially as a dental technician, then dentist, and later as a medical
doctor, treated the broken jaws of American soldiers and pioneered plastic surgery in the
United States. Collaborating with John Marquis Converse, another luminary in plastic surgery, Kazanjian coauthored the 1920 landmark textbook Plastic Surgery of the Face, paying
homage to Valadier’s work.
The specialty text guiding my co-internship in general surgery was The Surgical Treatment
of Facial Injuries by Kazanjian and Converse (1974). At that time, surgical reconstruction
(mobilization, reduction, and wire osteosynthesis) had already gained in popularity, but
IMF was still the counterstone of treating facial fractures.
IMF is always used when occlusion is surgically altered. The array of currently used techniques is described in a workbook offered by the European Association for Cranio-MaxilloFacial Surgery (EACMFS): Intermaxillary Fixation Techniques (2010). As a joint effort by
myself, Julio Acero, and Jose Arcas Lopez, this publication is freely available online in PDF
format: www.mauricemommaerts.eu, go to “publications”, make yourself a log-in and go to
“general cranio-maxillo-facial surgery.” There pick “2010 Intermaxillary fixation techniques”.
The file used to be on www.EACMFS2010.org and on www.eurofaces.com. The first site
was replaced and the file was removed from the second.
For all orthognathic surgeries, custom archbars make a good lifeboat.
460 | Keying the occlusion
1. and 2. Standard fracture
archbars come in hard and soft
I always have these at hand in case fixation via orthodontic brackets fails. Custom archbars of a heavier build (casted chrome-cobalt) are essential for segmental osteotomies,
although they are not comfortable for the patient.
Transpalatal bars of the Goshgarian type help maintain overcorrection in Le Fort I midline
splits with expansion if the orthodontist has selected lingual sheets on molar bands. Sizes
vary and can be adapted through surgical modeling. The bars are fixed to lingual sheets
using 0.3 mm ligature wire.
When twisting a wire, it is critical to tighten clockwise. Failing to do so leads to considerable frustration due to wire breakage and lost time.
Elastomeric ligature modules
For many applications, small elastomeric ligature modules (e.g., Sanitie) have replaced
wire in securing the arch wires in brackets. These modules are installed with a twirl–on
instrument or a mosquito.
3. and 4. Elastomeric module
applied with hemostat.
Kobayashi tie hooks
Kobayashi tie hooks are available in long and short versions of .010, .012, and .014 wire.
Although orthodontists often opt for the comfort of .012 “Koba’s,” the short .014 version is
actually the best choice.
Keying the occlusion | 461
5. Hook on bracket, Kobayashi tie
hook, and power pin (all in one
6. Kobayashi tie (gently bent at
neck) slipped horizontally over
7. Twisted tie with loop directed
8. and 9. Crimpable hook.
A crimpable hook is mounted on the arch wire between two adjacent brackets prior or
subsequent to placement of the arch wire in brackets. If mounted prior to placement, a
closed hook is used; if mounted subsequent to placement, a peripherally split hook is
used. Both options allow appropriate positioning of the hook along the arch wire, and
there is no laboratory time involved. The surgeon can easily apply the surgical hook to the arch wire as needed. The
crimpable hook, as designed for surgical patients, has a
rectangular body with four interconnected walls that enable use of a rectangular wire.
462 | Keying the occlusion
A standard pair of wire cutters or other crimping device is used to secure the gingival and
occlusal sides of the tubular member onto the arch wire. This appliance incorporates an
elongated bar/arm with a ball–shaped free end for patient comfort, eliminating a sharp
point that could snag a surgeon’s glove.
The major disadvantage of crimpable hooks is that the excessive force required for
fastening may result in distortion or gabling of the arch wire or introduce unwanted wire
tension. If distortion of the arch wire occurs after impressions are made and the splint is
constructed (during surgical modeling), the teeth may not fit into the splint at the time of
surgery due to positional disparity. This point underscores the need for integrating timing
and techniques in combined surgical–orthodontic treatments.
All currently manufactured crimpable or collapsible hooks and/or stops suffer from lack
of adequate friction, tending to slide along the wire even when forcibly crimped. Arch wire
hooks that slide when loaded during IMF are a source of frustration for surgeons, although
they remain functional.
The sliding is generally limited to interbracket distance. On the other hand, hooks that
spin about the arch wire are functionally inadequate. The superior performance of coated
hooks is conferred by a hard, abrasive tungsten carbide finish that generates significant
friction when forcibly challenged. Once in place, they resist sliding and twisting around the
softer stainless steel arch wires.
Power pins (arms)
10. and 11. Power pin.
A power pin is a traction hook that can be fitted in the bracket’s vertical slot. Fashioned
from soft stainless steel, it will normally insert from the gingival aspect and be fastened
in-slot by a 90-degree bend in the occlusally projecting tail. The bend should be directed
opposite to elastic pull. This will discourage a loosely
turned pin from rotating 180 degrees and being ripped
from its mooring by elastic.
In side view, it is evident that the head
of the power pin is angled relative to
the shaft. The pin should therefore be
inserted with the head inclined away
from rather than toward the tooth or
gingival margin. Once fitted, the power
pin can be left in place for as long as
Keying the occlusion | 463
necessary; it does not interfere with arch checks. The power pin is easily removed by
straightening its tail to be clipped by ligature cutters.
Buttons are ideal on buccal surfaces when lingual orthodontics are in place and surgery is
indicated, and on palatal surfaces for cross–elastics. Metallic buttons are glued to dental
enamel by first applying a self–etching primer (Transbond plus) for 3–4 seconds and using an adhesive paste (Transbond XT) that sets in 6 seconds under luminous curing light
(Ortholux). Drying and rinsing are not required, facilitating application during surgery.
12. Buttons are a useful option with
lingual orthodontics when orthognathic surgery anticipated.
13. Metallic buttons (upper arch),
power pins, and hooks on
brackets (lower arch).
For an inexpensive and aesthetically pleasing solution in equivalent time, composite
buttons (Mini–Mold) may be shaped in a number of ways from a transparent mold. The
appliances are light–cured firmly in place.
14. Transbond plus primer with
applicator and mixing device.
15. Transbond XT paste injection
into rubber mold.
16. Utensil tip applying acid and
primer (3 seconds).
17. Transbond XT (pink) turns
tooth-colored when cured
under Ortholux light.
18. Handle removed from rubber
19. Rubber mold removed and button in place.
20.Mini-Molds as an unobtrusive
means to apply postoperative
rubber bands, in absence of
conventional buccal brackets.
464 | Keying the occlusion
Applying the intermaxillary loops
The wafer (splint) is adjusted the evening before surgery. Any premature contacts or
interference points (as indicated by surgical model) are removed using a green silicium
21. Green silicium carbide bur to
eliminate premature contacts.
22. IMF instrumentation and wafer.
After a type of hook is selected, loops are applied over a
wafer with soft stainless steel 0.4 mm wire (Remanit) using Obwegeser wire twisters (2) and Luniatschek tools (2).
A 0.5 mm wire wire supports the mandible in advancements.
23. In mandibular advancement:
0.5 mm loop inserted behind
canine teeth and under orthodontic arch bar.
24. Wire (0.5 mm) twisted and cut
25. Loop grasped by Obwegeser
wire twister in effort to guide
26. Maxillary advancement into
occlusion: orthodontic brackets
should withstand pull of strong
surgical tweezers (archbar
27. Luniatschek wire director in
use, conveniently guiding loop
Twisting of loops is done swiftly by rotating the wire twister around the ring finger. Through experience, one learns to judge whether the degree of twisting is sufficient. Placing an index finger
on the loop (with fingernail directed at the breakpoint) will indeed cause the wire to break where
intended. The difference in wire temperature while under fixation creates a weak spot.
Keying the occlusion | 465
28. -33. Twisting and cutting IMF
With the use of Mini-Molds, fixation is via dental floss or Vicryl sutures. Metallic wire may
loosen the brackets.
34. Two-piece Le Fort I osteotomy
stabilized with Mini-Mold
(composite arch bar between
two molds) and Vicryl suture
as means of IMF.
Infraorbital, supraorbital, and zygoma suspensions are no longer in use, and certainly not
for orthognathic surgery. Occasionally, however, a piriform aperture suspension is useful for
sandwiching the maxilla between the mandible and the rest of the skull. Rigid IMF (preoperatively) and elastic IMF (postoperatively) keep open bites closed, without extrusion of
35. and 36. A piriform aperture
suspension wire, fixed above
the Le Fort I osteotomy line
through a small hole in the
bone; the wire pierces the
incision wound and suspends
the mandible while sandwiching the maxilla (complex
facial rotation in hemifacial
466 | Keying the occlusion
Protection of lips and wounds from the pins and hooks
Utility wax or orthodontic wax in small bits or as a short strip are pressed onto the
brackets and hooks. Patients are instructed on proper care after each meal and with tooth
brushing. Gishy Goo, a two-component silicone available as an alternative to wax, is more
durable but costs more.
37. and 38. Orthodontic wax and
Gishy Goo silicone compound
for covering hooks, pins, and
ligatures, to protect oral
mucosa (cheek and lip).
39. Intramaxillary fixation of
2-piece Le Fort I osteotomy
with self-curing acrylic (Unifast).
RefeRences to pRoducts and mateRials
gishy goo: opal orthodontics
green siliciumcarbide bur: Komet gebr. Brasseler
Kieferbruchschiene hart/Weich: scheu Dental gmbh
Kobayashi tie hook: ortho organizers, tP orthodontics
luniatschek gauze and wire director: stryker
Mini–Mold: g&h Wire company
obwegeser wire twister with tungsten carbide inserts: stryker
orthodontic wax: Vitis, Dentaid sl
ortholux: 3M unitek
Remanit soft-weich: Remanium, Dentaurum
transbond plus: 3M unitek
transbond Xt: 3M unitek
tungsten carbide coated crimpable hooks: tP orthodontics
RefeRences to liteRatuRe
Kanzanjian Vh, converse JM. The Surgical Treatment of Facial Injuries. 3d ed. Baltimore: Williams and Wilkins; 1974.
McAuley Je. charles Valadier: a forgotten pioneer in the treatment of jaw injuries. Proc R Soc Med. 1974;67:785-789.