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 Table of Contents  
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 89-91

Lefort I osteotomy in combination with modified Wassmund technique: A new combination for surgery- first orthognathic approach

Department of Dental Surgery Oral Health Sciences, Division of Oral and Maxillofacial Surgery, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission15-Mar-2020
Date of Acceptance20-May-2020
Date of Web Publication15-Jul-2020

Correspondence Address:
Abhishek Mishra
Department of Dental Surgery Oral Health Sciences, Division of Oral and Maxillofacial Surgery, Armed Forces Medical College, Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JODD.JODD_13_20

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Objective: The aim of this technical note is to present a unique combination of orthognathic surgery which incorporates Wassmund technique and Lefort I osteotomy a part of surgery- first orthognathic approach (SFOA) in prognathic maxilla.
Methods: Usually, the SFOA indications are minimally involved skeletal discrepancy and most often procedure is bilateral sagittal split ramus osteotomy (BSSRO) for setback or Lefort I osteotomy with superior repositioning. The current report illustrated SFOA in case of gummy smiling with maxillary anteroposterior excess. We have used Lefort I osteotomy in conjunction with Wassmund procedure (incorporating our own modification) for setback of premaxilla in SFOA.
Results: The gummy smile was reduced from 9 mm to 3 mm with excellent occlusion in one surgery with improved psychological benefit to the patient.
Conclusion: In contrast to the limited skeletal abnormality as an indication of SFOA, the current report presentation reveals a unique technique for dealing with a large skeletal discrepancy with the combination of Lefort I osteotomy and Wassmund technique. A growing acceptance in surgical and orthodontic communities toward SFOA lead an increasing demand in the patients with wide range of skeletal deformity correction in a short period of time. The surgeons should not restrict his horizon to BSSRO or Lefort I osteotomy in SFOA. The comprehensive knowledge of different surgical technique can widened the extent of SFOA.

Keywords: Lefort I, surgery- first orthognathic approach, Wassmund

How to cite this article:
Bhandari S K, Issar Y, N Babu B K, Mishra A. Lefort I osteotomy in combination with modified Wassmund technique: A new combination for surgery- first orthognathic approach. J Dent Def Sect. 2020;14:89-91

How to cite this URL:
Bhandari S K, Issar Y, N Babu B K, Mishra A. Lefort I osteotomy in combination with modified Wassmund technique: A new combination for surgery- first orthognathic approach. J Dent Def Sect. [serial online] 2020 [cited 2022 Jan 25];14:89-91. Available from: http://www.journaldds.org/text.asp?2020/14/2/89/289744

  Introduction Top

Expectations of rapid treatment outcome and high esthetic demands are obvious among young patients. This need of early esthetic result gives the birth to the new era of concept known as “surgery- first orthognathic approach” (SFOA).[1] A well known procedure which reduce total duration of treatment due to incorporation of surgery, before the orthodontic correction. Most commonly selected cases for SFOA are class III malocclusion with minimal crowding, flat to moderate curve of spee.[2] Prognathic premaxilla with class II skeletal pattern has never been documented for SFOA. The present case is an exceptional successful attempt of SFOA in such a case.


A 23-year-old female patient reported to for the correction of gummy smile [Figure 1]. The evaluation reveals the following significant findings:
Figure 1: Preoperative photograph

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  1. Cephalometrics for orthognathic surgery revealed prognathic maxilla (N-A [II HP] =5 mm) with increased lower facial height (ANS-Gn [I HP] =73 mm)
  2. Gingival exposure of 09 mm on smile with noncompetent lip at repose.
  3. Upper incisor-to-NA angle 35°
  4. Upper incisor-to-NA linear 10 mm.

The patient has specific demand of short duration of treatment due to her personal reasons. Commiserating all skeletal, dental pattern, and normal curve of spee, with absence of transverse discrepancy, it was decided to prescribe SFOA as a treatment option. The technique was discussed elaborately with combine orthosurgical team which resulted in prescription of Lefort I osteotomy with superior repositioning of 6 mm, followed by intraoperative bilateral upper 1st premolar extraction with modification of Wassmund procedure for setback of maxillary anterior segment. Modifications done in Wassmund procedure which was performed in conjunction with Lefort I osteotomy [Figure 2] and [Figure 3] were as follows: first, the mucoperiosteal layer was reflected over the premolar area with nasal periosteal elevator and second, the vertical incision was not given in this approach. Finally, the palatal osteotomy was carried out from the nasal surface, under direct vision with the help of piezoelectric hand piece. With these modifications, we were able to maintain blood supply of Lefort segment without any alteration.
Figure 2: Lefort I osteotomy

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Figure 3: Modified Wassmund procedure

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  Results Top

This is the first case in the literature, in which prognathic maxilla, gummy smile with proclined upper anterior was treated with surgery- first approach incorporating modified Wassmund principal. Upper incisor-to-NA angle was achieved 26° (preoperative value 35°) and linear value achieved 6 mm (preoperative value 10 mm). Gingival exposure significantly improved from 9 mm to 3 mm [Figure 4].
Figure 4: Postoperative photograph

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  Discussion Top

The case which would have been solved in 36 month is hopefully going to be solved in 5–6 months of duration with extreme psychological benefit to the patient. Incorporating anterior subapical osteotomy along with Lefort I osteotomy resulted in correction of facial esthetics in both transverse and superoinferior axis. The avoidance of vertical incision in Wassmund results in uncompromised blood supply of maxilla. A comprehensive study of an orthognathic case and evaluation of all treatment options is an important facet in treatment planning. It also signifies that surgeon should not restrict himself in classical bilateral sagittal split osteotomy and Lefort osteotomy in SFOAn but our complete knowledge of different modality of surgery with little modification can result in a unique treatment plan with excellent outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Behrman SJ, Behrman DA. Oral surgeons' considerations in surgical orthodontic treatment. Dent Clin North Am 1988;32:481-507.  Back to cited text no. 1
Sharma V, Tandon P, Yadav K. An overview of surgery- first approach: Recent advances in orthognathic surgery. J Orthod Sci 2015;4:9.  Back to cited text no. 2


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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