ly light digital pressure into the desired relationship to the mandible. Using a previously prepared interocclusal splint as an index, the maxilla is immobilized .for six to eight weeks with stainless steel wires ligated between previously placed arch bars or orthodontic arch wires. Before placing the intermaxillary fixation, a nasogastric tube is placed in the nasal passage opposite the side of the nose that has been intubated in facilitate evacuation of blood from the stomach and to prevent vomiting in the early postoperative period. The tube, which is periodically irriogated, is usually removed within 24 hours when the aspirant of intermittent suction is clear.
The mobilized maxilla is fixed directly to the piriform rims and zygomatic buttresses with transosseous wires whenever feasible. When, however, the bone in these areas is too thin to support interosseous wires, the use of infraorbifalrim or circumzygomatic suspension wires to the maxillary fixation appliance is necessary. In many cases it seems preferable to use suspension wires to the mandible for optimum stabilization.
Although bone grafting has been utilized in the majority of patients, it is not routinely used. Indications for the use of bone grafts are determined from preoperative clinical and cephalomet studies, model analysis, and clinical judgment. Substantial advancement or widening of the maxilla; augmentation of the nasolabial, molar, or infraorbital areas; increase in vertical midfacial height; and residual bone clefts are indications for bone grafting
. Wedge-shaped corticocancellous bone blocks are inlaid with the cancellous bone facing the antrum so that they will not dislodge into the antrum or nasopharynx. In most cases where the advancement is less than 6 mm, bone grafts are not used in the pterygoid-maxillary or lateral maxillary areas. Through the intraoral incisions, bone can be placed over the lateral and anterior maxilla infraorbital rim, and zygoma for restoration of the contour of these areas. The mucoperiosteal incisions are closed with interrupted horizontal mattress sutures.
If an airway problem is anticipated in the im
Mediate postoperative period, the mobilized maxilla may be suspended by vertical lugs or eyelets previously incorporated into the acrylic wafer splint. The immediate need for intermaxillary fixation is thereby obviated. The mandible is immobilized four or five days after surgery when the nasal passages are patent.
The use of nasopharyngeal airways for one or two days may help maintain patency of the nasal passages, mold the nasal mucosa against the superior surface of the maxilla, and obliterate dead space beneath the nasal mucosa. Nasopharyngeal airways must be carefully monitored, changed, and cleaned frequently so that they do not become obstructed with blood and mucus.
After the airways are removed, the nasal passages are sprayed periodically with oxymetazoline hydrochloride nasal spray. Three or four days after surgery, the nasal passages are cleared of inspissated blood clots and mucus with a small aspirating tip. Patients are routinely given antibiotics and decongestants for seven days postoperatively or until such 'time as the soft tissue incisions have healed.
After the mandible is mobilized, the splint is removed and several intermaxillary elastics are worn at night only for two or three weeks. This regimen is continued until there are synchronous jaw func
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