J Oral Maxillofac Surg

69:352-355, 2011

Medial Canthal Region as an External

Reference Point in Orthognathic Surgery
José Nazareno Gil, DDS, PhD,*
Felipe Eduardo Baires Campos, DDS,†
Jonathas Daniel Paggi Claus,‡ Luiz Fernando Gil, DDS,§
Charles Marin, DDS,储 and
Sérgio Fernando Torres de Freitas, PhD¶

Purpose: The aim of this investigation was to evaluate the effectiveness of using the medial canthal
region (MCR) as an external reference point to determine the vertical dimension during maxillary
repositioning as planned in model surgery and predictive tracing.
Materials and Methods: The analyzed group consisted of 43 consecutive patients who underwent
maxillary or bimaxillary orthognathic surgery. Before downfracture, the vertical height was established
from the distance of the MCR to the incisal edge of the right upper central incisor (UCI). The vertical
dimension was obtained with frequent measurements by use of calipers as desired during cephalometric
tracing and model surgery. After rigid fixation, the vertical height was verified again. The UCI was traced
from the postoperative cephalogram and predictive tracing onto a preoperative tracing. Repositioning of
the maxilla and postsurgical movements of the UCI were registered at the horizontal and vertical planes.
Comparison was made between the predicted maxillary position on the cephalometric tracing and the
actual position, as well as between the planned maxillary position in model surgery and the actual
position.
Results: The mean difference between the planned UCI position on predictive tracing and postsurgical
position was 0.30 mm (SD, 0.21 mm; P ⬎ .05) in the vertical plane. The variation between the planned
maxillary position in model surgery and the actual position was 0.37 mm (SD, 0.31 mm; P ⬎ .05) in the
vertical plane.
Conclusions: Good surgical accuracy in positioning the mobilized maxilla can be achieved by use of
the MCR as an external reference point.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:352-355, 2011

A major challenge for oral maxillofacial surgeons is reference points (IRPs)3-5 and external reference
locating the maxilla in maxillary orthognathic surgery. points (ERPs).1,2,6-8
The ability to predict the outcome of surgery is re- Both techniques (IRP and ERP) use a mobile refer-
lated to the ability of the surgeon to reproduce the ence mark in the maxilla, which is in the upper
planned model surgery and to use predictive tracing central incisor (UCI), that will be moved and another
in the surgery room.1,2 Several techniques have been immovable mark above the Le Fort I osteotomy. This
published for accurate intraoperative positioning of mark is located directly above the bone cut in the IRP
the maxilla. The most cited are the use of internal technique, and the mark is typically a Kirschner wire

*Chairman, Oral and Maxillofacial Surgery Department, College ¶Professor, Public and Health Department, College of Dentistry,
of Dentistry, Santa Catarina Federal University, Florianópolis, Brazil. Santa Catarina Federal University, Florianópolis, Brazil.
†Resident, Oral and Maxillofacial Surgery Department, College of Address correspondence and reprint requests to Dr Gil: Depart-
Dentistry, Santa Catarina Federal University, Florianópolis, Brazil. ment of Oral Maxillofacial Surgery, University Hospital, College of
‡Surgeon, Oral and Maxillofacial Surgery Department, Santa Ca- Dentistry, Santa Catarina Federal University, Rua Tenente Silveira,
tarina Federal University, Florianópolis, Brazil. 293 Sala 1001, Edifício Reflex, Centro, Florianópolis, SC-Brazil, CEP
§Resident, Oral and Maxillofacial Surgery Department, College of 88010-301; e-mail: [email protected]
Dentistry, Santa Catarina Federal University, Florianópolis, Brazil. © 2011 American Association of Oral and Maxillofacial Surgeons
储Surgeon, Oral and Maxillofacial Surgery Department, Santa Ca- 0278-2391/11/6902-0007$36.00/0
tarina Federal University, Florianópolis, Brazil. doi:10.1016/j.joms.2010.07.023

352
GIL ET AL 353

Maxillary surgery was performed in 9 patients, Le

Fort I osteotomy and mentoplasty were performed in
2 patients, and 32 patients underwent bimaxillary
surgery. The maxilla was first mobilized in all patients
during bimaxillary surgery. The intact mandible with
the intermediate splint provided the anteroposterior
and transverse maxilla position. Plates and screws
were applied to maxillae in all patients to provide
rigid internal fixation (2 plates, n ⫽ 18; 4 plates, n ⫽
25). Allogeneic bone grafts were used in 6 patients
who underwent maxillary advancement and inferior
repositioning.
The mandible was mobilized by use of the follow-
ing methods: vertico-sagittal ramus osteotomy in 14
patients, intraoral vertical ramus osteotomy in 7 pa-
FIGURE 1. Anterior view of right eye and specific MCR used as
ERP (asterisk). tients, and bilateral sagittal split osteotomy in 11 pa-
Gil et al. Medial Canthal Region as Reference Point. J Oral Max-
tients.
illofac Surg 2011.
SURGICAL PROCEDURES
All procedures were performed by the same sur-
(K-wire) fixed at the nasal bone in the ERP technique. geon (J.N.G.). The oral and facial area was draped to
An alternative marker for a fixed reference point expose the perioral region and the right MCR (Fig 1).
would be the medial canthal region (MCR) instead of Vertical height was obtained preoperatively by use of
the K-wire. calipers and by measuring the distance from the right
An intermediate splint makes maxillary reposition- MCR to the incisal edge of the right UCI (Fig 2).
ing relatively simple and provides the proper 3-dimen- After downfracture, the maxillomandibular com-
sional position. With this technique, the surgeon only plex was manipulated with the condyles seated in the
has to ensure that the condyles are properly seated fossae. The intermediate (2-jaw surgery) or final splint
and determine the desired vertical dimension. The was applied at this time. The surgeon could control
purpose of this study was to evaluate the effective- the vertical dimension with frequent measurements
ness of use of MCR as an ERP during maxillary repo- using calipers as desired during cephalometric tracing
sitioning as planned in model surgery and predictive and model surgery. After rigid fixation, the vertical
tracing. height was verified again.

Materials and Methods

For this retrospective study, 43 consecutive pa-
tients were selected (22 female and 21 male patients),
ranging in age from 13 to 58 years (mean age, 29
years), and were submitted to maxillary or bimaxillary
orthognathic surgery during the period from Decem-
ber 2006 to April 2009. The inclusion criteria were
patients with complete preoperative and postopera-
tive (7-10 days after surgery) radiographic documen-
tation, predictive tracings, model surgery casts, and
records with planned movements of maxillary sur-
gery. This study was submitted to and approved by
the Ethical Committee for Research in Human Beings
of Santa Catarina Federal University, Florianópolis,
Brazil.
The casts for all patients were mounted on a semi-
adjustable articulator with face-bow transfer and cen- FIGURE 2. Preoperative measurement of distance between MCR
tric relation interocclusal registration.9 Cast measures and maxillary central incisor edge.
were made on the Erickson Model Surgery Platform Gil et al. Medial Canthal Region as Reference Point. J Oral Max-
(Florianópolis, Santa Catarina/Brasil). illofac Surg 2011.
354 MEDIAL CANTHAL REGION AS REFERENCE POINT

CEPHALOMETRIC ANALYSIS
Tracings of all cranial structures were performed
with preoperative cephalograms. These were first
superimposed on the postoperative cephalogram
film and then on the predictive tracings by 1 chief
resident using cranial base structures. The resident
was blinded to the specific movements of the maxilla.
The UCI was traced from the postoperative cephalo-
gram and predictive tracing onto the preoperative
tracing. Repositioning of the maxilla and postsurgical
movements of the UCI were determined for both
horizontal and vertical planes. Changes in the vertical
position of the UCI were assessed by measurement
perpendicular to the preoperative Frankfort horizon-
tal line. The horizontal position of the UCI was mea-
sured parallel to the Frankfort horizontal plane. To
eliminate bias, half of the patients were randomly
selected and retraced to confirm data obtained during
the first measurement.

STATISTICAL ANALYSIS
Changes in UCI movement from preoperatively to
the follow-up immediately postoperatively (7-10 days)
were analyzed in the horizontal and vertical direc-
tions. All measurements were converted to positive
numbers for statistical analysis to remove directional
differences between subjects. A paired t test was used
to compare the predicted maxillary position on ceph-
alometric tracing and the actual position, as well as
the planned maxillary position in model surgery and
the actual position. Statistical significance was set at
P ⬍ .05. Any association between planned surgical
movements and postsurgical changes was investi-
gated with Pearson correlation.

Results
The mean desired horizontal movements of the UCI
in predictive tracing and model surgery were 3.24 FIGURE 3. A, Relationship between predictive tracing and actual
mm (SD, 3.23 mm) and 3.16 mm (SD, 3.28 mm), surgical position of UCI in vertical movement. B, Relationship be-
tween model surgery and postoperative surgical position of UCI in
respectively. In the vertical plane, the mean predicted vertical movement (correlation coefficient, R ⫽ 0.98).
maxillary movements in predictive tracing and model Gil et al. Medial Canthal Region as Reference Point. J Oral Max-
surgery were 2.49 mm (SD, 2.08 mm) and 2.36 mm illofac Surg 2011.
(SD, 1.98 mm), respectively. There was a strong pos-
itive correlation between the maxillary position in the
planned model surgery, predictive tracings, and sur- actual position was 0.37 mm (SD, 0.31 mm; P ⬎ .05)
gical results. in the vertical plane (Fig 3B). Only 2 cases (4.6%)
The mean difference between the planned UCI presented a variation greater than 1.0 mm, with dif-
position in predictive tracing and postsurgical posi- ferences of 1.19 and 1.32 mm.
tion was 0.30 mm (SD, 0.21 mm; P ⬎ .05) in the
vertical plane (Fig 3A). One case presented a differ-
Discussion
ence of 1.07 mm, which was relatively close to satis-
factory (difference ⱕ1.0 mm). The majority (86%) of In 1985 Johnson7 first described the use of the
cases varied less than 0.5 mm. The variation between nasion mark as an ERP for vertical maxillary reposi-
the planned maxillary position in model surgery and tioning. The technique described involved the place-
GIL ET AL 355

ment of a suture through the skin at the soft tissue anterior cranial fossa.12 Disadvantages also include
nasion. Nishioka and Van Sickels8 considered soft screw loosening or movement during surgical manip-
tissue mobility during surgery to be a problem. A ulation and hypertrophic scarring related to the skin
modified ERP technique was demonstrated in 1987, incision. The disadvantage of the technique presented
involving fixation of a K-wire in the nasal bone, which herein is the inherent effects of triangulation, espe-
has become the most common method for vertical cially when vertical repositioning is accomplished
maxillary control during orthognathic surgery. with large anteroposterior movements of the maxilla.
Our results confirm that accurate vertical control of This effect can be eliminated with the use of a specific
the UCI can be achieved while using the MCR as the gauge, as previously shown by Cope.6
ERP. This is similar to previously published data that Although the MCR is a soft tissue, it is a well-fixed
used a K-wire fixed at the nasal bone as the ERP. This structure that does not exhibit mobility or distortion
method presents horizontal accuracy within 2 mm during manipulation of the maxillomandibular skele-
and vertical accuracy within 1 mm of predictive trac- tal complex or by the intratracheal tube. The intraop-
ings.3,4 erative edema does not influence the use of this land-
Van Sickels et al3 compared the predictability of mark, because the most superior subperiosteal
postoperative UCI positioning in patients in whom dissection extends to the infraorbital foramen and
IRP or ERP had been used. In the ERP group, UCI was nerve. Moreover, the operatory field was decreased.
outside of the predicted measurement for a mean of This is the first study found in the literature that
1.1 mm in the horizontal plane and 0.7 mm in the evaluated the effectiveness of the MCR as a reference
vertical plane. Polido et al10 compared ERP with IRP for maxillary repositioning in orthognathic surgery.
and found no difference between the 2 groups in Therefore this technique using the MCR is a viable
horizontal positioning accuracy of the maxilla, but option with a relatively easy clinical application in
there was a significant difference in vertical reposi- comparison to the technique involving a K-wire set-
tioning. Use of an ERP proved to be a more accurate tled in the nasal bone.
method for vertical maxillary repositioning.
In contrast to these 2 previous studies, Ong et al11
achieved intraoperative control of the mobilized max- References
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