The skeletal stability of one-piece Le Fort 1 osteotomy to advance the maxilla; Part 2. The influence of uncontrollable clinical variables

The stability of orthognathic surgery has been the subject of numerous publications over the last 20 years. It is now apparent that studies must pay attention to the homogeneity of the patients investigated and in particular, surgical techniques. In Part 2 of our study of 45 patients who had a uniform one-piece maxillary advancement with rigid fixation to advance the maxilla, we found that uncontrollable variables, including patients age, sex, the degree of advancement, and simultaneous mandibular advancement, had no effect on post-operative skeletal stability.     

The skeletal stability of Le Fort I downfracture osteotomies with rigid fixation

Twenty subjects receiving Le Fort I downfracture osteotomies stabilized with rigid fixation were studied for relapse. The analysis was based on longitudinal cephalometric radiographs taken within 2 weeks presurgically, 1 week postsurgically, and after a minimum period of 6 months postsurgically. Vertical and sagittal changes in the maxilla were evaluated in reference to the Frankfort horizontal plane. It was found that the mean postsurgical relapse was minimal and not significant. It was smaller than that reported for patients who had received stabilization of the maxilla with intraosseous and maxillomandibular wiring. It was concluded that the rigid fixation technique is dependable and yields stable postsurgical results in the maxilla.     

Stability of the Le Fort I osteotomy for maxillary advancement using rigid fixation and porous block hydroxyapatite grafting

PURPOSE: The purpose of this study was to evaluate the stability of maxillary advancement using bone plates for skeletal stabilization and porous block hydroxyapatite (PBHA) as a bone graft substitute for interpositional grafting. PATIENTS AND METHODS: The records of 78 patients (55 female, 23 male) with a diagnosis of anteroposterior maxillary hypoplasia were retrospectively evaluated. All patients underwent greater than 5 mm Le Fort I maxillary advancement with rigid fixation and PBHA interpositional grafting. The study sample was divided into 3 groups on the basis of the concurrent superior or inferior positioning of the maxillary incisors. Presurgery (T1), immediately postsurgery (T2), and longest follow-up (T3) lateral cephalometric tracings were superimposed to analyze for horizontal and vertical changes at the following landmarks: (1) point A, (2) incisal edge of the maxillary incisor, and (3) mesial cusp tip of maxillary first molar. RESULTS: The maxilla was inferiorly repositioned in 27 patients, superiorly repositioned in 21 patients, and advanced horizontally without a significant vertical change in 30 patients. All groups showed 0.5 mm or less horizontal and vertical relapse. There was no statistically significant difference between the 3 groups. CONCLUSIONS: Maxillary advancement with Le Fort 1 osteotomies by using rigid fixation and interpositional PBHA grafting is a stable and predictable procedure regardless of the direction of vertical maxillary movement.     

The behaviour of the maxilla in vertical movements after Le Fort I osteotomy.

In 15 cases of ordinary Le Fort I osteotomy with simultaneous vertical displacement, the behaviour of the maxilla in respect to vertical movement was examined. It was observed that out of 12 maxilla which had been tilted downwards, 10 moved upwards again. One maxilla remained stable and another one moved further downwards. Of 3 cases with upward movement, two remained stable whereas one moved further upwards. Therefore, the authors conclude that the downward displacement especially is unstable and that one has either to overcorrect or search for possibilities of stabilization other than wiring suspension. Since these movements occur during postoperative intermaxillary fixation, no occlusal changes are observed.     

Postoperative skeletal stability and accuracy of a new combined Le Fort I and horseshoe osteotomy for superior repositioning of the maxilla

Postoperative skeletal stability and accuracy were evaluated in a combination of Le Fort I and horseshoe osteotomies for superior repositioning of maxilla in bi-maxillary surgeries in 19 consecutive patients. 9 underwent Le Fort I osteotomy alone (preoperative planned superior movement <3.5 mm). 10 underwent Le Fort I and horseshoe osteotomy (combination group) (preoperative planned superior movement >3.5 mm). The maxilla was osteotomized and fixed with 4 titanium Le Fort plates followed by bilateral sagittal split ramus osteotomy of the mandible, fixed with 2 semi-rigid titanium miniplates. Maxillomandibular fixation was performed for 1 week. Lateral cephalograms were obtained preoperatively, 1 week postoperatively, 3, 6, 12 months later. The changes in point A, point of maxillary tuberosity, and upper molar mesial cusp tip were examined. Discrepancy between the planned and measured superior movement of the maxilla in the Le Fort I and combination groups was 0.30 and 0.23 mm, respectively. The maxillae in both groups were repositioned close to their planned positions during surgery. 1 year later, both groups showed skeletal stability with no significant postoperative changes. When high superior repositioning of the maxilla is indicated, horseshoe osteotomy combined with Le Fort I is reliable and useful for accuracy and postoperative stability.     

Fractures of the atrophic, edentulous maxilla during Le Fort I osteotomy

The incidence of unfavorable fractures of the maxilla during Le Fort I osteotomy was compared between patients with atrophic, edentulous maxillae and patients with normal dentate maxillae. Unfavorable fractures frequently occurred in atrophic, edentulous maxillae. The most common maxillary fracture involved the junction of the horizontal plate of the palatine bone and posterior part of the maxilla. Prevention strategies and treatment options are discussed.     

Endoscopically assisted Le Fort I osteotomy to correct transverse and sagittal discrepancies of the maxilla.

PURPOSE: The purpose of this report was to show the feasibility of the combination of a minimally invasive endoscopic approach to the maxilla with transverse and sagittal distraction procedures. MATERIALS AND METHODS: Four human cadavers were used for training of a minimally invasive access to the maxilla to perform a endoscopically assisted Le Fort I osteotomy, before this technique was applied in 3 patients with transverse and sagittal growth deficits of the maxilla. Access to the maxilla was gained through a small mucosa incision in the vestibule to create a visualization port to the maxillary sinus through a bur hole. Landmarks were identified through the endoscope before a Le Fort I osteotomy was performed using chisels of different shapes and angulations. In 2 patients the maxilla was split sagittally to perform a transverse maxillary expansion; in 1 patient, a buried distractor was applied close to the piriform aperture to correct a sagittal growth deficit in a hypoplastic maxilla. RESULTS: Endoscopic exposure of the maxillary sinus walls from within the sinus, the accurate identification of landmarks, and the creation of a Le Fort I osteotomy were achieved in all cases. Distractor application close to the piriform aperture rendered good stability. CONCLUSION: The results of these cases indicate that the endoscopic approach to the maxillary sinus allows excellent exposure of the sinus walls to perform a endscopically assisted Le Fort I osteotomy. The combination of endoscopy and osteodistraction processes supports the tendency to perform minimally invasive, less-traumatizing surgical procedures, especially in individuals who are still growing.     

Stability of the Le Fort I osteotomy with anterior internal fixation alone: a case series.

PURPOSE: The purpose of this case series was to evaluate the late postsurgical stability of the Le Fort I osteotomy with anterior internal fixation alone and no posterior zygomaticomaxillary buttress internal fixation. PATIENTS AND METHODS: Sixty patients with maxillary vertical hyperplasia and mandibular retrognathia underwent a 1-piece Le Fort I osteotomy of the maxilla with superior repositioning and advancement or setback. A bilateral sagittal split ramus osteotomy for mandibular advancement was also performed in 22 patients. Stabilization of each maxillary osteotomy was achieved using transosseous stainless steel wires and/or 3-hole titanium miniplates in the piriform aperture region bilaterally, with no zygomaticomaxillary buttress internal fixation. (Twelve of the 60 identified patients were available for a late postoperative radiographic evaluation.) Lateral cephalometric radiographs were taken preoperatively (T1), early postoperatively (T2), and late postoperatively (T3) to analyze skeletal movement. RESULTS: These 12 patients (5 male, 7 female) had a mean age of 24.5 years at surgery. Mean time from surgery to T2 was 41.2 days; mean time from surgery to T3 was 14.8 months. One patient received anterior wire osteosynthesis fixation, while 11 patients received both anterior titanium miniplate internal skeletal fixation and anterior wire osteosynthesis fixation. Six patients underwent Le Fort I osteotomy with genioplasty, 1 patient underwent Le Fort I osteotomy with bilateral sagittal split ramus osteotomy, and 5 patients underwent Le Fort I osteotomy with bilateral sagittal split ramus osteotomy and genioplasty. These 12 patients all underwent maxillary superior repositioning with either advancement (11 patients) or setback (1 patient). Statistically significant surgical (T2-T1) changes were found in all variables measured. In late postsurgical measurements (T3-T2), all landmarks in the horizontal and vertical plane showed statistically significant skeletal stability. CONCLUSION: This case series suggests that anterior internal fixation alone in cases of 1-piece Le Fort I maxillary superior repositioning with advancement has good late postoperative skeletal stability.     

An analysis of factors influencing stability of surgical advancement of the maxilla by the Le Fort I osteotomy

Skeletal stability after maxillary surgical advancement was studied in 30 patients. Postoperative movement of all measured skeletal and dental points were on the average negligible. Equal stability was seen in maxillary advancement alone and with concomitant mandibular surgery. Eight cases examined individually showed larger than desired postoperative movements. In six of these cases the undesirable postoperative changes were secondary to undesirable preoperative orthodontic flaring of the incisors. The Begg orthodontic technique, because of its tendency to axially rotate teeth, was shown to produce more variability in tooth position than edgewise orthodontics. This study confirms that no preoperative flaring of the maxillary incisors should be attempted; instead, the teeth should be retracted and placed over basal bone with a normal axial inclination. Occlusal correction should then be accomplished by surgery. Suspension wires and bone grafting are sufficient to obtain skeletal stability in cases of maxillary advancement up to 11 mm. In cases where the surgery is more complex, rigid fixation is recommended.     

Comparison of postoperative skeletal stability of maxillary segments after Le Fort I osteotomy,using patient-specific implant versus mini-plate fixation

BackgroundThree-dimensionally (3D) designed osteotomies and customised osteosynthesis are rapidly becoming standard in maxillofacial reconstructive and deformity surgery. Patient-specific implants (PSIs) have been in use for a few years in orthognathic surgery as well. In Le Fort I osteotomy, wafer-free fixation of the maxillary segment can be performed by individually manufactured cutting and drill guides together with PSIs.AimThis retrospective study was performed to compare the postoperative skeletal stability of the maxillary segment fixed by patient-specific implants versus mini-plates after Le Fort I osteotomy.PatientsFifty-one patients were divided into subgroups according to the fixation method and the advancement of the sub-spinal point. The postoperative skeletal stability of the maxillary segment was evaluated from lateral cephalometric radiographs one year postoperatively.ResultsNo statistically significant differences were found between the postoperative skeletal stability of the PSI and mini-plate fixed maxillae. Prospective studies, possibly with 3D fusion analysis, are warranted to confirm the results.ConclusionThe choice between the two fixation methods does not seem to affect the postoperative skeletal stability of the maxillary segments.     

Le FortⅠ型骨切开上颌骨整体后退术矫治骨性Ⅱ类上颌骨前突畸形

目的：探讨Le Fort Ⅰ型骨切开（Le Fort Ⅰ osteotomy）上颌骨整体后退术在矫治骨性Ⅱ类上颌骨前突畸形中的价值。方法：对16例骨性Ⅱ类上颌前突患者（上颌骨前突伴下颌骨后缩14例,其中同时伴颏后缩6例;单纯上颌骨前突2例）进行外科-正畸联合治疗。患者治疗前头影测量∠ANB为7.0°～13.1°,平均9.3°。行Le Fort Ⅰ型骨切开上颌骨整体后退术,其中14例同期行双侧下颌支矢状骨劈开术（bilateral sagittal split ramus osteotomy,BSSRO）前移下颌骨,6例行颏成形术（genioplasty）前移颏部。结果：本组行LeFortⅠ型骨切开上颌骨整体后退4～8mm,14例BSSRO下颌骨前移4～7mm,6例颏成形术颏前移6～8mm。1例一侧腭降动脉术中损伤断裂,经结扎处理,无感染及骨块坏死。16例患者伤口均一期愈合。术后及正畸结束后∠ANB为1.6°～3.5°,平均2.9°。结束治疗后随访6～24个月,牙弓形态及[牙合]曲线正常,牙排列整齐,咬合关系良好,外形明显改善,疗效满意。结论：对于骨性Ⅱ类上颌骨前突畸形患者,Le Fort Ⅰ型骨切开上颌骨整体后退术是一种安全、合理、有效的正颌外科术式。     

Comparison of the postsurgical stability of the Le Fort I osteotomy using 2- and 4-plate fixation.

PURPOSE: This study was conducted to evaluate the postoperative stability of Le Fort I osteotomies accomplished with 2-plate versus 4-plate fixation. METHODS: This is a retrospective study involving 32 patients who underwent Le Fort I 1-piece osteotomy concurrent with orthodontic therapy. All patients were treated by 1 attending surgeon during an 18-month period. Sixteen patients were treated by plate and screw fixation consisting of 4 miniplates (group I), and an additional 16 patients were treated using 2 miniplates (group II). In group I, fixation was accomplished with 2.0-mm low-profile Lorenz (Walter Lorenz Surgical Inc, Jacksonville, FL) plates and screws placed at the piriform aperture and at the maxillary buttress. Four screws were placed in each of the plates. In group II, fixation was accomplished with 2.0-mm low-profile Lorenz plates and screws placed at the piriform aperture. Again, 4 screws were placed in each of the plates. RESULTS: Serial cephalometric evaluation at arbitrary anterior nasal spine and posterior nasal spine for both groups showed that postoperative skeletal changes in the direction of the surgical movement were seen in approximately 20% of cases; these changes averaged less than 1 mm. Postoperative skeletal changes opposite to the direction of the surgical movement were seen in approximately 30% of cases; these changes also averaged less than 1 mm. No postoperative skeletal changes were seen in approximately 50% of cases. For all measured changes about arbitrary anterior nasal spine and posterior nasal spine, there was no significant difference between groups I and II. CONCLUSION: This study suggested that postoperative skeletal changes associated with the use of 2-plate fixation do not appear to differ significantly from those seen with 4-plate fixation.     

Two-point nasomaxillary fixation of the Le Fort I osteotomy: assessment of stability at one year postoperative

The purpose was to assess maxillary position among patients undergoing Le Fort I maxillary advancement with internal fixation placed only at the nasomaxillary buttresses. This was a retrospective study of patients undergoing a Le Fort I osteotomy for maxillary advancement, with internal fixation placed only at the nasomaxillary buttresses. Demographic and cephalometric measures were recorded. The outcome of interest was the change in maxillary position between immediately postoperative (T1), 6 weeks postoperative (T2), and 1 year postoperative (T3). Fifty-eight patients were included as study subjects (32 male, 26 female; mean age 18.4 ± 1.8 years). Twenty-five subjects (43.1%) had a diagnosis of cleft lip and palate. Forty-three subjects (74.1%) had bimaxillary surgery, 16 (27.6%) had bone grafts, and 18 (31.0%) had segmental maxillary osteotomies. At T3, there were no subjects with non-union, malunion, malocclusion, or relapse requiring repeat surgery. Mean linear changes between T1 and T3 were ≤1 mm. Mean angular changes between T1 and T3 were <1°. There was no significant difference in stability in multi-segment maxillary osteotomies (P =  0.22) or with bone grafting (P =  0.31). In conclusion, anterior fixation alone in the Le Fort I osteotomy results in a stable maxillary position at 1 year postoperative.     

Stability and morbidity of Le Fort I osteotomy with bioresorbable fixation: a randomized controlled trial

A randomized controlled clinical trial was conducted to compare the use of bioresorbable and titanium mini-plates and screws in Le Fort I maxillary osteotomies for evaluation of clinical morbidity and stability. Forty patients requiring Le Fort I osteotomies were randomly assigned to two groups. One group underwent bioresorbable mini-plate fixation and the other titanium mini-plate fixation. Stability of the maxilla was determined by serial cephalometric analysis at 2 and 6 weeks and at 3, 6 and 12 months postoperatively. Subjective and objective assessment of clinical morbidity was made prospectively. There were no differences in complications between the two fixation materials. Maxillae with bioresorbable fixation were significantly more mobile at the second postoperative week. Bioresorbable plates were initially more easily palpable, but their palpability decreased with time. Titanium plates became significantly more palpable at the 1-year follow-up. There was no difference in neurosensory disturbance between groups. Patients with bioresorbable plate fixation showed significantly more upward displacement in anterior maxilla following impaction and posterior maxilla following downgrafting from the 2nd to 6th postoperative week. The horizontal and angular relapses in the two groups were comparable. Le Fort I osteotomy with bioresorbable fixation results in no greater morbidity than with titanium fixation up to 1 postoperative year.     

Influence of routine bone grafting on the stability of the non-cleft Le Fort 1 osteotomy

Although bone grafting is known to improve stability after midface cleft osteotomy, it is advocated only rarely for people without clefts. To assess the influence of routine bone grafting on stability in such patients we analysed radiographic data of 112 patients retrospectively. All patients had had Le Fort 1 osteotomy with autogenous bone grafts harvested by trephine from the iliac crest, and 76 had had concurrent mandibular procedures. Rigid internal fixation was adopted throughout. Impaction proved to be the most stable move. While there was little postoperative relapse of the anterior maxilla (0.9%), the posterior maxilla tended to move further upwards with time (2.3%). Overall relapse after advancement and inferior repositioning was low (3.5% and 5%, respectively). The only complication noted at the iliac crest donor site was spread of the scar, which affected three patients. When we compared these results with previously published data, they suggested that in patients without clefts rigid internal fixation combined with bone grafting may improve stability after selected Le Fort 1 osteotomy moves.     

Intracranial hemorrhage resulting from skull base fracture as a complication of Le Fort III osteotomy

Various complications of Le Fort osteotomies have been reported. We describe a lethal complication of Le Fort III osteotomy we encountered in a 9-year-old boy with Crouzon syndrome. A standard Le Fort III osteotomy, including pterygomaxillary dysjunction with a curved osteotome and down-fracture manipulation, was performed uneventfully. When the intraoral buccal wound was closed after fixation of the external midface distraction devices, we discovered hemorrhage originating from the right posterior maxillary region. Although it was stopped with pressure on the osteotomized maxilla, the volume of intraoperative blood loss was nearly 2,000 ml. During the observation period in the intensive care unit, the patient suffered brain death, and he died 3 months later. A computed tomography scan obtained the day after surgery revealed vigorous subarachnoid and intraventricular hemorrhage and transverse fracture of the middle cranial fossa. This skull base fracture was believed to result from intraoperative maneuvers, including the pterygomaxillary dysjunction and down-fracture manipulation. We emphasize the risk of intracranial hemorrhage with Le Fort osteotomy and advise discussing this risk with patients and family members during preoperative consultations.     

Changes after correction of maxillary retrusion by Le Fort I osteotomy. A comparison of 2 methods of skeletal fixation

2 methods of skeletal fixation are compared in 24 patients with maxillary retrusion treated with Le Fort I osteotomy only: group I, intraosseous fixation only (10 patients); group II, enhanced fixation, intraosseous and suspension wires (14 patients). Follow-up checks on the patients were carried out using lateral cephalograms. The changes of the maxillary position in relation to the anterior cranial base were analyzed via a technique of superimposition in a computer system without using conventional landmarks. Vertical and horizontal changes and rotations were studied. The method error was small. In the vertical direction, there was a significant difference between the groups. In group I, the vertical relapse during the early postoperative period was 55%, while in group II, it was only 15%. The conclusion is that a rigid vertical fixation is needed.     

Rehabilitation of the severely atrophied maxilla by horseshoe Le Fort I osteotomy (HLFO)

OBJECTIVE: The purpose of this study was to determine the long-term outcome of the horseshoe Le Fort I osteotomy (HLFO) as a preprosthetic operation technique for implant insertion in the extremely atrophied maxilla. STUDY DESIGN: 36 patients (8 male, 28 female, average age 57.6 years) underwent HLFO combined with iliac crest bone grafting. They were divided into 2 groups: group A with 12 patients who simultaneously received 100 implants; group B with 24 patients where 176 implants were inserted in 18 patients in a second-stage procedure. Clinical and radiographic outcome with regard to implant osseointegration, alveolar bone height in the canine and molar regions, peri-implant bone loss and satisfaction of patients (esthetics, masticatory function, overall treatment) were investigated in all cases. RESULTS: The overall 2-year failure-free fraction of implants was 95.5%; the 5-year failure-free fraction was 89.3%. In the 1-step group the 2-year and 5-year failure-free fractions were 95.9% and 86.9%, respectively, in the 2-step group 95.0% and 91.3% (log rank test P=.57). A total of 27 implants were lost during the entire follow-up: 14 in 6 patients of the 1-stage and 13 in 9 patients of the 2-stage group. The mean loss of alveolar bone after augmentation in the canine and molar regions was almost equal in both groups (overall means for the 2 regions 3.67 +/- 2.77 and 4.42 +/- 2.72 mm, respectively). The relationship between the jaws and thereby the esthetic profile could be improved in all cases. All patients were satisfied with the dental rehabilitation and the achieved new esthetic appearance. CONCLUSIONS: HLFO combined with iliac bone grafting is a feasible preprosthetic technique prior to implant insertion in cases of severe atrophy of the maxillary alveolar ridge, leading to satisfying implant survival and rehabilitation of function.