Strategies for surgically assisted rapid maxillary expansion according to the region of transverse maxillary deficiency

This study evaluated different techniques for surgically assisted rapid maxillary expansion (SARME) according to the type of transverse maxillary deficiency using computed tomography (CT). Six adult patients with bilateral transverse maxillary deficiencies underwent SARME. The patients were equally divided into three groups: Group I, maxillary atresia in both the anterior and posterior regions; Group II, greater maxillary atresia in the anterior region; and Group III, increased maxillary atresia in the posterior region. In Group I, a subtotal Le Fort I osteotomy was used. In Group II, a subtotal Le Fort I osteotomy was used without pterygomaxillary suture disjunction. In Group III, a subtotal Le Fort I osteotomy was used with pterygomaxillary suture disjunction and fixation of the anterior nasal spine with steel wire. The midpalatal suture opening was evaluated preoperatively and immediately after the activation period using CT. For Group I, the opening occurred parallel to midpalatal suture; for Group II, the opening comprised a V-shape with a vertex on the posterior nasal spine; and for Group III, the opening comprised a V-shape with a vertex at the anterior nasal spine. The conclusion was that the SARME technique should be individualized according to the type of transverse maxillary deficiency.     

Avascular necrosis in cleft maxillary repositioning: a review of cases and introduction of the ‘delayed maxillary flap’

There is a low incidence of serious complications with the Le Fort I maxillary osteotomy, but avascular necrosis is a serious problem that occurs at a higher frequency in the cleft population compared to non-cleft patients. In this retrospective study, cleft patients who had exhibited any manifestation of avascular necrosis of the maxilla following a Le Fort I advancement were identified. Five patients were found to have had vascular compromise, ranging from loss of gingival tissue to necrosis of bone and loss of teeth. In each case, possible risk factors were assessed, and secondary revision palatal surgery prior to maxillary advancement, particularly closure of oronasal fistulae with transpositional flaps, was noted to be present. Drawing on this finding and a review of the literature, clinical recommendations are made for minimizing the risk of this major complication. The use of the ‘delayed maxillary flap’ technique is introduced and described as a potentially beneficial procedure for cleft patients with a high risk of vascular compromise.     

Adie's pupil following Le Fort I maxillary osteotomy. A complication or coincidence?

A case is reported of right-sided tonic pupil in isolation (Adie's pupil) following Le Fort I maxillary osteotomy. It is difficult to identify whether this rare finding immediately postoperatively is either a pure coincidence or a genuine complication of surgery.     

Passive repositioning of maxillary fractures: An occasional impossibility without osteotomy

PURPOSE: To present cases where passive repositioning of maxillary fractures was not achievable during surgery, and a method to provide passive occlusal positioning in those cases. PATIENTS AND METHODS: Over a 10-year period, the maxillae of 24 patients with fractures of the maxilla could not be passively repositioned during surgery. In these cases, a Le Fort I osteotomy was performed in addition to reduction and fixation of the other midfacial fractures. RESULTS: All patients had passive restoration of their pretrauma occlusion during surgery. All patients except 1 had maintenance of their pretrauma occlusion at the last follow-up visit (6 weeks or more) following surgery. CONCLUSION: When passive positioning of the maxilla is not possible, a concomitant Le Fort I osteotomy can provide passive positioning of the occlusion.     

上颌前徙术对上颌发育不足患者腭咽部结构影响的临床探讨

目的：探讨上颌前移术对上颌发育不足患者腭咽部结构的影响。方法：选择2011-2013年行上颌Le FortI型截骨前移术的上颌发育不足患者12例,男7例,女5例,其中唇腭裂患者5例,非唇腭裂患者7例,平均年龄22．21岁,所有患者在术前、术后1月拍摄头颅定位侧位片,并对腭咽部结构指标进行测量分析。结果：上颌骨最大前移幅度8mill,最小3mm,平均前移（5．28±2．32）mm,术后咽腔深度明显增大（P〈0．05）;同时软腭长度及软硬腭夹角较术前11月显增大（P〈0．05）,软腭厚度减小。结论：上颌骨前移术造成患者咽腔深度显著增加,对腭咽闭合功能可能有不利影响：术后腭叫部软组织发生适应性变化,这种代偿性改变会在一定程度上减轻腭咽闭合不全。     

Upper lip length after V-Y versus continuous closure for Le Fort I level maxillary osteotomy

PURPOSE: The purpose of this report is to document changes in lip length and thickness after Le Fort I maxillary osteotomy by using continuous versus V-Y closure.Materials and Methods: This is a retrospective analysis of 18 patients who underwent Le Fort I maxillary osteotomy. Ten patients had a single midline V-Y closure and 8 patients had simple continuous closure. Lateral cephalometric analysis was performed, and preoperative and 12-month postoperative changes in lip dimensions were calculated. Lip length and thickness were analyzed at 5 points: A-point (A), subnasale (Sn), cervical margin of incisor (C), stomion superius (Ss) and labrale superius (Ls). The lengths from A to Sn, C to Ls, and Sn to Ss were calculated. RESULTS: After 12 months, there was no significant difference in lip length (P =.39) or thickness of the upper lip in its upper (P =.75) or lower (P =.19) parts, between the 2 groups. CONCLUSION: Lip length and width show no significant differences before surgery versus after surgery with either closure technique after Le Fort I osteotomy.     

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。     

Postoperative stability following maxillary downward movement with Le Fort I inclined osteotomy at the lateral nasal cavity wall

Downward movement of the maxilla is regarded as one of the less stable long-term orthognathic surgical procedures. To increase postoperative stability with direct bone contact, the conventional Le Fort I osteotomy was modified with an inclined osteotomy at the lateral nasal cavity wall. The aim of this study was to evaluate the postoperative stability of the new method for Le Fort I inclined osteotomy for downward maxillary movement.The study included 27 patients with anterior vertical deficiency of the maxilla who underwent Le Fort I inclined osteotomy for downward maxillary movement. Patients were classified into two groups according to the amount of downward movement. The amounts of relapse (cephalometric changes) of the two groups were compared and statistically analyzed.The mean amount of relapse was about 1 mm. The tendency of relapse was not increased by a large initial downward movement with Le Fort I inclined osteotomy. Le Fort I inclined osteotomy was used safely for downward movement in order to increase bone height at the piriform aperture area and resulted in direct bone contact, suggesting it is a useful technique for maintaining postoperative stability. A further study with a larger number of patients is necessary.     

上颌骨牵引成骨术矫治上颌牙弓狭窄

目的 观察上颌骨牵引成骨术矫治上颌牙弓狭窄的疗效。方法 对１０例成年患者行上颌Ｌｅ Ｆｏｒｔ Ｉ型截骨术（不移动骨块）,并手术截开腭中缝骨联结。以上颌快速扩弓装置（６４１４６带环）,每日打开螺旋４次,共１．０ｍｍ。其中２例行单侧扩大牙弓,矫正上颌单侧牙弓宽度不足。利用计算机图形数据分析系统对扩弓前后的后前位头颅定位片进行测量（上颌骨、上颌牙弓基骨、上颌后牙间的宽度）并通过上颌前部咬合片观察腭中缝的     

Relapse rate after surgical treatment of maxillary hypoplasia in non-growing cleft patients: a systematic review and meta-analysis

Maxillary hypoplasia in cleft lip and palate is a complex deformity. Despite surgical improvements, postoperative relapse persists. This systematic review was performed to determine the mean horizontal relapse rates for the surgical techniques used to treat maxillary hypoplasia: Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis. This study followed the PRISMA statement. The PubMed, Embase, Science Direct, and Web of Science databases were searched through to June 2018. Studies on non-growing cleft lip and palate patients who had undergone one of the three surgical procedures and who had postoperative horizontal maxillary changes assessed at >6 months post-surgery were included. Stata SE was used to estimate pooled means, heterogeneity, and publication bias. The search strategy identified 326 citations, from which 24 studies were selected. Relapse rates following Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis were 20%, 12%, and 12%, respectively. Relapse rates with and without bone grafting were 19% and 66%, respectively. The relapse rate following distraction osteogenesis with internal distraction was lower than that with external distraction. Study limitations were heterogeneity, which was above moderate, the low number of high-quality studies, and unidirectional assessment of postoperative maxillary movement.     

Tooth pulp changes following Le Fort I maxillary osteotomy in a primate model

Le Fort I maxillary 'down-fracture' osteotomy with 8 mm advancement was performed in 15 adult rhesus monkeys. Forty-five tooth pulps were examined histologically at intervals from 0 to 24 weeks after surgery. Cell degeneration occurred in 31% of pulps examined, necrosis in 16% of pulps and osteo-dentine was found in 7% of pulps. Almost half of the teeth examined (47%) showed marked cellular changes, more frequently found in posterior teeth. Other features noted were inflammation (13%) and reactive dentine in pulps (24%). Axons degenerated initially but recovered by 24 weeks. It is concluded that Le Fort I maxillary osteotomy caused pulpal disturbances in an animal model and the extent to which this occurs in patients needs to be carefully monitored.     

颌骨畸形600例正颌手术治疗

目的 总结正颌外科矫正颌骨畸形的临床经验。方法 对600例颌骨畸形患者进行正颌外科手术,其中上颌Le FortⅠ截骨与下颌体部截骨术212例,单纯上颌Le Fort Ⅰ截骨56例,单纯双下颌升支矢状劈开截骨(SSRO)30例,下颌体部截骨145例,行Downfracture或Wassmund法矫治112例,下颌前突伴偏颌畸形行下颌体部截骨45例。结果 60X例中术后部分复发28例,完全复发2例,下唇感觉异常9例,术后感染6例,其余术后面容和咀嚼功能获得满意效果。结论 上颌Le Fort Ⅰ截骨与下颌体部截骨术能较好地矫正上颌后缩及下颌前突畸形,但牙颌关系恢复不良。前牙根尖下截骨是纠正双颌前突畸形的理想术式,SSRO矫正下颌前突畸形效果满意。     

Embolization of pseudoaneurysm of the internal maxillary artery after orthognathic surgery

In orthognathic surgery, Le Fort I osteotomy is one of the most often used methods for the correction of dental-facial deformities and is considered technically safe. However, this procedure may lead to diverse complications, including uncommon vascular complications. A clinical case is described of late development of pseudoaneurysm in one of the branches of the maxillary artery in a 20-year-old patient who had undergone Le Fort I osteotomy, bilateral sagittal osteotomy of mandibular branch, and mentoplasty and subsequently treated with embolization. The main forms of treating vascular injuries are reviewed, and embolization is demonstrated to be a technically safe procedure with few complications.     

Effect of segmental Le Fort I osteotomy on maxillary tooth type-related pulpal blood-flow characteristics

Laser Doppler flowmetry (LDF) is a noninvasive method to assess pulpal blood-flow (PBF). Osteotomies may have segment-related losses of pulpal sensibility. OBJECTIVES: To determine the effect of segmental Le Fort I osteotomy on tooth-type related PBF values. MATERIALS AND METHODS: In 12 volunteers, maxillary incisors, canines, and premolars were investigated bilaterally by LDF to assess local PBF values before and after surgery. Perfusion units (PU) were in 3 sessions, on the day before surgery and at 4 and 56 days after osteotomy. RESULTS: Measurements before surgery were significantly higher than at 4 days after surgery for the canine (P <.01) and for the overall PBF values (P <.01). At 4 days assessment, PBF values of tooth types adjacent to vertical osteotomy cuts showed a significant decrease for the lateral incisors (P <.05), canines, and first premolars (P <.05), with no significant differences between the preoperative and postoperative values for tooth types not adjacent to vertical osteotomy cuts (P <.05). CONCLUSIONS: Segmental Le Fort I osteotomy induced a short-term and long-term decrease in maxillary PBF values of tooth types adjacent to vertical osteotomy cuts.     

Blood-flow change and recovery of sensibility in the maxillary dental pulp during and after maxillary distraction: a pilot study

OBJECTIVE: To examine the change in blood flow and recovery of sensibility in the maxillary dental pulp during and after maxillary distraction. STUDY DESIGN: The subjects included 5 patients undergoing high Le Fort I osteotomy and maxillary distraction (D-group) and a reference group of 14 patients who underwent a common single-segment Le Fort I osteotomy, 1-stage maxillary advancement, and mandibular setback surgery (C-group). Eleven (D-group) and 54 (C-group) maxillary incisors were assessed preoperatively and at 1-7 days, 14 days, and 3 months postoperatively. Pulpal blood flow (PBF) was measured by laser Doppler flowmetry, and pulpal sensibility (PS) was investigated by electrodiagnostics. RESULTS: From postoperative days 1 to 5 (the latency period), the PBF tended to be higher in the D-group than in the C-group. From day 6 to 3 months postoperatively (during and after maxillary distraction), the PBF values of the 2 groups were similar. The PS remained negative up to 14 days postoperatively in both groups. However, at 3 months after the operation, a higher proportion (90.9%) of teeth in the D-group was positive for PS. CONCLUSION: These results suggest that maxillary distraction is a favorable technique for maintenance of PBF and recovery of PS in the maxillary teeth after surgery.     

The origin of the Le Fort I maxillary osteotomy: Cheever's operation

The Le Fort I maxillary osteotomy so commonly performed today for a variety of reasons had its primitive beginnings in 1867 in the search for a more simple, direct, and less mutilating approach to the nasal cavity for tumor removal. David Cheever, firstly by his successfully repeated downfracture of the right hemimaxilla in one patient, who had complete recovery, followed by the technically successful total maxillary downfracture (although the patient died postoperatively), must occupy a foundation position in the history of the Le Fort I maxillary osteotomy.     

Dynamic analysis of maxillary perfusion during Le Fort I osteotomy using indocyanine green

The aim of this study was to evaluate the dynamic perfusion of the maxilla during various stages of a Le Fort I osteotomy using indocyanine green (ICG) dye angiography. This was a retrospective evaluation of patients who underwent a Le Fort I osteotomy. ICG was used to assess perfusion at specific time points during the procedure. Twenty-four patients underwent a Le Fort I osteotomy with dynamic perfusion ICG angiography. Statistically significant differences in perfusion were noted at all three locations assessed between preoperative (T0), post down-fracture (T1), and postoperative (T2) time points. When controlling for mean arterial pressure, statistically significant differences were noted at all three locations assessed between T0 and T1, and between T0 and T2. There were no statistically significant differences in patient age, heart rate, preservation or sacrifice of the descending palatine arteries, or conventional vs. segmental Le Fort I osteotomies across T0, T1, and T2. In conclusion, there was a statistically significant decrease in perfusion, as assessed by intraoperative dynamic angiography, to the anterior maxilla following maxillary down-fracture. Patient age, conventional vs. segmental Le Fort I osteotomy, changes in mean arterial pressure and/or heart rate, and preservation of the descending palatine vessels had no statistically significant effect on perfusion.     

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.     

A pilot study of the effects of transpalatal maxillary advancement on velopharyngeal closure in cleft palate patients

BACKGROUND AND AIMS: Impaired velopharyngeal closure function is sometimes a complication of a standard Le Fort I maxillary advancement in cleft palate patients. The transpalatal Le Fort I osteotomy has been suggested as an alternative technique that may avoid this problem. The aim of this pilot study was to examine the effects of the transpalatal approach on velopharyngeal function in a series of cleft palate patients. PATIENTS: Sixteen consecutive patients with a history of cleft palate exhibiting maxillary hypoplasia who underwent a transpalatal Le Fort I osteotomy. METHODS: All patients had a simultaneous audio/video speech recording and nasopharyngoscopy examination prior to maxillary advancement, followed by a repeat of the same examinations at least 1 year post-operatively. Velopharyngeal function was measured in two ways: by direct observation using nasopharyngoscopy, and indirectly by means of perceptual assessment. Reliability studies of the two measures were performed with satisfactory results. RESULTS: No statistically significant difference was found between the pre- and post-operative data in either the perceptual speech assessment or nasopharyngoscopy examination. CONCLUSION: These results indicate that maxillary advancement by transpalatal Le Fort I osteotomy does not adversely affect velopharyngeal closure function.     

Blood-flow and neurosensory changes in the maxillary dental pulp after differing Le Fort I osteotomies

PURPOSE: The objective of this study was to examine changes in blood flow and the recovery of sensibility in the maxillary dental pulp after two different types of maxillary osteotomies.Study design Nine patients (C-group) who underwent a combined of Le Fort I and horseshoe osteotomy and 14 patients (NC-group) who underwent a single-segment Le Fort I osteotomy were compared. Thirty-two (C-group) and 54 (NC-group) maxillary incisors were examined preoperatively and at 1-7 days, 14 days, and 3, 6, and 12 months postoperatively. The pulpal blood flow (PBF) was measured by laser Doppler flowmetry, and the pulpal sensibility (PS) was investigated by electrodiagnostics. RESULTS: In both groups, the PBF dropped to its lowest value at 1 day after surgery and increased thereafter. Though a temporary drop of the PBF was observed in the NC-group on day 4, the PS recovered earlier in the NC-group than in the C-group. CONCLUSION: These results suggest that the method of maxillary osteotomy influences the postoperative change of the PBF and recovery of the PS in the maxillary teeth.