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。     

Condylar and temporomandibular joint disc positions after mandibular osteotomy for prognathism

PURPOSE: The purpose of this study was to compare the changes in temporomandibular joint (TMJ) morphology and clinical symptoms after sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO) with and without a Le Fort I osteotomy. PATIENTS AND METHODS: Of 43 patients with a diagnosed jaw deformity, 20 underwent IVRO without internal fixation and 23 underwent SSRO with rigid internal fixation. Some operations were performed in combination with a Le Fort I osteotomy. The TMJ symptoms and joint morphology, including the disc position, were assessed preoperatively and postoperatively using magnetic resonance imaging (MRI) and axial cephalography. RESULTS: A significant difference in the direction of condylar rotation was seen in horizontal axial cephalography images (P <.01). Fewer or no TMJ symptoms were reported postoperatively by 88% of the patients who underwent IVRO with or without a Le Fort I osteotomy and by 66.7% of patients who underwent SSRO with or without a Le Fort I osteotomy. In sagittal images, no change was seen in anterior disc displacement after SSRO; however, improvement was seen in 44.4% of patients with anterior disc displacement who underwent IVRO with or without a Le Fort I osteotomy. CONCLUSION: These results suggest that SSRO does not improve anterior disc displacement; IVRO improves anterior disc displacement in the initial postsurgical period, and both procedures may improve TMJ symptoms.     

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.     

Stability of skeletal Class III malocclusion after combined maxillary and mandibular procedures

The aim of this study was to evaluate the skeletal stability and time course of postoperative changes after surgical correction of skeletal Class III malocclusion. Combined maxillary and mandibular procedures were performed in 40 consecutive patients. Bilateral sagittal split osteotomy stabilized with wire osteosynthesis for mandibular setback and low-level Le Fort I osteotomy stabilized with plates and screws for maxillary advancement were performed. Maxillomandibular fixation (MMF) was in place for 6 weeks. Lateral cephalograms were taken before surgery, immediately postoperatively, 8 weeks after surgery, and 1 year postoperatively. Patients were divided into 2 groups according to vertical maxillary movement at surgery: a maxilla-up group with upward movement of the posterior nasal spine of 2 mm or more (group 1, n = 22), and a minimal vertical change group with less than 2 mm of vertical repositioning (group 2, n = 18). The results indicate that surgical correction of Class III malocclusion with combined maxillary and mandibular osteotomies appears to be fairly stable. One year postsurgery, maxillary stability was excellent, with a mean horizontal relapse at point A that represented 10.7% of maxillary advancement in group 1 and 13.4% in group 2. In the vertical plane, maxillary stability was also excellent, with a mean of 0.18 mm of superior repositioning at point A for group 1 and 1.19 mm for group 2. The mandible relapsed a mean of 2.97 mm horizontally at pogonion in group 1 (62% of mandibular setback) and 3.41 mm (49.7% of setback) in group 2. Bilateral sagittal split osteotomy with wire osteosynthesis and MMF was not as stable as maxillary advancement and accounted for most of the total horizontal relapse (almost 85%) observed. A trend to relapse was observed for maxillary advancement greater than 6 mm, while the single variable accounting for mandibular relapse in group 1 was the amount of surgical setback. Clockwise rotation of the ascending ramus at surgery was not correlated with mandibular relapse in relation to the type of fixation performed and therefore does not seem to be responsible for relapse.     

Soft tissue changes associated with advancement genioplasty performed concomitantly with superior repositioning of the maxilla

A retrospective study of the osseous and soft tissue changes of the chins of ten patients treated for vertical maxillary excess by Le Fort I osteotomy and advancement genioplasty was undertaken. The patients were characterized by excessive lower anterior facial height, obtuse or normal nasolabial angles, prominent maxillary incisors, lip incompetence, everted lower lips, anterior open bites, lack of chin prominence, and excessive chin height. A change in the proportion of osseous to soft tissue of 1.0 to 0.87 was obtained by advancement genioplasty and concomitant superior repositioning of the maxilla by Le Fort I osteotomy.     

Stability of skeletal class III malocclusion after combined maxillary and mandibular procedures: rigid internal fixation versus wire osteosynthesis of the mandible.

PURPOSE: The aim of this study was to evaluate skeletal stability after double-jaw surgery for correction of skeletal Class III malocclusion to assess whether there were any differences between wire and rigid fixation of the mandible. PATIENTS AND METHODS: Thirty-seven Class III patients had Le Fort I osteotomy stabilized with plate and screws for maxillary advancement. Bilateral sagittal split osteotomy for mandibular setback was stabilized with wire osteosynthesis and maxillomandibular fixation for 6 weeks in 20 patients (group 1) and with rigid internal fixation in 17 patients (group 2). Lateral cephalograms were taken before surgery, immediately after surgery, 8 weeks after surgery, and 1 year after surgery. RESULTS: Before surgery, both groups were balanced with respect to linear and angular measurements of craniofacial morphology. One year after surgery, maxillary sagittal stability was excellent in both groups, and bilateral sagittal split osteotomy accounted for most of the total horizontal relapse observed. In group 1, significant correlations were found between maxillary advancement and relapse at the posterior maxilla and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. In group 2, significant correlations were found between mandibular setback and intraoperative clockwise rotation of the ramus and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. No significant differences in postoperative skeletal and dental stability between groups were observed except for maxillary posterior vertical position. CONCLUSIONS: Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure independent of the type of fixation used to stabilize the mandible.     

Maxillary stability following Le Fort I osteotomy in combination with sagittal split ramus osteotomy and intraoral vertical ramus osteotomy: a comparative study between titanium miniplate and poly-L-lactic acid plate.

PURPOSE: The purpose of this study was to compare changes in maxillary stability after Le Fort I osteotomy with titanium miniplate and poly-L-lactic acid (PLLA) plate (Fixsorb-MX; Takiron Co, Osaka, Japan). PATIENTS AND METHODS: The subjects were composed of 47 Japanese patients with diagnosed jaw deformity: 24 underwent Le Fort I osteotomy and sagittal split ramus osteotomy (SSRO); and 23 underwent Le Fort I osteotomy intraoral vertical ramus osteotomy without internal fixation. Each group was divided into titanium plate and PLLA plate groups. Time course changes between plate groups were compared using lateral and posteroanterior cephalography. RESULTS: Significant differences were identified between titanium plate and PLLA plate groups in A point after Le Fort I osteotomy and SSRO (P < .05). Significant differences existed between titanium plate and PLLA plate groups in vertical component of posterior nasal spine after Le Fort I osteotomy in both combinations with SSRO and intraoral vertical ramus osteotomy (P < .05). However, no significant differences were identified in measurements on posteroanterior cephalography. CONCLUSION: These results suggest a slight tendency for vertical impaction after Le Fort I osteotomy both in combination with SSRO and intraoral vertical ramus osteotomy with PLLA plates, although differences in time course changes were not clinically apparent, and normal occlusion was established in all patients.     

Post-operative stability of the maxilla treated with Le Fort I and horseshoe osteotomies in bimaxillary surgery

In this study, the post-operative change of the maxilla in six non-cleft patients who underwent combination (Le Fort I and horseshoe) osteotomy for superior repositioning of the maxilla was investigated. In all patients, the maxilla was first osteotomized and fixed with four Luhr plates. No iliac bone graft was applied to the maxilla. A bilateral sagittal split ramus osteotomy of the mandible (BSSRO) was then carried out and titanium screw fixation was performed. No maxillo-mandibular fixation (MMF) with stainless steel wire was used post-operatively in any patient. Lateral cephalograms were obtained pre-operatively, 5 days post-operatively, and 3, 6, and 12 months after surgery. The changes in anterior nasal spine (ANS), point A, upper incisor (U1), and point of maxillary tuberosity (PMT) were examined. The maxillae in the six subjects were repositioned nearly in their planned positions during surgery and no significant post-operative changes in the examined points of the maxilla were found. These results suggest that a combination of a Le Fort I and horseshoe osteotomy is a useful technique for reliable superior repositioning of the maxilla. The post-operative change in the maxilla using this combination osteotomy is comparatively stable.     

Maxillary stability after Le Fort I osteotomy with self-setting α-tricalcium phosphate and an absorbable plate

The purpose of this study was to compare retrospectively postoperative differences in maxillary stability after Le Fort I osteotomy and fixation with an unsintered hydroxyapatite (u-HA)/poly-l-lactic acid (PLLA) plate with or without self-setting α-tricalcium phosphate (Biopex^®) as interpositional material. Subjects comprised 45 patients diagnosed with mandibular prognathism with maxillary retrognathism and mandibular prognathism with bimaxillary asymmetry. All patients underwent Le Fort I osteotomy and bilateral sagittal split ramus osteotomy with fixation by uHA/PLLA plates. Patients were divided into 4 groups consisting of 9 maxillary impaction cases with Biopex^® (group 1) to fill the gap between the bone segments, 14 maxillary advancement cases with Biopex^® (group 2), 8 maxillary impaction cases without Biopex^® (group 3) and 14 maxillary advancement cases without Biopex^® (group 4). Changes in cepahalometric parameters at time intervals (1, 3 and 12 months) between the groups were compared. Results showed that stability did not depend on the use or otherwise of Biopex^®.     

2种不同正颌术式对骨性Ⅲ类错畸形患者上气道形态的影响

目的： 建立骨性Ⅲ类错畸形患者正颌手术前、后上气道三维模型，比较不同正颌术式对骨性Ⅲ类错畸形患者上气道各截面积及容积的影响。方法： 28例骨性Ⅲ类错畸形患者经正颌-正畸联合会诊，制定手术方案，分为2组，实验A组（12例）为单纯双侧下颌支矢状劈开术（BSSRO）后退，即单颌手术组，实验B组（16例）为下颌骨BSSRO 后退 +上颌骨Le Fort I型截骨术前移，即双颌手术组。所有患者于正颌手术前（T1）和术后3个月（T2）分别行CT扫描，基于CT图像，应用Dolphin Imaging 11.7软件建立包含腭咽、舌咽和喉咽腔在内的上气道三维模型，测量、比较2组患者在正颌手术前、后的上气道各截面、腔隙的矢状径、冠状径、横截面积和容积改变的差异。采用SPSS 16.0 软件包进行统计学分析。结果： 在腭咽段，实验A组手术后各项数值均较术前减小；实验B组手术后除冠状径外，其余数值均较术前增大，且2组变化有显著差异（P<0.05）。在舌咽段及喉咽段，2组手术后数值均减小。在横截面积和容积方面，实验A组较实验B组减小更加明显，2组的减小量有显著差异（P<0.05）。结论： 与单颌手术相比，双颌手术对骨性Ⅲ类错畸形患者上气道形态的减小改变影响较小。     

An orthodontic-orthognathic patient with obstructive sleep apnea treated with Le Fort I osteotomy advancement and alar cinch suture combined with a muco-musculo-periosteal V-Y closure to minimize nose deformity

In some severe skeletal Class III patients, mandibular setback surgery using sagittal split ramus osteotomy (SSRO) is performed to correct mandibular protrusion. However, in patients diagnosed with obstructive sleep apnea syndrome (OSAS), the risk of OSAS worsening as a result of the SSRO is very high. Maxillary advancement could reduce the degree of mandibular retropositioning and expand the skeletal framework in the pharyngeal region, leading to enlargement of the airway. However, nasal deformity is an undesirable outcome of the procedure. This case report describes a 23-year-old man with a retruded maxilla and OSAS. The maxillary retrusion was treated using Le Fort I osteotomy with an alar cinch suture and a muco-musculo-periosteal V-Y closure (ACVY). After treatment, better occlusal relationships and improvement in OSAS were observed. Thus, an ACVY could minimize nasolabial deformity.     

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唇腭裂患者常伴有不同程度的颌骨畸形,需要进行正颌外科治疗,手术方法包括常规正颌外科手术和上颌骨牵引成骨术。常规正颌外科手术最常用的是Le Fort Ⅰ型截骨术,适用于轻至中度的上颌后缩畸形,有时还需要配合双侧下颌升支矢状劈开截骨术(BSSRO)和颏成形术,以进一步改善面型和咬合关系。上颌骨牵引成骨术可采用外置式或内置式牵引器进行,截骨线可根据治疗需要采用Le Fort Ⅰ型截骨线或上颌前部截骨线。正颌外科和牵引成骨术各有其优点和局限性,如何选择合适的治疗方案应综合分析患者病情及医生临床经验,并与患者充分沟通,才能取得良好的矫治效果。     

Stability of orthodontic-maxillofacial surgical treatment of anterior open bite deformities]

A sample of 267 patients with maxillary hyperplasia, a Class I or Class II occlusion and anterior open bite, collected from three different institutions, was analysed regarding stability after Le Fort I intrusion osteotomies or bimaxillary osteotomies. Skeletal and dento-alveolar stability of the maxilla, postional changes of the mandible and of incisors were evaluated on cephalometric radiographs. The stability of maxillary arch dimensions after correction of the open bite is measured on dental casts. Patients with anterior open bite, treated with a Le Fort I osteotomy in one-piece or in multi-segments, with or without bilateral sagittal split osteotomy exhibited good skeletal stability of the maxilla. Rigid internal fixation showed better maxillary and mandibular stability than intraosseous wire fixation. Considerable relapse of transverse dimensions, however, was measured after orthodontic and surgical expansion. The mean overbite at the 69 months follow-up was 1.24 mm and lacking of overlap between opposing incisors was present in 19%.     

Le Fort Ⅰ型截骨术对上颌后缩患者腭咽部结构影响的研究

目的:探讨上颌Le Fort Ⅰ型截骨术对上颌后缩患者腭咽部结构的影响.方法:选择2007-2009年行上颌Le Fort Ⅰ型截骨术的上颌后缩伴随下颌前突患者42例(男20例,女22例,平均年龄21.6岁),所有患者在术前、术后1周、术后1年拍摄静止位头颅定位侧位片,然后对腭咽部软组织结构指标进行测量分析.结果:上颌...     

LactoSorb resorbable osteosynthesis after sagittal split osteotomy of the mandible: a 2-year follow-up

Twenty patients had sagittal split osteosynthesis performed with three or four 2.5-mm resorbable screws on each side without additional fixation. The screws consisted of a poly-L-latic/polyglycolic copolymer (LactoSorb). Of the 20 patients, 17 had mandibular advancement, two had mandibular setback, and one underwent unilateral mandibular advancement after previous condylectomy. Six patients underwent simultaneous Le Fort I osteotomy and four patients had simultaneous genioplasty. Postoperative training elastics were maintained for an average of 2.5 weeks. Six of the patients have been followed for 2 years, and 14 have been followed between 1 and 2 years without observable relapse and without clinical, radiological, or histological signs of healing complications. The resorbable osteosynthesis utilized in this series of sagittal split osteotomy seems to offer reliable stability during the period of bony healing without any adverse tissue reactions.     

Two-stage orthognathic treatment of severe class III malocclusion: report of a case

We report a two-stage orthognathic operation for a 16-year-old boy with a repaired isolated cleft palate. He had a severe class III malocclusion with an overjet of 20.4 mm. In the first stage, we did an anterior subapical segmental osteotomy with symphyseal ostectomy to reposition the mandibular anterior segment posteriorly and to reduce the transverse width of the mandible. During the second stage, we did a maxillary advancement by Le Fort I osteotomy, mandibular set-back by sagittal split osteotomy, reduction genioplasty, and shortening of the tongue. This unique two-stage surgical and orthodontic treatment considerably improved his overall facial aesthetics and occlusion.     

The impact of Le Fort I advancement and bilateral sagittal split osteotomy setback on ventilation during sleep

The impact of orthognathic surgery for class III malocclusion on ventilation during sleep was examined using a comparison of pre- and post-surgical respiratory parameters. 21 patients with both maxillary hypoplasia and mandibular excess underwent Le Fort I osteotomy and advancement together with bilateral sagittal split osteotomy (BSSO) setback. Respiratory parameters, ECG and position of the body were monitored before surgery and postoperatively after the fixation removal (mean 8.5 months). Average Le Fort I advancement was 4.44 mm, BSSO setback was 4.96 mm. Generally, the orthognathic procedure worsened breathing function during sleep, as reflected in significant increase of index of flow limitations and decrease in oxygen saturation. The posterior airways space decreased to 75% of its original volume, the distance between mandibular plane and hyoid bone increased to 133%. The results indicate that bimaxillary surgery for class III malocclusion increased upper airway resistance. A young person would probably be able to balance such a decline in respiratory function using different adaptive mechanisms, but the potential impact of orthognathic surgery on the upper airways should be incorporated in a treatment plan.     

Stability of skeletal Class III malocclusion after combined maxillary and mandibular procedures: titanium versus resorbable plates and screws for maxillary fixation.

PURPOSE: The aim of this study was to evaluate skeletal stability after double jaw surgery for correction of skeletal Class III malocclusion to assess if there were any differences between resorbable plate and screws and titanium rigid fixation of the maxilla. PATIENTS AND METHODS: Twenty-two Class III patients had bilateral sagittal split osteotomy for mandibular setback stabilized with rigid internal fixation. Low level Le Fort I osteotomy for maxillary advancement was stabilized with conventional titanium plate and screws in 12 patients (group 1) and with resorbable plate and screws in 10 patients (group 2). Lateral cephalograms were taken before surgery, immediately postoperatively, 8 weeks after surgery, and 1 year postoperatively. RESULTS: Before surgery both groups were balanced with respect to linear and angular measurements of craniofacial morphology. One year after surgery, maxillary stability was excellent in both groups. In group 1 no significant correlations were found between maxillary advancement and relapse. In group 2, significant correlations were found between maxillary advancement and relapse at A point and posterior nasal spine. No significant differences in postoperative skeletal and dental stability between groups were observed. CONCLUSION: Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure for maxillary advancements up to 5 mm independently from the type of fixation used to stabilize the maxilla. Resorbable devices should be used with caution for bony movements of greater magnitude until their usefulness is evaluated in studies with large maxillary advancements.     

One-stage approach to the correction of facial skeletal deformity with malocclusion

A total of 40 patients with varying degrees of facial skeletal deformity and Class III malocclusion were treated by bimaxillary osteotomy combining maxillo-malar augmentation and/or osseous genioplasty at the same sitting by the author. In all patients, the maxillary advancement and mandibular set back were performed, using Le Fort I maxillary osteotomy and bilateral sagittal split osteotomy of the mandibular rami. In additional bimaxillary osteotomy, simultaneous maxillo-malar augmentation and genioplasty in 20 patients, genioplasty in 12 patients, maxillo-malar augmentation in eight patients, were performed to improve facial harmony. All patients were followed clinically and radiographically for at least 1 year and as much as 5 years after undergoing surgical correction. No cases with relapse or other major complications have been encountered up to now. There were, however, persisting unilateral inferior alveolar nerve damage in two patients, prolonged nerve anesthesia or hypoesthesia in four patients, and short period anesthesia or hypoesthesia in 11 patients, wide alar base in three patients and slight deviation of cartilage septum in two patients. There were no other complications encountered and an unexpected result. The facial skeletal deformity and malocclusion were always treated satisfactorily as patient and plastic surgeon's expectations in one-stage operation, without significant complications and morbidity.     

Comparison of the long-term skeletal stability between a biodegradable and a titanium fixation system following BSSO advancement — A cohort study based on a multicenter randomised controlled trial

Biodegradable fixation systems could reduce or eliminate the problems associated with removal of titanium plates. A multicenter randomised controlled trial (RCT) was performed in the Netherlands from December 2006-July 2009, and originally 230 injured and orthognathic patients were included. The patients were randomly assigned to either a titanium control group (KLS Martin) or to a biodegradable test group (Inion CPS). The aim of the present study was to compare the long-term skeletal stability of advancement bilateral sagittal split osteotomies (BSSO) of a biodegradable system and a titanium system. Only patients from the original RCT who were at least 18 years old and who had a BSSO advancement osteotomy were included. Those who had simultaneous Le Fort I osteotomy or genioplasty were excluded. Analysis of skeletal stability was made by digital tracing of lateral cephalograms.