A complication of Le Fort I osteotomy

Le Fort I osteotomy is a routine procedure for oral and maxillofacial surgeons. Following advances in instrumentation and anaesthesia, it is usually carried out safely as an elective procedure in hospitals with no adverse complications. Life-threatening complications are rare although the operation is performed in an area with an extensive vascular supply. The authors report a case of Le Fort I osteotomy that resulted in an unusual complication of cerebrospinal fluid leak.     

Evaluation of Post-operative Complication Rate of Le Fort I Osteotomy: A Retrospective and Prospective Study

Le Fort I osteotomy has become a routine procedure in elective orthognathic surgery. This procedure is often associated with significant but rare post-operative complications. The study was conducted to evaluate the rate of post-operative complications following conventional Le Fort I osteotomy. Twenty-five healthy adult patients who had to undergo Le Fort I osteotomy without segmentalization of maxilla were included in the study based on indications of surgery. All the patients were followed up for a period of 6 months post-operatively to assess the rate of various post-operative complications such as neurosensory deficit, pulpal sensibility, maxillary sinusitis, vascular complications, aseptic necrosis, unfavourable fractures, ophthalmic complications and instability or non-union of maxilla, etc. The results of our study showed a post-operative complications rate of 4 %. Neurosensory deficit and loss of tooth sensibility were the most common findings during patient evaluation at varying follow-up periods while one patient presented with signs and symptoms of maxillary sinusitis post-operatively. Neurosensory as well as sinusitis recovery took place in almost all the patients within 6 months. It was concluded that thorough understanding of pathophysiological aspects of various complications, careful assessment, treatment planning and the use of proper surgical technique as well as instrumentation may help in further reducing the complication rate.     

Cranial nerve injury after Le Fort I osteotomy

A Le Fort I osteotomy is widely used to correct dentofacial deformity because it is a safe and reliable surgical method. Although rare, various complications have been reported in relation to pterygomaxillary separation. Cranial nerve damage is one of the serious complications that can occur after Le Fort I osteotomy. In this report, a 19-year-old man with unilateral cleft lip and palate underwent surgery to correct maxillary hypoplasia, asymmetry and mandibular prognathism. After the Le Fort I maxillary osteotomy, the patient showed multiple cranial nerve damage; an impairment of outward movement of the eye (abducens nerve), decreased vision (optic nerve), and paraesthesia of the frontal and upper cheek area (ophthalmic and maxillary nerve). The damage to the cranial nerve was related to an unexpected sphenoid bone fracture and subsequent trauma in the cavernous sinus during the pterygomaxillary osteotomy.     

Delayed presentation of pseudoaneurysm after Le Fort I osteotomy

Although the osteotome is positioned in close vicinity to the maxillary artery and its branches during ptergomaxillary separation in a Le Fort I osteotomy, postoperative complications from vascular injuries are rare. The following report describes an unusual occurrence of a maxillary artery pseudoaneurysm following a Le Fort I and bilateral sagittal-split osteotomies for correction of mandibular and maxillary asymmetries in a patient with Goldenhar syndrome. This was recognized 8 months after the procedure when the patient developed acute facial swelling and required an emergent angiogram for uncontrolled bleeding. Vascular anatomy in the ptergomaxillary area is reviewed. A level of suspicion of occult vascular injuries in patients with sudden onset of unilateral facial swelling after orthognathic surgery, even months after the procedure, is recommended.     

Le Fort I osteotomy using an ultrasonic bone curette to fracture the pterygoid plates

PURPOSE: The purpose of this study was to evaluate the advantageous use of an ultrasonic bone curette and to assess the mobilization of the pterygoid process after a Le Fort I osteotomy. MATERIAL AND METHODS: 14 Japanese adults (ranging in age from 17 to 30 years, mean 22.4) with jaw deformities diagnosed as mandibular prognathism or bimaxillary asymmetry underwent Le Fort I osteotomy with bilateral sagittal split ramus osteotomy or intraoral vertical ramus osteotomy. During the Le Fort I osteotomy, the Sonopet UST-2000 ultrasonic bone curette was used to fracture the pterygoid process slightly above the level of the maxillary osteotomy without damaging the descending palatine artery or other blood vessels and nerves. After surgery, the pterygoid process osteotomy and its mobility were evaluated from three-dimensional computed tomographic images. RESULTS: In all cases, the mobility of the pterygoid process could be achieved by using the device safely with minimal bleeding and no notable complications. The maxillary segment could be fixed in an ideal position and in all 14 cases, an ideal profile was achieved. CONCLUSION: Ultrasonic bone curette offers a safe procedure for performing pterygoid process fractures without damaging the surrounding tissue such as the descending palatine artery.     

Prospective study of the incidence of serious posterior maxillary haemorrhage during a tuberosity osteotomy in low level Le Fort I operations

The incidence of serious haemorrhage in Le Fort I osteotomy is low and attempts to reduce this further have led to the development of various techniques to minimise vascular injury. This includes the tuberosity osteotomy and was published over two decades ago. This technique has not been widely adopted as shown by a recent UK survey of consultants, which suggested that only 12 (7%) of the 175 surgeons who responded, routinely use tuberosity osteotomy in non-cleft low level Le Fort I procedures. The aim of the study was to examine prospectively the incidence of serious haemorrhage from the posterior maxilla during tuberosity osteotomy. We report 35 consecutive patients who have had no operative or postoperative vascular complications.     

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.     

Traumatic arteriovenous malformation following maxillary Le Fort I osteotomy.

OBJECTIVE: Complications following maxillary Le Fort I osteotomy are rare. The authors present the rare complication of an arteriovenous malformation following such a procedure in a 25-year-old woman with a cleft lip and palate that was treated successfully with radiologically guided embolization.     

Modified Le Fort I (maxillary-zygomatic) osteotomy: rationale, basis, and surgical technique

A modified version of the Le Fort I maxillary osteotomy is described. The esthetic and anatomic basis, the surgical technique, and possible complications are discussed and two representative cases are shown. This technique has been used to treat 38 patients with various degrees of combined maxillary-zygomatic deficiency in the last 3 years. Based on this experience, it is concluded that this procedure provides a predictable esthetic result and excellent skeletal stability with few intraoperative and postoperative complications. Furthermore, the need for simultaneous bone grafting or alloplastic implants, as in the conventional Le Fort I, is virtually eliminated using this osteotomy.     

Quadrangular Le Fort I osteotomy: surgical technique and review of 54 patients

Technical aspects and indications for the quadrangular Le Fort I osteotomy are described. The records of 54 consecutive patients who underwent this procedure for primary correction are reviewed in general terms, and those of 3 patients with significant follow-up are presented in some detail. The procedure gave predictable results, provided acceptable midfacial aesthetic improvement, and was surgically reproducible with few complications. Low surgical and postoperative morbidity was documented. This procedure was used in a similar patient population as the quadrangular Le Fort II osteotomy, and the rationale for choosing between these two procedures is discussed.     

唇腭裂患者牵张成骨术后的侧貌变化

目的：通过对唇腭裂术后继发上颌骨发育不足患者进行口外支架式前牵张治疗术后6～24个月的随访,观察分析其侧貌变化,为合理使用牵张器提供参考。方法：选取1998—2002年间上海交通大学医学院附属第九人民医院进行牵张成骨治疗、按时随访的唇腭裂患者14例进行术后随访分析。随访期分别为术后3、6、12、24个月,分别拍摄头颅定位侧位片及照片,记录患者的侧貌变化。结果：14例患者在牵张成骨术后6个月,至术后24个月,3例表现为双颌前突畸形,3例仍表现为面中部凹陷,1例表现为前牙开。结论：牵张成骨术治疗唇腭裂术后上颌骨发育不足患者具有一定优势,但牵张方向及牵张量难以控制,术后侧貌时不尽满意。因此,唇腭裂患者继发上颌骨发育不足在行牵张成骨术治疗时,应综合考虑多种因素的影响。     

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.     

The 2-piece Le Fort I osteotomy for cranial base access: an evaluation of 9 patients.

PURPOSE: This article discusses the use of the 2-piece Le Fort I osteotomy to gain access to the cranial base and the authors' experiences with this technique. METHODS: Medical records of patients who required surgical access to the cranial base were retrospectively reviewed, and demographic data, procedures done, postoperative results, and complications were recorded. RESULTS: Nine patients underwent a 2-piece Le Fort I osteotomy. Complications included development of a pseudoaneurysm of the internal carotid artery in 1 patient, 2 cerebrospinal fluid leaks, both of which resolved, and 1 patient who lost 2 teeth and some associated bone. CONCLUSION: The 2-piece Le Fort I osteotomy provides excellent access to the clival region of the cranial base with minimal complications.     

The modified Le Fort III osteotomy in the correction of mid-facial deficiency. Case reports

Maxillary hypoplasia is a common diagnosis in the spectrum of dentofacial deformities and is usually corrected by a Le Fort I maxillary advancement osteotomy. The modified Le Fort III osteotomy enables correction of mid-face hypoplasia where the maxillary hypoplasia is associated with infraorbital and zygomatic deficiency. This procedure is described and illustrated in two case reports. It is considered to be a superior technique to the maxillary osteotomy and onlay procedure and is recommended for use in selected patients.     

Pattern of pterygomaxillary disarticulation associated with Le Fort I maxillary osteotomy

Pterygomaxillary disarticulation (PMD) contributes to surgical complications of Le Fort 1 osteotomy and is associated with undesirable fractures of the pterygoid plates. The aim of this paper was to investigate the patterns of PMD in Le Fort I osteotomies using Rowe's disimpaction forceps, and to evaluate correlations with age and anatomical measurements. Cone-beam computed tomography (CBCT) scans of 70 consecutive orthognathic patients were retrospectively evaluated to study four patterns of PMD: Type 1 - PMD at, or anterior to, the pterygomaxillary junction (PMJ); Type 2 - PMD posterior to the PMJ; Type 3 - PMJ separation with comminuted fracture of the pterygoid plates; Type 4 - disarticulation of the maxilla involving the pterygoid plates above the level of the osteotomy line. The preoperative anteroposterior and mediolateral thicknesses of the PMJ and the length of the medial and lateral pterygoid plates were assessed. Satisfactory PMD was achieved in all cases and no severe complications were reported, including vascular, dental, mucosal, or neural damage. The most common PMD was Type 1 (54.3%), followed by Type 2 (40%). Comminuted fracture of the pterygoid plates was limited to 5.7% of cases, and no Type 4 was detected. A weak correlation was detected between PMJ thickness and PMD pattern (p = 0.04). No statistically significant correlation was detected between patients’ age and type of PMD. PMD of Le Fort I maxillary osteotomy using a Smith spreader and Rowe's disimpaction forceps proved safe, with minimal damage to the pterygoid plates.     

Blindness after Le Fort I osteotomy: a possible complication associated with pterygomaxillary separation.

INTRODUCTION: Visual loss after Le Fort I osteotomy is a devastating complication the mechanism of which is not always clear. METHODS: A case report of blindness following Le Fort I osteotomy is presented. The literature on the various skull base complications associated with Le Fort I osteotomies is reviewed and the mechanisms of these complications discussed. CONCLUSION: The radiological findings in this case are similar to those previously reported. They strongly support the hypothesis that an adverse transmission of forces associated with pterygomaxillary separation via the sphenoid bone to the intra- and extracranial portions of the skull base is the main reason for injury to the optic and other cranial nerves as well as to the branches of the carotid artery.     

Blindness and basal ganglia hypoxia as a complication of Le Fort I osteotomy attributable to hypoplasia of the internal carotid artery: a case report

Le Fort I osteotomy is used as a surgical procedure for correction of maxillofacial deformities. The common complications of this procedure are hemorrhage and infection, with incidence of 6% to 9%. Blindness associated with Le Fort I osteotomy was reported in 8 patients. An 18-year-old female complained of loss of sight in the left eye after recovery from hypotensive general anesthesia. The visual field of the left eye was dark and only perceived some movement. She presented with motor dysfunction and regressive behavior 2 weeks later as a result of hypoxia of bilateral basal ganglia. Two months later, her visual acuity recovered gradually and regressive behavior improved. Carotid angiography showed congenital hypoplasia of the left internal carotid artery. We suspected that hypoplasia could cause hypoxia of the central nervous system.     

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.     

Peri- and postoperative complications in Le Fort I osteotomies

This retrospective study was performed to report the peri- and postoperative complications encountered by patients who underwent Le Fort I osteotomy, as well as predictor variables affecting the risk of complications.Patients who underwent only Le Fort I osteotomy were included in the study. Information on peri- and postoperative complications were collected from the patient data records. The effects of certain predictor variables on complication rates were also studied.Twenty-four per cent of the patients suffered from complications, six (6.1%) of whom were reoperated. Most of the complications were minor and transient. Compared with one-piece osteotomy, segmental osteotomy was a significant risk factor predisposing patients to postoperative complications (p = 0.04619). Additionally, the use of patient-specific implants seemed to increase the risk of both perioperative and postoperative complications (p = 0.0248).Currently, the conventional plate fixation method is the primary method in Le Fort I osteotomies. Careful patient selection, surgical planning, and selection of surgical technique seem to be the most important factors in reducing the complication risk. Special attention should be paid with segmental osteotomy surgery.     

Long-term evaluation of human teeth after Le Fort I osteotomy: a histologic and developmental study

Transient pulpal vascular ischemia and direct injury to the apices of the teeth have been implicated as the causes of degenerative and atrophic pulpal changes in experimental animals after Le Fort I osteotomy despite the presence of collateral circulation. The long-term clinical effect of these pathologic changes in human teeth has not been studied. Seventeen maxillary third molar teeth from 10 patients whose postsurgical follow-up ranged from 6 months to 78 months (mean, 40 months) were extracted. The long-term biologic effects of Le Fort I osteotomy on the pulp and on the development of teeth were retrospectively evaluated with clinical and standard histologic techniques. Normal teeth from patients who were not operated on were used as controls. Histologic examination revealed an intact pulpal circulation and minimal pathologic changes in the pulpal tissue. Clinical and radiographic studies showed that the growing teeth developed normally after surgery. The Le Fort I downfracture procedure had little discernible long-term effect on the pulp and on the development of human third molar teeth.