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A case of maxillary partial aseptic necrosis after Le Fort I osteotomy
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Case Report
A case of maxillary partial aseptic necrosis after Le Fort I osteotomy ⁎
Hiroshi Katoa, , Akira Watanabea, Masayuki Takanoa, Mitsutaka Yoshidab, Yasutomo Yajimab, Takahiko Shibaharaa a b
Department of Oral and Maxillofacial Surgery, Tokyo Dental College, Japan Department of Oral and Maxillofacial Implantology, Tokyo Dental College, Japan 2-9-18 Kanda Misakicho, Chiyoda-ku, Tokyo, 100-0061, Japan
A R T I C LE I N FO
A B S T R A C T
Keywords: Complication Aseptic necrosis Maxilla Le Fort I osteotomy Reconstruction
While orthognathic surgery is now a safe and established procedure, it poses associated complications, similarly to every surgical procedure. Aseptic necrosis is an ischemic complication associated with orthognathic surgery. Although aseptic necrosis is a serious complication, treatment protocol has not yet been established. Herein we reported a case of aseptic necrosis occurring in the maxilla following Le Fort I (LFI) osteotomy. The patient was a 25-year-old woman referred to our hospital with a chief complaint of maxillary alveolar bone exposure. She had been submitted to horseshoe-type LFI osteotomy and bilateral sagittal split ramus osteotomy two months earlier. At initial visit, osseous non-union of the maxilla and exposure of the right anterior maxillary alveolar bone were observed. At first surgery, necrotic alveolar bone and soft tissue were debrided, titanium plates were removed, and a new titanium plate was provided for adequate osteosynthesis in left-side bone gap under general anesthesia. At second surgery, 11.12.13.14 were extracted and alveolus was reconstructed by iliac crest graft. In addition, 21 was extracted under local anesthesia owing to tooth mobility, and root canal treatment to 22.23 was performed. After 6 months, the plates were removed, and four implants were placed. At third surgery, oral vestibular extension operation was performed. Five years following the initial procedure, the patient achieved normal occlusion and dentofacial appearance.
1. Introduction
2. Case report
Le Fort I (LFI) osteotomy has become a common surgery for maxillary deformities. However, similarly to most other orthognathic surgical procedures, it has several associated complications [1–4]. Recently, ultrasonic bone scalpel has enabled to start performing orthognathic surgery with less complications [5–7]. Although orthognathic surgery is now a safe and established procedure, careful attention should be paid to prevent complications. Ischemic maxilla complications have been reported in the literature as one of LFI osteotomyrelated complications [8]. Aseptic necrosis is reported to be caused by several factors, including transversal segmental LFI osteotomy, extensive anterior dislocation of the maxilla over 9 mm, perforation of the palatal mucosa, descending palatine artery (DPA) injury, anatomical irregularity, and smoking habits, among others [9]. Although some reports of aseptic necrosis treatment can be found in the literature, treatment protocol has not been established yet [10–12]. In this report, a case of maxillary partial aseptic necrosis after LFI osteotomy, reconstructed by iliac bone grafting and dental implant prostheses, is described.
A 25 year-old-woman was referred to our hospital with a chief complaint of maxillary alveolar bone exposure. Two months earlier, she had been submitted to orthognathic surgery with LFI osteotomy and bilateral sagittal split ramus osteotomy in another hospital for occlusion and gummy smile improvement. Postoperatively, the patient was aware of the right anterior maxillary alveolar bone exposure and nasal leakage owing to a fistula in the right-side posterior palatal mucosa. After hyperbaric oxygen treatment, nasal leakage and palatal mucosa condition improved; however, maxilla condition did not completely improve. At initial visit to our hospital, osseous non-union of the maxilla and exposure of the right anterior maxillary alveolar bone were observed. Intraoral findings indicated that the patient had been submitted to LFI osteotomy with gingival incision, and the condition of the palatal mucosa was cured. Computed tomography indicated that LFI osteotomy that the patient had undergone was the horseshoe-type osteotomy and that segmental cuts of the palatal bone, separating the right anterior alveolar and palatal bones, were not necrotic (Fig. 1). As initial treatment, sequestra were irrigated with normal saline until no pus
⁎
Corresponding author at: Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 2-9-18 Kanda Misakicho, Chiyoda-ku, Tokyo, 100-0061, Japan. E-mail address: [email protected] (H. Kato).
https://doi.org/10.1016/j.ajoms.2019.08.002 Received 3 July 2019; Received in revised form 20 August 2019; Accepted 26 August 2019 2212-5558/ © 2019 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd All rights reserved.
Please cite this article as: Hiroshi Kato, et al., Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, https://doi.org/10.1016/j.ajoms.2019.08.002
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
H. Kato, et al.
Fig. 1. Oral findings (A: frontal view, B: lateral view, C: occlusal view) and imaging findings at first visit. Arrows show exposure of the right anterior maxillary alveolar bone (A, B, C). Panoramic radiographs showing the radiolucent area in the right anterior maxilla (D). Computed tomography images showing maxilla cut into horseshoe shape, segmental cuts of the palatal bone, and separated right anterior alveolar bone (E, F, G, H).
6.4% of patients experience surgery-related complications, including nasal septum deviations (1.6%), osseous non-unions (1.0%), insufficient osteofixations (0.5%), hemorrhages requiring blood transfusion (1.1%), infections (1.1%), and ischemic complications (1.0%, including 0.2% of aseptic alveolar process necrosis and 0.8% of gingival retraction) [8]. Aseptic necrosis is one possible ischemic problem arising from maxilla multiple segmentation, together with others as conjunction with superior positioning, transversal segmental LFI osteotomy, extensive anterior dislocation of the maxilla over 9 mm, perforation of palatal mucosa, DPA injury, anatomical irregularity, and smoking habits [9]. In the present clinical case, as the initial surgical team’s original records and comments were unavailable, ischemic factors, such as DPA injury, palatal mucosa perforations, and segmental LFI osteotomy with gingival incision, were hypothesized as underlying causes because the patient had no anatomical abnormalities, was a nonsmoker, and presented little extensive anterior maxilla dislocation. For repositioning the superior maxilla in LFI osteotomy, it was required to remove the bony interference around DPA, which often torments operators due to technical difficulty. To circumvent this problem, instruments for DPA protection have been developed and surgical procedures have been accordingly adapted [13]. Johnson and Arnett [14] previously reported pyramidal osseous release around DPA using a rotary bur and Molt curette or fine chisel for maxillary impaction. Regan and Bharadwaj [15] described a modified technique of bony release from palatine bone’s pyramidal process using spatula osteotomies around DPA. More recently, surgical devices have been developed—such as ultrasonic bone scalpel—which allow to reduce injury to the DPA. It has been suggested that preserving DPA during LFI osteotomy is important to optimize maxillary integrity by maintaining blood nutrition to the anatomical area and decreasing ischemic necrosis risk. Additionally, compared with vestibular incision, gingival incision may have a negative impact on mucosa vascular flow, potentially eliciting ischemic
Fig. 2. Panoramic radiograph after first surgery. Separated sequestra and 11.12 dental roots are removed.
persisted. Subsequently, at first surgery, necrotic alveolar bone and soft tissue were debrided, titanium plates were removed, and a new titanium plate was provided for adequate osteosynthesis in left-side bone gap under general anesthesia (Fig. 2). At second surgery, 11.12.13.14 were extracted and alveolus was reconstructed with an iliac crest graft (Fig. 3). Additionally, 21 was extracted under local anesthesia due to tooth mobility, and root canal treatment was performed on 22.23. After 6 months, the plates were removed, and four implants were placed. At third surgery, oral vestibular extension operation was performed; mucosa was peeled on the periosteum and covered with collagen-based artificial dermis (Fig. 4). Five years after the initial procedure, the patient acquired good occlusion and dentofacial appearance (Fig. 5). 3. Discussion Although orthognathic surgery is a safe and common procedure in oral and maxillofacial surgery, it has several associated complications. A review of LFI osteotomy complications in 1000 patients revealed that
Fig. 3. Surgical findings at second surgery: iliac bone graft operation (A). Panoramic radiograph and cone-beam computed tomography images after second surgery. 11.12.13.14 were extracted and alveolus was reconstructed with an iliac crest graft (B, C). 2
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
H. Kato, et al.
Fig. 4. Surgical findings at third surgery: oral vestibular extension operation. Incision line (A) and wound surface is covered with collagen-based artificial dermis (B).
Fig. 5. Oral and imaging findings after treatment. (A) Intraoral view. (B) Panoramic radiograph. Prosthesis is in place and function is good.
Funding
problems in horseshoe-type LFI osteotomy. Severe cases of aseptic necrosis have been described in past reports [10–12]. One case improved with antibiotics and hyperbaric oxygen, whereas others required bone graft reconstruction. According to recommendations, in cases of serious postoperative vascular flow circulation problems, surgeons should immediately return the segment to original position [9]. Aseptic necrosis treatment initially requires optimal oral hygiene, accomplished by frequent saline solution irrigation and self-home care. In parallel, patients should be treated with hyperbaric oxygen, and antibiotics should be considered to prevent secondary infection. Surgical debridement is required to remove necrotic bone fragments, allowing earlier wound healing, and hard and soft tissue reconstruction is subsequently executed as necessary [10,11]. Finally, implant-supported fixed prosthesis is performed for adequate esthetic outcomes. In the present case, the patient could achieve good occlusion and dentofacial appearance through iliac crest graft reconstruction and dental implants. To recover bone volume, autogenous bone graft currently remains the standard of care [16]. When large bone amounts are required, extraoral sources—as calvaria, iliac crest, tibia, and fibula—are preferred. Extraoral grafts have been acknowledged as a good solution to correct bone lack, obtaining a large quantity of bone tissue and having a lower resorption rate than intraoral bone graft during healing process [17,18]. Iliac bone graft, one of the most common donor sites for autogenous bone graft, was selected in the present case due to bone accessibility and adequate cortical and cancellous bone availability. Aseptic necrosis may have substantial detrimental consequences to patients. Although the incidence of aseptic necrosis in LFI osteotomy is low, clinicians should seek to further reduce its risk by using optimal surgical devices and operation techniques.
This report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Competing Interest None declared. Acknowledgment The authors would like to thank Enago (www.enago.jp) for the English language review. References [1] Iannetti G, Fadda TM, Riccardi E, Mitro V, Filiaci F. Our experience in complications of orthognathic surgery: a retrospective study on 3236 patients. Eur Rev Med Pharmacol Sci 2013;17:379–84. [2] Kim SG, Park SS. Incidence of Complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 2007;65:2438–44. [3] Patel PK, Morris DE, Gassman A. Complications of orthognathic surgery. J Craniofac Surg 2007;18:975–85. [4] Panula K, Finne K, Oikarinen K. Incidence of complications and problems related to orthognathic surgery: a review of 655 patients. J Oral Maxillofac Surg 2001;59:1128–36. [5] Silva LF, Carvalho-Reis ENR, Bonardi JP, de Lima VN, Momesso GAC, Garcia-Junior IR, et al. Comparison between piezoelectric surgery and conventional saw in sagittal split osteotomies: a systematic review. Int J Oral Maxillofac Surg 2017;46:1000–6. [6] Dammous S, Dupont Q, Gilles R. Three-dimensional computed tomographic evaluation of bilateral sagittal split osteotomy lingual fracture line and le fort I pterygomaxillary separation in orthognathic surgery using cadaver heads: ultrasonic osteotome versus conventional saw. J Oral Maxillofac Surg 2015;73:1169–80. [7] Landes CA, Stübinger S, Ballon A, Sader R. Piezoosteotomy in orthognathic surgery versus conventional saw and chisel osteotomy. Oral Maxillofac Surg 2008;12:139–47. [8] Figueroa AA, Polley JW. Intra- and perioperative complications of the LeFort I osteotomy: a prospective evaluation of 1000 patients. J Craniofac Surg 2004;15:978–9. [9] Pereira FL, Yaedú RY, Sant’Ana AP, Sant’Ana E. Maxillary aseptic necrosis after le fort I osteotomy: a case report and literature review. J Oral Maxillofac Surg 2010;68:1402–7.
Ethical approval This report received ethical approval from our institution’s Ethics Review Board and informed consent was obtained. 3
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
H. Kato, et al.
[15] Regan BO, Bharadwaj G. The identification and protection of the descending palatine artery in Le Fort I osteotomy: a forgotten technique? Br J Oral Maxillofac Surg 2007;45:412–4. [16] Cunha G, Rocha AFL, Filho VAP, Gabrielli MFR, Gabrielli MAC. Atrophic maxilla reconstruction with autogenous iliac graft and guided dental implants. J Craniofac Surg 2018;29:2218–9. [17] Dreiseidler T, Kaunisaho V, Neugebauer J, Zöller JE, Rothamel D, Kreppel M. Changes in volume during the four months’ remodelling period of iliac crest grafts in reconstruction of the alveolar ridge. Br J Oral Maxillofac Surg 2016;54:751–6. [18] Tetè S, Vinci R, Zara S, Zizzari V, De Carlo A, Falco G, et al. Long-term evaluation of maxillary reconstruction by iliac bone graft. J Craniofac Surg 2011;22:1702–7.
[10] Behnia H, Nazerani S, Motamedi MH, Dashti H. Comprehensive reconstruction of the maxilla after a failed premaxillary osteotomy: a case report with long-term follow-up. Ann Plast Surg 2009;62:59–62. [11] Singh J, Doddridge M, Broughton A, Goss A. Reconstruction of post-orthognathic aseptic necrosis of the maxilla. Br J Oral Maxillofac Surg 2008;46:408–10. [12] Lanigan DT, Hey JH, West RA. Aseptic necrosis following maxillary osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48:142–56. [13] Omura S, Iwai T, Murata S, Tohnai I. Use of a simple handmade retractor to protect the descending palatine artery during removal of posterior osseous interferences for maxillary impaction in Le Fort I osteotomy. J Craniofac Surg 2013;24(May):978–9. [14] Johnson LM, Arnett GW. Pyramidal osseous release around the descending palatine artery: a surgical technique. J Oral Maxillofac Surg 1991;49:1356–7.
4
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Case Report
A case of maxillary partial aseptic necrosis after Le Fort I osteotomy ⁎
Hiroshi Katoa, , Akira Watanabea, Masayuki Takanoa, Mitsutaka Yoshidab, Yasutomo Yajimab, Takahiko Shibaharaa a b
Department of Oral and Maxillofacial Surgery, Tokyo Dental College, Japan Department of Oral and Maxillofacial Implantology, Tokyo Dental College, Japan 2-9-18 Kanda Misakicho, Chiyoda-ku, Tokyo, 100-0061, Japan
A R T I C LE I N FO
A B S T R A C T
Keywords: Complication Aseptic necrosis Maxilla Le Fort I osteotomy Reconstruction
While orthognathic surgery is now a safe and established procedure, it poses associated complications, similarly to every surgical procedure. Aseptic necrosis is an ischemic complication associated with orthognathic surgery. Although aseptic necrosis is a serious complication, treatment protocol has not yet been established. Herein we reported a case of aseptic necrosis occurring in the maxilla following Le Fort I (LFI) osteotomy. The patient was a 25-year-old woman referred to our hospital with a chief complaint of maxillary alveolar bone exposure. She had been submitted to horseshoe-type LFI osteotomy and bilateral sagittal split ramus osteotomy two months earlier. At initial visit, osseous non-union of the maxilla and exposure of the right anterior maxillary alveolar bone were observed. At first surgery, necrotic alveolar bone and soft tissue were debrided, titanium plates were removed, and a new titanium plate was provided for adequate osteosynthesis in left-side bone gap under general anesthesia. At second surgery, 11.12.13.14 were extracted and alveolus was reconstructed by iliac crest graft. In addition, 21 was extracted under local anesthesia owing to tooth mobility, and root canal treatment to 22.23 was performed. After 6 months, the plates were removed, and four implants were placed. At third surgery, oral vestibular extension operation was performed. Five years following the initial procedure, the patient achieved normal occlusion and dentofacial appearance.
1. Introduction
2. Case report
Le Fort I (LFI) osteotomy has become a common surgery for maxillary deformities. However, similarly to most other orthognathic surgical procedures, it has several associated complications [1–4]. Recently, ultrasonic bone scalpel has enabled to start performing orthognathic surgery with less complications [5–7]. Although orthognathic surgery is now a safe and established procedure, careful attention should be paid to prevent complications. Ischemic maxilla complications have been reported in the literature as one of LFI osteotomyrelated complications [8]. Aseptic necrosis is reported to be caused by several factors, including transversal segmental LFI osteotomy, extensive anterior dislocation of the maxilla over 9 mm, perforation of the palatal mucosa, descending palatine artery (DPA) injury, anatomical irregularity, and smoking habits, among others [9]. Although some reports of aseptic necrosis treatment can be found in the literature, treatment protocol has not been established yet [10–12]. In this report, a case of maxillary partial aseptic necrosis after LFI osteotomy, reconstructed by iliac bone grafting and dental implant prostheses, is described.
A 25 year-old-woman was referred to our hospital with a chief complaint of maxillary alveolar bone exposure. Two months earlier, she had been submitted to orthognathic surgery with LFI osteotomy and bilateral sagittal split ramus osteotomy in another hospital for occlusion and gummy smile improvement. Postoperatively, the patient was aware of the right anterior maxillary alveolar bone exposure and nasal leakage owing to a fistula in the right-side posterior palatal mucosa. After hyperbaric oxygen treatment, nasal leakage and palatal mucosa condition improved; however, maxilla condition did not completely improve. At initial visit to our hospital, osseous non-union of the maxilla and exposure of the right anterior maxillary alveolar bone were observed. Intraoral findings indicated that the patient had been submitted to LFI osteotomy with gingival incision, and the condition of the palatal mucosa was cured. Computed tomography indicated that LFI osteotomy that the patient had undergone was the horseshoe-type osteotomy and that segmental cuts of the palatal bone, separating the right anterior alveolar and palatal bones, were not necrotic (Fig. 1). As initial treatment, sequestra were irrigated with normal saline until no pus
⁎
Corresponding author at: Department of Oral and Maxillofacial Surgery, Tokyo Dental College, 2-9-18 Kanda Misakicho, Chiyoda-ku, Tokyo, 100-0061, Japan. E-mail address: [email protected] (H. Kato).
https://doi.org/10.1016/j.ajoms.2019.08.002 Received 3 July 2019; Received in revised form 20 August 2019; Accepted 26 August 2019 2212-5558/ © 2019 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd All rights reserved.
Please cite this article as: Hiroshi Kato, et al., Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, https://doi.org/10.1016/j.ajoms.2019.08.002
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
H. Kato, et al.
Fig. 1. Oral findings (A: frontal view, B: lateral view, C: occlusal view) and imaging findings at first visit. Arrows show exposure of the right anterior maxillary alveolar bone (A, B, C). Panoramic radiographs showing the radiolucent area in the right anterior maxilla (D). Computed tomography images showing maxilla cut into horseshoe shape, segmental cuts of the palatal bone, and separated right anterior alveolar bone (E, F, G, H).
6.4% of patients experience surgery-related complications, including nasal septum deviations (1.6%), osseous non-unions (1.0%), insufficient osteofixations (0.5%), hemorrhages requiring blood transfusion (1.1%), infections (1.1%), and ischemic complications (1.0%, including 0.2% of aseptic alveolar process necrosis and 0.8% of gingival retraction) [8]. Aseptic necrosis is one possible ischemic problem arising from maxilla multiple segmentation, together with others as conjunction with superior positioning, transversal segmental LFI osteotomy, extensive anterior dislocation of the maxilla over 9 mm, perforation of palatal mucosa, DPA injury, anatomical irregularity, and smoking habits [9]. In the present clinical case, as the initial surgical team’s original records and comments were unavailable, ischemic factors, such as DPA injury, palatal mucosa perforations, and segmental LFI osteotomy with gingival incision, were hypothesized as underlying causes because the patient had no anatomical abnormalities, was a nonsmoker, and presented little extensive anterior maxilla dislocation. For repositioning the superior maxilla in LFI osteotomy, it was required to remove the bony interference around DPA, which often torments operators due to technical difficulty. To circumvent this problem, instruments for DPA protection have been developed and surgical procedures have been accordingly adapted [13]. Johnson and Arnett [14] previously reported pyramidal osseous release around DPA using a rotary bur and Molt curette or fine chisel for maxillary impaction. Regan and Bharadwaj [15] described a modified technique of bony release from palatine bone’s pyramidal process using spatula osteotomies around DPA. More recently, surgical devices have been developed—such as ultrasonic bone scalpel—which allow to reduce injury to the DPA. It has been suggested that preserving DPA during LFI osteotomy is important to optimize maxillary integrity by maintaining blood nutrition to the anatomical area and decreasing ischemic necrosis risk. Additionally, compared with vestibular incision, gingival incision may have a negative impact on mucosa vascular flow, potentially eliciting ischemic
Fig. 2. Panoramic radiograph after first surgery. Separated sequestra and 11.12 dental roots are removed.
persisted. Subsequently, at first surgery, necrotic alveolar bone and soft tissue were debrided, titanium plates were removed, and a new titanium plate was provided for adequate osteosynthesis in left-side bone gap under general anesthesia (Fig. 2). At second surgery, 11.12.13.14 were extracted and alveolus was reconstructed with an iliac crest graft (Fig. 3). Additionally, 21 was extracted under local anesthesia due to tooth mobility, and root canal treatment was performed on 22.23. After 6 months, the plates were removed, and four implants were placed. At third surgery, oral vestibular extension operation was performed; mucosa was peeled on the periosteum and covered with collagen-based artificial dermis (Fig. 4). Five years after the initial procedure, the patient acquired good occlusion and dentofacial appearance (Fig. 5). 3. Discussion Although orthognathic surgery is a safe and common procedure in oral and maxillofacial surgery, it has several associated complications. A review of LFI osteotomy complications in 1000 patients revealed that
Fig. 3. Surgical findings at second surgery: iliac bone graft operation (A). Panoramic radiograph and cone-beam computed tomography images after second surgery. 11.12.13.14 were extracted and alveolus was reconstructed with an iliac crest graft (B, C). 2
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
H. Kato, et al.
Fig. 4. Surgical findings at third surgery: oral vestibular extension operation. Incision line (A) and wound surface is covered with collagen-based artificial dermis (B).
Fig. 5. Oral and imaging findings after treatment. (A) Intraoral view. (B) Panoramic radiograph. Prosthesis is in place and function is good.
Funding
problems in horseshoe-type LFI osteotomy. Severe cases of aseptic necrosis have been described in past reports [10–12]. One case improved with antibiotics and hyperbaric oxygen, whereas others required bone graft reconstruction. According to recommendations, in cases of serious postoperative vascular flow circulation problems, surgeons should immediately return the segment to original position [9]. Aseptic necrosis treatment initially requires optimal oral hygiene, accomplished by frequent saline solution irrigation and self-home care. In parallel, patients should be treated with hyperbaric oxygen, and antibiotics should be considered to prevent secondary infection. Surgical debridement is required to remove necrotic bone fragments, allowing earlier wound healing, and hard and soft tissue reconstruction is subsequently executed as necessary [10,11]. Finally, implant-supported fixed prosthesis is performed for adequate esthetic outcomes. In the present case, the patient could achieve good occlusion and dentofacial appearance through iliac crest graft reconstruction and dental implants. To recover bone volume, autogenous bone graft currently remains the standard of care [16]. When large bone amounts are required, extraoral sources—as calvaria, iliac crest, tibia, and fibula—are preferred. Extraoral grafts have been acknowledged as a good solution to correct bone lack, obtaining a large quantity of bone tissue and having a lower resorption rate than intraoral bone graft during healing process [17,18]. Iliac bone graft, one of the most common donor sites for autogenous bone graft, was selected in the present case due to bone accessibility and adequate cortical and cancellous bone availability. Aseptic necrosis may have substantial detrimental consequences to patients. Although the incidence of aseptic necrosis in LFI osteotomy is low, clinicians should seek to further reduce its risk by using optimal surgical devices and operation techniques.
This report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Competing Interest None declared. Acknowledgment The authors would like to thank Enago (www.enago.jp) for the English language review. References [1] Iannetti G, Fadda TM, Riccardi E, Mitro V, Filiaci F. Our experience in complications of orthognathic surgery: a retrospective study on 3236 patients. Eur Rev Med Pharmacol Sci 2013;17:379–84. [2] Kim SG, Park SS. Incidence of Complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 2007;65:2438–44. [3] Patel PK, Morris DE, Gassman A. Complications of orthognathic surgery. J Craniofac Surg 2007;18:975–85. [4] Panula K, Finne K, Oikarinen K. Incidence of complications and problems related to orthognathic surgery: a review of 655 patients. J Oral Maxillofac Surg 2001;59:1128–36. [5] Silva LF, Carvalho-Reis ENR, Bonardi JP, de Lima VN, Momesso GAC, Garcia-Junior IR, et al. Comparison between piezoelectric surgery and conventional saw in sagittal split osteotomies: a systematic review. Int J Oral Maxillofac Surg 2017;46:1000–6. [6] Dammous S, Dupont Q, Gilles R. Three-dimensional computed tomographic evaluation of bilateral sagittal split osteotomy lingual fracture line and le fort I pterygomaxillary separation in orthognathic surgery using cadaver heads: ultrasonic osteotome versus conventional saw. J Oral Maxillofac Surg 2015;73:1169–80. [7] Landes CA, Stübinger S, Ballon A, Sader R. Piezoosteotomy in orthognathic surgery versus conventional saw and chisel osteotomy. Oral Maxillofac Surg 2008;12:139–47. [8] Figueroa AA, Polley JW. Intra- and perioperative complications of the LeFort I osteotomy: a prospective evaluation of 1000 patients. J Craniofac Surg 2004;15:978–9. [9] Pereira FL, Yaedú RY, Sant’Ana AP, Sant’Ana E. Maxillary aseptic necrosis after le fort I osteotomy: a case report and literature review. J Oral Maxillofac Surg 2010;68:1402–7.
Ethical approval This report received ethical approval from our institution’s Ethics Review Board and informed consent was obtained. 3
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
H. Kato, et al.
[15] Regan BO, Bharadwaj G. The identification and protection of the descending palatine artery in Le Fort I osteotomy: a forgotten technique? Br J Oral Maxillofac Surg 2007;45:412–4. [16] Cunha G, Rocha AFL, Filho VAP, Gabrielli MFR, Gabrielli MAC. Atrophic maxilla reconstruction with autogenous iliac graft and guided dental implants. J Craniofac Surg 2018;29:2218–9. [17] Dreiseidler T, Kaunisaho V, Neugebauer J, Zöller JE, Rothamel D, Kreppel M. Changes in volume during the four months’ remodelling period of iliac crest grafts in reconstruction of the alveolar ridge. Br J Oral Maxillofac Surg 2016;54:751–6. [18] Tetè S, Vinci R, Zara S, Zizzari V, De Carlo A, Falco G, et al. Long-term evaluation of maxillary reconstruction by iliac bone graft. J Craniofac Surg 2011;22:1702–7.
[10] Behnia H, Nazerani S, Motamedi MH, Dashti H. Comprehensive reconstruction of the maxilla after a failed premaxillary osteotomy: a case report with long-term follow-up. Ann Plast Surg 2009;62:59–62. [11] Singh J, Doddridge M, Broughton A, Goss A. Reconstruction of post-orthognathic aseptic necrosis of the maxilla. Br J Oral Maxillofac Surg 2008;46:408–10. [12] Lanigan DT, Hey JH, West RA. Aseptic necrosis following maxillary osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48:142–56. [13] Omura S, Iwai T, Murata S, Tohnai I. Use of a simple handmade retractor to protect the descending palatine artery during removal of posterior osseous interferences for maxillary impaction in Le Fort I osteotomy. J Craniofac Surg 2013;24(May):978–9. [14] Johnson LM, Arnett GW. Pyramidal osseous release around the descending palatine artery: a surgical technique. J Oral Maxillofac Surg 1991;49:1356–7.
4