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Modified Le Fort I osteotomy with preservation of the anterior nasal spine position: preliminary report
Modified Le Fort I osteotomy with preservation of the anterior nasal spine position: preliminary report Francisco J. Díaz-González, MD,a and Raúl González-García, MD,b Madrid, Spain DEPARTMENT OF ORAL AND MAXILLOFACIAL-HEAD AND NECK SURGERY, UNIVERSITY HOSPITAL LA PRINCESA
We present a modification of the traditional Le Fort I osteotomy by means of which the anterior nasal spine is left intact. The osteotomies advance from the posterior-lateral side of the maxillary bone through the tuberosity to the inferior-lateral wall of the piriform opening. Two other vertical osteotomies from the lateral side of the piriform opening are placed in a 90° fashion to connect with another horizontal osteotomy that runs 5 mm below the floor of the nasal cavity and the anterior nasal spine. In a series of 50 patients with Le Fort I osteotomies, we have performed this new technique in 5 patients. We have observed better esthetic results in terms of nasal tip position and a more predictable value for the nasolabial angle. We believe that this technique is more appropriate for larger advancements in which a large gap may occur at the end of the movement. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:616-7)
Orthognathic surgical procedures have become standard in the treatment of patients with severe dentofacial deformities. Sagittal split osteotomy for mandibular surgery and Le Fort I osteotomy for maxillary downfracture are the most-used procedures in bimaxillary surgery. Pretreatment cephalometric studies and surgical models are widely used to diagnose the deformity, to minimize postoperative pitfalls, and to improve final results in terms of occlusion and facial harmony. However, small variations of scheduled movements are available after osteotomies during the surgical procedure. In relation to Le Fort I osteotomy, a commonly poorly predicted movement is present at the end of the surgery. It is based on an anterior and inferior displacement of the anterior nasal spine of the maxillary bone. This condition may lead to an excessive advancement of the anterior nasal spine and a substantial decrease of the nasolabial angle. This change is acceptable in cases with little advancement of the maxilla, but it is often unacceptable in larger advancements (more than 4 mm). This situation may be present in conventional orthognathic procedures or in larger advancements of maxillary distraction procedures. Maxillary advancement with a 1-piece LeFort I osteotomy is a relatively stable procedure.1 Moreover, as reported by Semaan and Goonewardene,2 a Le Fort I maxillary osteotomy can be considered to be a fairly
accurate procedure but can have a wide range of discrepancy. Several modifications of the Le Fort I osteotomy have been reported in the literature. In 1990, in a series of 54 patients, Keller and Sather3 referred to the quadrangular Le Fort I osteotomy as a predictable procedure. It provided acceptable midfacial esthetic results and was surgically reproducible with few complications. We present a modification of the conventional Le Fort I osteotomy by means of which the anterior nasal spine is not detached as part of the osteotomized bone. Similarly to the traditional technique, an undermining of the nasal floor is required. The osteotomies advance from the posterior-lateral side of the maxillary bone through the tuberosity to the inferior and lateral wall of the piriform opening. Two other vertical osteotomies
a
Department Head. Maxillofacial Surgeon. Received for publication Dec 3, 2006; returned for revision Jan 11, 2007; accepted for publication Feb 28, 2007. 1079-2104/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2007.02.023
b
616
Fig. 1. Modified Le Fort I osteotomy.
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in Fig. 1. The nasal septum is not detached. Downfracture is performed in the classic manner. The osseous septum and the anterior nasal spine are not displaced despite the advancement of the maxilla. There is no special technical difficulty in relation to the completion of the osteotomy, although special care must be taken to design the horizontal osteotomy above the roots of the upper incisors. We have performed this new technique in 5 out of 50 patients with Le Fort I osteotomies (Fig. 2). We have obtained better esthetic results in relation to the nasal tip position and nasolabial angle. No complications have been observed. We believe that this technique is more appropriate for larger advancements in which a great gap may be present at the end of the maxillary movement. This condition may be present in many conventional orthognathic procedures. A segmentary maxillary osteotomy is also possible with this technique. We believe that this procedure is also ideal for distraction procedures, where large movements of more than 1 cm may be present. This situation should be further analyzed. REFERENCES
Fig. 2. Intraoperative views of the modified Le Fort I osteotomy.
1. Dowling PA, Espeland L, Sandvik L, Mobarak KA, Hogevold HE. LeFort I maxillary advancement: 3-year stability and risk factors for relapse. Am J Orthod Dentofacial Orthop 2005;128:560-7. 2. Semaan S, Goonewardene MS. Accuracy of a LeFort I maxillary osteotomy. Angle Orthod 2005;75:694-73. 3. Keller EE, Sather AH. Quadrangular Le Fort I osteotomy: surgical technique and review of 54 patients. J Oral Maxillofac Surg 1990;48:2-11.
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from the lateral side of the piriform aperture are placed in a 90° fashion (Fig. 1). A horizontal osteotomy 5 mm below the floor of the nasal cavity and the anterior nasal spine is performed. This last osteotomy connects the contralateral modified Le Fort I osteotomy, as depicted
Raúl González-García, MD Department of Oral and Maxillofacial-Head and Neck Surgery University Hospital La Princesa Madrid 28047 Spain [email protected]
We present a modification of the traditional Le Fort I osteotomy by means of which the anterior nasal spine is left intact. The osteotomies advance from the posterior-lateral side of the maxillary bone through the tuberosity to the inferior-lateral wall of the piriform opening. Two other vertical osteotomies from the lateral side of the piriform opening are placed in a 90° fashion to connect with another horizontal osteotomy that runs 5 mm below the floor of the nasal cavity and the anterior nasal spine. In a series of 50 patients with Le Fort I osteotomies, we have performed this new technique in 5 patients. We have observed better esthetic results in terms of nasal tip position and a more predictable value for the nasolabial angle. We believe that this technique is more appropriate for larger advancements in which a large gap may occur at the end of the movement. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:616-7)
Orthognathic surgical procedures have become standard in the treatment of patients with severe dentofacial deformities. Sagittal split osteotomy for mandibular surgery and Le Fort I osteotomy for maxillary downfracture are the most-used procedures in bimaxillary surgery. Pretreatment cephalometric studies and surgical models are widely used to diagnose the deformity, to minimize postoperative pitfalls, and to improve final results in terms of occlusion and facial harmony. However, small variations of scheduled movements are available after osteotomies during the surgical procedure. In relation to Le Fort I osteotomy, a commonly poorly predicted movement is present at the end of the surgery. It is based on an anterior and inferior displacement of the anterior nasal spine of the maxillary bone. This condition may lead to an excessive advancement of the anterior nasal spine and a substantial decrease of the nasolabial angle. This change is acceptable in cases with little advancement of the maxilla, but it is often unacceptable in larger advancements (more than 4 mm). This situation may be present in conventional orthognathic procedures or in larger advancements of maxillary distraction procedures. Maxillary advancement with a 1-piece LeFort I osteotomy is a relatively stable procedure.1 Moreover, as reported by Semaan and Goonewardene,2 a Le Fort I maxillary osteotomy can be considered to be a fairly
accurate procedure but can have a wide range of discrepancy. Several modifications of the Le Fort I osteotomy have been reported in the literature. In 1990, in a series of 54 patients, Keller and Sather3 referred to the quadrangular Le Fort I osteotomy as a predictable procedure. It provided acceptable midfacial esthetic results and was surgically reproducible with few complications. We present a modification of the conventional Le Fort I osteotomy by means of which the anterior nasal spine is not detached as part of the osteotomized bone. Similarly to the traditional technique, an undermining of the nasal floor is required. The osteotomies advance from the posterior-lateral side of the maxillary bone through the tuberosity to the inferior and lateral wall of the piriform opening. Two other vertical osteotomies
a
Department Head. Maxillofacial Surgeon. Received for publication Dec 3, 2006; returned for revision Jan 11, 2007; accepted for publication Feb 28, 2007. 1079-2104/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2007.02.023
b
616
Fig. 1. Modified Le Fort I osteotomy.
OOOOE Volume 104, Number 5
Díaz-González and González-García 617
in Fig. 1. The nasal septum is not detached. Downfracture is performed in the classic manner. The osseous septum and the anterior nasal spine are not displaced despite the advancement of the maxilla. There is no special technical difficulty in relation to the completion of the osteotomy, although special care must be taken to design the horizontal osteotomy above the roots of the upper incisors. We have performed this new technique in 5 out of 50 patients with Le Fort I osteotomies (Fig. 2). We have obtained better esthetic results in relation to the nasal tip position and nasolabial angle. No complications have been observed. We believe that this technique is more appropriate for larger advancements in which a great gap may be present at the end of the maxillary movement. This condition may be present in many conventional orthognathic procedures. A segmentary maxillary osteotomy is also possible with this technique. We believe that this procedure is also ideal for distraction procedures, where large movements of more than 1 cm may be present. This situation should be further analyzed. REFERENCES
Fig. 2. Intraoperative views of the modified Le Fort I osteotomy.
1. Dowling PA, Espeland L, Sandvik L, Mobarak KA, Hogevold HE. LeFort I maxillary advancement: 3-year stability and risk factors for relapse. Am J Orthod Dentofacial Orthop 2005;128:560-7. 2. Semaan S, Goonewardene MS. Accuracy of a LeFort I maxillary osteotomy. Angle Orthod 2005;75:694-73. 3. Keller EE, Sather AH. Quadrangular Le Fort I osteotomy: surgical technique and review of 54 patients. J Oral Maxillofac Surg 1990;48:2-11.
Reprint requests:
from the lateral side of the piriform aperture are placed in a 90° fashion (Fig. 1). A horizontal osteotomy 5 mm below the floor of the nasal cavity and the anterior nasal spine is performed. This last osteotomy connects the contralateral modified Le Fort I osteotomy, as depicted
Raúl González-García, MD Department of Oral and Maxillofacial-Head and Neck Surgery University Hospital La Princesa Madrid 28047 Spain [email protected]