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Removal of Large Complex Odontoma Using Le Fort I Osteotomy
950
LETTERS TO THE EDITOR
to a normal level. At present, the patient continues to receive supplementation, with regular assessments of his serum levels every 3 months. YU CHEN, DDS, MD XUEQIANG DING, DDS, MD Guangzhou, China
References 1. Furlanetto TW: Etiology of hyperparathyroidism in McCuneAlbright syndrome. J Oral Maxillofac Surg 67:2037, 2009 (letter) 2. Chen Y, Ding X, Yang Y, et al: Craniofacial fibrous dysplasia associated with McCune-Albright syndrome. J Oral Maxillofac Surg 67:637, 2009
doi:10.1016/j.joms.2009.12.017
REMOVAL OF LARGE COMPLEX ODONTOMA USING LE FORT I OSTEOTOMY To the Editor:—We read with great interest the article by Korpi et al on “Removal of Large Complex Odontoma Using Le Fort I Osteotomy,”1 and we would like to share our personal experience regarding the use of Le Fort I-type osteotomy as a surgical approach for removal of large maxillary lesions. First, we believe that this technique is reserved not only to posteriorly located maxillary lesions as reported by the authors, but equally for removal of lesions involving 1 or more maxillary walls. Second, the “panoramic” view of both the maxillary sinus and the nasal cavity makes this approach incontestably unique not only for removal of large lesions but also to access specific not otherwise easily viewable anatomical regions, such as the lacrymal recess of the maxillary sinus, the inferior part of the orbital floor, the posterior palatine vessels and nerves, and the pterygomaxillary fossa. Third, this technique allows a safe and circumferential control of the entire lesion, thus guaranteeing its in toto removal, avoiding “blind” damage of
FIGURE 1. Patient suffering from a Gorlin syndrome. Preoperative axial CT scan view showing 2 large intramaxillary odontogenic keratocysts. Note the upper right third molar located within the right pterygoid process (arrow).
FIGURE 2. Intraoperative view in the same patient, following the Le Fort I osteotomy, revealing the 2 odontogenic keratocysts within the 2 maxillary sinuses (arrows). Note the left upper third molar associated with the right cyst (arrowhead).
adjacent vital structures (ie, infraorbital and palatine vessels and nerves, etc). For these reasons, we have also been using this technique for removal of either solitary large odontogenic keratocysts or multiple odontogenic keratocysts as found in patients suffering from basal cell nevus syndrome (Gorlin-Goltz syndrome) (Figs 1, 2), given that these cysts are locally aggressive and known to have a high rate of recurrence.2 In our experience, this is an optimal treatment capable of allowing the whole removal of the cyst wall, which is the seat of satellite cysts and rests on the odontogenic epithelium responsible for late recurrence. Since the introduction of this technique in our department 10 years ago, 12 patients underwent removal of 1 or more odontogenic keratocysts by a Le Fort I osteotomy. The longest follow-up is now 7 years; the shortest is 1 year, and none of the patients developed recurrences. To note, the authors compared the Le Fort I osteotomy to the Caldwell-Luc approach as the only alternative. For the sake of accuracy, we also discuss another technical approach, ie, the maxillary lateral antrotomy with bone flap repositioning and fixation with a titanium plate. In 2009, we first reported on this technique, which is characterized by the in toto removal and repositioning with rigid internal fixation of an osteotomized bone window.3 This technique differs from the Caldwell-Luc approach mainly in that the bone defect is immediately and completely restored. This avoids facial neurologic pain and numbness, resulting from large residual bony wall defect, which is responsible for cheek soft tissue retraction and collapse through the sinus as well as around the foramen infra-orbitalis. Although this approach enables good vision, in our experience it only allows removal of limited sized lesions (up to 3 cm in diameter). In conclusion, Le Fort I-type osteotomy enables an excellent surgical exposure for the safe removal of maxillary lesions in those particular cases in which the use of conventional techniques, such as the Caldwell-Luc approach, could considerably increase the risk of complications or result in an unacceptable bone defect. Nevertheless, an alternative could be the lateral antrotomy approach with rigid internal fixation of the bone flap using a titanium plate, which is more appropriate for removal of small and primarily located lesions within the maxillary antral floor. PAOLO SCOLOZZI, MD, DMD TOMMASO LOMBARDI, MD, DMD Geneva, Switzerland
951
LETTERS TO THE EDITOR
References 1. Korpi JT, Kainulainen VT, Sandor GK, et al: Removal of large complex odontoma using Le Fort I osteotomy. J Oral Maxillofac Surg 67:2018, 2009 2. Scolozzi P, Lombardi T, Jaques B: Le Fort I type osteotomy and mandibular sagittal osteotomy as a surgical approach for removal of jaw cysts. J Oral Maxillofac Surg 65:1419, 2007 3. Scolozzi P, Martinez A, Lombardi T, et al: Lateral antrotomy as a surgical approach for maxillary sinus: A modified technique with free bone flap repositioning and fixation with a titanium plate. J Oral Maxillofac Surg 67:689, 2009
doi:10.1016/j.joms.2009.11.018
In reply:—It is always heartening to read that surgeons in different parts of the world can independently come to the same conclusions about the great utility of a surgical approach that can be used in the treatment of both tumors and orthognathic problems. Such is the case with the Le Fort I maxillary osteotomy. Here we see the Le Fort I as a procedure that was initially described by Cheevers as a means to remove maxillary tumors.1 Later the Le Fort I osteotomy was popularized as an important osteotomy technique in orthognathic surgery. Now over the past 20 years the Le Fort I osteotomy’s role has also been defined as a procedure to access tumors of the maxilla, base of the skull, and upper cervical spine.2 Drs Scolozzi and Lombardi illustrate this concept beautifully, not only in their current letter to the Editor but also in their previous publication in this Journal.3 They have shown us how both the maxillary Le Fort I osteotomy and the mandibular sagittal ramus osteotomy can be used to access pathologic lesions of both the maxilla and the mandible. This is a testament to the versatility of these 2 osteotomies, which for the Le Fort I osteotomy provides an unprecedented view and access to the maxillary sinus. Drs Scolozzi and Lombardi have also illustrated how the lateral antrotomy technique with free bone flap can be adapted to smaller lesions of the maxilla.4 Perhaps just to be more complete, the use of fiberoptic endoscopic surgical techniques could also be added to the list of surgical approaches useful in the management of small benign lesions of the maxillary sinus. GEORGE K. B. SÁNDOR, MD, DDS, PHD Oulu, Finland
References 1. Moloney F, Worthington P: The origin of the Le Fort I maxillary osteotomy: Cheever’s operation. J Oral Surg 39:731, 1981 2. Sándor GK, Charles DA, Lawson VG, et al: Oral approach to the nasopharynx and clivus using the Le Fort I osteotomy with midpalatal split. Int J Oral Maxillofac Surg 19:352, 1990 3. Scolozzi P, Lombardi T, Jaques B: Le Fort I type osteotomy and mandibular sagittal osteotomy as a surgical approach for removal of jaw cysts. J Oral Maxillofac Surg 65:1419, 2007 4. Scolozzi P, Martinez A, Lombardi T, et al: Lateral antrotomy as a surgical approach for maxillary sinus: A modified technique with free bone flap repositioning and fixation with a titanium plate. J Oral Maxillofac Surg 67:689, 2009
doi:10.1016/j.joms.2009.12.005
HIGH CERVICAL TRANSMASSETERIC ANTEROPAROTID APPROACH FOR LOW SUBCONDYLAR FRACTURE OF MANDIBLE To the Editor:—I read the recent publication by Trost et al with great interest.1 Trost et al concluded that “Low subcondylar fracture fixation with modus TCP plates using a high cervical transmasseteric anteroparotid approach is a safe and reproducible procedure providing excellent functional results.”1 Indeed, according to the report, a high cervical transmasseteric anteroparotid approach for low subcondylar fracture is acceptable. However, there are also other presently used approaches such as retromandibular and short retromandibular approaches. Acceptability of those other approaches is also confirmed in scientific reports.2,3 There are many studies that are required for decision-making for using this approach. First, there should be a comparative effectiveness and efficacy of this approach to other existing approaches. Second, there should be a costeffective and cost-utility analysis for this approach, comparing it with others. VIROJ WIWANITKIT, MADA Wiwanitkit House, Bangkhae, Bangkok, Thailand
References 1. Trost O, Trouilloud P, Malka G: Open reduction and internal fixation of low subcondylar fractures of mandible through high cervical transmasseteric anteroparotid approach. J Oral Maxillofac Surg 67:2446, 2009 2. Chossegros C, Cheynet F, Blanc JL, et al: Short retromandibular approach of subcondylar fractures: Clinical and radiologic longterm evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 82:248, 1996 3. Cheynet F, Aldegheri A, Chossegros C, et al: The retromandibular approach in fractures of the mandibular condyle. Rev Stomatol Chir Maxillofac 98:288, 1997
doi:10.1016/j.joms.2009.11.019
In reply:—I really appreciated Dr Wiwanitkit’s comments on my article. The choice of surgical approach is of primary importance to achieve good exposure of the fracture line and optimal osteosynthesis. In my experience, mandibular condylar fractures can be separated into 2 categories: 1) articulator (diacapitular) and subcapital fractures, managed using a preauricular approach; and 2) subcondylar fractures (low and high subcondylar), requiring a lower approach. Therefore, several techniques have been reported (Fig 1). I believe the classic Risdon technique should be forgotten because of the high rate of facial nerve injury, which probably results from the necessity of a tough retraction of the upper flap related to the long distance between the incision line and the fracture level. The retromandibular approach is the most popular technique; it has been promoted by the staff of Timone University Hospital Center (Marseille, France).1 Although I have no experience with this technique, I believe that the marginal branch of the facial nerve is more likely to be injured using this technique because the dissection automatically crosses this nerve. In the experience of Chossegros et al,1 transient palsies were observed in 2 (10%) of 19 patients, and no definitive palsy developed. In contrast, using the high cervical transmasseteric anteroparotid approach,2 the marginal branch is avoided, because superficial dissection over the superficial musculo-aponeu-
LETTERS TO THE EDITOR
to a normal level. At present, the patient continues to receive supplementation, with regular assessments of his serum levels every 3 months. YU CHEN, DDS, MD XUEQIANG DING, DDS, MD Guangzhou, China
References 1. Furlanetto TW: Etiology of hyperparathyroidism in McCuneAlbright syndrome. J Oral Maxillofac Surg 67:2037, 2009 (letter) 2. Chen Y, Ding X, Yang Y, et al: Craniofacial fibrous dysplasia associated with McCune-Albright syndrome. J Oral Maxillofac Surg 67:637, 2009
doi:10.1016/j.joms.2009.12.017
REMOVAL OF LARGE COMPLEX ODONTOMA USING LE FORT I OSTEOTOMY To the Editor:—We read with great interest the article by Korpi et al on “Removal of Large Complex Odontoma Using Le Fort I Osteotomy,”1 and we would like to share our personal experience regarding the use of Le Fort I-type osteotomy as a surgical approach for removal of large maxillary lesions. First, we believe that this technique is reserved not only to posteriorly located maxillary lesions as reported by the authors, but equally for removal of lesions involving 1 or more maxillary walls. Second, the “panoramic” view of both the maxillary sinus and the nasal cavity makes this approach incontestably unique not only for removal of large lesions but also to access specific not otherwise easily viewable anatomical regions, such as the lacrymal recess of the maxillary sinus, the inferior part of the orbital floor, the posterior palatine vessels and nerves, and the pterygomaxillary fossa. Third, this technique allows a safe and circumferential control of the entire lesion, thus guaranteeing its in toto removal, avoiding “blind” damage of
FIGURE 1. Patient suffering from a Gorlin syndrome. Preoperative axial CT scan view showing 2 large intramaxillary odontogenic keratocysts. Note the upper right third molar located within the right pterygoid process (arrow).
FIGURE 2. Intraoperative view in the same patient, following the Le Fort I osteotomy, revealing the 2 odontogenic keratocysts within the 2 maxillary sinuses (arrows). Note the left upper third molar associated with the right cyst (arrowhead).
adjacent vital structures (ie, infraorbital and palatine vessels and nerves, etc). For these reasons, we have also been using this technique for removal of either solitary large odontogenic keratocysts or multiple odontogenic keratocysts as found in patients suffering from basal cell nevus syndrome (Gorlin-Goltz syndrome) (Figs 1, 2), given that these cysts are locally aggressive and known to have a high rate of recurrence.2 In our experience, this is an optimal treatment capable of allowing the whole removal of the cyst wall, which is the seat of satellite cysts and rests on the odontogenic epithelium responsible for late recurrence. Since the introduction of this technique in our department 10 years ago, 12 patients underwent removal of 1 or more odontogenic keratocysts by a Le Fort I osteotomy. The longest follow-up is now 7 years; the shortest is 1 year, and none of the patients developed recurrences. To note, the authors compared the Le Fort I osteotomy to the Caldwell-Luc approach as the only alternative. For the sake of accuracy, we also discuss another technical approach, ie, the maxillary lateral antrotomy with bone flap repositioning and fixation with a titanium plate. In 2009, we first reported on this technique, which is characterized by the in toto removal and repositioning with rigid internal fixation of an osteotomized bone window.3 This technique differs from the Caldwell-Luc approach mainly in that the bone defect is immediately and completely restored. This avoids facial neurologic pain and numbness, resulting from large residual bony wall defect, which is responsible for cheek soft tissue retraction and collapse through the sinus as well as around the foramen infra-orbitalis. Although this approach enables good vision, in our experience it only allows removal of limited sized lesions (up to 3 cm in diameter). In conclusion, Le Fort I-type osteotomy enables an excellent surgical exposure for the safe removal of maxillary lesions in those particular cases in which the use of conventional techniques, such as the Caldwell-Luc approach, could considerably increase the risk of complications or result in an unacceptable bone defect. Nevertheless, an alternative could be the lateral antrotomy approach with rigid internal fixation of the bone flap using a titanium plate, which is more appropriate for removal of small and primarily located lesions within the maxillary antral floor. PAOLO SCOLOZZI, MD, DMD TOMMASO LOMBARDI, MD, DMD Geneva, Switzerland
951
LETTERS TO THE EDITOR
References 1. Korpi JT, Kainulainen VT, Sandor GK, et al: Removal of large complex odontoma using Le Fort I osteotomy. J Oral Maxillofac Surg 67:2018, 2009 2. Scolozzi P, Lombardi T, Jaques B: Le Fort I type osteotomy and mandibular sagittal osteotomy as a surgical approach for removal of jaw cysts. J Oral Maxillofac Surg 65:1419, 2007 3. Scolozzi P, Martinez A, Lombardi T, et al: Lateral antrotomy as a surgical approach for maxillary sinus: A modified technique with free bone flap repositioning and fixation with a titanium plate. J Oral Maxillofac Surg 67:689, 2009
doi:10.1016/j.joms.2009.11.018
In reply:—It is always heartening to read that surgeons in different parts of the world can independently come to the same conclusions about the great utility of a surgical approach that can be used in the treatment of both tumors and orthognathic problems. Such is the case with the Le Fort I maxillary osteotomy. Here we see the Le Fort I as a procedure that was initially described by Cheevers as a means to remove maxillary tumors.1 Later the Le Fort I osteotomy was popularized as an important osteotomy technique in orthognathic surgery. Now over the past 20 years the Le Fort I osteotomy’s role has also been defined as a procedure to access tumors of the maxilla, base of the skull, and upper cervical spine.2 Drs Scolozzi and Lombardi illustrate this concept beautifully, not only in their current letter to the Editor but also in their previous publication in this Journal.3 They have shown us how both the maxillary Le Fort I osteotomy and the mandibular sagittal ramus osteotomy can be used to access pathologic lesions of both the maxilla and the mandible. This is a testament to the versatility of these 2 osteotomies, which for the Le Fort I osteotomy provides an unprecedented view and access to the maxillary sinus. Drs Scolozzi and Lombardi have also illustrated how the lateral antrotomy technique with free bone flap can be adapted to smaller lesions of the maxilla.4 Perhaps just to be more complete, the use of fiberoptic endoscopic surgical techniques could also be added to the list of surgical approaches useful in the management of small benign lesions of the maxillary sinus. GEORGE K. B. SÁNDOR, MD, DDS, PHD Oulu, Finland
References 1. Moloney F, Worthington P: The origin of the Le Fort I maxillary osteotomy: Cheever’s operation. J Oral Surg 39:731, 1981 2. Sándor GK, Charles DA, Lawson VG, et al: Oral approach to the nasopharynx and clivus using the Le Fort I osteotomy with midpalatal split. Int J Oral Maxillofac Surg 19:352, 1990 3. Scolozzi P, Lombardi T, Jaques B: Le Fort I type osteotomy and mandibular sagittal osteotomy as a surgical approach for removal of jaw cysts. J Oral Maxillofac Surg 65:1419, 2007 4. Scolozzi P, Martinez A, Lombardi T, et al: Lateral antrotomy as a surgical approach for maxillary sinus: A modified technique with free bone flap repositioning and fixation with a titanium plate. J Oral Maxillofac Surg 67:689, 2009
doi:10.1016/j.joms.2009.12.005
HIGH CERVICAL TRANSMASSETERIC ANTEROPAROTID APPROACH FOR LOW SUBCONDYLAR FRACTURE OF MANDIBLE To the Editor:—I read the recent publication by Trost et al with great interest.1 Trost et al concluded that “Low subcondylar fracture fixation with modus TCP plates using a high cervical transmasseteric anteroparotid approach is a safe and reproducible procedure providing excellent functional results.”1 Indeed, according to the report, a high cervical transmasseteric anteroparotid approach for low subcondylar fracture is acceptable. However, there are also other presently used approaches such as retromandibular and short retromandibular approaches. Acceptability of those other approaches is also confirmed in scientific reports.2,3 There are many studies that are required for decision-making for using this approach. First, there should be a comparative effectiveness and efficacy of this approach to other existing approaches. Second, there should be a costeffective and cost-utility analysis for this approach, comparing it with others. VIROJ WIWANITKIT, MADA Wiwanitkit House, Bangkhae, Bangkok, Thailand
References 1. Trost O, Trouilloud P, Malka G: Open reduction and internal fixation of low subcondylar fractures of mandible through high cervical transmasseteric anteroparotid approach. J Oral Maxillofac Surg 67:2446, 2009 2. Chossegros C, Cheynet F, Blanc JL, et al: Short retromandibular approach of subcondylar fractures: Clinical and radiologic longterm evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 82:248, 1996 3. Cheynet F, Aldegheri A, Chossegros C, et al: The retromandibular approach in fractures of the mandibular condyle. Rev Stomatol Chir Maxillofac 98:288, 1997
doi:10.1016/j.joms.2009.11.019
In reply:—I really appreciated Dr Wiwanitkit’s comments on my article. The choice of surgical approach is of primary importance to achieve good exposure of the fracture line and optimal osteosynthesis. In my experience, mandibular condylar fractures can be separated into 2 categories: 1) articulator (diacapitular) and subcapital fractures, managed using a preauricular approach; and 2) subcondylar fractures (low and high subcondylar), requiring a lower approach. Therefore, several techniques have been reported (Fig 1). I believe the classic Risdon technique should be forgotten because of the high rate of facial nerve injury, which probably results from the necessity of a tough retraction of the upper flap related to the long distance between the incision line and the fracture level. The retromandibular approach is the most popular technique; it has been promoted by the staff of Timone University Hospital Center (Marseille, France).1 Although I have no experience with this technique, I believe that the marginal branch of the facial nerve is more likely to be injured using this technique because the dissection automatically crosses this nerve. In the experience of Chossegros et al,1 transient palsies were observed in 2 (10%) of 19 patients, and no definitive palsy developed. In contrast, using the high cervical transmasseteric anteroparotid approach,2 the marginal branch is avoided, because superficial dissection over the superficial musculo-aponeu-