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Use of Anterior Fixation Alone in Le Fort I Osteotomy
LETTER TO THE EDITOR J Oral Maxillofac Surg 65:819, 2007
USE OF ANTERIOR FIXATION ALONE IN LE FORT I OSTEOTOMY
In reply—We thank Drs Gibbons and Cousley for their comments on our article describing anterior fixation alone in Le Fort I osteotomy. In general, the orthodontists we work with do not initiate postsurgical orthodontic treatment until 6 weeks post surgery. On occasion, the surgeon will selectively use light guiding intermaxillary elastics to make a minor vertical or horizontal movement to correct unsatisfactory occlusion. The latter are generally secondary to improper condylar positioning intraoperatively. With rigid internal fixation, these changes are dental and achieve minimal correction. For major corrections, the patient will need to be taken back to surgery for refixation and repositioning of the osseous segments. If the needed occlusal correction is vertical in the posterior region, the postsurgical elastics and function will correct the problem, provided there is no posterior internal rigid fixation. This is one advantage of our treatment approach when vertical condylar sag occurs. The type of anterior rigid fixation will be dictated by the quality and quantity of bone and the degree of horizontal and/or vertical osseous correction. On occasion we use 4to 6-hole miniplates rather than the 3-hole miniplate described in the article (the different styles and stiffness of miniplates vary from vendor to vendor, which alters the surgeon’s selection). We agree with the statement regarding caution in use of anterior elastics. Ideally, we prefer light anterior vertical elastics (2 to 4 in number) without a splint and with an error toward a deep bite occlusion. The transosseous wires we use are purely positional wires (2 to 4 in number) and allow the surgeon to place the rigid fixation on a properly positioned and transosseous wire-stabilized maxilla. These transosseous wires are frequently removed before wound closure or can be left as backup fixation if skeletal fixation fails, especially in cases of extreme bone thinness of the osteotomy sites.
To the Editor:—We read with interest the article by Yoon et al entitled “Stability of the Le Fort I Osteotomy With Anterior Internal Fixation Alone: A Case Series” (J Oral Maxillofac Surg 63:629-634, 2005). We have also used anterior internal fixation alone in 6 cases of Le Fort I impaction over the past year. Common to all our cases was slight clinical mobility of the posterior maxilla postoperatively that took up to 6 weeks to fully stabilize. Apart from recommending light anterior elastic guidance post-operatively, Yoon et al make no specific comments on immediate postsurgical orthodontics. Given the forces placed on the maxilla by the use of elastics we feel that adequate stability of the anterior plates is an important factor. We use carefully adapted L-shaped miniplates either side of the piriform rim with 2 stable and well-seated screws each side of the osteotomy. Furthermore, as Class III elastic traction may pull the posterior maxilla inferiorly causing a clockwise mandibular rotation, we make sure that a positive overbite is built into the surgical plan. Ideally, only anterior vertical or Class II elastics should be used postoperatively in such cases. Yoon et al recommend the use of short 3-hole miniplates with only 1 screw on each side of the osteotomy site. However, if one of these screws loosens the Le Fort I osteotomy would become unstable. In nearly all of their reported cases the miniplates were augmented with anterior transosseous wires. If a screw had loosened in the immediate postoperative stage in these cases, the wire would still have provided some support. Although we agree that the use of anterior fixation alone in Le Fort I impaction osteotomies gives adequate stability, we advocate the use of miniplates with 2 screws on each side of the osteotomy site and advise the judicious use of postsurgical intermaxillary elastics. ANDREW J. GIBBONS, MA (CANTAB), FDSRCS, FRCS RICHARD COUSLEY, BSC, BDS, MSC, MORTH FDS, FDS (ORTH) Peterborough, UK
EUGENE E. KELLER, DDS, MSD ROCHESTER, MN
doi:10.1016/j.joms.2005.09.030
doi:10.1016/j.joms.2006.12.002
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters responding to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
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USE OF ANTERIOR FIXATION ALONE IN LE FORT I OSTEOTOMY
In reply—We thank Drs Gibbons and Cousley for their comments on our article describing anterior fixation alone in Le Fort I osteotomy. In general, the orthodontists we work with do not initiate postsurgical orthodontic treatment until 6 weeks post surgery. On occasion, the surgeon will selectively use light guiding intermaxillary elastics to make a minor vertical or horizontal movement to correct unsatisfactory occlusion. The latter are generally secondary to improper condylar positioning intraoperatively. With rigid internal fixation, these changes are dental and achieve minimal correction. For major corrections, the patient will need to be taken back to surgery for refixation and repositioning of the osseous segments. If the needed occlusal correction is vertical in the posterior region, the postsurgical elastics and function will correct the problem, provided there is no posterior internal rigid fixation. This is one advantage of our treatment approach when vertical condylar sag occurs. The type of anterior rigid fixation will be dictated by the quality and quantity of bone and the degree of horizontal and/or vertical osseous correction. On occasion we use 4to 6-hole miniplates rather than the 3-hole miniplate described in the article (the different styles and stiffness of miniplates vary from vendor to vendor, which alters the surgeon’s selection). We agree with the statement regarding caution in use of anterior elastics. Ideally, we prefer light anterior vertical elastics (2 to 4 in number) without a splint and with an error toward a deep bite occlusion. The transosseous wires we use are purely positional wires (2 to 4 in number) and allow the surgeon to place the rigid fixation on a properly positioned and transosseous wire-stabilized maxilla. These transosseous wires are frequently removed before wound closure or can be left as backup fixation if skeletal fixation fails, especially in cases of extreme bone thinness of the osteotomy sites.
To the Editor:—We read with interest the article by Yoon et al entitled “Stability of the Le Fort I Osteotomy With Anterior Internal Fixation Alone: A Case Series” (J Oral Maxillofac Surg 63:629-634, 2005). We have also used anterior internal fixation alone in 6 cases of Le Fort I impaction over the past year. Common to all our cases was slight clinical mobility of the posterior maxilla postoperatively that took up to 6 weeks to fully stabilize. Apart from recommending light anterior elastic guidance post-operatively, Yoon et al make no specific comments on immediate postsurgical orthodontics. Given the forces placed on the maxilla by the use of elastics we feel that adequate stability of the anterior plates is an important factor. We use carefully adapted L-shaped miniplates either side of the piriform rim with 2 stable and well-seated screws each side of the osteotomy. Furthermore, as Class III elastic traction may pull the posterior maxilla inferiorly causing a clockwise mandibular rotation, we make sure that a positive overbite is built into the surgical plan. Ideally, only anterior vertical or Class II elastics should be used postoperatively in such cases. Yoon et al recommend the use of short 3-hole miniplates with only 1 screw on each side of the osteotomy site. However, if one of these screws loosens the Le Fort I osteotomy would become unstable. In nearly all of their reported cases the miniplates were augmented with anterior transosseous wires. If a screw had loosened in the immediate postoperative stage in these cases, the wire would still have provided some support. Although we agree that the use of anterior fixation alone in Le Fort I impaction osteotomies gives adequate stability, we advocate the use of miniplates with 2 screws on each side of the osteotomy site and advise the judicious use of postsurgical intermaxillary elastics. ANDREW J. GIBBONS, MA (CANTAB), FDSRCS, FRCS RICHARD COUSLEY, BSC, BDS, MSC, MORTH FDS, FDS (ORTH) Peterborough, UK
EUGENE E. KELLER, DDS, MSD ROCHESTER, MN
doi:10.1016/j.joms.2005.09.030
doi:10.1016/j.joms.2006.12.002
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters responding to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
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