LE FORT IOSTEOTOMIESEN ORTHOONATIC SURGERY
İsmail ERMİŞ, Atakan AYDIN, Ufuk EMEKLİ, Bedrettin GÖRGÜN, Tahir HAYIRLIOĞLU, AtiUa ARINCI
İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Plastik ve Rekonstrüktif Cerrahi Anabilim Dah, İSTANBUL
SÜMMARY
Le Fort I maxiUaıy osteotomies have been performed in 29 patients with dentofacial deformüies. 12 cases underment Le, Fort I osteotomy alone, 14 cases had bimaxillary surgery (bilateral sagittal split o f the mandibular ramus in 8, extraoral vertical ramus osteotomy in 6) and 3 cases had segmental, or total m,axillary expansion folloıving Le Fort 1 osteotomy. The aesthetic and fu n c tio n a l improvements produced by surgery w as good. İn this study, loe report the indications, pre-surgical preparations, surgical procedures, d in im i and, cephalometric results and complications o f the patients above udi,o have had orthogn,athic surgery.
Koy fVords: Orthognathic surgery, Le Fort I osteotomy, maxilla.
INTRODU CTION
T he goals o f o rth o g n a th ic su rg ery can be s u m ın a riz e d as to e s ta b lis h th e o p tim a l fu n c tio n a l a n d aesth etic re la tio n sh ip bettveen the m axilla an d m andible and to place the jaws op timally, in th re e planes of s par. e, rvîthin the facial skeleton. Surgical m ovem ents o f th e jaws are com plicated three-dim ensional probleıns o f g e o m e tr ic a lly c o m p le x s tr u e t u r e s . T h e d i a g n o s t i c in f o r m a ti o n g a in e d fr o rn p r e - o p e r a tiv e c lin ic a l a n d r a d io g r a p h i c ex a m in a tio n s a n d m o d els m u st b e carefully iııteg red to establish a surgical tre a tm e n t plan.
T he final trea tm e n t p lan should b e expressed in analytic m o d el surgery ’7=16, T h ere have b ee n various o steotom y techniques d eserib ed in the lite ra tü re eith e r fo r sıngle jaw o r fo r b o th jaws.
T h e y a li p o s s e s s t h e i r a d v a n ta g e s , disadvantages, dificulties an d d iffe re n t factors
Ö ZE T
D entofasiyal deformüeli 2 9 hastada Le Fort I maksiller osteotomisi uygulanmıştır. 12 hastaya 'sadece Le Fort I osteotomisi, 14 hastaya bimaksiller osteotomi (8'ine bilateral sagital split ramus osteotomisi, 6 sına ekstraoral vertikal ram us osteotomisi) ve 3 hastaya Le Fort I osteotomisini takiben segmental ya da total maksiller ehspansiyon yapılmıştır. Cerrahi tedavi sonrası estetik ve fonksiyonel sonuçlar sağlarım ıştır. B u yazıda, ortognatik cerrahi gören hastalarımızdaki endikasyonlar, preoperatif hazırlıklar, cerrahi girişim, klinik ve sefalometrik, analiz ve komplikasyonlar sunulmaktadır.
A n a h ta r Kelimeler: Ortognatik cerrahi, Le Fort I osteotomisi, maksilla.
influeııcing the relap se rates i-3.8-i i,is-15,17_ T he p u rp o s e o f this p a p e r is to p r e s e n t th e osteotom y tech n iq u es u s e d ? th e com plications met. a n d th e follow -up results obLained in a g ro u p o f 29 p a tie n ts w ith d e n to -fa c ia l d efo m ıities w ho h a d e ith e r u rıd e rg o n e single nıaxillary osteotom ies alone o r bim axillary jaw surgery.
MATERIAL AND METHOD
29 cases with dento-facial defo rm ities w ere su b jected to L e F o rt I m axillary o steo to m ie s w ith o r w ith o u t s im u lta n e o u s m a n d ib u la r surgery an d seg m en ter m axillary o steotom ies (Table 1). 15 o f th e p atien ts w ere m ale an d 14 w ere fem ale w ith 'arı average age o f 20 at the tim e o f surgery- In ali p atien ts the n e e d fo r s u rg ic a l c o r r e c tio n was b a s e d o n b o t h fu n c tio n a l d is tu r b a n c e (d is c o m f o r t w h e n
* P rese n ted af, the 16 th N ational C ongress o f T urkish Plastic a n d R econstnıctive Surgery, A nkara, 1994.
D ergiye Geliş T arih i: 06.06.1995 D üzeltm e Sonrası K abul T arihi: 28.06.1995
m
LE FORT I OSTEOTOMİES
chew ing, sp eech pro b lem s, com plaints re la te d to th e t e m p o r o m a n d i b u l a r j o i n t ) a n d psychological aspects fro m th e aesthetic p o in t o f view. Ali w ere deeply c o n c e m e d ab ou t their facial appearan ce, b u t w ere othenvise healthy.
Table 1: Orthognathic pracedures used for dento-facial deformities
Type of osteotomy Number
of patients
Le Fort I maxillary osteotomy alone 12
Le Fort I osteotomy + Bilateral sagittal split ramus osteotomy 8 Le Fort I osteotomy + Erctraoral vertical ramus osteotomy 6 Le Fort I osteotomy + Segmentai ortotal maxi!lary expansion 3
S ta n d a r d fa c ia l a n d o c c lu s a l slid e s, o r th o p a n to m o g r a p h ie s a n d c e p h a lo m e tric tra c in g s w e re ta k e n a n d p la s te r ca st study m odels w ere p re p a re d . Ali cases w ere re fe rre d to o r th o d o n tic s f o r occlusal in v e stig a tio n . P re-o p erativ e o rth o d o n tic th erap y cou îd only b e ca rrie d o u t in 12 patien ts varying from six m o n th s to e ig lıte e n m o n th s . In o th e rs p ro sth o d o n tic c o n trib u tio n was re q u ired . T he p la n n e d o ste o to m ie s w e re ac co m p lish e d o n m o d el surgery. A n in te rim occlusal splint was p re p a re d w hen bim axillary surgery was to be p e r fo rm e d . A fin al in te ro c c lu sa l sp lin t was m a d e re a d y f o r p a tie n ts w ho w o u ld lıave s e g m e n ta i o s te o to m ie s o f th e m a x illa , b im a x illa ry su rg e ry a n d fo r p a tie n ts w ith i n c o m p l e t e o r w i t h o u t o r t h o d o n t i c p re p a ra tio n .
T h e Le F o rt I osteotom y was p e rfo rm e d at le a st fo u r to five m m above th e roo ts o f the m ax illary te e th . T h e o ste o to m y was c a rrie d across th e a n te r io r m axilla a n d th ro u g h the lateral a n d m edial m axillary walls. T he septum was s e p a r a te d fro m th e n asa l flo o r. A n o s te o to m y was p e r f o r m e d b e tw e e n th e m axillary tu berosity a n d the p terygoid p late of th e s p lıe n o id th ro u g h th e p a la tin e b o n e . M axilla c o u ld th e n b e m obİlized by digital p res sure o r witiı an aid o f Rowe disim paction forceps. T he m axillary segm ents w ere stabilized e it h e r by m ın ip la te s a n d screw s o r by intero seo u s wiring.
T otal o r segm entai expansıon o f th e m axilla was m a d e follow ing L e F o rt I o steo to m ie s.
S e g m e n t a i m a x i l la r y e x p a n s io n a n d a d v a n c e m e ııt was a c co m p lish e d in a n a d u lt cleft lip an d p alate p atien t. Sagittal splitting of
th e ın a n d ib u la r ram u s was a c c o m p lish e d by m eans o f a lingual cut exten d in g the full w idth o f th e ram us an d a buccal cortical cu t dire ete d tow ard th e angle re g io n . T h e vertical ra m u s osteotom y was p erfo rm e d th ro u g h a cu tan eo u s in c is io n o n e cm b elo w th e a n g le o f th e m andible paralleling the n a tu ra l skin creases o f the neck. T h e osteotom y was m ad e fro m the m id-sigm oid noteh to th e angle o f th e m andible p o sterio r to th e lingula. T he proxim al seg m en t was re fle e te d la te ra l to th e d istal se g m e n t, allowing fo r the setback o f th e m andible. T h ere was n o t any k in d o f fix a tio n a c c o m p lish e d betw een th e p ro x im al a n d distal segm ents in any o f th e cases w lıo h a d u n d e r g o n e m and ib u lar osteotom ies.
T he m axillary osteotom y was d o n e first in bim ax illary p ro c e d u re s. F ollo w in g a d e q u a te m obilization o f th e maxilla, it was m oved to its p re p la n n e d p o s itio n g u id e d by th e in te rim splint. Follow ing fix atio n o f th e m axilla to İts n e w p o sitio n , th e in te rim occlusal w afer was re m o v e d a n d th e m a n d ib u la r o steo to m y was p e r f o r m e d u s in g o n e o f th e te c h n iq u e s d eseribed above. T he final occlusal sp lin t was th en placed in position an d in te rd e n ta l fixation was accom plished. T he post-operative p h ase o f orthodontics a n d / o r p ro sth o d o n tics was sta rte d w lıen th e re h a d b e e n ad e q u a te b o n e h ea lin g an d fu n e d o n achieved a n d this was usually six to eight weeks post-operatively.
P o st-o p era tiv e la te ra l ce p h a lo g ra m s w ere tak en follow ing th e re le a se o f in term ax illary fix atio n a n d w ithin th e s u b se q u e n t 10 to 18 m onths. T he SNA, SNB an d ANB angles w ere r e c o r d e d p re -o p e ra tiv e ly , e a rly a n d la te p o st-o p e ra tiv e ly . T h e c e p h a lo m e tric m e a n values betw een th e d iffe ren t tim e p erio d s w ere sta tisd c a lly analy sed u sin g S tu d e n t’s T -test re g a rd in g statistica l sig n ific a n c e o f re la p s e betw een th e post-operative Controls. E valuation o f so ft üs su e clıanges was p e r f o r m e d w ith regard to R icketts1 aestheüc line (Eline) wİth its relation to the u p p e r an d low er lips.
RESULTS
T he ra n g e o f follow -up tim e fo r th e se 29 patients is from ten m o n th s to six years. In ali c a s e s t h e a e s t h e t i c a n d f u n c t i o n a l im provem ents p ro d u c e d by surgery was g o o d
Türk Plast Cer Dtırg (1995) Cilt: 3, Sayı: 2 (F igures 1-6). M ajör co m p licatio n s su ch as
severe b leed in g o r necrosis o f tire jaw segm ents d id n o t o cc u r. N o te e th o r d en to -a lv eo lar se g m e n ts w e re lo s t as a r e s u lt o f th e se p r o c e d u r e s a n d n o p a tie n t s u s ta in e d any p e rm a n e n t disability.
I n th e b im a x illa ry g ro u p w itlı b ila te ra l sa g itta l s p lit o f th e m a n d ib u la r ra m u s , unilateral dam age to th e in ferio r alveolar nerve was o b se rv e d in f o u r cases a n d b ila te ra l dam age in two cases which reco v ered w ithin a y ea r except oııe p a tie n t. T he skeletal relapse was observed in two cases in tlıis group.
In th e b im ax illa ry g ro u p w ith e x tra o ra l vertical ram u s osteotom y no nerve dam age was observed. T h e skin scar d id n o t b o th e r the p atients. T he skeletal relapse was n o te d in one case o f tlıis group.
In tra -o p erativ e com plications w ere ra re. A p e rio d o n ta l clefect o c c u red a t an in te rd e n ta l o steotom y site in o n e p atien t, a p e rfo ra tio n of palatal m u co sa w ith an o steo to m e occu red in a n o th e r p a tie n t w hich h ea le d uneventfully and an ex tru sio n o f in te rp o sitio n a l b o n e graft was se e n in a n o th e r p a tie n t in th e m ax illary expansion gr oup.
T e m p o ra ry u p p e r lip h y p o e s th e s ia was n o te d in ali patients which recovered w ithin six to 18 m onths. T h ere w ere th ree patients wİth a skeletal re la p se in th e g ro u p w ith Le F o rt I m axillary osteotom y alone. T h e skeletal relapse in ali cases o f ali g ro u p s o c c u re d m ainly b e tw e e n th e th r e e m o n th s to o n e y e a r post-operatively.
C e p h a l o m e t r i c m e a ş u r e m e n t s o f interm axİllary relations with re g ard to SNA and S N B a n g l e s p r e - o p e r a t i v e l y , e a r l y postroperatively (after tlıe release o f in terd e n ta l fix atio n ) a n d late p o st-operatively (up to 18 m o n th s ) a r e s h o w n in T a b le 2. T h e post-operative early a n d late value changes fo r b o th SNA a n d SNB angles w ere statistically insignificant (p>0.5).
S oft tissue evaluations p r e-o p e r ati v ely, early a n d late post-operatively w ith Ricketts aestheüc line (E-line) re la tio n to the u p p e r and lower lips a re show n in T ab le 3. T h e p o s t o p e ra tiv e m easu rem en t changes betw een th e u p p e r lip to th e E-line a n d b e tw e e n th e low er lip to the E-line w ere statistically insignificant (p>0.5).
Table 2: Cephalometric values of SNA and SNB angles pre-and post-operaîively up to 18 months
Cephalometric measurements
Pre-op Post-op Late post-op
SNA 74.±11.1 78.3112.7 77.6+12.5
SNB 80.74±13.1 79.4114 79112.4
Table 3: Soft tissue evaluation pre-and up to 18 months
post-operatively with Rickett’s Eline relation to the upper and lower lips
Cephalometric measurements
Pre-op Post-op Late post-op
Upper lip-E-line 5.93±1.71 mm 3.5510.42 mm 3.2710.97 mm Lower lip-E-line 2.8911.22 mm 1.8811.04 mm 1,96+0.26 mm
d i s c u s s i o n
W ith only lim ite d n u m b e r o f p a tie n ts in each g ro u p in clu d ed in this study, th e resu lts rrıay n o t b e lia b le to d e ta ile d s ta tis tic a l evaluation, how ever certaın im pressions m ay be gained.
T h e Le F o rt I o ste o to m y is a v e rsa tile p ro c e d u re fo r th e m o v e m e n t o f th e lo w e r maxilla, horizontally, vertically o r transversely.
O fte n m o v em en t in a c o m b in a tio n o f th ese directions is p e rfo rm e d sim ultaneously. T he Le F o rt I ex tru sio n o steo to m y has tra d itio n a lly b e e n th e m o s t u n s ta b le o f o r th o g n a th ic p ro c e d u re s a n d th e o n e m o st likely to b e follow ed by early o r la te relap se. T lıe re are techniques described to m ain tain the m obilized m a x illa 13’14, yye have u s e d iliac b o n e grafts across the osteotom y to m ain tah ı the ex tru sio n an d to enhance b o n e healing.
Succesful tra ııs p o s itio n o f th e ın ax illa ry dento-osseous segm ents by Le F o rt I osteotom y depends on th e p reserv atio n o f viability o f th e segm ent by p ro p e r design o f the soft tissues an d bony incisions. T he collateral circu latio n w ithin the m axilla an d eııveloping soft tissues an d th e vascular an a sto m o ses in th e m axilla, p e r m it ınany technical m odifications o f th e L e F o rt I o s t e o t o m y 4'12 \ y e n o t o b se rv e any devitalizadon o f th e dental o r bon y structures.
G ertain positional m ovem ents o f th e m axilla are potentially p ro b lem ad c: excessive p o s te rio r an d su p e rio r re p o s itio n in g o f th e m axilla is technically difficult, b ecau se th e re a re m o re areas o f bony co n tact th a t m u st b e re d u c e d to
133
TE FORT 1 OSTEO'FOMIES
Figüre 3: Case 1, pre-operative occlusal view. Figüre 4: Case 1, posToperative occlusal view.
Türk Plast Cer D erg (1995) Cilt: 3, Sayı: 2 facilitate passive a d a p ta tio n o f t.he m argins o f
th c o s te o to m iz e d se g m e n ts 3. W e d id n o t e n c o u n te r such p ro b le m s since we d id n o t p e rfo rn ı s ü p e rio r p o sitio n in g o f th e m axilla.
A sym nıctric m o v em cn l o f tbe m axilla in lıigh Le F ort I osteotom ies rrıay p ro d u c e asyınınetric p ro m in e n c e o f th e zygom as 1>8. W e trie d to avo id su ch p ro b le m s by in d iv id u a liz n g th e osteotom y desigıı.
M u ltip le s e ğ m e n t Le F o rt I o ste o to m ie s p ro v id e th e plastic su rg e o n to tre a t com plex d entofacial d eform ities in clu d in g th a t o f cleft lip a n d p alate p a tie n ts . T h e in d ic a tio n s are tra n s v er s e m axillary defi ci e ney, different.ial v ertic al dysplasia belvveen tire a n te r io r and p o s te rio r re g io n s o f Üre m axilla a n d sagittal m a x illa ry ex cess l5j 17. W e h a d p e r fo rm e d se g m e n te r o steo to m ies d u e to th e trans ver s e uıaxillary delici en cy in o u r patients.
T h e in d ic a tio n s fo r b im a x illa ry sn rg e ry in e lu d e p a tie n ts w ith asy ın ın etric al m İd-aııd lotver facial deform ities, long face deform ity in w hom the co rrec tio n re q u ire d is n ıo re than 10 m m a n d bim axillary p ro tru s io n o r re d 'u sio n 2,9,ıo_ x h e am o u n t o f m an d ib u îar relapse in the bim axillary ap p ro ach ten d s to b e slightly less th a n in th e single jaw m a n d ib u îa r o steotom y p robably d u e a m in ö r h o rizo n tal m o v em en t of th e m an d ib le in the bim axillary p ro c ed u re . The re la p s e te n d e n e y is o b v io u sly n o t m o re extensive in e ith e r o f th e jaws w hen b o th are d o n e at th e sam e tim e th an af ter a single jaw o p e r a tio n 10. Tlıis \vas clearly observed in o u r patients.
G areful a n d p re c ise o re h e s tra tio n o f the o p e ra tio n s w ith an o rth o d o n tis t is crucial to tre a tm e n t is to p re p a re th e d e n titio n fo r the surgical co rrectio n so th at the dental arehes are co m p atib le in th e p o st-operative p o sid o n . Iıı c h o o sin g an o rth o d o n tis t to w ork w ith, the im p o rta n c e o f m u tu a l u n d e rs ta n d in g , clear co m ın u n ic a tio n an d teehnieal ability can n o t b e o v e r e m p h a s iz e d 5,e. T h u s we tr ie d to p e rfo rm p re -a n d p o st-o p e ra tiv e o rtlıo d o n tic trea tm e n t in m ost o f th e patients.
T h e in te rim s p lin t is very im p o r ta n t in c o n tro llin g th e h o rizo n ta l p lan e ro ta tio n s and a d v a n c e m e n ts o f th e ın o b iliz e d m ax illa is m o ve d to its d e sire d p o sitio n , in term ax illary Fıxation is o b ta in e d using th e in te rim splint.
T h e m a x illa r y - m a n d ib u la r u n i t is th e n m a n ip u la te d to place th e m an d ib le in centric position an d then th e m axilla is stabilized 2)9_n.
W h e th e r one uses vertical ram u s o steotom y or sagittal s p litd n g o f th e ra m u s o r a n o th e r uıan d ib u îar osteotom y tech n iq u e is a m a tte r o f su rg e o n ’s choice. T h e binıaxillary surgery is, in o u r o p in io n , a m o r e tim e c o n s u n ıin g p ro c e d u re b u t gives a sad sfy in g a n d s tabi e p o st-o p e ra tiv e re su lt. So fa r we h a v e n o t e n c o u n te r e d atıy s ig n ific a n t c o m p lic a tio n s d u rin g o r a f te r su rg e ry w ith th e m ax illary o s te o to m ie s w ith o r w ith o u t m a n d ib u îa r osteotom ies deseribed above.
As a c o n c lu s io n , d e te r m in a tio n o f th e i ı ı d i v i d u a l a e s th e tic . a n d f u n e t i o n al re q u ire u ıc n ts w ould seem to dec.ide rv h e th e r siın u lta n e o u s su rg ical re p o s itio n in g o f th e m axilla an d m andible to g e th e r o r rep o sitio n in g o f o n e o f th e jaw s alo n e, w o u ld b e m o re desirable. F u rth er investigadons w ith re g a rd to th e stability o f v ario u s o rth o g n a th ic su rg e ry p ro c e d u re s in tre a tin g dento-facial d efo rm id e s are required.
İsmail ERMİŞ İstanbul Tıp Fakültesi
Plastik ve Rekonstrüktif Cerrahi Anabüim Dalı Çapa, 34390, Topkapı, İstanbul.
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