Le Fort I Segmental Osteotomy

Armamentarium

  • #9 Molt periosteal elevator

  • #15 Scalpel blade

  • Appropriate sutures

  • Curved Mayo scissors

  • Double-guarded septal osteotome

  • Freer elevator

  • Kirschner wire

  • Local anesthetic with vasoconstrictor

  • Mallet

  • Medium Langenbeck (toe-in) retractors (two)

  • Monopolar cautery

  • Needle driver

  • Pterygoid chisel

  • Round bur

  • Safe-edge saw

  • Sagittal saw

  • Seldin retractor

  • Spatula osteotome

  • Straight osteotome

  • Suture scissors

  • Woodson elevator

History of the Procedure

Understanding the history of the Le Fort I osteotomy requires an appreciation of several aspects of surgery on the maxilla, including the history of the osteotomy, the associated blood supply that maintains a viable maxilla, and the fixation methods used to stabilize the segment or segments and minimize relapse. In 1859, von Langenbeck described a maxillary osteotomy to access to nasopharyngeal polyps. Seven years later, Cheever performed the first maxillary down-fracture in the United States, to address complete nasal obstruction. Although René Le Fort published his landmark paper in 1901 describing the natural planes of maxillary fractures, it was not until 1927 that Wassmund first described use of a Le Fort I osteotomy for the correction of midface deformities (using orthopedic devices instead of intraoperative mobilization/fixation). Various modifications of Le Fort I surgery were produced by a multitude of surgeons, including Axhausen (complete mobilization and repositioning in 1934) and Schuchardt (separation of the pterygoid plates from the maxilla in 1942); additional major contributions were made by Obwegeser in 1965 with his implementation of bimaxillary mobilization with repositioning to achieve superior esthetic results.

The maxillofacial surgeon should also be familiar with the studies supporting the viability of the surgically treated maxilla. Landmark papers by Bell in 1975 elucidated the vascular supply to the down-fractured maxilla, demonstrating the importance of the buccal and palatal soft tissue pedicles and accompanying vasculature. He also documented the ability to sacrifice the descending palatine vessels while maintaining adequate blood supply. Equally important are the studies demonstrating the viability of the dentition after a subapical osteotomy. Over the ensuing years, various modifications of the osteotomies, in addition to fixation methods and bone grafting to the mobilized maxilla, have continued to evolve and progress.

History of the Procedure

Understanding the history of the Le Fort I osteotomy requires an appreciation of several aspects of surgery on the maxilla, including the history of the osteotomy, the associated blood supply that maintains a viable maxilla, and the fixation methods used to stabilize the segment or segments and minimize relapse. In 1859, von Langenbeck described a maxillary osteotomy to access to nasopharyngeal polyps. Seven years later, Cheever performed the first maxillary down-fracture in the United States, to address complete nasal obstruction. Although René Le Fort published his landmark paper in 1901 describing the natural planes of maxillary fractures, it was not until 1927 that Wassmund first described use of a Le Fort I osteotomy for the correction of midface deformities (using orthopedic devices instead of intraoperative mobilization/fixation). Various modifications of Le Fort I surgery were produced by a multitude of surgeons, including Axhausen (complete mobilization and repositioning in 1934) and Schuchardt (separation of the pterygoid plates from the maxilla in 1942); additional major contributions were made by Obwegeser in 1965 with his implementation of bimaxillary mobilization with repositioning to achieve superior esthetic results.

The maxillofacial surgeon should also be familiar with the studies supporting the viability of the surgically treated maxilla. Landmark papers by Bell in 1975 elucidated the vascular supply to the down-fractured maxilla, demonstrating the importance of the buccal and palatal soft tissue pedicles and accompanying vasculature. He also documented the ability to sacrifice the descending palatine vessels while maintaining adequate blood supply. Equally important are the studies demonstrating the viability of the dentition after a subapical osteotomy. Over the ensuing years, various modifications of the osteotomies, in addition to fixation methods and bone grafting to the mobilized maxilla, have continued to evolve and progress.

Indications for the Use of the Procedure

Le Fort I osteotomies (single and multipiece) are performed to correct bony deformities that result in malocclusions and esthetic concerns and, less frequently, for access to pathologic conditions. Severe midface deficiencies, canting of the maxilla, excessive or inadequate gingival and/or tooth show, transverse deficiencies, apertognathia, and malocclusions have all been cited as indications for a Le Fort I osteotomy. Segmentalization of the Le Fort I osteotomy is performed to correct malocclusions in which transverse discrepancies exist in addition to the need for anteroposterior correction.

Limitations and Contraindications

Contraindications to performing a Le Fort I osteotomy include bone disorders (e.g., osteogenesis imperfecta, Paget’s disease of bone), which would impair the surgeon’s ability to attain desirable fractures and also impede the healing process. Limitations of Le Fort I surgery are due to the stability of movements. Anterior movements greater than 10 mm become increasingly unstable due to the decreased bony overlap as the maxilla is advanced. The soft tissue tension as the maxilla is brought forward also can increase the propensity for relapse or hardware failure. In general, transverse movements accomplished with segmental Le Fort I osteotomies with a single paramedian split should be limited to transverse widening of 2 to 4 mm; a second paramedian split on the contralateral side would allow for movements of 4 to 6 mm. For transverse widening greater than 6 mm, the use of surgically assisted rapid palate expanders should be considered. Exceeding the limits of the soft tissues can lead to problems such as oronasal fistulas, which can be difficult to correct.

Technique: Le Fort I Segmental Osteotomy

Step 1:

Head Wrap

After nasoendotracheal intubation with a nasal Ring-Adair-Elwyn (RAE) tube, the tube should be secured to the head wrap. Care should be taken to avoid any pressure from the endotracheal tube on the nasal ala by securing the circuit at the top of the head wrap. Special attention to preventing pressure necrosis on the forehead at the connection from the endotracheal tube (ETT) to the circuit is also imperative; this can be done by placing foam between the connector and the skin. Time taken to secure a tube before prepping and draping is time well spent and helps avoid the risks and inconvenience of a dislodged ETT during the procedure. The patient’s head is then placed on a gel donut for stabilization. A local anesthetic can be injected using 1% lidocaine with epinephrine 1 : 100,000 along the maxillary vestibule. The patient is then prepped and draped in a sterile fashion. At the onset of the case, a K-wire can be placed at the region of the nasion, and measurements on the unoperated maxilla can be taken to reference for planned vertical movement ( Figure 39-1, A ).

Only gold members can continue reading. Log In or Register to continue

Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Le Fort I Segmental Osteotomy
Premium Wordpress Themes by UFO Themes