Background : The possible sequelae of maxillary osteotomies are numerous. High Le Fort and pyramidal osteotomies can be susceptible to nasolacrimal duct injury, hemorrhage and blindness. High Le Fort I osteotomy can usually be safely performed by techniques previously described if its osteotomy’s horizontal trajectory is parallel and below the inferior orbital nerve; while the execution of the Le Fort II osteotomy as described by can safely avoid iatrogenic trauma when the surgeon’s execution includes a medial orbital osteotomy. However, previous studies either record their findings from high Le Fort osteotomies on a population of homogenous dry skulls; or describe a pyramidal osteotomy posterior to the lacrimal fossa necessitating medial orbital access. A novel solution to decrease morbidity of these maxillary osteotomies is to perform virtual treatment planning; verify the patients’ adjacent critical anatomy; and if needed, modified the osteotomies’ design, create cutting guides, and utilize intra-operative navigation.

Methods : Three patients with severe maxillary hypoplasia (Binder’s syndrome, nonsyndromic dentofacial, and nonsyndromic cleft) underwent virtual treatment planning (MATERIALISE ^® , Leuven, Belgium) to analyze their anatomy. Intra-operative splints were fabricated by CAM-CAD for the first two “double-jaw” cases and all received rigid fixation (SYNTHES ^® , Zuchwil, Switzerland). The first patient’s complex osteotomies’ design (multi-piece Le Fort II) was aided with the help of cutting guides and trajectory’s was determined by intra-operative navigation (BrainLab ^® , Feldkirchen, Germany). The second and third patients underwent high-Le Fort I osteotomies.

Results : None of the patients experienced visual acuity changes (20/20 uncorrected, 20/20 uncorrected, 20/20 uncorrected). The only the first patient had epiphora which resolved in one week. Intra-operative hemorrhage was individually less than 300 mL for all cases.

Conclusion : Nonstandard Le Fort maxillary osteotomies can be arduous techniques, but provide predictable down fractures and low morbidity if surgeons use virtual treatment planning and intra-operative navigation.

Key words : midface deformity; virtual treatment planning; maxillary osteotomy