Abstract
The primary purpose of this study was to evaluate the long-term skeletal stability of the maxillary quadrangular Le Fort I osteotomy, and secondarily to determine patient overall experience and satisfaction with the surgical outcome. This retrospective cohort study evaluated a sample of patients with midface zygomatic-maxillary deficiency and Class III skeletal malocclusion. The primary outcome measure, on the basis of cephalometric analysis, was long-term vertical and horizontal skeletal stability in cleft and non-cleft patients, with and without interpositional autogenous iliac bone graft stabilization. A questionnaire measured patient overall experience and satisfaction with the surgery. One hundred twenty-one patients completed the questionnaire. Of these, 53 satisfied the cephalometric study inclusion criteria. Horizontal and vertical intraoperative movement and late postoperative movement showed overall high skeletal stability. No statistical difference in horizontal skeletal stability was noted between cleft and non-cleft patients, or between patients receiving or not receiving a bone graft. Mean satisfaction with the overall treatment result was 9.2 of 10 (10 being highest satisfaction). We conclude that the quadrangular Le Fort I osteotomy is a functionally stable and surgically predictable procedure for cleft and non-cleft patients with or without interpositional iliac bone graft, with a midfacial zygomatic-maxillary deficiency.
In 1969, Obwegeser described a Le Fort I osteotomy in which the bone cut was made ‘as high as possible from the tuberosity around the whole maxilla, staying just beneath the infra-orbital foramen.’ Stabilizing interpositional bone grafts were placed between the pterygoid plate and the palatine bone or tuberosity posteriorly. In addition, bone graft placement was provided anteriorly ‘from the zygomatic cortex to the piriform rim.’ Obwegeser also noted that the interpositional bone grafts could be extended superiorly as high as the infraorbital rim to provide an aesthetic benefit as well as skeletal stability of the advanced maxilla.
The work of Bell et al., published in 1975, on the vascularity of the Le Fort I osteotomy, established the scientific basis of this procedure and led to its increased use and popularity. Other authors in the 1970s and 1980s reported on their experience and clinical use of the Le Fort I osteotomy.
In 1990, Keller and Sather published a review of 54 consecutive patients who underwent ‘modified high Le Fort I osteotomy,’ as described by Obwegeser , to correct midfacial deficiency and Class III skeletal malocclusion. The authors coined the term ‘quadrangular Le Fort I osteotomy’ (QLF-I), because the indications, osteotomy level, and projected outcome were similar to the Le Fort II osteotomy initially described by Kufner in 1971 and named the ‘quadrangular Le Fort II osteotomy’ (QLF-II) by Steinhäuser in 1980. Additional reports on the QLF-I and QLF-II osteotomies were published by Keller and colleagues, utilizing intraoral incisions and stabilizing corticocancellous block bone grafts. In 2011, Stork completed a stability study on QLF-I patients, and Kim et al. described their study on the stability of the QLF-I in 2001.
The primary purpose of this study was to evaluate the long-term horizontal and vertical stability and clinical outcome in patients undergoing maxillary horizontal advancement with vertical augmentation or impaction, via the intraoral QLF-I, with and without interpositional autogenous iliac bone grafting, in cleft and non-cleft patients. The secondary purposes were to study patient satisfaction with the operative and postoperative experience and outcome, and to study the skeletal stability relative to patient age (<18 years, or ≥18 years).
Patients and methods
A minimal-risk institutional review board protocol was submitted and approved. The study was a retrospective analysis of patients who had been treated with maxillary QLF-I by a single oral and maxillofacial surgeon. Patient information was obtained from the institutional database for the period January 1, 1984, through December 31, 2010. A total of 212 patients who had undergone the QLF-I were sent an invitation letter and questionnaire. Of these patients, 121 completed the questionnaire, and 80 of the 121 patients surgically treated between July 1984 and August 2009 returned for long-term follow-up and evaluation. Fifty-three of the 80 patients met selection criteria for the cephalometric stability study and had agreed to the use of their data for research purposes.
Inclusion criteria were used to identify patients with a Class III skeletal malocclusion with a bilateral zygomatic-maxillary deficiency and normal nasoethmoidal projection, determined through clinical examination, who had undergone a maxillary QLF-I and had appropriate serial complete cephalometric orthodontic records. In addition to preoperative lateral cephalometric radiography (T1), short-term postoperative radiography (T2) had to have been done within 6 months of the surgery, and long-term radiography (T3) had to have been done more than 12 months after surgery. Exclusion criteria were incorrect or missing contact information, non-diagnostic lateral cephalometric radiographs, incomplete records (clinical or surgical notes), and records outside the inclusion date range.
Surgical procedure
The surgical procedure was a high Le Fort I osteotomy, the QLF-I ( Figs. 1 and 2 ). The horizontal osteotomy was just below the infraorbital foramen and extended from the piriform rim medially to the body of the zygoma laterally. Interpositional autogenous corticocancellous block iliac bone grafts were placed behind the advanced maxilla (pterygoid–palatine bone) and grafted as an onlay on the infraorbital rim and body of the zygoma. The bone graft functioned as an interpositional stabilizing graft and provided horizontal augmentation for aesthetic enhancement of the deficient infraorbital rim and zygoma. Patients who received simultaneous maxillary impaction, or whose maxilla was advanced a lesser amount horizontally, frequently did not require or receive interpositional autogenous corticocancellous block iliac bone grafting. This decision was always made intraoperatively and was based on the presence or absence of adequate bone contacts for predictable healing. The cosmetic benefit of onlay bone grafting was also a consideration. Guiding intermaxillary elastics were used for 6–8 weeks in all patients; rigid mandibulomaxillary fixation was not used. Figure 1 illustrates and compares the vertical level of the QLF-I with the standard low-level Le Fort I osteotomy. Figure 2 is a surgical photograph of the osteotomy before and after immobilization and interpositional bone grafting.
