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1、UnitTwentySevenLeForteIosteotomyforcorrectionofmaxillarydeformitiesWilliamH.Bell,DDS.DallasCompletemobility,preservationofviability,andadequatefixationduringhealingisessentialtosurgicalrepositioningofthemaxillatoobtainastablerelationshipwiththemandible.LeForteIosteotomytechniqueswereusedtoconnectvar

2、iousdeformitiesofthemaxillain15adultpatients.In1927,MartinWassmundintroducedasurgicalprocedureformovingtheentireinaxilla.Theoperation,whichhassincebeencalledLeForteIosteotomyortotalmaxillaryosteotomy,wasfirstusedtocorrectananterioropenbite.Themaxillawasnotcompletelysectionedfromitsbonyattachments,an

3、dnoattemptwasmadetomobilizethemaxillaatthetimeofsurgery.Postopcrativcly,incrmaillaryelastictractionwasusedtoclosetheopenbiteandstabilizethemaxilla.Inviewofthestateofartofanesthesiaatthetime,thelackofantibioticsandchemotherapeutics,andtheempiricalbasisformaxillarysurgery,thiswastrulyaremarkablefeat.W

4、assmundsdirectapproachtothemaxillarydeformitywasclearlyyearsaheadofitstime.Thedesignofthebonyandsofttissueincisionshavebeencontinuallymodifiedtofacilitatemovementofthemaxillaandtomaintaincirculationtothemaxillaryboneandteeth.SchuchardtandKoledevisedatwo-stageproceduretopreventimpairmentofthevascular

5、supplytothemaxilla.Postopcrativcly,Schuchardtusedweightsfromanoverheadtractiondevicetorepositionthemaxillaforward.Thesecondstageofhistechniqueinvolvedseparationofthepterygoidprocessesfromthemaxillarytuberosities.Despitesuchmeasures,hebecamedisenchantedwith(heprocedureandconcludedthattheoperationshou

6、ldnotbeusedtotreatpatientswithclefts.Axhausenusedelastictractionaftersurgerytofacilitateanteriormovementandretentionofatraumaticallyrelrodisplacedmaxilla.Inanapparentattempttocircumventtheseshortcomings,GilliesandConverseandShapiroadvocatedadvancingthemaxillabymeansofatransversepalatalcutofthe3uncti

7、onofthepalatineandmaxillarybone.Thesuccessofthisapproachwasnotcommentedon.Bonegraftinghasbeenadocatedtopromotebonyregenerationbetweenthebuccalbonecutsinthelateralportionsoftheinaxilla.Obwcgcscrmaintainedthatgraftingthespacebetweentheposteriormaxillaandthepterygoidplateswasessentialforstability.Inabi

8、litytomovethemaxillathedesiredamountandrelapsewascommonfortheinnovatorsofthisoperation.Thesurgeonsfearthatmobilizationofthemaxillawoulddevascularizeanddevitalizetheboneandteethwasthedominantreasonforsuchproblems.Thefearoftraumatizingvascularstructures,suchasthegreaterpalatineandinternalmaxillaryarte

9、ries,wasalsoamajorobjectiontothetechnique.Still,thebiologicbasisandsurgicalprinciplesformaxillaryosteotomiesremainedobscureandobviouslycontributedtopostoperativedevitalizationandlossofboneandteeth.Microangiographicandhistologicstudiesoftotalmaxillaryosteotomyperformedinadultrhesusmonkeysshowedonlytr

10、ansientvascularischemia.Minimalosteonecrosis,andearlyosseousunionwhenthemaxillawaspedicledessentiallyonlytothepalatalmucosa.Preservationofthehorizontalportionofthehardpalate.Pedicledtopalatalmucosaismovableandseparatedfromthenasalseptum.Theseproblemscanbeobviatedwhenthesurgeryisexecutedfromthebuccal

11、vestibulethroughthreeverticalincisionsandtheseptumandhorizontalpartofthepalatearemaintainedintact.Thesurgicaltreatmentplanmustbeflexible.Techniquesusingbothincisionshavebeenusedsuccessfullyandprovidethesurgeonmorelatitudeincorrectingmaxillarydeformitiesthanhasbeenpossiblewithpreviouslyreportedtechni

12、ques.ResultsSince1971,theLeForteIdownfracturingTechniquehasbeenusedtoadvance,retract,raise,narrow,orexpandthemaxillain15patients(Table).Complexdcntofacialproblems(Fig5-7)suchasmaxillaryretrusion,skeletaltypeanterioropenbite,maxillaryasymmetry,bilateralbuccalorpalatalcrossbite,maxillarydcnto-alvcolar

13、protrusion,andmaxillaryalveolarhyperplasiahavebeensuccessfullycorrected.Thesurgicalandorthodonticprinciplesusedintreating(hewdeformitiesareillustratedbythreecasereports(casenumberscorrespondwiththoseintheTable).CASEI-Figure5showshowmaxillaryretrusionassociatedwithmandibularprognathismina16year-oldbo

14、ywasconectedbymaxillaryadvancement(surgicaltechniqueillustratedinFig1)andorthodontictreatment.Awideningofthealarbasesofthenoseandadecreaseofthenasolabialangleproducedapronouncedimprovementofthepatient*soverallfacialbalance(Fig5B,D,F,G).Interocclusalharmonywaslikewiseattained(Fig5H-J).-Comment.Allobt

15、usenasolabialangleisprobablythesinglemostimportantdiagnosticcriterionfortotalmaxillaryadvancement.Theupperlip-nosebalancecanbesignificantlyimprovedbyreductionofsuchanangle.Fig6-Case2.A,B,21-year-oldwomanwithshortupperlip,contour-deficientchin,narrownasalalarbeses,andlackofprominenceinmidfacialregion

16、beforetreatment(reposeposition).C,D:Improvedfacialbalance,wideningofnasalalarbases,andincreasedprominenceinzygomxaticomaxillaryandnasomaxillaryregionsaftermaxillarysurgery(techniqueshewninpartG).E:Preoperativecephalometrictracingshowinghighmandibularplane,7mmoverjet,andskeletal-typeClassIImalocclusi

17、onandunilateralpalatalcrossbite.G:Diagrammaticplanofmaxillarysurgery.Simultaneousanteriorandposteriormaxillaryosteotomiesinrepositionmaxillasuperiorlyandfacilitatemaxillomandibulararchalignment.H:Postoperativeocclusion.I:Compositecephalometrictracingsbefore(solidline-21year,3months)andthreemonthsaft

18、ersurgery(brokenline-21years,6months)showingautorotationofmandible,reductionofanteriorfacialheight,restorationofchincontour,improvedupperlipline-inciserrelationship,andfunctionaloverbiteandoverjet.Maxillaissuperimposedoveranteriorportionofmaxilla;mandibleissuperimprovedovermandible.(Dr.CraigWilliams

19、,residentinoralsurgery,ParktandMemorialHospital,Dallas,wasresponsiblefortheprimarycareofthispatient.)CASE2-A21-year-oldwomansoughttreatmenttodecreasetheprominenceofhermaxillaryteethandtoimprovethecontourofherface(Fig6A-B).Clinicalandcephalometricanalysesdisclosedahighmandibularplaneangle,totalmaxill

20、aryalveolarhyperplasia,ahighpalatalvault,shortupperlip.contour-deficientchin,andlackofprominenceinthemidfacialregion(Fig6A,B,E).HerClassnmalocclusionwasassociatedwithaunilateralpalatalcrossbite,constrictedmaxillarycanines,anda7mmoveijet(Fig6F).ThesurgicaltechniqueshowninFigures24wasusedtorepositiont

21、hemaxiIliasuperiorly.Theanteriorportionoftheinaxillawasraised7mmandtheposteriorportionwasraised9mmtoimprovetheupperlip-incisorrelationship,tofacilitateautorotationofthemandible,andtocorrecttheoveijet(Fig6G).Verticalostectomiesweremadein(hesecondpremolarregionstofacilitatecorrectionoftheunilateralcro

22、ssbiteandalignmentofthedentalarches.Bymovingtheposteriormaxillarydcnto-alvcolarsegmentsforward6mm,theextractionspaceswereclosedwithoutretractionoftheanteriorpartofthemaxilla.Theanteriormaxillarysegmentwassectionedbetweenthecentralincisorstoincreasetheintercaninewidthandtoimprovethefirstpremolarrelat

23、ionship.Facialharmonyandocclussalbalancewereattainedafterthreemonthsoftreatment(Fig6C,D,H,I).Arhinoplastyisplannedforthefuturetoreducethenasaldorsumandwidthofthealarbasesandtoraisethetipofthenose.-Comment.Inpatientswhodisplayanexcessiveamountofgingivaandteethinapositionofreposeorwhensmiling,eitherbe

24、causeofashortupperlipormaxillaryalveolarhyperplasia,orboth,(heentiremaxillaordenlo-alveolarportionofthemaxillacanberepositionedsuperiorlytoimprovetheupperliplinc-to-incisorrelationship.Theconsequentautorotationofthemandibleisaneffectivemeansofincreasingchinprominence.Tofacilitatesuperiormovementofth

25、emaxilla,themaxillarybasalspineisreducedunderdirectvision.Theanteriornasalfloorcanbegroovedtoaccommodatethecartilaginousseptum.Submucosalresectionofthecartilaginousseptumortubinectomy,orboth,mayindeedbenecessarywhenthemaxillaissuperiorlyrepositionedinexcessof10mm.CASE3-Figure7showshowmandibularprogn

26、athismassociatedwithretroniaxillismina21-year-oldwomanwascorrectedbymaxillaryadvancement,mandibularbodyostectomies,andorthodontics.Abroadnose,hypoplastic-appearingmidfacialregion,andprominentchinwerethedominantfacialfeaturesofthepatient(Fig7A-B).Cephalometricstudiesshowedretroinclinationofthemaxilla

27、ryandmandibularanteriorteeth(Fig7E).ExaminationofherocclusiondisclosedaClassmmolarrelationshipwithposteriorteethillcompletecrossbite.Themaxillarylateralincisors,secondandthirdmolars,andmandibularfirstmolarswerecongenitallymissing.Theloweranteriordentitionwaspositionedapproximately12mmanteriortothema

28、xillarydentition.Therewere7mmspacesbetweentherightandleftmandibularfirstandsecondpremolars.Afterthemaxillaryandmandibularteethwerealignedandtherotationscorrectedwithedge-wiseorthodonticappliances,themaxillawasadvanced6inmandthemandiblewasretracted7mmsimultaneously.Overallfacialbalance(Fig7C-D)wasach

29、ievedfivemonthslaterbyrhinoplasty(nasalsurgerywasperformedbyDr.JackP.Gunter,Dallas).Fig7-Case3.A,B,Preoperativeappearance(age,21years,1months).C,D,Appearanceaftertreatment.E,Cephalometrictracingbeforesurgery(age,21year,7months)showingmandibularprognathismassociatedwithmaxillaryrestrusion.F:Composite

30、cephalemetrictracingbeforesurgery(age,21years,7months)andfourmonthsaftersurgery(age21year,11months).Maxillaissuperimposedovermaxilla;mandibleissuperimposedoveranteriorpotionetmandible.G:Surgicaltreatmentplan.SimultaneousmaxillaryadvancementbyLeForteIosteotomyandretractionofmandiblebybodyostectomies(

31、maxillarysurgicaltechniqueillustratedinFigureI).Althoughthemaxillaandmandiblewerepositionedasplanned,thefinalalignmentofthearcheswascompromisedbylackofpatientcooperation(retentionapplianceswerenotwornasprescribedaftertheorthodonticapplianceswereremoved).Whenthepatientwasseenagaintenmonthsafterjawsur

32、gery,theanteriorteethwereendto-end;theposteriorteethwereincrossbiteandslightopenbite.Coordinatedstudyofthebefore-and-aftercephalometricradiographsandstudymodelsshowedslightproclinationoflowerincisors,interdentalspacingofthemaxillaryandmandibularpremolars,anda6-mmincreasein(hewidthofthemandibulardent

33、alarchintheinterpremolarregion.Occlusalbalancewasachievedafterthemaxillawassurgicallyadvanced3mmandwidened5mmintheinterpremolarregion.ComplicationsWoundHealing-Theincisionalwoundshealedwithoutdiscerniblevascularischemia,infection,ordehiscence.Postoperativestudieshaveshownminimalbonelossilltheinterde

34、ntalosteotomysitesandnoperiodontalproblems.Stabilty-Significantocclusalandskeletalrelapsehasbeendiscernibleinonlyonepatientwhosemaxillawasadvancedwithouthonegrafting(case8,Tabic).Thispatientwithacleftlipandcleftpalatewasanimpressiveillustrationoftheneedforbonegrafting.Itisbeyondlhescopeofthispaperto

35、discusssmallpositionalchangesofthesurgicallyrepositionedmaxiliasthatoccurredinsomepatientsafterfixationapplianceswereremoved.Clinically,however,suchchangesappearedminimal.Esthetica-Inapatientwithpreviouslyrepairedcleftlipandcleftpalate(case4,Table),thenasalestheticswascompromisedbyobvioussplayingoft

36、healarbaseofonesideofthenoseaftermaxillaryadvancement.Inanotherpatient,therewasbilateralsplayingofthealarbasesandbucklingofthecartilaginousnasalseptumafterthemaxillawasraised10mm(case13,Table).Inbothpatients,facialbalancewasachievedafterrhinoplasty.BecauseLeForteIosteotomyforanteriororsuperiorreposi

37、tioningofthemaxillawillprobablyalternasalestheticsfavorablyorunfavorably,toalesserorgreaterdegree,thepreoperativecoordinationoftreatmentisessential.Prospectivepatientsmustbeapprisedofthepossibleneedforrhinoplastyafterthemaxillaisadvancedorraised.Althoughtheoperationhasnotyetbeenusedtolengthenthemidf

38、acialregion,itisinterestingtospeculateontheresultsofsuchaprocedure.Onthebasisofourclinicalobservationstodate,thenasalandmolarregionsmightbeexpectedtodecreaseinprominence.Theuseofsuchproceduresinthetreatmentofpatientswithdeepbitesandlowmandibularplaneanglesisafruitfulfieldibrfurtherclinicalresearchan

39、dfbrexperimentsinanimals;itisalsoanotherfertilemeetingplacefororthodontistsandoralsurgeons.SummaryWithproperplanning,execution,andfollow-upcare,themaxillacanbesurgicallyrepositionedintoastablerelationshipwiththemandible.Completemobility,preservationofviabilitybyproperdesignofthebonyandsofttissueinci

40、sionsandadequatefixationduringthehealingphasearcessentialtoobtainthisobjective.Variablemaxillarydeformitiesin15adultswerecorrectedbyLeForteIosteotomytechniques.Thetechnicalproblemsinplanninganddesignforthenecessarybonyandsofttissueincisionsarediscussedandillustratedbythreecasereports.VOCABULARYKJSis

41、gs1. inviewoffacilitate2. circulationpterygoidprocesses3. maxillofacialtuberositiesbymeanof4. relapsedevascularies5. devitalizeobscureII.microangiographic12.rhesusmonkeys13.ischemia局部缺血14.osteonecrosis骨壞死15.pedicled帶蒂16greaterpalatinearteries腭大動脈17.collateralcirculation側枝循環(huán)18.anastomoses吻合支19.maxill

42、azygomaticcrest顫牙槽崎20.infraorbitalforamens眶下孔21.piriformapertures梨狀孔22.visualization可視性23.pleryomaxillarysuture翼上頜縫24.reposition復位25.repositioning復位26.malletted錘擊27.transantrally通過上頜竇28.hamulus小鉤29.manipulation操作30.nopracticalconsequence無實際意義31.perpendicularprocessof(hepalatine腭骨垂直板32.nasogastrictub

43、e鼻胃管33.evacuation排空34.vomiting嘔吐35.transosseouswires骨內(nèi)結扎鋼絲36.circumzygomaticsuspensionwires環(huán)額弓懸吊鋼絲37.corticocanccllous皮髓質的38.nasopharynx鼻咽部39.contour外形40.interruptedhorizontalmattresssutures間斷水平褥式縫合41.iug夾板的金屬突起42.nasopharyngealairways鼻咽通氣道43.deadspace死腔44.sprayed噴霧45.intermaxillaryelastics間彈力牽引46.l

44、evelingofthelowerarch排齊下牙integrityofthegreaterpalatinearterieswasnotessentialtomaintaincirculationtothemaxilla.FigI-IncisionsofsontimeandboneforcorrectionofmaxillaryretrusionbyLeForteIosteotomytechnique.A:Typicaldental,facialandskeletalcharacteristicsofmandibularprognathismassociatedwithmaxillaryret

45、rusion.B,C:Horizontalincisionthroughmucoperiosteuminthebuccolabialaspectofdepthofvestibule.Horizontalsupraapicalosteotomyoflabialmaxillaextendingfrompiriformrimposteriorlytopterygomaxillaryfissure.D:Separationofnasalseptumfromsuperiorpartofmaxillawithosteotome;posteriorlateralnasalwallsectionedwitho

46、steotome.E:Separationofmaxillafrompterygoidplatewithcurvedosteotome;surgeonsfingerispositionedbelowpalatalmucosatofeelosteotomeasittranssectsbone.F:Maxillaindownfracturedposition.Mucoperiosteumhasbeendetachedandretractedawayfromentiresuperiorsurfaceofmaxillaandhorizontalplateofpalatinebone;Posterior

47、maxillaisseparatedfromthepterygoidplatesandperpendicularprocessofpalatinebonewithosteotomeandbur.G:Repositionedmaxillafixedtothepiriformrimsandzygomaticbuttresseswithtransosseouswires.Thecollateralcirculationwithinthemaxillaanditsenvelopingsofttissueandthenumerousvascularanastomosesin(heanteriorandp

48、osteriorpartsof(hemaxillapermitmanyvariationsofthetotalmaxillaryosteotomytechnique.Intraosseousandintrapulpalcirculationwasnotsignificantlyalteredby(hebuccalsubapicalosteotomieswhenbonecutsweremadeawayfromtheapicesofteethandmaximalattachmentofthemucoperiosteumonthepalatalandbuccolabialgingivaofthemo

49、bilizedmaxillawaspreserxed.Theseresultsgeneratedclinicalconfidenceinperformingtotalmaxillaryosteotomies.Thecurrentsurgicaltechniquewasmodifiedaftertheseanalogousinvestigationsinanimalsandpreviouslyreportedclinicaltechniques.AnesthesiaTheoperationisperformedinthehospitalwiththepatientundergeneralanes

50、thesiadeliveredviathenasoendotrachealroute.Successfullyadministeredhypotensiveanesthesiahasreducedbleedingandfacilitatedsurgicaldissection.Itisrarelynecessarytousetransfusions,althoughtwounitsofpackedcellsareroutinelyavailableforuseatthelimeofsurgeryiftheneedshouldarise.Reducedoperativeshocksanddecr

51、easedpostoperativenausea,vomiting,andedemaisadditionaladvantagesofhypotensiveanesthesia.Becausesubmucosaloozingisdecreased,postoperativewoundhealingmayalsobeenhanced.Despitethesesignificantadvantages,theuseofhypotensiveanesthesiaisjustifiedonlywhenitenablesthesurgeontocarryouttheoperationbetter(hanh

52、ecouldwithconventionalanesthetictechniques.Theadvantagestothepatientandsurgeonmustbeweighedagainsttheincreasedrisks.Thetechnicalskillandexperienceoftheanesthesiologistmustbeofahighorder.SurgicalTechnique(Fig1,A-G)Ahorizontalincisionismadethroughthebuccolabialmucoperiosteumabovethemucogingivaljunctio

53、nextendingfromone-secondmolarregiontotheother(FigI,B).Theincisionisplacedinthebuccolabialaspectofthedepthofthevestibule,atabouttheleveloftheapicesoftheteeth.Themarginsofthesuperiorflapareraisedtoexposetheentirelateralwallsofthemaxillazygomaticcrests,infraorbitalforamens,andthepiriformapertures.Thein

54、feriornwcoperioscealtissuesareminimallyelevatedsothat(heyprovideadditionalvascularsupplytothemaxillaryboneandteeth.Goodvisualizationoftheposterolateralportionofthemaxillaisessentialandisaccomplishedbypositioningthetipofacurvedcheekretractorathepterjgomaxillarysuture(Fig1,B).Anothercheekretractorispl

55、acedanteriorlytofacilitatevisualizationoftheanterolateralportionofthemaxilla.Directvisualizationandpalpationoftheboneencasingtheapicesoftheteethassessthelengthoftheteeth.Thesefindingsarecorrelatedwithnieasurenientstakenfrompanoramicorlateralcephalometricradiographyorboth.Sothatahorizontallinecanbeet

56、chedinthebone3to5mmabove(heapicesoftheleeih.Horizontalsupraapicalosteotomiesofthelateralportionsofthemaxiliasaremadefromthelateralpartofthepiriformrimposteriorlyacrossthecaninefossaandthroughthezygomaticmaxillarycresttothepterygomaxillaryfissureusingafissureburinastraighthandpieceorahighspeedrecipro

57、catingsaw.Insomecases,dependingontheexistingfacialdcfbrmify,greateraugmentationof(hemidfacialregionwillresultfromplacementoftheanteriorosteotomymoresuperiorly.Ideally,thesupraapicalbonecutsarcmade3to4mmormoreabovetheapicesofthemaxillaryteeth.Themucoperiosteumiselevatedfromtheanteriorfloorofthenose,n

58、asalseptum,andlateralwallsofthenasalcavitytofacilitateseparationofthemaxillafromthesestructures.Anasalseptalosteotomeispositionedabovetheanteriornasalspineparallelwiththehardpalateandmallcttcdtoseparatethenasalsepunifromthemaxilla(Fig1,D).Theanteriorlaternasalwallissectioned(ransantrallywithafissure

59、burinastraighthandpiece.Theposteriorlateralnasalwallissectionedwithasharposteotomeabovethelevelofthenasalfloor.Inmanyinstances,however,thisboneismthinthatdoesnothavetobeosteotoinized.Finally,sharppterygoidosteotomeismalJettedintopterygomaxillarysuturetoseparatethemaxillaryfromthepterygoidplates(FigI

60、,E).Digitalpressureonthepalatalmucosaintheregionthehamuluspermitsthesurgeontofeelosteotomeasittransectsthebonewithoutfrallmatizingtheunderlyingmucoperiosteum.Theosteotomeispositionedinferiorlytominimizedangertothevascularstructuresintheptetygomaxillaryfissure.Bymanipulationofthecurvedosteotomeandman

61、ualpressureagainstthetuberosities,themaxillaismadepartiallymobile.Atthispoint,downwardmovementfracturesthemaxilla.Graduallyincreasingintopressureontheanteriorportionsofthemaxillafacilitatesvisualizationofthesuperiorsurfaceofthemaxillaandlateralnasalwalls(Fig1,F).Theniucoperiosteumiselevatedandretrac

62、tedawayfromtheentiresuperiorsurfaceofthemaxilla,horizontalplateofthepalatinebone,andlateralnasalwalls.Transectionofthegreaterpalatinevesselsisofnopracticalconsequence.Digitalpressuregraduallycompletesfracturingoftheinaxilla,withouttheuseofdisimpactionforceps.Thedownwardpositionofthemaxillaprovidesex

63、cellentaccessforcompletelyseparatingthemaxillafrom(hepterygoidplatesandperpendicularprocessofthepalatinebone(Fig1,F).Thiscanbeaccomplishedwithaburoranosteotome.Bycarefulmanipulationoftheosteotomeandforwardpressureagainstthetuberositiesandlowerpartofthemaxilla,themaxillaismadecompletelymobileandmoved

64、intotheplannedposition.Themaxillamustbemadesomobilethatitcanbemovedwithonlylightdigitalpressureintothedesiredrelationshiptothemandible.Usingapreviouslypreparedinterocclusalsplintasanindex,themaxillaisimmobilized.forsixtoeightweekswithstainlesssteelwiresligatedbetweenpreviouslyplacedarchbarsororthodo

65、nticarchwires.Beforeplacingtheintermaxillaryfixation,anasogastrictubeisplacedinthenasalpassageoppositethesideofthenosethathasbeenintubatedinfacilitateevacuationofbloodfromthestomachand(opreventvomitingintheearlypostoperativeperiod.Thetube,whichisperiodicallyirriogated,isusuallyremovedwithin24hourswhentheaspirantofintermittentsuctionisclear.Themobilizedmaxillaisfixeddirectlytothepiriformrimsandzygomaticbuttresseswithtransosseouswireswheneverfeasible.When,however,theboneintheseareasistoothintosupportinterosseouswires,theuseofinfraorbifalrimor