UnitTwentySevenLeForteIosteotomyforcorrectionofmaxillarydeformitiesWilliamH.Bell,DDS.DallasCompletemobility,preservationofviability,andadequatefixationduringhealingisessentialtosurgicalrepositioningofthemaxillatoobtainastablerelationshipwiththemandible.LeForteIosteotomytechniqueswereusedtoconnectvariousdeformitiesofthemaxillain15adultpatients.In1927,MartinWassmundintroducedasurgicalprocedureformovingtheentireinaxilla.Theoperation,whichhassincebeencalledLeForteIosteotomyortotalmaxillaryosteotomy,wasfirstusedtocorrectananterioropenbite.Themaxillawasnotcompletelysectionedfromitsbonyattachments,andnoattemptwasmadetomobilizethemaxillaatthetimeofsurgery.Postopcrativcly,incrmaillaryelastictractionwasusedtoclosetheopenbiteandstabilizethemaxilla.Inviewofthestateofartofanesthesiaatthetime,thelackofantibioticsandchemotherapeutics,andtheempiricalbasisformaxillarysurgery,thiswastrulyaremarkablefeat.Wassmund'sdirectapproachtothemaxillarydeformitywasclearlyyearsaheadofitstime.Thedesignofthebonyandsofttissueincisionshavebeencontinuallymodifiedtofacilitatemovementofthemaxillaandtomaintaincirculationtothemaxillaryboneandteeth.SchuchardtandKoledevisedatwo-stageproceduretopreventimpairmentofthevascularsupplytothemaxilla.Postopcrativcly,Schuchardtusedweightsfromanoverheadtractiondevicetorepositionthemaxillaforward.Thesecondstageofhistechniqueinvolvedseparationofthepterygoidprocessesfromthemaxillarytuberosities.Despitesuchmeasures,hebecamedisenchantedwith(heprocedureandconcludedthattheoperationshouldnotbeusedtotreatpatientswithclefts.Axhausenusedelastictractionaftersurgerytofacilitateanteriormovementandretentionofatraumaticallyrelrodisplacedmaxilla.Inanapparentattempttocircumventtheseshortcomings,GilliesandConverseandShapiroadvocatedadvancingthemaxillabymeansofatransversepalatalcutofthe3unctionofthepalatineandmaxillarybone.Thesuccessofthisapproachwasnotcommentedon.Bonegraftinghasbeenadocatedtopromotebonyregenerationbetweenthebuccalbonecutsinthelateralportionsoftheinaxilla.Obwcgcscrmaintainedthatgraftingthespacebetweentheposteriormaxillaandthepterygoidplateswasessentialforstability.Inabilitytomovethemaxillathedesiredamountandrelapsewascommonfortheinnovatorsofthisoperation.Thesurgeon'sfearthatmobilizationofthemaxillawoulddevascularizeanddevitalizetheboneandteethwasthedominantreasonforsuchproblems.Thefearoftraumatizingvascularstructures,suchasthegreaterpalatineandinternalmaxillaryarteries,wasalsoamajorobjectiontothetechnique.Still,thebiologicbasisandsurgicalprinciplesformaxillaryosteotomiesremainedobscureandobviouslycontributedtopostoperativedevitalizationandlossofboneandteeth.Microangiographicandhistologicstudiesoftotalmaxillaryosteotomyperformedinadultrhesusmonkeysshowedonlytransientvascularischemia.Minimalosteonecrosis,andearlyosseousunionwhenthemaxillawaspedicledessentiallyonlytothepalatalmucosa.Preservationofthehorizontalportionofthehardpalate.Pedicledtopalatalmucosaismovableandseparatedfromthenasalseptum.Theseproblemscanbeobviatedwhenthesurgeryisexecutedfromthebuccalvestibulethroughthreeverticalincisionsandtheseptumandhorizontalpartofthepalatearemaintainedintact.Thesurgicaltreatmentplanmustbeflexible.Techniquesusingbothincisionshavebeenusedsuccessfullyandprovidethesurgeonmorelatitudeincorrectingmaxillarydeformitiesthanhasbeenpossiblewithpreviouslyreportedtechniques.ResultsSince1971,theLeForteI"downfracturing"Techniquehasbeenusedtoadvance,retract,raise,narrow,orexpandthemaxillain15patients(Table).Complexdcntofacialproblems(Fig5-7)suchasmaxillaryretrusion,skeletaltypeanterioropenbite,maxillaryasymmetry,bilateralbuccalorpalatalcrossbite,maxillarydcnto-alvcolarprotrusion,andmaxillaryalveolarhyperplasiahavebeensuccessfullycorrected.Thesurgicalandorthodonticprinciplesusedintreating(hewdeformitiesareillustratedbythreecasereports(casenumberscorrespondwiththoseintheTable).CASEI-Figure5showshowmaxillaryretrusionassociatedwithmandibularprognathismina16year-oldboywasconectedbymaxillaryadvancement(surgicaltechniqueillustratedinFig1)andorthodontictreatment.Awideningofthealarbasesofthenoseandadecreaseofthenasolabialangleproducedapronouncedimprovementofthepatient*soverallfacialbalance(Fig5B,D,F,G).Interocclusalharmonywaslikewiseattained(Fig5H-J).-Comment.Allobtusenasolabialangleisprobablythesinglemostimportantdiagnosticcriterionfortotalmaxillaryadvancement.Theupperlip-nosebalancecanbesignificantlyimprovedbyreductionofsuchanangle.Fig6-Case2.A,B,21-year-oldwomanwithshortupperlip,contour-deficientchin,narrownasalalarbeses,andlackofprominenceinmidfacialregionbeforetreatment(reposeposition).C,D:Improvedfacialbalance,wideningofnasalalarbases,andincreasedprominenceinzygomxaticomaxillaryandnasomaxillaryregionsaftermaxillarysurgery(techniqueshewninpartG).E:Preoperativecephalometrictracingshowinghighmandibularplane,7mmoverjet,andskeletal-typeClassIImalocclusionandunilateralpalatalcrossbite.G:Diagrammaticplanofmaxillarysurgery.Simultaneousanteriorandposteriormaxillaryosteotomiesinrepositionmaxillasuperiorlyandfacilitatemaxillomandibulararchalignment.H:Postoperativeocclusion.I:Compositecephalometrictracingsbefore(solidline-21year,3months)andthreemonthsaftersurgery(brokenline-21years,6months)showingautorotationofmandible,reductionofanteriorfacialheight,restorationofchincontour,improvedupperlipline-inciserrelationship,andfunctionaloverbiteandoverjet.Maxillaissuperimposedoveranteriorportionofmaxilla;mandibleissuperimprovedovermandible.(Dr.CraigWilliams,residentinoralsurgery,ParktandMemorialHospital,Dallas,wasresponsiblefortheprimarycareofthispatient.)CASE2-A21-year-oldwomansoughttreatmenttodecreasethe"prominence"ofhermaxillaryteethandtoimprovethecontourofherface(Fig6A-B).Clinicalandcephalometricanalysesdisclosedahighmandibularplaneangle,totalmaxillaryalveolarhyperplasia,ahighpalatalvault,shortupperlip.contour-deficientchin,andlackofprominenceinthemidfacialregion(Fig6A,B,E).HerClassnmalocclusionwasassociatedwithaunilateralpalatalcrossbite,constrictedmaxillarycanines,anda7mmoveijet(Fig6F).ThesurgicaltechniqueshowninFigures24wasusedtorepositionthemaxiIliasuperiorly.Theanteriorportionoftheinaxillawasraised7mmandtheposteriorportionwasraised9mmtoimprovetheupperlip-incisorrelationship,tofacilitateautorotationofthemandible,andtocorrecttheoveijet(Fig6G).Verticalostectomiesweremadein(hesecondpremolarregionstofacilitatecorrectionoftheunilateralcrossbiteandalignmentofthedentalarches.Bymovingtheposteriormaxillarydcnto-alvcolarsegmentsforward6mm,theextractionspaceswereclosedwithoutretractionoftheanteriorpartofthemaxilla.Theanteriormaxillarysegmentwassectionedbetweenthecentralincisorstoincreasetheintercaninewidthandtoimprovethefirstpremolarrelationship.Facialharmonyandocclussalbalancewereattainedafterthreemonthsoftreatment(Fig6C,D,H,I).Arhinoplastyisplannedforthefuturetoreducethenasaldorsumandwidthofthealarbasesandtoraisethetipofthenose.-Comment.Inpatientswhodisplayanexcessiveamountofgingivaandteethinapositionofreposeorwhensmiling,eitherbecauseofashortupperlipormaxillaryalveolarhyperplasia,orboth,(heentiremaxillaordenlo-alveolarportionofthemaxillacanberepositionedsuperiorlytoimprovetheupperliplinc-to-incisorrelationship.Theconsequentautorotationofthemandibleisaneffectivemeansofincreasingchinprominence.Tofacilitatesuperiormovementofthemaxilla,themaxillarybasalspineisreducedunderdirectvision.Theanteriornasalfloorcanbegroovedtoaccommodatethecartilaginousseptum.Submucosalresectionofthecartilaginousseptumortubinectomy,orboth,mayindeedbenecessarywhenthemaxillaissuperiorlyrepositionedinexcessof10mm.CASE3-Figure7showshowmandibularprognathismassociatedwithretroniaxillismina21-year-oldwomanwascorrectedbymaxillaryadvancement,mandibularbodyostectomies,andorthodontics.Abroadnose,hypoplastic-appearingmidfacialregion,andprominentchinwerethedominantfacialfeaturesofthepatient(Fig7A-B).Cephalometricstudiesshowedretroinclinationofthemaxillaryandmandibularanteriorteeth(Fig7E).ExaminationofherocclusiondisclosedaClassmmolarrelationshipwithposteriorteethillcompletecrossbite.Themaxillarylateralincisors,secondandthirdmolars,andmandibularfirstmolarswerecongenitallymissing.Theloweranteriordentitionwaspositionedapproximately12mmanteriortothemaxillarydentition.Therewere7mmspacesbetweentherightandleftmandibularfirstandsecondpremolars.Afterthemaxillaryandmandibularteethwerealignedandtherotationscorrectedwithedge-wiseorthodonticappliances,themaxillawasadvanced6inmandthemandiblewasretracted7mmsimultaneously.Overallfacialbalance(Fig7C-D)wasachievedfivemonthslaterbyrhinoplasty(nasalsurgerywasperformedbyDr.JackP.Gunter,Dallas).Fig7-Case3.A,B,Preoperativeappearance(age,21years,1months).C,D,Appearanceaftertreatment.E,Cephalometrictracingbeforesurgery(age,21year,7months)showingmandibularprognathismassociatedwithmaxillaryrestrusion.F:Compositecephalemetrictracingbeforesurgery(age,21years,7months)andfourmonthsaftersurgery(age21year,11months).Maxillaissuperimposedovermaxilla;mandibleissuperimposedoveranteriorpotionetmandible.G:Surgicaltreatmentplan.SimultaneousmaxillaryadvancementbyLeForteIosteotomyandretractionofmandiblebybodyostectomies(maxillarysurgicaltechniqueillustratedinFigureI).Althoughthemaxillaandmandiblewerepositionedasplanned,thefinalalignmentofthearcheswascompromisedbylackofpatientcooperation(retentionapplianceswerenotwornasprescribedaftertheorthodonticapplianceswereremoved).Whenthepatientwasseenagaintenmonthsafterjawsurgery,theanteriorteethwereendto-end;theposteriorteethwereincrossbiteandslightopenbite.Coordinatedstudyofthebefore-and-aftercephalometricradiographsandstudymodelsshowedslightproclinationoflowerincisors,interdentalspacingofthemaxillaryandmandibularpremolars,anda6-mmincreasein(hewidthofthemandibulardentalarchintheinterpremolarregion.Occlusalbalancewasachievedafterthemaxillawassurgicallyadvanced3mmandwidened5mmintheinterpremolarregion.ComplicationsWoundHealing-Theincisionalwoundshealedwithoutdiscerniblevascularischemia,infection,ordehiscence.Postoperativestudieshaveshownminimalbonelossilltheinterdentalosteotomysitesandnoperiodontalproblems.Stabilty-Significantocclusalandskeletalrelapsehasbeendiscernibleinonlyonepatientwhosemaxillawasadvancedwithouthonegrafting(case8,Tabic).Thispatientwithacleftlipandcleftpalatewasanimpressiveillustrationoftheneedforbonegrafting.Itisbeyondlhescopeofthispapertodiscusssmallpositionalchangesofthesurgicallyrepositionedmaxiliasthatoccurredinsomepatientsafterfixationapplianceswereremoved.Clinically,however,suchchangesappearedminimal.Esthetica-Inapatientwithpreviouslyrepairedcleftlipandcleftpalate(case4,Table),thenasalestheticswascompromisedbyobvioussplayingofthealarbaseofonesideofthenoseaftermaxillaryadvancement.Inanotherpatient,therewasbilateralsplayingofthealarbasesandbucklingofthecartilaginousnasalseptumafterthemaxillawasraised10mm(case13,Table).Inbothpatients,facialbalancewasachievedafterrhinoplasty.BecauseLeForteIosteotomyforanteriororsuperiorrepositioningofthemaxillawillprobablyalternasalestheticsfavorablyorunfavorably,toalesserorgreaterdegree,thepreoperativecoordinationoftreatmentisessential.Prospectivepatientsmustbeapprisedofthepossibleneedforrhinoplastyafterthemaxillaisadvancedorraised.Althoughtheoperationhasnotyetbeenusedtolengthenthemidfacialregion,itisinterestingtospeculateontheresultsofsuchaprocedure.Onthebasisofourclinicalobservationstodate,thenasalandmolarregionsmightbeexpectedtodecreaseinprominence.Theuseofsuchproceduresinthetreatmentofpatientswithdeepbitesandlowmandibularplaneanglesisafruitfulfieldibrfurtherclinicalresearchandfbrexperimentsinanimals;itisalsoanotherfertilemeetingplacefororthodontistsandoralsurgeons.SummaryWithproperplanning,execution,andfollow-upcare,themaxillacanbesurgicallyrepositionedintoastablerelationshipwiththemandible.Completemobility,preservationofviabilitybyproperdesignofthebonyandsofttissueincisionsandadequatefixationduringthehealingphasearcessentialtoobtainthisobjective.Variablemaxillarydeformitiesin15adultswerecorrectedbyLeForteIosteotomytechniques.Thetechnicalproblemsinplanninganddesignforthenecessarybonyandsofttissueincisionsarediscussedandillustratedbythreecasereports.VOCABULARYKJSisgs1. 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.maxillazygomaticcrest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.nasogastrictube鼻胃管33.evacuation排空34.vomiting嘔吐35.transosseouswires骨內結扎鋼絲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.levelingofthelowerarch排齊下牙integrityofthegreaterpalatinearterieswasnotessentialtomaintaincirculationtothemaxilla.FigI-IncisionsofsontimeandboneforcorrectionofmaxillaryretrusionbyLeForteIosteotomytechnique.A:Typicaldental,facialandskeletalcharacteristicsofmandibularprognathismassociatedwithmaxillaryretrusion.B,C:Horizontalincisionthroughmucoperiosteuminthebuccolabialaspectofdepthofvestibule.Horizontalsupraapicalosteotomyoflabialmaxillaextendingfrompiriformrimposteriorlytopterygomaxillaryfissure.D:Separationofnasalseptumfromsuperiorpartofmaxillawithosteotome;posteriorlateralnasalwallsectionedwithosteotome.E:Separationofmaxillafrompterygoidplatewithcurvedosteotome;surgeon'sfingerispositionedbelowpalatalmucosatofeelosteotomeasittranssectsbone.F:Maxillain"downfractured"position.Mucoperiosteumhasbeendetachedandretractedawayfromentiresuperiorsurfaceofmaxillaandhorizontalplateofpalatinebone;Posteriormaxillaisseparatedfromthepterygoidplatesandperpendicularprocessofpalatinebonewithosteotomeandbur.G:Repositionedmaxillafixedtothepiriformrimsandzygomaticbuttresseswithtransosseouswires.Thecollateralcirculationwithinthemaxillaanditsenvelopingsofttissueandthenumerousvascularanastomosesin(heanteriorandposteriorpartsof(hemaxillapermitmanyvariationsofthetotalmaxillaryosteotomytechnique.Intraosseousandintrapulpalcirculationwasnotsignificantlyalteredby(hebuccalsubapicalosteotomieswhenbonecutsweremadeawayfromtheapicesofteethandmaximalattachmentofthemucoperiosteumonthepalatalandbuccolabialgingivaofthemobilizedmaxillawaspreserxed.Theseresultsgeneratedclinicalconfidenceinperformingtotalmaxillaryosteotomies.Thecurrentsurgicaltechniquewasmodifiedaftertheseanalogousinvestigationsinanimalsandpreviouslyreportedclinicaltechniques.AnesthesiaTheoperationisperformedinthehospitalwiththepatientundergeneralanesthesiadeliveredviathenasoendotrachealroute.Successfullyadministeredhypotensiveanesthesiahasreducedbleedingandfacilitatedsurgicaldissection.Itisrarelynecessarytousetransfusions,althoughtwounitsofpackedcellsareroutinelyavailableforuseatthelimeofsurgeryiftheneedshouldarise.Reducedoperativeshocksanddecreasedpostoperativenausea,vomiting,andedemaisadditionaladvantagesofhypotensiveanesthesia.Becausesubmucosaloozingisdecreased,postoperativewoundhealingmayalsobeenhanced.Despitethesesignificantadvantages,theuseofhypotensiveanesthesiaisjustifiedonlywhenitenablesthesurgeontocarryouttheoperationbetter(hanhecouldwithconventionalanesthetictechniques.Theadvantagestothepatientandsurgeonmustbeweighedagainsttheincreasedrisks.Thetechnicalskillandexperienceoftheanesthesiologistmustbeofahighorder.SurgicalTechnique(Fig1,A-G)Ahorizontalincisionismadethroughthebuccolabialmucoperiosteumabovethemucogingivaljunctionextendingfromone-secondmolarregiontotheother(FigI,B).Theincisionisplacedinthebuccolabialaspectofthedepthofthevestibule,atabouttheleveloftheapicesoftheteeth.Themarginsofthesuperiorflapareraisedtoexposetheentirelateralwallsofthemaxillazygomaticcrests,infraorbitalforamens,andthepiriformapertures.Theinferiornwcoperioscealtissuesareminimallyelevatedsothat(heyprovideadditionalvascularsupplytothemaxillaryboneandteeth.Goodvisualizationoftheposterolateralportionofthemaxillaisessentialandisaccomplishedbypositioningthetipofacurvedcheekretractorathepterj'gomaxillarysuture(Fig1,B).Anothercheekretractorisplacedanteriorlytofacilitatevisualizationoftheanterolateralportionofthemaxilla.Directvisualizationandpalpationoftheboneencasingtheapicesoftheteethassessthelengthoftheteeth.Thesefindingsarecorrelatedwithnieasurenientstakenfrompanoramicorlateralcephalometricradiographyorboth.Sothatahorizontallinecanbeetchedinthebone3to5mmabove(heapicesoftheleeih.Horizontalsupraapicalosteotomiesofthelateralportionsofthemaxiliasaremadefromthelateralpartofthepiriformrimposteriorlyacrossthecaninefossaandthroughthezygomaticmaxillarycresttothepterygomaxillaryfissureusingafissureburinastraighthandpieceorahighspeedreciprocatingsaw.Insomecases,dependingontheexistingfacialdcfbrmify,greateraugmentationof(hemidfacialregionwillresultfromplacementoftheanteriorosteotomymoresuperiorly.Ideally,thesupraapicalbonecutsarcmade3to4mmormoreabovetheapicesofthemaxillaryteeth.Themucoperiosteumiselevatedfromtheanteriorfloorofthenose,nasalseptum,andlateralwallsofthenasalcavitytofacilitateseparationofthemaxillafromthesestructures.Anasalseptalosteotomeispositionedabovetheanteriornasalspineparallelwiththehardpalateandmallcttcdtoseparatethenasalsepunifromthemaxilla(Fig1,D).Theanteriorlaternasalwallissectioned(ransantrallywithafissureburinastraighthandpiece.Theposteriorlateralnasalwallissectionedwithasharposteotomeabovethelevelofthenasalfloor.Inmanyinstances,however,thisboneismthinthatdoesnothavetobeosteotoinized.Finally,sharppterygoidosteotomeismalJettedintopterygomaxillarysuturetoseparatethemaxillaryfromthepterygoidplates(FigI,E).Digitalpressureonthepalatalmucosaintheregionthehamuluspermitsthesurgeontofeelosteotomeasittransectsthebonewithoutfrallmatizingtheunderlyingmucoperiosteum.Theosteotomeispositionedinferiorlytominimizedangertothevascularstructuresintheptetygomaxillaryfissure.Bymanipulationofthecurvedosteotomeandmanualpressureagainstthetuberosities,themaxillaismadepartiallymobile.Atthispoint,downwardmovementfracturesthemaxilla.Graduallyincreasingintopressureontheanteriorportionsofthemaxillafacilitatesvisualizationofthesuperiorsurfaceofthemaxillaandlateralnasalwalls(Fig1,F).Theniucoperiosteumiselevatedandretractedawayfromtheentiresuperiorsurfaceofthemaxilla,horizontalplateofthepalatinebone,andlateralnasalwalls.Transectionofthegreaterpalatinevesselsisofnopracticalconsequence.Digitalpressuregraduallycompletesfracturingoftheinaxilla,withouttheuseofdisimpactionforceps.Thedownwardpositionofthemaxillaprovidesexcellentaccessforcompletelyseparatingthemaxillafrom(hepterygoidplatesandperpendicularprocessofthepalatinebone(Fig1,F).Thiscanbeaccomplishedwithaburoranosteotome.Bycarefulmanipulationoftheosteotomeandforwardpressureagainstthetuberositiesandlowerpartofthemaxilla,themaxillaismadecompletelymobileandmovedintotheplannedposition.Themaxillamustbemadesomobilethatitcanbemovedwithonlylightdigitalpressureintothedesiredrelationshiptothemandible.Usingapreviouslypreparedinterocclusalsplintasanindex,themaxillaisimmobilized.forsixtoeightweekswithstainlesssteelwiresligatedbetweenpreviouslyplacedarchbarsororthodonticarchwires.Beforeplacingtheintermaxillaryfixation,anasogastrictubeisplacedinthenasalpassageoppositethesideofthenosethathasbeenintubatedinfacilitateevacuationofbloodfromthestomachand(opreventvomitingintheearlypostoperativeperiod.Thetube,whichisperiodicallyirriogated,isusuallyremovedwithin24hourswhentheaspirantofintermittentsuctionisclear.Themobilizedmaxillaisfixeddirectlytothepiriformrimsandzygomaticbuttresseswithtransosseouswireswheneverfeasible.When,however,theboneintheseareasistoothintosupportinterosseouswires,theuseofinfraorbifalrimor