The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 2. Intraoperative view shows the fronto-orbital bone segment and the cyst. Arrow shows the location of the cyst.
Brief Clinical Studies
presented with a nonreducible type. Seven patients with an incomplete Le Fort I fracture had a contralateral Le Fort I osteotomy, and 2 patients with an incomplete Le Fort III fracture had a true bilateral Le Fort I-type osteotomy. We recorded age and sex, mechanism of injury, level of Le Fort fracture, concomitant mandibular fractures, concomitant maxillomandibular fixation (MMF) and its duration, surgical approach, status of healing, and complications. Follow-ups were at 1 week and 1, 3, 6, and 12 months. All patients recovered their normal pretrauma occlusion without the need for postoperative elastic guidance, except for 1 patient who required light class III traction elastics for 3 weeks to achieve the correct occlusion. None of the patients presented with intraoperative or postoperative complications. The present study has demonstrated that completion of nonreducible Le Fort fractures by Le Fort I osteotomy results in a high rate of success. Key Words: Le Fort fractures, Le Fort osteotomy, malocclusion
FIGURE 3. A number of laminar strata lined with squamous epithelium and multinucleated giant cells of epidermoid cyst presented in histologic evaluation (hematoxylin-eosin stain, original magnification 40).
In conclusion, craniofacial surgeons should realize the importance of asymptomatic intradiploic masses even if these are unrelated to their initial surgical treatment plan.
REFERENCES 1. Wu B, Zhu H, Liu W. Intradiploicepidermoid cyst presenting as spontaneous intracerebral hematoma: a case report. Clin Neurol Neurosurg 2013;115: 617–620 2. Samdani S, Kalra GS, Rawat DS. Posttraumatic intradiploic epidermoid cyst of frontal bone. J Craniofac Surg 2013;24:e128–e130 3. Patnaik A, Mishra SS, Das S, et al. Giant intradiploic dermoid cyst of the frontal bone with involvement of frontal sinus in an elderly patient. Neurol India 2012;60:542–543 4. Moraes Júnior LC, Wanderley EC, Montini A, et al. Intradiploic dermoid cyst of the skull: report of a case. Arq Neuropsiquiatr 1984;42:68–71 5. Akbaba M, Karsloglu S, Damlack A, et al. Intradiploic epidermoid cyst of frontal bone with spontaneous fistulization to eyelid. Ophthal Plast Reconstr Surg 2012;28:e15–e17 6. Inci S, Akbay A, Bertan V. Intradiploic epidermoid cyst of the temporal bone. Turk Neurosurg 1992;2:155–157 7. Berti AF, Lovaas GC, Santillan A, et al. Primary intradiploic pterional epidermoid cyst. South Med J 2010;103:87–89
Completion of Nonreducible Le Fort Fractures by Le Fort I Osteotomy: Sometimes an Inevitable Choice to Avoid Postoperative Malocclusion Paolo Scolozzi, MD, DMD, Benoît Imholz, MD, DMD Abstract: The aim of this study was to prospectively evaluate the use of a simultaneous Le Fort I osteotomy for completion of nonreducible Le Fort fractures. We analyzed the clinical and radiological data of 44 patients with Le Fort fractures, 9 of whom
R
estoration of pretrauma occlusion still represents one of the most critical steps in the management of Le Fort fractures.1–5 This is particularly true for incomplete Le Fort or “greenstick” fractures. In such circumstances, it is often extremely difficult, if not impossible, to completely disimpact the maxilla. This often leads the surgeon to literally force a maxillary repositioning in an attempt to reduce the fracture and to obtain a satisfactory intraoperative occlusal relationship.1–5 In so doing, the dental occlusion is often “locked” with the condyles improperly positioned too far posteriorly and/or inferiorly. The condylar malpositioning is certainly the main etiopathogenic factor involved in the postoperative malocclusion that can typically occur immediately after release of the maxillomandibular fixation (MMF). In fact, the condyles regaining their original position into the glenoid fossa lead to a relative prognathism and/or anterior or lateral open bite malocclusion.3,5 Thus, in some specific cases, the completion of the fracture by performing an additional contralateral maxillary osteotomy becomes a logical and unavoidable necessity to obviate this rare but insidious occlusal drawback. The purpose of this preliminary study was to prospectively evaluate the efficacy of Le Fort I osteotomy in the surgical treatment of nonreducible Le Fort fractures.
PATIENTS AND METHODS Forty-four consecutive patients with Le Fort fractures were treated at the Hôpitaux Universitaires de Genève in Geneva, Switzerland, from January 2009 through August 2012. Nine patients with nonreducible Le Fort fractures treated by a simultaneous Le Fort I osteotomy were included in this study (Fig. 1). Nonreducible Le From the Service of Oral and Maxillofacial Surgery, Department of Surgery, Hôpitaux Universitaires de Genève, Faculty of Medicine, Geneva, Switzerland. Received March 3, 2014. Accepted for publication June 20, 2014. Address correspondence and reprint requests to Paolo Scolozzi, MD, DMD, Service of Oral and Maxillofacial Surgery, Department of Surgery, Hôpitaux Universitaires de Genève, Faculty of Medicine, 1211 Genève, Switzerland. E-mail: [email protected] The authors have received no financial support for this research. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001178
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Brief Clinical Studies
and clavulanic acid 1.2 g 3 times a day intravenously), which were maintained for 3 days postoperatively. Le Fort I and Le Fort III fractures were, respectively, exposed by an intraoral gingival buccal incision and by a combined coronal and intraoral gingival buccal incision. Incomplete Le Fort I fractures were completed by a contralateral Le Fort I type. The Le Fort III fractures presented on one side an incomplete disjunction of the zygomaticofrontal suture as well as an incomplete fracture of the zygomatic arch. For this reason, the completion of the fracture at the Le Fort III level was judged nonnecessary and too invasive. Thus, in order to restore the occlusion, a bilateral Le Fort I osteotomy was performed. Le Fort I-type osteotomy was performed with a reciprocating saw, without performing a separation of the pterygomaxillary junction with an osteotome. The osteotomized side of the maxilla was first mobilized by inserting Tessier spreading forceps in the osteotomy line at the nasomaxillary and the zygomaticomaxillary buttresses. Then, the entire maxilla was mobilized by using Rowe and Killey disimpaction forceps and placed into MMF with wires using metal arch bars (Dautrey type). Internal fixation was performed with two 5-hole 1.5-mm L-plates at the zygomatic buttress and two 5-hole 1.5-mm straight or L-plates at the piriform rim. Le Fort III fractures with frontonasal and/or frontozygomatic instability were also fixed at these levels. The intraoral incision was sutured with a running 3-0 Vicryl suture, and the coronal incision was closed in 2 layers, the galea with uninterrupted 2-0 Vicryl and the scalp with staples.
RESULTS FIGURE 1. Patient 1: A 44-year-old woman with a complete Le Fort I type fracture on the right side and an incomplete Le Fort I fracture on the left side. A, Preoperative three-dimensional CT scan showing the complete fracture on the right side (black arrows) and the incomplete fracture on the left side (white arrows). B, Intraoral view revealing a circular dental open bite related to a premature contact on the first and second molars on the right side. C, Intraoperative view showing the complete comminuted fracture on the right side (black arrows) and an incomplete fracture involving only the nasomaxillary buttress on the left side (white arrows), D, the completion of the fracture on the left side by a standard horizontal Le Fort I osteotomy. E, The MMF with wires using metal arch bars (Dautrey type) following maxillary’s disimpaction and mobilization and (F) internal fixation performed with two 5-hole 1.5-mm L-plates at the zygomatic buttress and at the piriform rim on both sides. G, Intraoral view revealing the occlusal relationships at 1-year follow-up.
Fort fractures were defined as fractures impossible to surgically disimpact and mobilize. The clinical and radiological data of those 9 patients were prospectively analyzed at follow-up intervals of 1 week and 1, 3, 6, and 12 months. The variables reviewed included age and sex, mechanism of injury, level of Le Fort fracture, concomitant mandibular fractures, concomitant MMF and its duration, surgical approach, status of healing, and complications. The procedure followed in this prospective study was in accordance with the Helsinki Declaration of 1975, as revised in 2000 and was approved by our local ethical board. Location of the fracture was classified according to Le Fort’s6–8 description. Postsurgical complications that were recorded as minor were those that did not require surgical intervention; major complications required further surgical intervention.
Surgical Considerations All of the operations were performed under nasoendotracheal general anesthesia. Upon admission, all patients were placed on parenteral antibiotics (either amoxicillin 1 g 3 times a day or amoxicillin
e60
The prevalence found for incomplete Le Fort fractures was 20%. All 9 patients were whites, and 7 had a Le Fort I and 2 had a Le Fort III incomplete fracture. Handicapping malocclusion together with maxillary immobility was present in all patients preoperatively. The mean age of the patients was 41 years (range, 21– 87 years) with a male predominance (n = 7). The mechanism of injury was traffic accident in 4 patients, falls in 2, sporting accident in 2, and interpersonal violence in 1. A concomitant mandibular fracture was present in 2 patients. All of the patients recovered their normal pretrauma occlusion at the 1-month follow-up without the need for postoperative elastic guidance, except for 1 patient who required light class III traction elastics for 3 weeks to achieve the correct occlusion. There were no intraoperative or postoperative complications.
DISCUSSION The present study explored the occlusal outcome following Le Fort I osteotomy in the treatment of nonreducible Le Fort fractures. Our findings showed that this treatment allowed for the recovery of pretrauma occlusion in all patients without complications. Although the management of Le Fort fractures has been extensively studied for a long time, little attention has been paid to the treatment of a particular subgroup of incomplete and nonmobile Le Fort–type fractures. Thus far, to the best of our knowledge, the literature contains only 3 references to the management of such a specific subgroup of fractures. In 1983, Vaughan et al2 were the first to report on the sometimes problematic management of irreducible maxillary fractures in 4 patients. They stressed the necessity of performing a Le Fort I osteotomy on the nonaffected side to mobilize the maxilla in order to obtain the correct relationship with the mandible. They found a satisfactory occlusion in all patients during the healing period.2 In a series of 217 patients having Le Fort fractures, Romano et al3 found an incidence of 9% of nonmobile fractures. They have also proposed to surgically complete these fractures to passively reposition the maxillomandibular complex into the proper occlusion, © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
but without detailing the incidence of postoperative malocclusion.3 Ellis5 has been the only investigator to specifically focus on the evaluation of the occlusal relationship in cases treated by a complementary osteotomy at the Le Fort I level for maxillary fractures that could not be passively mobilized during surgery. In a series of 24 patients, he found a pretrauma occlusion in all patients except one, who presented with a nonhandicapping minor malocclusion that did not require any further treatment.5 The absence of postoperative malocclusion found in this study corroborates the main advantage reported by the 3 previously mentioned studies, that is, the achievement of complete mobilization of the fracture, which allows for a passive maxillary repositioning without soft-tissue tension and/or bony interferences.2,3,5 This is certainly the fundamental prerequisite for an anatomical threedimensional maxillary reconstruction by means of correct positioning of the mandibular platform as reference for a proper occlusal relationship. Moreover, the surgical completion of a partial fracture by a controlled osteotomy also offers the advantage of avoiding the application of excessive disimpaction forces that could potentially produce untoward fractures extending to the skull base and/or the orbits. These fractures can result in severe complications such as blindness, carotid cavernous sinus fistula, or internal carotid dissection.9–11 Different studies have stressed that the risk for such devastating complications is related to the increased force necessary to obtain the maxillary downfracture. This risk is also related to the large number of pterygoid plate fractures that can occur when the pterygomaxillary separation is performed incompletely.9–11 In conclusion, the present study has demonstrated that treating nonreducible Le Fort fractures by a simultaneous Le Fort I osteotomy allows tension-free maxillary repositioning that guarantees an excellent occlusal outcome and is not associated with major complications. Although promising, the results of the present study should be interpreted with caution, given the limited number of patients, and in no case does it allow any definitive conclusions to be drawn, which can only be provided at the completion of our ongoing prospective study.
REFERENCES 1. Steidler NE, Cook RM, Reade PC. Residual complications in patients with major middle third facial fractures. Int J Oral Surg 1980;9:259–266 2. Vaughan ED, Obeid G, Banks P. The irreducible middle third fracture, a problem in management. Br J Oral Surg 1983;21:124–128 3. Romano JJ, Manson PN, Mirvis SE, et al. Le Fort fractures without mobility. Plast Reconstr Surg 1990;85:355–362 4. O'Sullivan ST, Snyder BJ, Moore MH, et al. Outcome measurement of the treatment of maxillary fractures: a prospective analysis of 100 consecutive cases. Br J Plast Surg 1999;52:519–523 5. Ellis E. Passive repositioning of maxillary fractures: an occasional impossibility without osteotomy. J Oral Maxillofac Surg 2004;62:1477–1485 6. Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Revue de Chirurgie 1901;23:208–227 7. Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Revue de Chirurgie 1901;23:360–379 8. Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Revue de Chirurgie 1901;23:479–505 9. Hes J, de Man K. Carotid-cavernous sinus fistula following maxillofacial trauma and orthognathic surgery. Int J Oral Maxillofac Surg 1988;17:295–297 10. Lanigan DT, Guest P. Alternative approaches to pterygomaxillary separation. Int J Oral Maxillofac Surg 1993;22:131–138 11. Hoffman GR, Islam S. The difficult Le Fort I osteotomy and downfracture: a review with consideration given to an atypical maxillary morphology. J Plast Reconstr Aesthet Surg 2008;61:1029–1033
Brief Clinical Studies
Cranial Base Deviation in Hemifacial Microsomia by Craniometric Analysis James Thomas Paliga, BA, Youssef Tahiri, MD, Jason Wink, MD, Scott P. Bartlett, MD, Jesse A. Taylor, MD Abstract: Although facial asymmetry in hemifacial microsomia (HFM) is well documented in the literature, no studies have concentrated on the morphology of the cranial base. This study aimed to evaluate the endocranial morphology in patients with HFM. Consecutive patients with unilateral HFM treated at a craniofacial center from 2000 to 2012 were included. The patients were grouped according to severity on the basis of the Kaban-Pruzansky classification: mild (0–1), moderate (2a), and severe (2b–3). Skull base angulation and transverse craniometric measures were recorded and then compared with those of age-matched controls. A total of 30 patients (14 males, 16 females) averaging 7.5 years of age (range, 1.1–15.7 y) were included. Four patients were classified as mild; 12, as moderate; and 14, as severe. The mean cranial base angle was found to be between 179 and 181 degrees with no significant difference between the severity groups (P = 0.57). The mean cranial base angle did not differ significantly in the patients compared with the controls(179.6 vs 180.0; P = 0.51) No significant differences between the affected and unaffected sides in the patients were found in distances from the midline to hypoglossal canal, internal acoustic meatus, lateral carotid canal, medial carotid canal, foramen ovale, and rotundum. There were no significant differences in transverse measurements between the severity classes using the same landmarks (P = 0.46, P = 0.30, P = 0.40, P = 0.25, P = 0.57, and P = 0.76, respectively). The cranial base axis is not deviated in the patients with HFM compared with the age-matched controls, and there exists little difference in endocranial morphologic measurements with increasing severity of HFM. These data are interesting, given the role of the cranial base in facial growth and the varying hypotheses regarding the mechanism of disease in HFM. Key Words: hemifacial microsomia, cranial base, craniometrics, three-dimensional computed tomography
From the Division of Plastic Surgery, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Received March 17, 2014. Accepted for publication June 20, 2014. Address correspondence and reprint requests to Jesse A. Taylor, MD, Division of Plastic Surgery, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Colket Translational Research Bldg, 3501 Civic Center Blvd, 9th Floor, Philadelphia, PA 19104; E-mail: [email protected] Supported by the Department of Surgery of The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania. The authors report no conflicts of interest. This study was reviewed and approved by the institutional review board of the Children’s Hospital of Philadelphia. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001182
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 2. Intraoperative view shows the fronto-orbital bone segment and the cyst. Arrow shows the location of the cyst.
Brief Clinical Studies
presented with a nonreducible type. Seven patients with an incomplete Le Fort I fracture had a contralateral Le Fort I osteotomy, and 2 patients with an incomplete Le Fort III fracture had a true bilateral Le Fort I-type osteotomy. We recorded age and sex, mechanism of injury, level of Le Fort fracture, concomitant mandibular fractures, concomitant maxillomandibular fixation (MMF) and its duration, surgical approach, status of healing, and complications. Follow-ups were at 1 week and 1, 3, 6, and 12 months. All patients recovered their normal pretrauma occlusion without the need for postoperative elastic guidance, except for 1 patient who required light class III traction elastics for 3 weeks to achieve the correct occlusion. None of the patients presented with intraoperative or postoperative complications. The present study has demonstrated that completion of nonreducible Le Fort fractures by Le Fort I osteotomy results in a high rate of success. Key Words: Le Fort fractures, Le Fort osteotomy, malocclusion
FIGURE 3. A number of laminar strata lined with squamous epithelium and multinucleated giant cells of epidermoid cyst presented in histologic evaluation (hematoxylin-eosin stain, original magnification 40).
In conclusion, craniofacial surgeons should realize the importance of asymptomatic intradiploic masses even if these are unrelated to their initial surgical treatment plan.
REFERENCES 1. Wu B, Zhu H, Liu W. Intradiploicepidermoid cyst presenting as spontaneous intracerebral hematoma: a case report. Clin Neurol Neurosurg 2013;115: 617–620 2. Samdani S, Kalra GS, Rawat DS. Posttraumatic intradiploic epidermoid cyst of frontal bone. J Craniofac Surg 2013;24:e128–e130 3. Patnaik A, Mishra SS, Das S, et al. Giant intradiploic dermoid cyst of the frontal bone with involvement of frontal sinus in an elderly patient. Neurol India 2012;60:542–543 4. Moraes Júnior LC, Wanderley EC, Montini A, et al. Intradiploic dermoid cyst of the skull: report of a case. Arq Neuropsiquiatr 1984;42:68–71 5. Akbaba M, Karsloglu S, Damlack A, et al. Intradiploic epidermoid cyst of frontal bone with spontaneous fistulization to eyelid. Ophthal Plast Reconstr Surg 2012;28:e15–e17 6. Inci S, Akbay A, Bertan V. Intradiploic epidermoid cyst of the temporal bone. Turk Neurosurg 1992;2:155–157 7. Berti AF, Lovaas GC, Santillan A, et al. Primary intradiploic pterional epidermoid cyst. South Med J 2010;103:87–89
Completion of Nonreducible Le Fort Fractures by Le Fort I Osteotomy: Sometimes an Inevitable Choice to Avoid Postoperative Malocclusion Paolo Scolozzi, MD, DMD, Benoît Imholz, MD, DMD Abstract: The aim of this study was to prospectively evaluate the use of a simultaneous Le Fort I osteotomy for completion of nonreducible Le Fort fractures. We analyzed the clinical and radiological data of 44 patients with Le Fort fractures, 9 of whom
R
estoration of pretrauma occlusion still represents one of the most critical steps in the management of Le Fort fractures.1–5 This is particularly true for incomplete Le Fort or “greenstick” fractures. In such circumstances, it is often extremely difficult, if not impossible, to completely disimpact the maxilla. This often leads the surgeon to literally force a maxillary repositioning in an attempt to reduce the fracture and to obtain a satisfactory intraoperative occlusal relationship.1–5 In so doing, the dental occlusion is often “locked” with the condyles improperly positioned too far posteriorly and/or inferiorly. The condylar malpositioning is certainly the main etiopathogenic factor involved in the postoperative malocclusion that can typically occur immediately after release of the maxillomandibular fixation (MMF). In fact, the condyles regaining their original position into the glenoid fossa lead to a relative prognathism and/or anterior or lateral open bite malocclusion.3,5 Thus, in some specific cases, the completion of the fracture by performing an additional contralateral maxillary osteotomy becomes a logical and unavoidable necessity to obviate this rare but insidious occlusal drawback. The purpose of this preliminary study was to prospectively evaluate the efficacy of Le Fort I osteotomy in the surgical treatment of nonreducible Le Fort fractures.
PATIENTS AND METHODS Forty-four consecutive patients with Le Fort fractures were treated at the Hôpitaux Universitaires de Genève in Geneva, Switzerland, from January 2009 through August 2012. Nine patients with nonreducible Le Fort fractures treated by a simultaneous Le Fort I osteotomy were included in this study (Fig. 1). Nonreducible Le From the Service of Oral and Maxillofacial Surgery, Department of Surgery, Hôpitaux Universitaires de Genève, Faculty of Medicine, Geneva, Switzerland. Received March 3, 2014. Accepted for publication June 20, 2014. Address correspondence and reprint requests to Paolo Scolozzi, MD, DMD, Service of Oral and Maxillofacial Surgery, Department of Surgery, Hôpitaux Universitaires de Genève, Faculty of Medicine, 1211 Genève, Switzerland. E-mail: [email protected] The authors have received no financial support for this research. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001178
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e59
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Brief Clinical Studies
and clavulanic acid 1.2 g 3 times a day intravenously), which were maintained for 3 days postoperatively. Le Fort I and Le Fort III fractures were, respectively, exposed by an intraoral gingival buccal incision and by a combined coronal and intraoral gingival buccal incision. Incomplete Le Fort I fractures were completed by a contralateral Le Fort I type. The Le Fort III fractures presented on one side an incomplete disjunction of the zygomaticofrontal suture as well as an incomplete fracture of the zygomatic arch. For this reason, the completion of the fracture at the Le Fort III level was judged nonnecessary and too invasive. Thus, in order to restore the occlusion, a bilateral Le Fort I osteotomy was performed. Le Fort I-type osteotomy was performed with a reciprocating saw, without performing a separation of the pterygomaxillary junction with an osteotome. The osteotomized side of the maxilla was first mobilized by inserting Tessier spreading forceps in the osteotomy line at the nasomaxillary and the zygomaticomaxillary buttresses. Then, the entire maxilla was mobilized by using Rowe and Killey disimpaction forceps and placed into MMF with wires using metal arch bars (Dautrey type). Internal fixation was performed with two 5-hole 1.5-mm L-plates at the zygomatic buttress and two 5-hole 1.5-mm straight or L-plates at the piriform rim. Le Fort III fractures with frontonasal and/or frontozygomatic instability were also fixed at these levels. The intraoral incision was sutured with a running 3-0 Vicryl suture, and the coronal incision was closed in 2 layers, the galea with uninterrupted 2-0 Vicryl and the scalp with staples.
RESULTS FIGURE 1. Patient 1: A 44-year-old woman with a complete Le Fort I type fracture on the right side and an incomplete Le Fort I fracture on the left side. A, Preoperative three-dimensional CT scan showing the complete fracture on the right side (black arrows) and the incomplete fracture on the left side (white arrows). B, Intraoral view revealing a circular dental open bite related to a premature contact on the first and second molars on the right side. C, Intraoperative view showing the complete comminuted fracture on the right side (black arrows) and an incomplete fracture involving only the nasomaxillary buttress on the left side (white arrows), D, the completion of the fracture on the left side by a standard horizontal Le Fort I osteotomy. E, The MMF with wires using metal arch bars (Dautrey type) following maxillary’s disimpaction and mobilization and (F) internal fixation performed with two 5-hole 1.5-mm L-plates at the zygomatic buttress and at the piriform rim on both sides. G, Intraoral view revealing the occlusal relationships at 1-year follow-up.
Fort fractures were defined as fractures impossible to surgically disimpact and mobilize. The clinical and radiological data of those 9 patients were prospectively analyzed at follow-up intervals of 1 week and 1, 3, 6, and 12 months. The variables reviewed included age and sex, mechanism of injury, level of Le Fort fracture, concomitant mandibular fractures, concomitant MMF and its duration, surgical approach, status of healing, and complications. The procedure followed in this prospective study was in accordance with the Helsinki Declaration of 1975, as revised in 2000 and was approved by our local ethical board. Location of the fracture was classified according to Le Fort’s6–8 description. Postsurgical complications that were recorded as minor were those that did not require surgical intervention; major complications required further surgical intervention.
Surgical Considerations All of the operations were performed under nasoendotracheal general anesthesia. Upon admission, all patients were placed on parenteral antibiotics (either amoxicillin 1 g 3 times a day or amoxicillin
e60
The prevalence found for incomplete Le Fort fractures was 20%. All 9 patients were whites, and 7 had a Le Fort I and 2 had a Le Fort III incomplete fracture. Handicapping malocclusion together with maxillary immobility was present in all patients preoperatively. The mean age of the patients was 41 years (range, 21– 87 years) with a male predominance (n = 7). The mechanism of injury was traffic accident in 4 patients, falls in 2, sporting accident in 2, and interpersonal violence in 1. A concomitant mandibular fracture was present in 2 patients. All of the patients recovered their normal pretrauma occlusion at the 1-month follow-up without the need for postoperative elastic guidance, except for 1 patient who required light class III traction elastics for 3 weeks to achieve the correct occlusion. There were no intraoperative or postoperative complications.
DISCUSSION The present study explored the occlusal outcome following Le Fort I osteotomy in the treatment of nonreducible Le Fort fractures. Our findings showed that this treatment allowed for the recovery of pretrauma occlusion in all patients without complications. Although the management of Le Fort fractures has been extensively studied for a long time, little attention has been paid to the treatment of a particular subgroup of incomplete and nonmobile Le Fort–type fractures. Thus far, to the best of our knowledge, the literature contains only 3 references to the management of such a specific subgroup of fractures. In 1983, Vaughan et al2 were the first to report on the sometimes problematic management of irreducible maxillary fractures in 4 patients. They stressed the necessity of performing a Le Fort I osteotomy on the nonaffected side to mobilize the maxilla in order to obtain the correct relationship with the mandible. They found a satisfactory occlusion in all patients during the healing period.2 In a series of 217 patients having Le Fort fractures, Romano et al3 found an incidence of 9% of nonmobile fractures. They have also proposed to surgically complete these fractures to passively reposition the maxillomandibular complex into the proper occlusion, © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
but without detailing the incidence of postoperative malocclusion.3 Ellis5 has been the only investigator to specifically focus on the evaluation of the occlusal relationship in cases treated by a complementary osteotomy at the Le Fort I level for maxillary fractures that could not be passively mobilized during surgery. In a series of 24 patients, he found a pretrauma occlusion in all patients except one, who presented with a nonhandicapping minor malocclusion that did not require any further treatment.5 The absence of postoperative malocclusion found in this study corroborates the main advantage reported by the 3 previously mentioned studies, that is, the achievement of complete mobilization of the fracture, which allows for a passive maxillary repositioning without soft-tissue tension and/or bony interferences.2,3,5 This is certainly the fundamental prerequisite for an anatomical threedimensional maxillary reconstruction by means of correct positioning of the mandibular platform as reference for a proper occlusal relationship. Moreover, the surgical completion of a partial fracture by a controlled osteotomy also offers the advantage of avoiding the application of excessive disimpaction forces that could potentially produce untoward fractures extending to the skull base and/or the orbits. These fractures can result in severe complications such as blindness, carotid cavernous sinus fistula, or internal carotid dissection.9–11 Different studies have stressed that the risk for such devastating complications is related to the increased force necessary to obtain the maxillary downfracture. This risk is also related to the large number of pterygoid plate fractures that can occur when the pterygomaxillary separation is performed incompletely.9–11 In conclusion, the present study has demonstrated that treating nonreducible Le Fort fractures by a simultaneous Le Fort I osteotomy allows tension-free maxillary repositioning that guarantees an excellent occlusal outcome and is not associated with major complications. Although promising, the results of the present study should be interpreted with caution, given the limited number of patients, and in no case does it allow any definitive conclusions to be drawn, which can only be provided at the completion of our ongoing prospective study.
REFERENCES 1. Steidler NE, Cook RM, Reade PC. Residual complications in patients with major middle third facial fractures. Int J Oral Surg 1980;9:259–266 2. Vaughan ED, Obeid G, Banks P. The irreducible middle third fracture, a problem in management. Br J Oral Surg 1983;21:124–128 3. Romano JJ, Manson PN, Mirvis SE, et al. Le Fort fractures without mobility. Plast Reconstr Surg 1990;85:355–362 4. O'Sullivan ST, Snyder BJ, Moore MH, et al. Outcome measurement of the treatment of maxillary fractures: a prospective analysis of 100 consecutive cases. Br J Plast Surg 1999;52:519–523 5. Ellis E. Passive repositioning of maxillary fractures: an occasional impossibility without osteotomy. J Oral Maxillofac Surg 2004;62:1477–1485 6. Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Revue de Chirurgie 1901;23:208–227 7. Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Revue de Chirurgie 1901;23:360–379 8. Le Fort R. Etude expérimentale sur les fractures de la mâchoire supérieure. Revue de Chirurgie 1901;23:479–505 9. Hes J, de Man K. Carotid-cavernous sinus fistula following maxillofacial trauma and orthognathic surgery. Int J Oral Maxillofac Surg 1988;17:295–297 10. Lanigan DT, Guest P. Alternative approaches to pterygomaxillary separation. Int J Oral Maxillofac Surg 1993;22:131–138 11. Hoffman GR, Islam S. The difficult Le Fort I osteotomy and downfracture: a review with consideration given to an atypical maxillary morphology. J Plast Reconstr Aesthet Surg 2008;61:1029–1033
Brief Clinical Studies
Cranial Base Deviation in Hemifacial Microsomia by Craniometric Analysis James Thomas Paliga, BA, Youssef Tahiri, MD, Jason Wink, MD, Scott P. Bartlett, MD, Jesse A. Taylor, MD Abstract: Although facial asymmetry in hemifacial microsomia (HFM) is well documented in the literature, no studies have concentrated on the morphology of the cranial base. This study aimed to evaluate the endocranial morphology in patients with HFM. Consecutive patients with unilateral HFM treated at a craniofacial center from 2000 to 2012 were included. The patients were grouped according to severity on the basis of the Kaban-Pruzansky classification: mild (0–1), moderate (2a), and severe (2b–3). Skull base angulation and transverse craniometric measures were recorded and then compared with those of age-matched controls. A total of 30 patients (14 males, 16 females) averaging 7.5 years of age (range, 1.1–15.7 y) were included. Four patients were classified as mild; 12, as moderate; and 14, as severe. The mean cranial base angle was found to be between 179 and 181 degrees with no significant difference between the severity groups (P = 0.57). The mean cranial base angle did not differ significantly in the patients compared with the controls(179.6 vs 180.0; P = 0.51) No significant differences between the affected and unaffected sides in the patients were found in distances from the midline to hypoglossal canal, internal acoustic meatus, lateral carotid canal, medial carotid canal, foramen ovale, and rotundum. There were no significant differences in transverse measurements between the severity classes using the same landmarks (P = 0.46, P = 0.30, P = 0.40, P = 0.25, P = 0.57, and P = 0.76, respectively). The cranial base axis is not deviated in the patients with HFM compared with the age-matched controls, and there exists little difference in endocranial morphologic measurements with increasing severity of HFM. These data are interesting, given the role of the cranial base in facial growth and the varying hypotheses regarding the mechanism of disease in HFM. Key Words: hemifacial microsomia, cranial base, craniometrics, three-dimensional computed tomography
From the Division of Plastic Surgery, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Received March 17, 2014. Accepted for publication June 20, 2014. Address correspondence and reprint requests to Jesse A. Taylor, MD, Division of Plastic Surgery, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Colket Translational Research Bldg, 3501 Civic Center Blvd, 9th Floor, Philadelphia, PA 19104; E-mail: [email protected] Supported by the Department of Surgery of The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania. The authors report no conflicts of interest. This study was reviewed and approved by the institutional review board of the Children’s Hospital of Philadelphia. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001182
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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![[Horseshoe Le Fort I osteotomy].](/assets/img/hold.png)
