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British Journal of Oral and Maxillofacial Surgery 52 (2014) 467–469
Short communication
Fracture of the clivus as an unusual complication of LeFort I osteotomy: case report Seung-Won Chung, Kyung-Ran Park, Young-Soo Jung, Hyung-Sik Park ∗ Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Republic of Korea Accepted 27 February 2014 Available online 27 March 2014
Abstract LeFort I osteotomy is a standard technique for the surgical correction of dentofacial deformities. Despite its low morbidity, it can lead to various complications at the base of the skull. We report the case of a fractured clivus as an unusual complication. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: LeFort I osteotomy; Pterygomaxillary dysjunction; Clivus fracture; Medial medullary infarction; Hemiparesis; Complications
Introduction LeFort I osteotomy is a standard technique in orthognathic surgery and, despite the number done, the incidence of associated complications at the base of the skull is relatively low.1 Some of the most severe ones that have been reported are blindness, fistula of the carotid cavernous sinus, and cranial nerve palsy.1–5 We report an unusual case of fracture of the clivus as a complication of LeFort I osteotomy.
Case report A 26-year-old man had been diagnosed with severe facial asymmetry and treated by orthognathic surgery under general anaesthesia. He was well developed with normal physical findings. The orthognathic surgery involved LeFort I osteotomy, bilateral sagittal split mandibular ramus osteotomies (SSRO), and advancement genioplasty. He had a ∗ Corresponding author at: Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea. Tel.: +82 2 2228 3135; fax: +82 2 2227 8022. E-mail addresses: [email protected] (S.-W. Chung), [email protected] (K.-R. Park), [email protected] (Y.-S. Jung), [email protected] (H.-S. Park).
standard LeFort I osteotomy that included pterygomaxillary dysjunction. An Epker osteotome (8 mm × 1.2 mm) was used to separate the pterygoid plates from the maxillary tuberosity by gentle tapping with a mallet. After the down fracture, the maxilla was repositioned according to our surgical plan and fixed with metal plates and screws. SSRO and genioplasty were done in the conventional manner. The operative course was uneventful. After the patient had returned to the general ward he complained of weakness in his right arm and leg, and neurological evaluation showed that he had a right hemiparesis, but with no facial weakness or sensory symptoms. Imaging was requested immediately. It was, however, difficult to obtain an adequate evaluation from the magnetic resonance image (MRI) of the brain because artefacts from the metal plates and screws had distorted the images of the central base of the skull. MRI of the cervical spine showed no abnormal findings that correlated with the symptoms. However, it did show a haemorrhage in the sacral spinal canal (Fig. 1). Further MRI of the brain showed a left medial medullary infarction (Fig. 2). Cranial computed tomography (CT) subsequently confirmed the cause of the infarction, showing a longitudinal fracture of the left clivus adjacent to the infarction site (Fig. 3). A neurosurgical consultation was sought for the management of the fractured clivus, but there was no indication for
http://dx.doi.org/10.1016/j.bjoms.2014.02.026 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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S.-W. Chung et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 467–469
Fig. 1. A sagittal T2 magnetic resonance image suggesting that there was a haemorrhage in the sacral spinal canal.
Fig. 2. An axial T2 magnetic resonance image showing the left medial medullary infarction.
surgical intervention and the patient was monitored closely for 2 weeks. After 3 months of physiotherapy he had partially recovered from the right hemiparesis.
Discussion The clivus lies deep within the base of the skull, and provides mechanical support for the cranial vault and protection for the brain stem.5 Because of its deep location, the incidence of fracture of the clivus is reported to be only 0.21–0.56% among patients who present with severe head injuries.6 Such fractures are associated with high mortality (24.4–58.8%) as a result of the associated injury to the brain stem.6
Fig. 3. An axial computed tomographic image showing the longitudinal fracture of the left clivus.
Several other fractures of the base of the skull have been reported as complications after LeFort I osteotomies.1–5 However, these were found on the middle cranial fossa and therefore associated with ophthalmic complications. To our knowledge, this is the first published report of an atypical fracture of the clivus as a complication.1,6,7 Pterygomaxillary dysjunction is required for effective separation of the maxilla during LeFort I osteotomy.7 Classic pterygomaxillary dysjunction entails a lateral approach to the pterygomaxillary fissure with a curved osteotome to achieve complete mobilisation of the maxilla for accurate repositioning.7 It is likely that this procedure was responsible for the complication. Correct positioning and precise control of the osteotome have been emphasised to prevent untoward fractures during pterygomaxillary dysjunction.1,5 However, whether pterygomaxillary osteotomy is required is controversial because of the possible complications associated with it.8 Lanigan and Guest stated that pterygomaxillary osteotomy should be avoided as it can lead to fractures of the base of the skull, and recommended the use of a micro-oscillating saw.9 Precious et al. reported that pterygomaxillary separation can be achieved by leverage alone, without the osteotomy.10 Careful surgical planning and good operative technique are the key factors for preventing unexpected complications during LeFort I osteotomy. In particular, we emphasise the risks of pterygomaxillary osteotomy for pterygomaxillary separation. Special care should be taken in doing a pterygomaxillary osteotomy if this cannot be avoided. Alternative techniques for safer pterygomaxillary dysjunction should also be considered.
S.-W. Chung et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 467–469
References 1. Cruz AA, dos Santos AC. Blindness after Le Fort I osteotomy: a possible complication associated with pterygomaxillary separation. J Craniomaxillofac Surg 2006;34:210–6. 2. Lanigan DT, Romanchuk K, Olson CK. Ophthalmic complications associated with orthognathic surgery. J Oral Maxillofac Surg 1993;51:480–94. 3. Hes J, de Man K. Carotid-cavernous sinus fistula following maxillofacial trauma and orthognathic surgery. Int J Oral Maxillofac Surg 1988;17:295–7. 4. Hanu-Cernat LM, Hall T. Late onset of abducens palsy after Le Fort I maxillary osteotomy. Br J Oral Maxillofac Surg 2009;47:414–6. 5. Girotto JA, Davidson J, Wheatly M. Blindness as a complication of Le Fort osteotomies: role of atypical fracture patterns and distortion of the optic canal. Plast Reconstr Surg 1998;102:1409–23.
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6. Ochalski PG, Spiro RM, Fabio A. Fractures of the clivus: a contemporary series in the computed tomography era. Neurosurgery 2009;65:1063–9. 7. Bell WH, Proffit WR, White RP, editors. Surgical correction of dentofacial deformities. Philadelphia: Saunders Elsevier; 1980. p. 281–7. 8. O’Regan B, Bharadwaj G. Pterygomaxillary separation in Le Fort I osteotomy UK OMFS consultant questionnaire survey. Br J Oral Maxillofac Surg 2006;44:20–3. 9. Lanigan DT, Guest P. Alternative approaches to pterygomaxillary separation. Int J Oral Maxillofac Surg 1993;22: 131–8. 10. Precious DS, Morrison A, Ricard D. Pterygomaxillary separation without the use of an osteotome. J Oral Maxillofac Surg 1991;49: 98–9.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 467–469
Short communication
Fracture of the clivus as an unusual complication of LeFort I osteotomy: case report Seung-Won Chung, Kyung-Ran Park, Young-Soo Jung, Hyung-Sik Park ∗ Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Republic of Korea Accepted 27 February 2014 Available online 27 March 2014
Abstract LeFort I osteotomy is a standard technique for the surgical correction of dentofacial deformities. Despite its low morbidity, it can lead to various complications at the base of the skull. We report the case of a fractured clivus as an unusual complication. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: LeFort I osteotomy; Pterygomaxillary dysjunction; Clivus fracture; Medial medullary infarction; Hemiparesis; Complications
Introduction LeFort I osteotomy is a standard technique in orthognathic surgery and, despite the number done, the incidence of associated complications at the base of the skull is relatively low.1 Some of the most severe ones that have been reported are blindness, fistula of the carotid cavernous sinus, and cranial nerve palsy.1–5 We report an unusual case of fracture of the clivus as a complication of LeFort I osteotomy.
Case report A 26-year-old man had been diagnosed with severe facial asymmetry and treated by orthognathic surgery under general anaesthesia. He was well developed with normal physical findings. The orthognathic surgery involved LeFort I osteotomy, bilateral sagittal split mandibular ramus osteotomies (SSRO), and advancement genioplasty. He had a ∗ Corresponding author at: Department of Oral & Maxillofacial Surgery, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea. Tel.: +82 2 2228 3135; fax: +82 2 2227 8022. E-mail addresses: [email protected] (S.-W. Chung), [email protected] (K.-R. Park), [email protected] (Y.-S. Jung), [email protected] (H.-S. Park).
standard LeFort I osteotomy that included pterygomaxillary dysjunction. An Epker osteotome (8 mm × 1.2 mm) was used to separate the pterygoid plates from the maxillary tuberosity by gentle tapping with a mallet. After the down fracture, the maxilla was repositioned according to our surgical plan and fixed with metal plates and screws. SSRO and genioplasty were done in the conventional manner. The operative course was uneventful. After the patient had returned to the general ward he complained of weakness in his right arm and leg, and neurological evaluation showed that he had a right hemiparesis, but with no facial weakness or sensory symptoms. Imaging was requested immediately. It was, however, difficult to obtain an adequate evaluation from the magnetic resonance image (MRI) of the brain because artefacts from the metal plates and screws had distorted the images of the central base of the skull. MRI of the cervical spine showed no abnormal findings that correlated with the symptoms. However, it did show a haemorrhage in the sacral spinal canal (Fig. 1). Further MRI of the brain showed a left medial medullary infarction (Fig. 2). Cranial computed tomography (CT) subsequently confirmed the cause of the infarction, showing a longitudinal fracture of the left clivus adjacent to the infarction site (Fig. 3). A neurosurgical consultation was sought for the management of the fractured clivus, but there was no indication for
http://dx.doi.org/10.1016/j.bjoms.2014.02.026 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
468
S.-W. Chung et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 467–469
Fig. 1. A sagittal T2 magnetic resonance image suggesting that there was a haemorrhage in the sacral spinal canal.
Fig. 2. An axial T2 magnetic resonance image showing the left medial medullary infarction.
surgical intervention and the patient was monitored closely for 2 weeks. After 3 months of physiotherapy he had partially recovered from the right hemiparesis.
Discussion The clivus lies deep within the base of the skull, and provides mechanical support for the cranial vault and protection for the brain stem.5 Because of its deep location, the incidence of fracture of the clivus is reported to be only 0.21–0.56% among patients who present with severe head injuries.6 Such fractures are associated with high mortality (24.4–58.8%) as a result of the associated injury to the brain stem.6
Fig. 3. An axial computed tomographic image showing the longitudinal fracture of the left clivus.
Several other fractures of the base of the skull have been reported as complications after LeFort I osteotomies.1–5 However, these were found on the middle cranial fossa and therefore associated with ophthalmic complications. To our knowledge, this is the first published report of an atypical fracture of the clivus as a complication.1,6,7 Pterygomaxillary dysjunction is required for effective separation of the maxilla during LeFort I osteotomy.7 Classic pterygomaxillary dysjunction entails a lateral approach to the pterygomaxillary fissure with a curved osteotome to achieve complete mobilisation of the maxilla for accurate repositioning.7 It is likely that this procedure was responsible for the complication. Correct positioning and precise control of the osteotome have been emphasised to prevent untoward fractures during pterygomaxillary dysjunction.1,5 However, whether pterygomaxillary osteotomy is required is controversial because of the possible complications associated with it.8 Lanigan and Guest stated that pterygomaxillary osteotomy should be avoided as it can lead to fractures of the base of the skull, and recommended the use of a micro-oscillating saw.9 Precious et al. reported that pterygomaxillary separation can be achieved by leverage alone, without the osteotomy.10 Careful surgical planning and good operative technique are the key factors for preventing unexpected complications during LeFort I osteotomy. In particular, we emphasise the risks of pterygomaxillary osteotomy for pterygomaxillary separation. Special care should be taken in doing a pterygomaxillary osteotomy if this cannot be avoided. Alternative techniques for safer pterygomaxillary dysjunction should also be considered.
S.-W. Chung et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 467–469
References 1. Cruz AA, dos Santos AC. Blindness after Le Fort I osteotomy: a possible complication associated with pterygomaxillary separation. J Craniomaxillofac Surg 2006;34:210–6. 2. Lanigan DT, Romanchuk K, Olson CK. Ophthalmic complications associated with orthognathic surgery. J Oral Maxillofac Surg 1993;51:480–94. 3. Hes J, de Man K. Carotid-cavernous sinus fistula following maxillofacial trauma and orthognathic surgery. Int J Oral Maxillofac Surg 1988;17:295–7. 4. Hanu-Cernat LM, Hall T. Late onset of abducens palsy after Le Fort I maxillary osteotomy. Br J Oral Maxillofac Surg 2009;47:414–6. 5. Girotto JA, Davidson J, Wheatly M. Blindness as a complication of Le Fort osteotomies: role of atypical fracture patterns and distortion of the optic canal. Plast Reconstr Surg 1998;102:1409–23.
469
6. Ochalski PG, Spiro RM, Fabio A. Fractures of the clivus: a contemporary series in the computed tomography era. Neurosurgery 2009;65:1063–9. 7. Bell WH, Proffit WR, White RP, editors. Surgical correction of dentofacial deformities. Philadelphia: Saunders Elsevier; 1980. p. 281–7. 8. O’Regan B, Bharadwaj G. Pterygomaxillary separation in Le Fort I osteotomy UK OMFS consultant questionnaire survey. Br J Oral Maxillofac Surg 2006;44:20–3. 9. Lanigan DT, Guest P. Alternative approaches to pterygomaxillary separation. Int J Oral Maxillofac Surg 1993;22: 131–8. 10. Precious DS, Morrison A, Ricard D. Pterygomaxillary separation without the use of an osteotome. J Oral Maxillofac Surg 1991;49: 98–9.
