J Oral Maxillofac

Surg

48:2-l 1, 1990

Quadrangular

Le Fort

I

Osteotomy:

Surgical Technique and Review of 54 Patients EUGENE E. KELLER, DDS, MS,* AND A. HOWARD SATHER, DDS, MSDt Technical aspects and indications for the quadrangular Le Fort I osteotomy are described. The records of 54 consecutive patients who underwent this procedure for primary correction are reviewed in general terms, and those of 3 patients with significant follow-up are presented in some detail. The procedure gave predictable results, provided acceptable midfacial aesthetic improvement, and was surgically reproducible with few complications. Low surgical and postoperative morbidity was documented. This procedure was used in a similar patient population as the quadrangular Le Fort II osteotomy, and the rationale for choosing between these two procedures is discussed.

Axhausen,’ in 1934, was the first to describe maxillary advancement by a Le Fort I osteotomy. The actual advancement was accomplished postoperatively with elastics, a detail that suggests incomplete mobilization intraoperatively. When one considers the level of anesthesia and surgical instrumentation development at that early date, the surgical accomplishment was certainly monumental. In 1969, 0bwegeser2 described a Le Fort I osteotomy procedure in which the bone cut was made “as high as possible, from the tuberosity area around the whole maxilla, staying just beneath the infraorbital foramen.” Bone grafts were placed between the pterygoid plates and the advanced maxilla. Obwegeser also described placement of bone grafts anteriorly “from the zygomatic crest to the pyriform aperture.” He acknowledged the large antral communication with the bone graft when it was placed in this manner, but indicated that healing was excellent “as shown by Gilies.“3 He also noted that the grafts could be extended superiorly as high

as the infraorbital rim to provide an esthetic benefit as well as skeletal stability for the advanced maxillary segment. Kaminishi et al. 4 in 1983 and Bennett and Wolford’ in 1985 presented modifications of a Le Fort I osteotomy designed to increase bone contact and segment stability after maxillary advancement procedures. These investigators did not use interpositional iliac bone grafts in the infraorbital region to either stabilize the advanced segment or augment the infraorbital-zygomatic region. In addition, they made the anterior portion of the osteotomy at the level of the floor of the nose. More recently, Wardrop and Wolford6 used the previously described Le Fort I step osteotomy for maxillary advancement; however, stabilization was achieved by placement of porous block hydroxyapatite interpositional grafts rather than autogenous iliac bone (as described previously).5 Since December 1981, one of us (E.E.K.) has performed a high modified Le Fort I osteotomy for 54 selected patients with maxillary deficiency (Fig 1). After complete mobilization and advancement, an inlay-onlay iliac crest corticocancellous graft is placed from the piriform aperture medially to the zygoma laterally. The graft extends to, and is stabilized by, the infraorbital rim superiorly and extends inferiorly to lie posterior to the anterior antral wall on the floor of the antrum. This procedure is best named the “quadrangular Le Fort I osteotomy,” because its indications, osteotomy level, and projected outcome are quite similar to the quadrangular Le Fort II osteotomy described ini-

Received from the Mayo Clinic and Mayo Foundation, Rochester, MN. * Consultant, Section of Oral and Maxillofacial Surgery; Associate Professor of Dentistry, Mayo Medical School. t Consultant, Section of Orthodontics; Associate Professor of Dentistry, Mayo Medical School. Address correspondence and reprint requests to Dr Keller: Mayo Clinic, 200 First St SW, Rochester, MN 55905. 0 1990 American

Association

of Oral and Maxillofacial

Sur-

geons 0278-2391/90/4801-0002$3.00/O

2

3

KELLER AND SATHER

complish the down-fracture maneuver. Fortunately, patient preparation, anesthesia technique, bone graft harvesting, and postoperative care are identical for both procedures. As noted in a previous communication,” the esthetic results are more readily achieved by the quadrangular Le Fort II osteotomy than by the lower level Le Fort I procedure; however, the more limited versatility and lack of proper anatomy may necessitate the lower level osteotomy and modified bone graft placement.

FIGURE 1. Surgical technique of quadrangular Le Fort 1 osteotomy. Frontal and lateral views of maxillary-zygomatic osteotomy and interpositional-onlay iliac bone graft. The graft is supported by the infraorbital rim medially and the zygoma laterally. Infraorbital-piriform aperture transosseous wiring is illustrated. (Reprinted with permission of the Mayo Foundation.)

tially by Kufner7 and modified by Souyris et al,8 Champy.’ Steinhauser,‘” and Keller and Sather.” Indications Patients with maxillary-zygomatic deficiency on clinical and cephalometric examinations who have class III skeletal malocclusion but a normal nasalethmoidal projection are potential candidates for quadrangular Le Fort I osteotomy. In contrast to patients who are candidates for the quadrangular Le Fort II osteotomy, Le Fort I patients may also have significant maxillary midline shift (>2 mm), significant vertical deficiency (>5 mm), significant vertical excess (>5 mm), or significant transverse maxillary deficiency. Because the orbital rims are not included in this osteotomy, its versatility is greater than that of the Le Fort II procedure. The quadrangular Le Fort I osteotomy is also performed in patients scheduled for the Le Fort II procedure who on surgical exposure lack adequate bone strength in the piriform aperture strut for the surgeon to ac-

Surgical Procedure After nasoendotracheal induction of anesthesia and preparation for an intraoral procedure, an incision is made approximately 4 mm above the mucogingival junction from the right to the left first premolar. The entire surface of the anterior maxilla is exposed by subperiosteal dissection extending from the right to the left posterior tuberosity and superiorly to the infraorbital rim. The infraorbital nerve and orbital rim periosteum are completely isolated to allow passive placement of the interpositionalonlay iliac bone graft. The mucosa of the floor of the nose is elevated to expose the maxillary rostrum. At this time, the cartilaginous septum and vomer are separated from the midline with a curette, and the maxillary rostrum is removed by a chisel technique. The lateral nasal wall is exposed up to, and frequently above, the anterior attachment of the inferior turbinate. An osteotomy is made bilaterally with an oscillating saw through the piriform aperture at the level of the infraorbital nerve and extended laterally just below the foramen to the tuberosity-pterygoid plate region posteriorly (Fig 2A). An inferior step in the osteotomy is frequently necessary at the anterior margin of the maxillary buttress. Because of the high position of the osteotomy, the posterior tuber-

FIGURE 2. A, Intraoperative view of osteotomy below the infraorbital nerve (arrowhead). B, Intraoperative view after advancement, placement of interpositional-onlay bone graft (left arrow), and placement of transosseous suspension wire (right arrow).

QUADRANGULAR

CEPHALOMETRIC

Facial

angle

1 SNA

FINDINGS Preop

postop

90.5

92

-2.5

ANB Soft

LE FORT I OSTEOTOMY

tissue APO

angle

-9

2 -1

10

3

74

78.5

FIGURE 3. Anterior facial profile before (A) and 5 years after (E) operation. Lateral facial profile before (C) and 5 years after (0) operation. Cephalograms before Q and 5 years after (F) operation. G, Preoperative and postoperative composite tracing. Maxillary occlusal view before (H) and 5 years after (fi operation. Anterior occlusion before (J) and 5 years after (K) operation.

osity osteotomy may have to be accomplished by a chisel technique. The maxilla is down-fractured by finger pressure and completely mobilized (by a disimpaction forceps in selected cases). To date, pterygoid chisels have not been used. With the maxilla pulled for-

ward with a transpalatal wire, all posterior palatal and tuberosity soft tissue attachments are released by finger dissection. The maxilla is placed passively into a prefabricated splint, and maxillomandibular fixation is applied. The cartilaginous septum is exposed in the mid-

3

FIGURE 3.

(cont’d).

line, and deflections (if present) are corrected by excision-incision techniques. The nasal midline wound is closed with a continuous suture. Transosseous suspension wires are placed from the medial orbital rim to the inferior portion of the piriform aperture. These wires are not tightened at this stage. In advancement cases, the proper vertical force is applied when the wire is placed as far posterior as possible on the lateral aperture. This position frequently is just mesial or distal to the canine root (Fig 2B). Block corticocancellous bone grafts are harvested from the superior-medial iliac crest, as described in an earlier article,” and placed as an onlay-inlay interpositional stabilizing block (Figs 1 and 2B). The proper width (amount of maxillary advancement) can be measured directly in selected cases, because the maxilla at this stage may be fixed to the mandible, which has not been operated on. In bimaxillary osteotomy cases, the mandibular procedure is accomplished either before or after the maxillary procedure, and skeletal fixation is applied (threaded pins). An interim splint may be used in selected cases. Careful preoperative and intraoperative measurements allow accurate maxillary positioning and anatomic osseous approximation. The bone graft extends to the superior level of the infraorbital rim and laterally to cover the zygomatic prominence to various degrees, depending on the cosmetic requirements in individual cases. Proper and equal bilateral contouring of the blocks is extremely important, because irregular contours are

noticeable after resolution of edema. The blocks are also notched to accommodate the infraorbital nerve. After final contouring, the transosseous suspension wires are placed through the graft for stabilization, and the mandible-maxilla is autorotated into the correct vertical position (when only the maxilla is operated or when the mandible is operated on first). In vertical augmentation cases, the correct height of the bone graft is determined intraoperatively by direct measurement from bone marks placed before the osteotomy. After the correct height is determined by observation of lip and tooth position, bone measurements, and preoperative clinical measurements, the transosseous suspension wires are tightened. At this stage, accuracy is very important; overshortening is quite possible because vertical bone stops may be absent when significant advancement has been accomplished. Additional transosseous iliac graft stabilizing wires are placed laterally on the zygomatic buttress in most cases. Cancellous chips are then packed in the lateral nasal and lateral orbital-zygoma areas to achieve a symmetrical contour and to eliminate dead space. From two to four resorbable sutures are placed to approximate the midline nasal and lip musculature, which in turn helps achieve desirable alar width. The maxillary incision is closed in a watertight fashion with a continuous horizontal mattress suture. Mucosal V-Y closure is not used, because the midline musculature closure has already accomplished the desired lip-nasal esthetics. Postoperative care and a hypotensive anesthesia protocol are identical to those in the quadrangular Le Fort II procedure described in a previous article. I1 In recent years, coinciding with use of skeletal fixation, maxillomandibular fixation time has been reduced whenever mandibular osteotomy procedures have been accomplished at the same time. Skeletal miniplate fixation of both the quadrangular Le Fort I and the quadrangular Le Fort II osteotomies is technically very difficult because of the high level of the osseous cut, and it has not been possible in the authors’ experience to date; however, the stabilizing interpositional graft has allowed us to reduce the maxillomandibular fixation time in selected cases to 1 to 3 weeks. Use of light nocturnal maxillomandibular elastics in concert with the surgical splint is maintained up to 6 weeks in most cases, and the patients are allowed a pureed soft diet during this period of limited function. We routinely provide antibiotics intravenously during the operation and from 48 to 72 hours postoperatively (intermittent doses). Administration is then discontinued and reinitiated only if sepsis is identified (4 of 54 patients in this report). Routinely,

6

QUADRANGULAR LE FORT I OSTEOTOMY

GG

CEPHALOMETRIC

FINDINGS Preop

Facial

angle

92

ANS Soft 1 SNA

Postop 93

9.5 tissue APO

angle

2 9.5 77

.5 3 2 85.5

FIGURE 4. Anterior facial profile before (A) and 3 years after (B) operation. Lateral facial profile before (C) and 3 years after (0) operation. Cephalograms before (E) and 3 years after (fl operation. G, Preoperative and postoperative composite tracing. Occlusion before (Hand I) and 3 years after (J and K) operation.

steroids are administered intravenously during and 48 hours after the operation (intermittent doses). Selected Patient Presentations Patient

1

A 20-year-old man (Fig 3) presented with a class III skeletal malocclusion associated with a unilateral maxillary cleft lip-palate deformity, maxillary-zygomatic hori-

zontal deficiency, mandibular protrusion, and mandibular anterior vertical excess. In November 1984, the following surgical procedures were accomplished: 1) Maxillary quadrangular Le Fort I osteotomy (two-piece) with 12-mm advancement and 6-mm width increase. 2) Mandibular bilateral sagittal osteotomy with 5-mm setback. 3) Mandibular anterior horizontal osteotomy with 6-mm anterior vertical reduction and lo-mm inferior border width reduction (midline ostectomy). 4) Infraorbital-zygomatic interpositional-onlay iliac bone graft. 5) Maxillary alveolarpalatal cleft iliac bone grafting and closure.

7

Patient 3 A 36-year-old man (Fig 5) presented with a class III skeletal malocclusion secondary to maxillary-zygomatic horizontal deficiency and mandibular protrusion. In November 1984, the following surgical procedures were accomplished: 1) Maxillary quadrangular Le Fort I osteotomy with 7-mm advancement. 2) Mandibular bilateral sagittal osteotomy with 11-mm setback. 3) Mandibular anterior horizontal osteotomy for 3-mm vertical height reduction. 4) Mandibular bilateral body ostectomy for closure of the first molar edentulous space. 5) Infraorbital-zygomatic inter-positional-onlay iliac bone graft. The intraoperative and postoperative course was free of significant complications. Operative blood loss was 1,000 mL, and one unit of autologous blood was administered. Hospitalization lasted 5 days, and maxillomandibular fixation was maintained for 7 weeks. Use of nocturnal elastics was maintained an additional 5 weeks because of prolonged segment mobility in the mandibular body ostectomy site. A 3-year follow-up evaluation (November 1987) (Fig 5) showed excellent skeletal and dental stability. This patient reported a significant functional improvement and was pleased with the esthetic change.

FIGURE 4. (cont’d).

No significant intraoperative and postoperative complications were encountered. Measured blood loss was 800 mL, hospitalization lasted 4 days, and maxillomandibular fixation was maintained for 6 weeks. In April 1986, a lip and nasal reconstruction procedure was performed by the attending plastic and reconstructive surgeon. A 3-year, 3-month postoperative follow-up evaluation (February 1988) (Fig 3) showed excellent skeletal and dental stability, and the patient reported excellent functional improvement in the oral-facial complex. He also was pleased with the esthetic change. The missing maxillary lateral incisor had not been replaced, but was present on the orthodontic retainer.

Patient 2 A 17-year-old boy (Fig 4) presented with a class III skeletal malocclusion secondary to maxillary-zygomatic horizontal deficiency and mandibular protrusion. Mandibular anterior vertical excess also was present. In June 1982, the following surgical procedures were accomplished: 1) Maxillary quadrangular Le Fort I osteotomy with 9-mm advancement. 2) Mandibular bilateral sagittal osteotomy with 4-mm setback. 3) Mandibular anterior horizontal osteotomy with 7-mm vertical reduction and 5-mm advancement. 4) Infraorbital-zygomatic interpositional-onlay iliac bone graft. 5) Mandibular bilateral body ostectomy for closure of first bicuspid extraction sites. The intraoperative and postoperative course was free of significant complications. Operative blood loss was 900 mL, hospitalization lasted 5 days, and maxillomandibular fixation was maintained for 6 weeks. A Syear follow-up evaluation (May 1986) (Fig 4) showed excellent skeletal and dental stability, and the patient was pleased with the functional and esthetic improvement.

Analysis of Results

Fifty-four patients underwent the maxillary quadrangular Le Fort I osteotomy as the primary orthog-

nathic procedure between December 198 1 and April 1988. Surgical, medical, hospital, and orthodontic records were reviewed, and data were retrieved on 1) associated mandibular orthognathic surgical procedures, 2) amount of surgical maxillary advancement, vertical augmentation, or transverse correction accomplished, 3) surgical operative data (blood loss, operating time, blood replacement, complications), hospitalization time, and maxillomandibular fixation time, and 4) postoperative complications.

ASSOCIATED MANDIBULAR ORTHOGNATHICPROCEDURES

Of the 54 patients in whom the quadrangular Le Fort I osteotomy was performed, 23 also had bilateral mandibular ramus sagittal osteotomies. In addition, 10 of the 54 patients underwent mandibular bilateral body osteotomy procedures, and 11 of the 54 had a mandibular anterior horizontal osteotomy . Additional procedures accomplished in one or two patients were bilateral posterior subapical osteotomy (one patient), anterior reduction genioplasty (two patients), midline vertical osteotomy (one patient), and total subapical osteotomy (one patient).

QUADRANGULAR

CEPHALOMETRIC Facial

angle

Preop. 101.5

SNA

5 4.5

tissueangle-3.5 l-APO

FINDINGS postop. 95

-9

ANB Soft

LE FORT I OSTEOTOMY

13.5 89

0.5 94

FIGURE 5. Anterior facial profile before (A) and 3 years after (B) operation. Lateral facial profile before (C) and 3 years after (0) operation. Cephalograms before (E) and 3 years after (F) operation. G, Preoperative and postoperative composite tracing. Occlusion before (H and I) and 3 years after (J and K) operation.

AMOUNT OF SURGICAL ADVANCEMENT

All patients received maxillary horizontal advancement ranging from 3 to 12 mm. Most (40 patients) had advancement in the 6- to lo-mm range. AMOUNT OF SURGICAL VERTICAL ALTERATION

Twenty-one patients received various amounts of maxillary vertical augmentation in addition to the advancement. This vertical augmentation ranged from 4 to 10 mm. One patient received 8 mm of posterior maxillary impaction in addition to maxillary advancement.

AMOUNT OF MAXILLARY TRANSVERSE INCREASE

Fourteen patients received various degrees of transverse augmentation (primarily in the molar region). This increase ranged from 3 to 10 mm. OPERATING TIME

Operating time varied greatly and reflected the wide range of associated procedures. Eleven of the

9

KELLERANDSATHER

more than 10 hours). 13.14In the autologous blood program was autologous red blood cells was patients operated on since that

summer of 1984, an begun. One unit of given to 6 of the 30 time.

HOSPITALIZATION TIME

Of the 54 patients, 3 1 were hospitalized for 4 days or less. Eleven patients were hospitalized for 5 days and seven for 6 days. The two patients who underwent extensive craniofacial reconstruction were hospitalized for 12 and 13 days, respectively. MAXILLOMANDIBULAR FIXATIONTIME

Beginning in the summer of 1986, all patients (18) except two underwent 3 weeks or less of maxillomandibular fixation. These two patients received 4 weeks of fixation. Of the 54 patients, 33 received from 4 to 6 weeks and 3 received from 7 to 8 weeks of maxillomandibular fixation. INTRAOPERATIVE COMPLICATIONS

FIGURE 5. (cont’df.

operations were completed in less than 3% hours and, for the most part, consisted of only the primary procedure (quadrangular Le Fort I osteotomy with iliac bone graft). Operating time in two patients was 10 hours because of multiple craniofacial procedures for correction of acromegalic facies.‘3,‘4 Most of the patients (28) had operating times of less than 5 hours; they received the primary procedure and additional mandibular procedures. BLOOD Loss

As expected from the wide range of associated procedures and operating times, blood loss varied greatly-from 130 mL (in a patient who underwent only the primary procedure) to 2,000 mL (in a patient who underwent multiple craniofacial procedures). Blood loss was determined by routine collection methods and usually varied proportionately with the length of the procedure. The donor site (iliac crest) procedure caused very little blood loss and generally did not alter the need for blood product replacement. The superior-medial iliac crest grafting technique was used in all patients.” BLOODREPLACEMENT Twenty-one units of blood were used in the 54 patients. Nine of the 21 units were given to two patients (5 and 4 units, respectively) who underwent extended craniofacial reconstructions (lasting

No complications were recorded on the operative reports or recalled by the attending surgeon (E.E.K.). POSTOPERATIVE COMPLICATIONS

All hospital and follow-up clinic records were reviewed. Thirteen patients received treatment for various complications, which can be categorized as follows: infection, bone sequestra without infection, neurologic problem, irregular orbital contour, nasolacrimal duct dysfunction, transosseous wire causing a problem, air injection into the infraorbital area, hip wound seroma, and oral-nasal fistula. Infection Four patients returned 18, 20, 21, and 30 days postoperatively, respectively, with recurrent swelling. In all cases, the swelling was associated with the incision line intraorally and caused unilateral upper lip and infraorbital swelling. Drainage was established intraorally by opening the involved incision. Antibiotics were administered orally in all patients (10 to 14 days), and resolution occurred promptly. No evidence of long-term untoward sequelae was recorded in the four patients. None had previous cleft deformities. Three had received maxillary vertical as well as horizontal lengthening procedures. Sequestra Formation

Without Infection

Three patients (all with maxillary alveolar palatal cleft deformities) had sequestra formations, which

QUADRANGULAR

10

were removed through an open dehisced incision. The sequestra were all small pieces of particulate graft and were removed from palatal or alveolar cleft areas. In all patients, the major infraorbital zygomatic corticocancellous block grafts were not involved, and the maxillary osteotomy surgical sites healed without complication. Neurologic

Problems

One patient experienced unilateral, sporadic infraorbital pain associated with recovery from paresthesia. This symptom required minimal medication (analgesics) and subsided in 4 to 6 months. Irregular

Infraorbital

Contour

In one patient, the infraorbital graft contour was irregular in the lateral nasal area bilaterally. This irregularity was cosmetically noticeable, and the graft was recontoured under local and intravenous anesthesia 7 months after the osteotomy procedure. Also, the associated transosseous wires were removed at that time. Nasolacrimal

Duct Dysfunction

In one patient, bilateral increased tearing was noted postoperatively. The tearing was mild, sporadic, and difficult to document by evaluation during postoperative examinations. It resolved spontaneously during the first postoperative year. Transosseous

Wires Causing Problems

Transosseous wires were removed in two patients. In one, a zygomatic buttress wire was found to be exposed intraorally 2 years postoperatively; it was removed under local anesthesia. The second patient returned 3 months postoperatively because of spontaneous pain in the right paranasal area. The infraorbital-piriform aperture wire was removed, but it was not associated with visible pathologic change; the pain resolved spontaneously. Emphysema

in Infraorbital

Tissues

In one patient, air was forced into the infraorbital tissues on the sixth postoperative day in association with vigorous nose blowing. Antibiotics were given, and the swelling resolved completely in 10 days. The patient was instructed to avoid nose blowing, and his nasal airway congestion was managed by local debridement, decongestants, and humidified air. Iliac Crest Wound Seroma

A classic seroma developed and was drained 2 weeks after the surgical procedure in one patient. Additional untoward sequelae were not recorded,

LE FORT I OSTEOTOMY

and this was the only hip wound problem identified in this group of patients. Oral-Nasal Fistula

An oral-nasal listula occurred in the palatal midline of a patient in whom significant maxillary widening was accomplished along with vertical lengthening and advancement. The Iistula (3 mm in diameter) was closed by rotating a soft tissue flap under local and intravenous anesthesia 6 months after the osteotomy procedure. No long-term sequelae occurred, Discussion Patients who have midfacial deficiency extending to the level of the infraorbital rims medially and the zygoma laterally, and have acceptable nasoethmoidal projection, should receive a maxillary advancement procedure commensurate with their deformity. The procedure of choice for these patients is the quadrangular Le Fort II osteotomy initially described by Kufner’ and later modified by Souyris et aL8 Champy,’ Steinhauser,” and Keller and Sather. ” With this proc edure, the dentoalveolar and infraorbital-zygomatic deficiencies are corrected. By normalization of the total specific deformity, a superior esthetic and functionally stable result should be realized. If the same patients also have significant maxillary vertical deficiency, maxillary vertical hyperplasia, maxillary transverse excess or deficiency, or maxillary asymmetry, the quadrangular Le Fort I osteotomy described here offers an acceptable alternative procedure. Potentially, the final esthetic result can be equal to that of the quadrangular Le Fort II procedure if the onlayinlay bone grafting is contoured and stabilized correctly. In our experience, the bone graft placement is technically more difficult in the quadrangular Le Fort I procedure than in the quadrangular Le Fort II procedure. One would also expect increased bone resorption of the infraorbital onlay bone graft in the quadrangular Le Fort I procedure. To compensate for this, significant overcontouring of the infraorbital-zygomatic onlay-inlay graft is done. When the quadrangular Le Fort II osteotomy is done intraoral1 y , ’ ’ an occasional patient may have significant thinning of the lateral nasal-infraorbital bone, so that the down-fracture maneuver is technically very difficult or impossible (an unfavorable fracture will occur below the infraorbital rim). In these patients, the surgeon may decide intraoperatively to perform the quadrangular Le Fort I osteotomy and potentially achieve equal esthetic and functional results with almost identical preoperative patient preparation and postoperative patient management .

11

KELLER AND SATHER Patients with maxillary alveolar-palatal clefts frequently have maxillary-zygomatic deficiency involving the lower and middle portions of the face; in addition, they frequently have dentoalveolar asymmetry and transverse or vertical deficiency. In this group of patients, the quadrangular Le Fort I osteotomy is an excellent procedure. Those patients with cleft palate also frequently require follow-up nasal-lip reconstructive procedures and may be candidates for the Le Fort II (pyramidal) or Le Fort III procedure in combination with a low-level Le Fort I osteotomy for sagittal, transverse, and vertical corrections. Two surgical operations are required in these patients (the higher level osteotomy is generally performed first). Associated mandibular procedures are quite common in patients receiving the quadrangular Le Fort I osteotomy (30 of the 54 patients received mandibular orthognathic procedures in concert with the maxillary procedure). This frequency reflects the fact that patients with facial deformity often have aberrant growth in both the maxilla and mandible. All patients who underwent the quadrangular Le Fort I osteotomy received horizontal advancement; however, 21 of the 54 patients also received maxillary vertical augmentation, 14 received maxillary transverse augmentation, and 1 received maxillary posterior impaction as part of their maxillary correction. The transverse and vertical corrections for this group of patients were generally greater than 5 mm; in contrast, 5 mm is the maximum allowable transverse; vertical, or midline correction acceptable in the quadrangular Le Fort II procedure (as discussed in our previous article”). Segmentalization is more easily accomplished in the lower level osteotomy, and the quadrangular Le Fort I osteotomy is often used in the patient with maxillary cleft because significant width and symmetry problems are common. The inlay-onlay bone grafting in combination with the infraorbital-nasal aperture transosseous wiring provides a very rigid advancement with osseous (skeletal) interlocking. For this reason, it has been possible to significantly reduce or eliminate maxillomandibular fixation in most patients. In selected patients with marginal bone contacts who have had significant vertical lengthening in addition to advancement, 3 or 4 weeks of maxillomandibular fixation is used. An increase in maxillomandibular fixation time was recorded in three patients. Two of the three were related to mandibular body procedures in which wire osseosynthesis was utilized. The third patient (early case, 1982) had signiftcant maxillary mobility at the 6-week evaluation, and maxillomandibular fixation was maintained for an additional week. Clinically normal bone healing occurred in all

54 patients irrespective of maxillomandibular Iixation time. Complete avoidance of maxillomandibular fixation or maintenance of elastic maxillomandibular fixation could be acceptable in selected patients, provided they were dependable and were monitored closely by the surgeon and orthodontist. The question of short- or long-term stability in this group of patients has not been scientifically evaluated. Our clinical results suggest suitable stability during the past 7 years, because reoperation for any cause has not been required. We routinely overcorrect 1 to 2 mm to counteract the compression of the postcondylar tissues in patients receiving only the maxillary or the bimaxillary advancement procedure when skeletal fixation is provided in the mandible. Long-term stability of the occlusion or the infraorbital bone graft (or both) has to date been clinically acceptable, as illustrated by our three case reports. If one provides proper correction of the facial deformity in the horizontal, vertical, and transverse dimensions and provides proper surgical and orthodontic procedures, long-term neuromuscular and skeletal balance should be achieved and maintained. References 1. Axhausen G: Zur behandlung veraheter disloziert geheilter oberkieferbrueche. Dtsch Zahn Mund Kief 1:334. 1934 2. Obwegeser HL: Surgical correction of small or retrodisplaced maxillae: The “dish-face” deformity. Plast Reconstr Surg 43:351, I%9 3. Gilies HG, in Rowe NL, Killie HC (eds): Fractures of the Facial Skeleton. Edinburgh, Scotland, Livingstone, 1955 4. Kaminishi RM, Davis WH, Hochwald DA, et al: Improved maxillary stability with modified Le Fort I technique. J Oral Maxillofac Surg 41:203, 1983 5. Bennett MA, Wolford LM: The maxillary step osteotomy and Steinmann pin stabilization. J Oral Maxillofac Surg 43:307. 1985 6. Wardrop RW, Wolford LM: Maxillary stability following downgraft and/or advancement procedures with stabihzation using rigid fixation and porous block hydroxyapatite implants. J Oral Maxillofac Surg 47:336, 1989 7. Kufner J: Four-year experience with major maxillary osteotomy for retrusion. J Oral Surg 29:549, 1971 8. Souyris F, Caravel JB. Reynaud JP: Osteotomies “intermtdiaires” de I’etage moyen de la face. Ann Chir Plast 18149, 1973 9. Champy M: Surgical treatment of midface deformities. Head Neck Surg 2:451, 1980 10. Steinhluser EW: Variations of Le Fort II osteotomies for correction of midfacial deformities. J Maxillofac Surg 8:258, 1980 11. Keller EE, Sather AH: Intraoral quadrangular Le Fort II osteotomy. J Oral Maxillofac Surg 45:223, 1987 12. Keller EE, Triplett WW: Iliac bone grafting: Review of 160 consecutive cases. J Oral Maxillofac Surg 45: 11, 1987 13. Brennan MD, Jackson IT, Keller EE, et al: Multidisciplinary management of acromegaly and its deformities. JAMA 253:682, 1985 14. Jackson IT, Meland NB, Keller EE, et al: Surgical correction of the acromegalic face: A one stage procedure with a team approach. J Craniomaxillofac Surg 17:2, 1989