J Oral Maxillofac 50:128-132.

Surg

1992

The Effects of the Le Fort Osteotomy on the Periodontium I

WILLIAM J. CARROLL, DDS, MSD,* RICHARD H. HAUG, DDS,t NABIL F. BISSADA, DDS, MSD,* JEROLD GOLDBERG, DDS,$ AND MARK HANS, DDS, MSD” Two age-matched populations of equal size (n = 40) one having orthodontic therapy and the other combined orthodontic therapy and orthognathic surgery, were evaluated for their periodontal status 1 to 10 years posttherapy. The parameters investigated were plaque index, gingival index, tooth mobility, width of keratinized tissue, probing depth, gingival recession, and attachment level. No significant differences were found (P < .05). Within the surgery group, patients with maxillary osteotomies segmentalized between the central incisors (n = 11) and between the canines and second premolars (n = 12) were evaluated using the same parameters and compared with their nonsegmental counterparts. No significant differences were found for patients with osteotomies segmentalized between the central incisors. However, a statistically significant increase in probe depth and loss of attachment level of up to 0.3 mm was found at the sites of osteotomies segmentalized between the canine and second premolar (P < .05). This difference was not considered clinically significant.

pleted only orthodontic therapy. Further, the effects of segmentalization were compared with similar nontreated sites within the surgical group.

The effects of osteotomies have been investigated from a number of different perspectives. These have included relapse, soft-tissue predictability, sensory deficit, hemorrhage, infection, undesirable bone fmgmentation, nonunion, methods of fixation, and devitalization of teeth. Only observations and illustrations regarding the effects of osteotomies on the periodontium have appeared in the oral and maxillofacial surgical literature.‘-’ The purpose of this study was to compare the long-term (1 to 10 years posttherapy) periodontal status of 40 patients who had undergone combined orthodontic and surgical therapy with an age-matched group of 40 individuals who had com-

Materials and Methods To investigate the effects of maxillary osteotomies on the periodontium, surgical and nonsurgical patients were compared. The nonsurgery group consisted of 40 patients who completed orthodontic therapy 1 to 10 years prior to the study (Table 1). The age range was from 16 to 51 years, with a mean of 29.4 years. The surgery group consisted of 40 patients who had both orthodontic therapy and maxillary osteotomies performed 1 to 10 years prior to the study (average, 40.1 months) (Table 2). The age range was 16 to 49 years, with a mean of 29.9 years. To investigate the effects of segmentalization on the periodontium, the surgery group was divided into patients having had two-piece osteotomies (Table 3) and patients having had three-piece osteotomies (Table 4), and these two groups were then compared with their nonsegmental counterparts within the surgery group (Tables 5, 6). The two-piece subgroup consisted of 11 patients who had osteotomies performed between the central incisors. The three-piece subgroup consisted of

* In the private practice of periodontics, Toledo, OH. t Assistant Professor of Surgery, MetroHealth Medical Center of Cleveland and the Case Western Reserve University. $ Professor and Chairman, Department of Periodontics, Case Western Reserve University. 4 Associate Professor and Chairman, Department of Oral and Maxillofacial Surgery, Case Western Reserve University. IIAssistant Professor and Graduate Program Director, Department of Orthodontics, Case Western Reserve University. Address correspondence and reprint requests to Dr Haug: Department of Oral and Maxillofacial Surgery, MetroHealth Medical Center of Cleveland, 3395 Scranton Rd, Cleveland, OH 44109. 0 1992 American

Association

of Oral and Maxillofacial

Surgeons

0276-2391/92/5002-0006$3.00/0

128

Table 1. Mean ( 2 SD) Periodontal Data From the Nonsurgery Ckoup (n = 40) 2

Tooth No.

3

4

-

Plaque index

-

.66 f .48

Gingival

-

.99 5 24 0

L D Probe depth M F L D

8

9

10

11

12

-

-

-

-

-

0.2 * 0.2 4.5 rt 1.1

5.3 * 1.2

3.9 ?I 1.4

3.2 f 1.1

14

15

-

-

0

0

4.3 f 1.0

4.5 + I.0

4.1 + 1.3

13 .43 f .38 .91

4.1 If- 1.2

4.3 + I.1

4.1 f 1.0

3.1 * 0.9

3.6 f 1.4

5.2 * 1.3

0.9 It 0.28 0.3 ?I 0.4 0.7 Z!I0.4 0.5 ?I 0.3

0.8 * 0.3 0.4 + 0.4 0.5 + 0.5 0.7 * 0.4*

0.8 + 0.4 0.4 + 0.5 0.6 * 0.3 0.7 f 0.3

0.7 I? 0.3 0.2 -t 0.6 0.7 * 0.4 0.9 + 0.2*

0.7 + 0.2 0.2 * 0.5 0.5 + 0.3 0.8 t- 0.4

0.7 * 0.3 0.3 + 0.3 0.6 * 0.9 0.8 f 0.3:

0.6 + 0.3 0.5 ? 0.4* 0.6 * 0.5 0.8 f 0.2:

0.7 * 0.2 0.4 + 0.3 0.6 f 0.6 0.7 f 0.3

0.7 + 0.3 0.3 * 0.4 0.6 f 0.5 0.6 + 0.2

0.8 + 0.3* 0.2 & 0.6 0.6 + 0.4 0.8 + 0.3*

0.7 * 0.5 0.1 * 0.5 0.7 + 0.5 0.8 + 0.3

0.7 f 0.3 0.3 + 0.4 0.6 f 0.4 0.7 * 0.3*

0.8 + 0.3 0.5 + 0.4 0.4 Z!Z0.4 0.7 + 0.3

0.8 5 0.3 0.6 + 0.8 0.6 f 0.4 0.6 f 0.4

2.9 + 0.4 2.1 -+ 0.4 2.5 & 0.5 2.7 f 0.4

2.8 + 0.4 2.1 * 0.4 2.1 + 0.4 2.6 f 0.3

2.9 f 0.4 1.7 f 0.4 2.2 f 0.5 2.5 f 0.3

2.8 * 0.2* 1.8 + 0.5 2.1 f 0.3 2.6 + 0.2

2.6 + 0.4 1.7 * 0.5 2.1 + 0.4 2.5 + 0.4

2.5 f 0.4 1.8 + 0.5 2.2 f 0.6 2.5 + 0.3

2.5 f 0.3* 2.1 f 0.6 2.2 * 0.5 2.4 f 0.4

2.5 + 0.3 2.0 + 0.5 2.0 f 0.4 2.4 f 0.3

2.6 + 0.4 1.8 f 0.5 2.2 + 0.5 2.5 f 0.3

2.7 * 0.3 1.9 f 0.5 2.3 -I- 0.5 2.6 -c 0.4

2.8 * 0.3 1.8 + 0.5 2.3 f 0.5 2.5 +_ 0.2

3.1 f 0.4* 1.9 * 0.4 2.4 + 0.5 2.6 + 0.3

3.0 + 0.5 21 *04 2.0 +05 27 *04

2.9 + 0.5 2.0 + 0.4 2.5 & 0.5 2.8 + 0.5

14

15

-

-

-

-

0

0

0

Tooth mobility

F

-

-

I

.44 + .38 1.01 + .28 0.1 i 0.1 4.3 + 1.4

index

Width of keratinized gingiva Recession M

6

5

0

0

0

0

0

0

0

rt .23 0

Abbreviations: D, distal; F, facial; L, lingual; M, mesial. * Denotes significant findings (P -c .05).

Table 2. Tooth No.

Mean (F SD) Periodontal Data From the Surgery Group (n = 40) 2

Plaque index

-

Gingival

-

3

4

-

-

-

-

-

-

0

0

-

-

.68 + .54’ 1.03 + .21 0

0.7 * 0.8 0.3 + 0.3 0.5 * 0.3 0.7 + 0.3

0.6 + 0.3 0.3 * 0.4 0.6 * 0.3 0.6 + 0.2

0.6 f 0.2 0.3 t 0.3 0.6 f 0.3 0.6 f 0.2

0.6 + 0.2 0.3 + 0.3 0.6 * 0.3 0.6 + 0.2

0.7 * 0.2 0.2 r 0.3 0.7 ? 0.4 0.6 f 0.2

0.6 * 0.3 0.1 & 0.4 0.6 f 0.3 0.6 f 0.3

0.6 * 0.3 0.3 t 0.4 0.6 + 0.4 0.7 + 0.2

0.6 f 0.3 0.3 ? 0.3 0.6 * 0.3 0.5 f 0.2

O.‘? f 0.3 0.5 i 0.3 0.7 r 0.g 0.6 & 0.3

0.7 * 0.3 0.4 * 0.3 0.5 * 0.3 0.5 -+ 0.3

2.8 + 0.4 1.7 -t 0.4 2.3 &OS 2.5 + 0.4

2.6 + 0.3 1.8 + 0.5 2.2 to.3 2.4 f 0.3

2.5 * 0.5 1.7 + 0.4 2.1 + 0.4 2.5 f 0.5

2.4 + 0.2 1.9 i 0.5 2.2 k 0.6 2.4 f 0.3

2.3 f 0.4 1.9 * 0.5 2.1 f 0.5 2.4 f 0.4

2.4 + 0.4 1.9 * 0.5 2.0 kO.5 2.4 + 0.4

2.4 * 0.4 1.8 2 0.5 2.3 kO.5 2.4 + 0.5

2.5 f 0.4 1.7 i 0.5 2.4 * 0.5 2.6 + 0.4

2.6 + 0.5 1.7 + 0.4 2.2 f 0.7 2.4 * 0.4

2.8 + 0.5 1.9 * 0.4 2.4 -e 0.5 2.5 +- 0.3

2.9 It 05 2.1 t 0.5 2.2 t 0.5 27 + 0.5

2.8 + 0.6 2.2 + 0.7 2.5 t 0.5 2.6 f 0.5

0.7 * 0.2 0.3 t 0.4 0.5 * 0.3 0.5 * 0.4

2.7 t 0.4 2.1 + 0.4 2.5 f 0.6 2.6 & 0.6

2.8 + 0.4 2.0 + 0.3 2.2 _t 0.6 2.6 + 0.5

D

-

13

0.6 * 0.3 0.2 2 0.3 0.6 t 0.3 0.7 Z!C0.3

0.7 2 0.3 0.2 + 0.4 0.7 Z!I0.4 0.5 I!I 0.3

L

12

0.8 + 0.3 0.3 + 0.4 0.6 + 0.4 0.6 f 0.3

5.0 + 1.5

F

11

3.8 -t 1.0*

5.2 ? 1.2+

Abbreviations: D, distal; F, facial; L, lingual; M, mesial. * Denotes significant findings (P -e .05).

129

-

10

0.1 +- 0.2 5.9 f 1.7

4.5 -1- 1.6

Probe depth M

9

0.1 +0.1 5.0 + 1.7:

Width of keratinized gingiva Recession M

D

8 .61 i .43 1.05 + .32 0.2 I? 0.2 5.0 * 1.7:

0

L

7

-

Tooth mobility

F

6

-

.83 + .53 1.02 ?Z .25 0

index

5

0.2 0.2 f 0.2 * 0.2 6.0 5.0 + 1.6 -+ 1.8*

0

0

4.7 f 1.7*

4.4 ?I 1.5,

5.2 + 1.3*

5.1 + 1.2*

4.5 + 1.4

130

EFFECTS OF LE FORT OSTEOTOMY ON PERIODONTIUM

Table 3. Mean ( * SD) Periodontal Data From the Two-Piece Osteotomy Subgroup (n = 11) Tooth No. 8 Plaque index Gingival index Tooth mobility Width of keratinized gingiva Recession M F L D Probe depth M F L D

.87 + .48 1.15 + .2l 0.3 * 0.3

Tooth No. 9 Tooth No. 8

0.2 * 0.3

4.9 * 1.2

5.0 f 1.5

0.5 0.4 0.6 0.7

+ 0.3 f 0.3 f 0.2 +- 0.2

0.6 0.3 0.4 0.5

f f f +

0.3 0.3 0.3 0.3

2.2 1.9 2.0 2.4

f f f +

2.3 + 1.9 + 1.9 + 2.2 f

0.4 0.3 0.3 0.3

0.3 0.4 0.4 0.3

six patients who had osteotomies performed between the canine and second premolar, the first premolar having been extracted (Table 5). The data for each osteotomy site in the three-piece subgroup were pooled to provide statistically significant information. The following periodontal parameters were identified. The plaque index was graded on a scale of 0 to 3 (0 having the least plaque and 3 the most) at the right first molar, right central incisor, and left second premolar, according to the system described by Silness and Lee.’ The gingival index was graded on a scale of 0 to 3 (0 being no inflammation and 3 the most inflamed) at the right first molar, right central incisor, and left second molar according to the system described

Table 4. Mean ( f SD) Pooled Periodontal Data From the Three-Piece Osteotomy Subgroup (n = 12) Tooth No. 4113 Plaque index Gingival index Tooth mobility Width of keratinized gingiva Recession M F L D Probe depth M F L D

Tooth No. 6/l 1

.65 ? .31 1.12 & .21 0.1 * 0.1

0.1 f 0.2

5.5 + 1.7

4.8 f 2.3

0.6 0.2 0.5 0.5

+ + f +

0.2 0.4 0.4 0.3

0.6 0.1 0.5 0.7

3.0 1.7 2.5 2.7

+ + + +

os* 0.4 0.7 0.4

2.8 f 1.5 + 2.3 f 2.9 +

* Denotes significant findings (P < .05)

Table 5. Mean ( f SD) Periodontal Data for the Maxillary Central Incisors in the Nonsegmentalised Surgery Subgroup (n = 28)

f + + +

0.1 0.3 0.3 0.3 0.3* 0.4 0.5 0.5 *

Plaque index Gingival index Tooth mobility Width of keratinized gingiva Recession M F L D Probe depth M F L D

Tooth No. 9

-

.58 _+ .45 1.00 ? .23 0.2 + 0.3

0.3 f 0.3

5.1 f 1.5

5.0 f 1.7

0.6 0.3 0.6 0.6

f f + f

0.2 0.3 0.3 0.2

0.6 0.3 0.7 0.6

+ + + +

0.2 0.3 0.3 0.2

2.4 1.9 2.2 2.4

+ f f +

0.4 0.5 0.6 0.4

2.4 f 1.9 + 2.0 f 2.4 f

0.4 0.5 0.6 0.4

by Loe and Silness. lo Tooth mobility was evaluated on a scale of 0 to 3 (0 being no physiological mobility and 3 the most mobile) according to the method described by Miller. I1 The width of the keratinized gingiva was measured in millimeters with a Michigan probe with Williams markings (Hu-Friedy, Chicago, IL). Probing depths were measured in millimeters at the mesiolingual, lingual, distolingual, distofacial, facial, and mesiofacial locations with the force-controlled, self-recording Interprobe (Bausch and Lomb Oral Care Division, Tucker, GA). The distofacial and distolingual as well as mesiofacial and mesiolingual measurements were averaged to provide one value for each tooth surface, distal and mesial, respectively. Gingival recession Table 8. Mean ( Z SD) Pooled Periodontal Data for the Canines and Second Premolars in the Nonsegmentalized Surgery Subgroup (n = 84)

Plaque index Gingival index Tooth mobility Width of keratinized gingiva Recession M F L D Probe depth M F L D

Tooth No. 4/ I3

Tooth No. 6/l 1

.7l ? .38 1.00 f .22 0.0 -t 0.2

0.0 + 0.0

5.1 f 1.3

4.9 -+ 1.5

0.7 0.3 0.6 0.6

f + + +

0.3 0.3 0.3 0.2

0.7 f 0.2 + 0.5‘* 0.7 f

0.6 0.4 0.3 0.3

2.7 1.8 2.3 2.5

+ 0.5 kO.5 + 0.5 + 0.4

2.5 f 1.8 + 2.2 + 2.5 +

0.4 0.5 0.5 0.4

CARROLL

131

ET AL

was measured in millimeters at the same six locations and recorded with the Inter-probe. The distofacial and distolingual as well as mesiofacial and mesiolingual measurements were averaged to provide one value for each tooth surface, distal and mesial, respectively. True gingival recession was defined as any measurement apical to the cementoenamel junction and was recorded as a negative value. Attachment levels were calculated for each tooth by adding the results of probe depth and recession. The means of all data were recorded and tested for significant differences between the nonsurgery and surgery groups (P < .05). The t test was used for parametric data and the Mann-Whitney test was used for nonparametric data. The two segmental subgroups were then evaluated individually for significant differences from their nonsegmental counterparts in the surgical group using the same statistical analysis (P < .05). Results Plaque index. The plaque index was low for all representative teeth in all groups (Tables l-6). The surgery group showed a slightly higher clinical score, but this was only significant for tooth no. 13 (P < .05). Gingival index. The gingival index was low for all representative teeth in all groups (Tables l-6). No significant differences were found (P < .05). Tooth mobility. Tooth mobility values were low for all teeth in all groups (Tables l-6). No significant differences were found (P < .05). Width of keratinized gingiva. There was an adequate zone of keratinized gingiva for all groups (Tables l-6), with almost every tooth in the surgery group demonstrating a wider zone of keratinized tissue (approximately 1.O mm) than the nonsurgery group. Probe depths. All groups displayed shallow probe depths (Tables l-6). The nonsurgery group exhibited deeper mean measurements at the right first premolar, right central incisor, and left second premolar than the surgery group. This difference was significant (P < .05). No difference from the nonsegmental counterparts were noted at the sites of osteotomies segmentalized between the central incisors, but slightly deeper measurements were noted at the sites of osteotomies segmentalized between the canine and second premolar. This difference was significant (P < .05). Gingival recession. No true recession was noted in any of the groups (Tables l-6). This meant that the margin of the gingiva was coronal to the cementoenamel junction in all instances. The right first and second molar, right first premolar, right lateral incisor, right central incisor, left canine, and left second premolar of the nonsurgery group had deeper measurements than the surgery group, but all were above the cementoenamel junction. Although this was not true

recession, the difference in measurements was significant (P < .05). Attachment level. There were no differences in attachment level between the nonsurgery and surgery group, nor were differences found with osteotomies segmentalized between the central incisors and their nonsegmental counterparts. However, mean loss of attachment of up to 0.3 mm was found at the sites of osteotomies segmentalized between the canine and second premolars. This difference was significant (P < .05). Discussion There are few reports of the effects of osteotomies on the periodontium in the oral and maxillofacial surgical literature. Those that exist do not provide adequate statistics or consistency of results. Kent and Hinds in 197 1 reviewed 30 alveolar osteotomies performed on 24 patients.’ They reported some bone loss and periodontal pocketing associated with the procedures. No statistical data were available. Steinhauser in 1972 described a procedure for midline splitting of the maxilla.* His comments on the relationship between this technique and the periodontium were illustrative and anecdotal. He did suggest that loss of periodontal ligament and bone may be a sequela. Bell and Dann in 1972 reviewed 25 patients on which supraapical osteotomies were performed.3 They observed that a relative absence of periodontal defects or bone loss occurred with these techniques. No statistical data were available. Merrill and Pederson in 1976 described a technique for interdental segmentalization of singletooth osteotomies.4 They reviewed 65 patients undergoing such procedures, with an age range of 19 to 41 years. Only four patients suffered gingival recession or pocket formation. Burk and coworkers, in 1977, developed a similar two-stage technique for multiple single-tooth osteotomies.5 In their report, five patients were presented. They found blunted papillae and periodontal pocket formation in many cases. These were observations, and no statistical information was available. Theirsen and Guernsey in 1976 reported the postoperative sequelae after anterior segmental osteotomies were performed on 16 patients.6 They offered that the periodontal condition remained unchanged, with only a few cases requiring periodontal recontouring. Sher in 1984 surveyed 135 oral surgeons and reported complications associated with 6,195 segmental osteotomies.’ Only five teeth with periodontal disease and mobility were noted. Duker and Schilli in 1985 analyzed purposeful periodontal damage secondary to osteotomies performed in beagle dogs.* They described various intraoperative violations of the periodontal ligament, cementum, or dentin. They reported ‘favorable repair of the periodontium and dentin even with de-

132 liberate injury. Our study indicated that relatively few clinical periodontal problems occurred in patients receiving total or segmental maxillary osteotomies. The population studied in our investigation had a healthy periodontium. The gingival index revealed a very low level of inflammation in both the nonsurgery and surgery groups. This was further borne out by the low plaque index. This was probably due to the higher level of oral hygiene maintained by private patients who electively sought orthodontic therapy. Tooth mobility was also not a factor in patients with orthodontic or combined orthodontic/surgical therapy. This has been illustrated previously in orthodontic patients by Sadowsky and DeBogle, and Polson and coworkers, who have shown that orthodontic therapy appears to have no long-term effect on the periodontium.12*‘3 Our study verifies that maxillary surgery, whether total or segmental, has no deleterious effects. The most obvious difference between the nonsurgery and surgery group was the additional width of attached gingiva found in the surgery group. The majority of the patients in the surgery group had vertical maxillary excess. Part of the clinical description of this entity includes a greater area of keratinized gingiva. Therefore, we can speculate that the additional width was a characteristic of the population studied and not a result of the surgery. Increases in probing depth and gingival recession were found exclusively in the nonsurgery group. Although these increases were statistically significant, they appear to be clinically insignificant, being 0.3 mm or less. Additionally, the differences in probe depths and attachment level of less than 0.3 mm between the threepiece osteotomies, the two-piece osteotomies, and the nonsegmental counterparts appear clinically insignif-

EFFECTS OF LE FORT OSTEOTOMY ON PERIODONTIUM

icant. Certainly the long-term benefits of satisfactory arch form, proper intercuspation, and correction of skeletal deformity outweigh the minor risk of less than 0.3 mm of increased probe depth or loss of attachment.

References

I. Kent JN, Hinds EC: Management of dental-facial deformities by anterior alveolar surgery. J Oral Surg 29: 13, 197 1 2. Steinhauser EW: Midline splitting of the maxilla for correction of malocclusion. J Oral Surg 30:413, 1972 3. Bell WH, Dann JJ: Correction of dentofacial deformities by surgery in the anterior part of the jaws. Am J Otthod 64:162, 1973 4. Merrill RG, Pederson GW: Interdental osteotomy for immediate repositioning of dental-osseous elements. J Oral Surg 34: 118, 1976 5. Burk JL, Provencher RF, McKean TW: Small segmental and unitooth ostectomies to correct dentoalveolar deformities. J Oral Surg 35:453, 1977 6. The&n FC, Guernsey LH: Postoperative sequelae after anterior segmental osteotomies. Oral Surg Oral Med Oral Path01 41: 139, 1976 7. Sher MR: A survey of complications in segmental orthognathic procedures. Oral Surg Oral Med Oral Path01 58537, 1984 8. Dtiker J, Schilli W: Rapid orthodontics after subtotal osteotomy-Biologic foundation and clinical implications, in Bell WH (ed): Surgical Correction of Dentofacial DeformitiesNew Concepts. Philadelphia, PA, Saunders, 1985 (chap 8) 9. Silness J, Doe H: Periodontal disease in pregnancy. II: Correlation between oral hygiene and periodontal condition. Acta OdontaI Stand 22121, 1964 10. Loe H, Silness J: Periodontal disease in pregnancy. I: Prevalence and severity. Acta Odontal Stand 21:533, 1963 1I. Miller SC: Diagnosis of Periodontal Disease, in Miller SC (ed): Textbook of Periodontics. Philadelphia, PA, Maple Press, 1950 (chap 5) 12. Sadowsky C, DeBogle EA: Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 80: 170, 198 1 13. Poison AM, Sebeiny JD, Meitner SW, et al: Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofacial Orthop I:5 1, 1988