Prospective study of the incidence of serious posterior maxillary haemorrhage during a tuberosity osteotomy in low level Le Fort I operations

Radiological Analysis of Maxillary Artery Relationships to Key Bony Landmarks in Maxillofacial Surgery

The maxillary artery (MA) is a key structure at risk of injury in numerous oral and maxillofacial surgical (OMS) procedures. Knowledge of safe distances from this vessel to surgically familiar bony landmarks could improve patient safety and prevent catastrophic haemorrhage. Distances between the MA and bony landmarks on the maxilla and mandible were measured using CT angiograms on 100 patients (200 facial halves). The vertical height of the pterygomaxillary junction (PMJ) was mean (SD) measurement of 16 (3) mm. The MA enters the pterygomaxillary fissure (PMF) a mean (SD) distance of 29 (3) mm from the most inferior point of the PMJ. The mean (SD) shortest distance between the MA and medial surface of the mandible was 2 (2) mm (with the vessel directly contacting the mandible in 17% of cases). The branchpoint (bifurcation of the superficial temporal artery (STA) and MA) was directly in contact with the mandible in 5% of cases. The mean (SD) distances between this bifurcation point and the medial pole of the condyle were 20 (5) mm and 22 (5) mm, respectively. A horizontal plane through the sigmoid notch perpendicular to the posterior border of the mandible is a good approximation of the trajectory of the MA. The branchpoint is usually within 5 mm of this line and inferior in 70% of cases. Surgeons should take note that both the branchpoint and the MA contact the surface of the mandible in a significant number of cases.

Linear and angular measurement using cone-beam computed tomography to enhance safety in Le Fort I osteotomy with tuberosity cut

OBJECTIVE

The study aimed to evaluate surgical angles for tuberosity cut and linear and angular measurements for all horizontal cuts in Le Fort I osteotomy using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

This study included 189 CBCT scans to assess the surgical angles on 3 different sites distal to maxillary second molars relative to the midsagittal plane (MSP) and the buccal cortical plane (BCP) in relation to the descending palatine foramen for tuberosity cut. The linear and angular measurements for all horizontal cuts in Le Fort I osteotomy were also evaluated.

RESULTS

The mean surgical angles for tuberosity cut varied from 58.90 to 95.28° and 74.85 to 100.93° according to the MSP and the BCP, respectively. For the horizontal cuts, mean lengths (angles) for posterior buccal and lateral nasal wall osteotomies were 27.44 mm (13.62°) and 33.20 mm (9.60°), respectively, and a mean length of 47.12 mm was measured for nasal septum osteotomy. Additionally, the presence of impacted third molar resulted in significantly higher mean surgical angles than those with fully erupted or without third molars (p < 0.01).

CONCLUSIONS

Overall, angles running through the buccal midpoint of the third molars relative to the MSP (76.56°) or the BCP (92.31°) might be the most appropriate in clinical practice. Furthermore, some caution seems warranted when performing tuberosity cuts with the impacted third molars.

CLINICAL RELEVANCE

To avoid potential damage to the descending palatine artery for tuberosity cut in Le Fort I osteotomy.

Aberrations in Maxillary Anatomy of Adult Patients with Cleft Maxillary Hypoplasia: A Computed Tomographic Study

Aim

The aim of this study was to evaluate the maxillary anatomy in patients with cleft maxillary hypoplasia using computed tomogram.

Materials and Methods

A cross-sectional observational study was carried out in all cleft patients reporting to our department for the correction of secondary cleft deformities. A preoperative computed tomogram of the midface (from the superior orbital rim to the maxillary occlusal plane) was recorded to assess the parameters which evaluate the maxillary and pterygomaxillary anatomy in cleft maxillary hypoplasia patients.

Results

A total of 18 adult patients (female-5; male-13) were included in the study, which includes 15 unilateral and 3 bilateral cleft lip and palate patients. All the patients had undergone palatoplasty in their early childhood. Evaluation of the circum maxillary and pterygo-maxillary anatomy on the computed tomogram revealed that the average width of maxillary tuberosity was (mean-6.91 mm on cleft side, 4.51 mm on noncleft side); distance between medial and lateral pterygoid plates was (mean-6.45 mm on cleft side, 5.94 mm on noncleft side); distance from greater palatine foramen to posterior palatal border was (mean-5.6 mm on cleft side, 6.1 mm on noncleft side); distance from greater palatine foramen to pterygoid process was (mean-4.83 mm on cleft side, 5.6 mm on noncleft side); distance from pyriform rim to greater palatine foramen was (mean-30.0 mm on cleft side, 31.8 mm on noncleft side); inter pterygoid distance between medial pterygoid plates at the level of pterygoidhamulus was (mean-3.3 cms = 33 mm); inter pterygoid distance between medial pterygoid plates at skull base was (mean-3.0 = 30 mm).

Conclusion

Maxillary hypoplasia in adult cleft patients distorts the circum maxillary and pterygomaxillary anatomy with cleft side being more hypoplastic compared to the noncleft side which needs to be evaluated prior to planning maxillary advancement.

Delayed Epistaxis which Was Developed after Orthognathic Surgery with Le Fort I Osteotomy and Managed by Endoscopic Cauterization

A case of delayed epistaxis from the mucosa behind the right side of the inferior nasal mucosa 11 days after orthognathic surgery by Le Fort I osteotomy is presented. The patient was a 31-year-old man who underwent orthognathic surgery under general anesthesia. No abnormal findings were found during or after the operation. The patient was discharged from the hospital 10 days postoperatively. However, bleeding from the right nasal cavity occurred suddenly on the night after discharge, and he presented to our hospital again. The epistaxis was stopped once by nasal packing containing 0.001% epinephrine and systemic infusion of carbazochrome sulfonic acid and tranexamic acid. However, when the nasal packing was removed the next day, right nasal epistaxis was observed again. Curvature of the nasal septum and thickening of the inferior turbinate mucosa were seen on inspection; although, no active bleeding point was identified. Decreased nasal mucosa thickening and bleeding were observed after nasal packing containing 0.02% epinephrine. When the inside of the nasal cavity was observed endoscopically, an approximately 2 mm laceration was found in the mucosa behind the side wall of the right inferior nasal mucosa, and bleeding from the same part was confirmed. After endoscopic cauterization for hemostasis of the nasal mucosa, no rebleeding was observed. Although delayed epistaxis after Le Fort I osteotomy are often performed CT angiography to confirm the bleeding site, endoscopic cauterization would be primarily useful because of less invasiveness.

Surgical procedures for correcting vertical maxillary excess: A review

INTRODUCTION

Vertical maxillary excess, a common orthodontic problem that leads to long faces and open bites, can be repositioned with a Le Fort I osteotomy. However, the Le Fort I osteotomy poses the risk of a variety of complications including descending palatine artery (DPA) injury. Although several Le Fort I osteotomy modifications were reported to avoid complications associated with this osteotomy, only a few of such studies were conducted in Japan, and details remain scarce.

PATIENTS AND METHODS

We performed a literature review regarding modifications of Le Fort I osteotomies, including Le Fort I with a horseshoe osteotomy, modified horseshoe osteotomy, unilateral horseshoe osteotomy, pyramidal osteotomy, and U-shaped osteotomy. We identified eight relevant studies conducted in Japan; one study did not provide the number of patients examined. The 77 patients (seven studies) with vertical maxillary excess who underwent orthognathic surgery were ≥17 years old.

DISCUSSION

There were no severe complications after the modified Le Fort I osteotomies. The postoperative maxillary changes obtained by the conventional horseshoe, modified horseshoe, unilateral type of horseshoe, pyramidal, and U-shaped osteotomies were nearly repositioned to the planned position and remained stable for ≥12 months post-surgery.

CONCLUSION

Our review indicates that preserving the DPA can lower the incidence of intra- and post-operative complications. Each modification of the Le Fort I osteotomy (i.e., conventional horseshoe, modified horseshoe, unilateral horseshoe, pyramidal, and U-shaped osteotomy) has its respective advantages and indications.

Vascular Complications in Le Fort I Osteotomy: Incidence, Reasons, and Management of the Intraoperative Hemorrhage

PURPOSE

The aim of this study was to investigate the incidence, types, and reasons for the intraoperative hemorrhage during Le Fort I osteotomy.

METHODS

The study sample was composed of the population of the patients who underwent orthognathic surgery from April 2011 to February 2017. The vascular complications of the patients who underwent Le Fort I osteotomy during the surgery were identified. Type of the bleeding, suspected vessel, amount of the intraoperative blood loss, cause, and management of the bleeding were specified and investigated. Descriptive statistics were computed for each study variable.

RESULTS

A total of 200 patients underwent Le Fort I osteotomy. The sample's mean age was 22.4 ± 5.8 and 55.5% of patients were female. The intraoperative vascular complication was seen in only 10 (5%) samples. The suspected source of the hemorrhage was the descending palatine artery (DPA) in 8 (4%) cases, while the pterygoid venous plexus in the other 2 (1%) cases. The cause of the bleeding was suspected down-fracture in 8 cases, while pterygomaxillary junction (PMJ) separation in the other 2 cases. DPA was ligated with ligation clips and cauterized in arterial injury cases. The hemorrhage was taken under control using a hemostatic matrix with thrombin (Surgiflo, Ethicon, USA) in the venous bleeding cases.

CONCLUSIONS

The down-fracture of the maxilla was found to be more related to the occurrence of vascular complications. Severe bleeding was managed by the use of the hemostatic matrix with thrombin and this hemostatic agent can be used to control this type bleedings in orthognathic surgery.

Complications or rather side effects? Quantification of patient satisfaction and complications after orthognathic surgery-a retrospective, cross-sectional long-term analysis

OBJECTIVES

The aim of this clinical analysis was to evaluate intraoperative and early postoperative complications as well as late findings and the overall patient satisfaction following orthognathic surgery.

MATERIALS AND METHODS

In a retrospective, cross-sectional study, 119 patients after orthognathic surgery were included. Surgical approaches were single bilateral sagittal split osteotomy (BSSO (n = 52)), single LeFort-I osteotomy (n = 5) and bimaxillary osteotomy (LeFort-I + BSSO (n = 62)). Intraoperative and early (0-4 weeks postoperative) complications were investigated retrospectively (n = 119), whereas late findings and quality of life were assessed via clinical follow-up and survey (mean: 59 months postoperative) on 48 patients.

RESULTS

Bad split (n = 4/114) was the most common intraoperative complication followed by one case of severe bleeding. Regarding early postoperative complications, temporary damage of the inferior alveolar nerve after BSSO was most common (n = 33/114), followed by facial nerve dysfunction (n = 3), failed osteosynthesis (n = 2) and one case of postoperative dyspnoea. Permanent hypaesthesia of the lower lip was the most prevalent (n = 28/45^{(BSSO and LeFort-I + BSSO)}) late finding with varying extent, followed by temporomandibular dysfunction (TMD) (n = 25/48). Skeletal relapse mostly occurred after class II treatment, followed by class III, posterior crossbite and open bite. Overall, the surgery improved the patients' self-perception (85.4%), with 60.4% of patients opting for surgery again.

CONCLUSIONS

Long-term complications after orthognathic surgery occurred more frequently than commonly described in the literature, and analyses of the quality of life show the need for more comprehensive preoperative patient education.

CLINICAL RELEVANCE

Hypaesthesia of the lower lip presented less as complication but rather as side effect following BSSO. As orthognathic surgery is mostly elective, preoperative patient education is of pivotal importance and should include proactive risk stratification.

Morphometric analysis of pterygomaxillary region by using cone beam computed tomography

PURPOSE

Many complications during Le Fort I osteotomy are encountered during pterygomaxillary separation. The study aimed to evaluate the pterygomaxillary region in regards to the Le Fort I osteotomy using cone-beam computed tomography (CBCT) images.

MATERIALS AND METHODS

The CBCT images of 200 patients (100 males, 100 females) aged 18-78 years were evaluated measuring the thickness and width of the pterygomaxillary region, the location of the descending palatine artery, and the length of the pterygoid plates on the axial section.

RESULTS

It has been determined that the distance between the descending palatine canal and the priform rim is longer in males (P=0.037). Medial plate was longer on the right (P=0.0001) and left (P=0.025) in females. The thickness of the pterygomaxillary region was longer in females (P=0.000). The distance between the pterygomaxillary fissure and the descending palatine canal was longer on the right (P=0.001).

CONCLUSION

The pterygomaxillary region may have different anatomies that predispose to specific complications associated with Le Fort I osteotomy. Therefore, before surgery, the pterygomaxillary region should be examined with CBCT, and necessary precautions should be taken preoperatively considering the possible complications.

Pyramidal and posterior osseous release for maxillary superior/posterior mobilization using an ultrasonic bone-cutting device after Le Fort I osteotomy

AIM

The purpose of this study was to evaluate the efficiency of pyramidal and posterior osseous release (PPOR) for maxillary impaction using an ultrasonic bone-cutting device after Le Fort I (LFI) osteotomy.

MATERIALS AND METHODS

In total, 31 Japanese adults with jaw deformities, diagnosed as having maxillary excess with mandibular prognathism or deficiency, underwent LFI osteotomy and bilateral sagittal split osteotomy. The patients were divided into two groups: a trimming group (15 patients, four men and 11 women; mean age 24.8 years) and a PPOR group (16 patients, seven men and nine women; mean age 22.8 years). In the trimming group, osseous interference around the descending palatine artery (DPA) was removed using forceps, rounding bur, and reciprocating rasp. The PPOR technique was used to remove osseous fragments created by V-shaped osteotomy around the DPA following vertical osteotomy behind the DPA using an ultrasonic bone-cutting device (Variosurg 3; NSK, Tochigi, Japan). The operative times for maxillary osteotomy, total operative times (including bilateral sagittal split osteotomy), and total blood loss were assessed.

RESULTS

The mean planned amounts of maxillary impaction were 4.37 ± 1.27 mm in the trimming group and 4.38 ± 1.36 mm in the PPOR group (p = 0.98). The mean maxillary operative time for the PPOR group was significantly shorter, by 25.5% (p < 0.001). Total operative time for the PPOR group was also significantly shorter, by 24.3% (p < 0.001). Mean blood loss was significantly lower in the PPOR group than in the trimming group (p = 0.003).

CONCLUSION

The PPOR technique for maxillary impaction after LFI osteotomy shortened the operative time and enabled secure reduction of the maxilla in patients who required the treatment of maxillary impaction with preservation of the DPA bundle.

Prognostic factors for maxillary sinus mucosal thickening following Le Fort I osteotomy: a retrospective analysis

Background

Le Fort I osteotomy is one of the surgical procedures now routinely and safely performed. It is possible to move the maxilla in three dimensions, but it is necessary to separate the bones around the maxillary sinus. Therefore, with surgery, maxillary sinus mucosal thickening occurs. By knowing the changes in the sinus mucosa after surgery and the factors affecting it, it is possible to better predict the outcomes of surgery and contribute to safer surgery. In this study, thickening of maxillary sinus mucosa before and after surgery in Le Fort I osteotomy was evaluated using multidetector-row computed tomography (MDCT) images, and the changes in mucosal thickening and the related factors were examined.

Methods

Using MDCT images, the maxillary sinus mucosa of 125 patients who had undergone Le Fort I osteotomy was retrospectively evaluated before surgery, 1 month after surgery, and 1 year after surgery. On the MDCT images, the maxillary sinus was judged as mucosal thickening and classified into three grades according to the proportion occupying the maxillary sinus. In the evaluation of factors related to mucosal thickening, the following eight factors were examined: sex, age, diagnosis, operating time, amount of postoperative bleeding, with/without bone graft, with/without multisegmental osteotomy, and with/without macrolide therapy after surgery.

Results

The mean age at the time of surgery was 25.6 ± 8 years. Of all 125 patients, 66 had bilateral thickening, 19 had unilateral thickening, and 40 had no thickening. Factors that were significantly related to mucosal thickening were the operative time for the maxilla, bone grafts, and macrolide therapy after surgery.

Conclusions

Operative time for the maxilla, bone grafts, and macrolide therapy after surgery were found to be related to mucosal thickening. In addition, MDCT scanning 1 month after surgery was considered to be appropriate for evaluation of maxillary sinus mucosal thickening.

Total Maxillary Alveolar Osteotomy: Surgical Technique and Review of Its Efficacy

PURPOSE

The total maxillary alveolar osteotomy (TMxAO) is not commonly used to manage maxillary skeletal deformities. This article describes the technique, reviews its stability, and discusses its advantages over the more popular Le Fort I osteotomy.

MATERIALS AND METHODS

A series of 177 TMxAO patients satisfying the inclusion criteria from a cadre of 234 patients undergoing TMxAO between 1985 and 1993 were evaluated in a retrospective cohort study regarding achievement of predicted anatomic movements, stability of skeletal results, and preservation of inter-alar dimension. The patients were evaluated early postoperatively and at 11 to 14 months postoperatively, and the data were exposed to the Shapiro-Wilk test and analysis of variance and analyzed using SPSS software (version 21; IBM, Armonk, NY) at the 99% level of confidence (P ≤ .01).

RESULTS

Only in 58% of patients did the designed millimetric study model changes correspond precisely to the millimetric changes disclosed in a comparison of preoperative and early postoperative cephalograms. Comparison of early and late postoperative cephalograms, with infrequent exceptions, described millimetric instabilities of less than 2 mm and angular instabilities of less than 2°. Despite 2 significant outliers, the average inter-alar instability as determined by direct measurement was 0.19 mm.

CONCLUSIONS

This study suggests that the TMxAO compares favorably in stability with the Le Fort I osteotomy as recorded in the literature and, in terms of versatility, mobility of segments, avoidance of anatomic hazard, and preservation of nasal width, offers advantages in comparison.

The pterygomaxillary junction: An imaging study for surgical information of LeFort I osteotomy

Maxillary osteotomy is a common surgical procedure and often involves separation of the pterygomaxillary junction (PMJ), which is a “blinded” procedure with inherent risks. Knowledge of the PMJ structure is essential. It remains unclear whether patients with different facial types have different PMJ structures, or different surgical outcome. This study evaluated the computed tomographic images of 283 consecutive patients who received orthognathic surgery. Patients were classified into Angle class I, II, III and cleft lip/palate groups. The results showed that the PMJ was 5.1 ± 1.4 mm in thickness, 9.7 ± 1.7 mm in width, and 102.0 ± 4.0 degrees relative to the sagittal plane in the level of posterior nasal spine. There were no statistically significant differences in these measurements among the groups. The class III group demonstrated significantly smaller angle relative to the maxillary occlusal plane. The cleft group showed significantly longer vertical distance between the posterior nasal spine and the lower border of PMJ, shorter distance between the second molar and PMJ, and longer distance between the descending palatine artery and PMJ. With regard to postoperative outcome, the cleft group showed higher incidence of pterygoid plate fracture. The results in this study provide additional surgical anatomic information.

Is an osteotome necessary for pterygomaxillary dysjunction or dysjunction through the tuberosity during Le Fort I osteotomy? A systematic review

Pterygomaxillary dysjunction with an osteotome is commonly used to mobilise the maxilla during Le Fort I osteotomy, despite the risk of serious complications. Different instruments and positions have been tried, including dysjunction through the tuberosity. Down fracture by digital pressure alone has also been advocated, but to our knowledge has not been widely adopted. We have therefore reviewed published papers to see if there is any clinical or anatomical evidence for the use of osteotomes to mobilise the maxilla vertically during a Le Fort I osteotomy for either pterygomaxillary dysjunction or dysjunction through the tuberosity. We found only one paper that analysed the anatomy of the pterygomaxillary fissure and described small bony bridges and syncondroses across the joint. We found no clinical or anatomical evidence for the use of osteotomes in pterygomaxillary separation or separation through the tuberosity. A large clinical trial on down fracture of the maxilla by digital pressure alone showed no serious complications, and we found no strong evidence to justify the use of osteotomes in pterygomaxillary dysjunction or dysjunction through the tuberosity. We have successfully used digital pressure alone in 138 consecutive Le Fort I osteotomies, and we encourage our colleagues to consider adopting this approach.

Preoperative, intraoperative, and postoperative complications in orthognathic surgery: a systematic review

Objectives

The aim of this study was to determine whether orthognathic surgery is associated with any complications, and what type of complications may occur.

Materials and methods

Data were obtained using PubMed (MEDLINE), ISI Web of Knowledge, Ovid, Cochrane Library, Embase Library, and an additional manual search. The titles and abstracts of the electronic search results were screened and evaluated by two observers for eligibility according to the inclusion and exclusion criteria.

Results

A total of 1924 articles were identified, and we retained 44 articles for the final analysis. The Prisma diagram flowchart demonstrates our selection scheme. For the purpose of this study, the Cochrane data extraction form was modified. One review author extracted data from the included studies, and the second author checked all of the forms. The hierarchy of evidence classification from the UK NHS Centre for Reviews and Dissemination was used to assess the level of evidence for the retrieved studies.

Conclusions

An evaluation of the obtained studies revealed the existence of a large number of varied complications associated with orthognathic surgery procedures.

Clinical relevance

Oral and maxillofacial surgeons, orthodontists, and the surgical team need to prevent such complications during preoperative, intraoperative, and postoperative periods to increase the safety of orthognathic surgery procedures. This review was registered on http://www.crd.york.ac.uk/PROSPERO as CRD42013004711.

Electronic supplementary material

The online version of this article (doi:10.1007/s00784-015-1452-1) contains supplementary material, which is available to authorized users.

Accuracy and reliability of linear measurements using 3-dimensional computed tomographic imaging software for Le Fort I Osteotomy

Our purpose was to compare the accuracy and reliability of linear measurements for Le Fort I osteotomy using volume rendering software. We studied 11 dried skulls and used cone-beam computed tomography (CT) to generate 3-dimensional images. Linear measurements were based on craniometric anatomical landmarks that were predefined as specifically used for Le Fort I osteotomy, and identified twice each by 2 radiologists, independently, using Dolphin imaging version 11.5.04.35. A third examiner then made physical measurements using digital calipers. There was a significant difference between Dolphin imaging and the gold standard, particularly in the pterygoid process. The largest difference was 1.85mm (LLpPtg L). The mean differences between the physical and the 3-dimensional linear measurements ranged from -0.01 to 1.12mm for examiner 1, and 0 to 1.85mm for examiner 2. Interexaminer analysis ranged from 0.51 to 0.93. Intraexaminer correlation coefficients ranged from 0.81 to 0.96 and 0.57 to 0.92, for examiners 1 and 2, respectively. We conclude that the Dolphin imaging should be used sparingly during Le Fort I osteotomy.

Delayed progressive haematoma after Le Fort I osteotomy: A possible severe complication in orthognatic surgery

Although the Le Fort I osteotomy is a safe surgical technique, many complications have been reported. We present a case of an extended cervico-facial haematoma due to delayed bleeding from the terminal branches of the maxillary artery after orthognatic surgery. A 23-year-old man was referred to our observation for the surgical correction of a class III asymmetric malocclusion. The patient underwent a Le Fort I osteotomy, with impaction of the maxilla, associated with an Epker mandibular bilateral sagittal split osteotomy, with maxillary advancement and rigid internal fixation of the mandible with four miniplates and another four for the upper maxilla as well. The first post-surgery day, the patient developed a gradual dispnea together with neck swelling. By second postoperative day, the patient's general condition improved with a progressive normalization of laboratory tests values. The Computerised Axial Tomography (CAT) scan confirmed a decrease in the parapharyngeal thickening. Total recovery was achieved within two months, the final clinical check showed a healthy appearance with good occlusion. An increased knowledge of the basic biology of the Le Fort I osteotomy, the development of instruments specially designed for the Le Fort I procedure and the use of hypotensive anaesthesia could reduce the morbidity and duration of this procedure.

Comparison of precision and accuracy of linear measurements performed by two different imaging software programs and obtained from 3D-CBCT images for Le Fort I osteotomy

OBJECTIVE

The purpose of this study was to compare the precision and accuracy of linear measurements for Le Fort I osteotomy performed by two different imaging software programs and obtained from three-dimensional cone beam CT (3D-CBCT) images.

METHODS

The study population consisted of 11 dried skulls submitted to CBCT, which generated 3D images. Linear measurements were based on craniometric anatomical landmarks pre-defined by the authors as specifically used for Le Fort I osteotomy and were identified by two radiologists twice each, independently, using Vitrea 3.8.1 (Vital Images Inc., Plymouth, MN) and open-source digital imaging communication in medicine viewer OsiriX 1.2 64-bit (Pixmeo, Geneva, Switzerland). Subsequently, a third examiner made physical measurements using a digital caliper (167 series; Mitutoyo Sul Americana Ltd, Suzano, SP, Brazil).

RESULTS

The results demonstrated a statistically significant difference between OsiriX and the gold standard, especially in the pterygoid process (TPtg L = 0.019, LLpPtg R = 0.016 and LLpPtg L = 0.012). Vitrea showed no statistical difference in comparison with the gold standard, and showed a high level of accuracy in all the measurements performed. The major difference found was 0.42 mm (LLpPtg R). Interexaminer analysis ranged from 0.90 to 0.97 using Vitrea and from 0.8 to 0.97 using OsiriX. Intraexaminer correlation coefficient ranged from 0.90 to 0.98 and from 0.84 to 0.98 for Examiners 1 and 2, respectively, using Vitrea and from 0.93 to 0.99 for Examiner 1 and from 0.64 to 0.96 for Examiner 2 using OsiriX.

CONCLUSION

Vitrea may be considered as precise and accurate, insofar as it was able to perform all the 3D linear measurements. On the other hand, linear measurements performed using OsiriX were not successful in producing accurate linear measurements for Le Fort I osteotomy.

Evaluation of Post-operative Complication Rate of Le Fort I Osteotomy: A Retrospective and Prospective Study

Le Fort I osteotomy has become a routine procedure in elective orthognathic surgery. This procedure is often associated with significant but rare post-operative complications. The study was conducted to evaluate the rate of post-operative complications following conventional Le Fort I osteotomy. Twenty-five healthy adult patients who had to undergo Le Fort I osteotomy without segmentalization of maxilla were included in the study based on indications of surgery. All the patients were followed up for a period of 6 months post-operatively to assess the rate of various post-operative complications such as neurosensory deficit, pulpal sensibility, maxillary sinusitis, vascular complications, aseptic necrosis, unfavourable fractures, ophthalmic complications and instability or non-union of maxilla, etc. The results of our study showed a post-operative complications rate of 4 %. Neurosensory deficit and loss of tooth sensibility were the most common findings during patient evaluation at varying follow-up periods while one patient presented with signs and symptoms of maxillary sinusitis post-operatively. Neurosensory as well as sinusitis recovery took place in almost all the patients within 6 months. It was concluded that thorough understanding of pathophysiological aspects of various complications, careful assessment, treatment planning and the use of proper surgical technique as well as instrumentation may help in further reducing the complication rate.

Factors predictive of pterygoid process fractures after pterygomaxillary separation without using an osteotome in Le Fort I osteotomy

OBJECTIVE

This study demonstrated pterygomaxillary disjunction patterns and elucidated factors related to unfavorable pterygomaxillary junction fractures in Le Fort I osteotomy without using an osteotome.

STUDY DESIGN

Clinical and anatomical data obtained from computed tomography images (100 sides) were analyzed for their ability to predict patterns of pterygomaxillary disjunction.

RESULTS

Separation of the pterygomaxillary junction was most frequently performed at the maxillary tuberosity (48.0%). Twenty-eight pterygoid plates were fractured. Male gender, increased age, thickness of the pterygomaxillary junction, and length of the maxillary tuberosity were significant risk factors for pterygoid process fractures. We also identified that a pterygomaxillary junction thickness less than 2.6 mm and a maxillary tuberosity length of more than 11.5 mm indicated a statistically significant risk of pterygoid process fractures.

CONCLUSIONS

Prediction of frangible pterygoid plates by preoperative quantitative evaluation of morphometric values provides useful information for selecting safe procedures.

Epistaxis and hemostatic devices

Epistaxis is a common medical problem that rarely requires surgical intervention. However, when medical or surgical intervention is required, epistaxis can sometimes be difficult to control. Knowledge of nasopharyngeal anatomy is absolutely essential to the proper management of epistaxis. This article begins with a discussion of the essential anatomy of the region and the basic epidemiology of epistaxis, followed by a review of initial treatment as well as devices and procedures specifically designed for the control of epistaxis. Advances and new devices for the control of epistaxis are described.

An arteriovenous fistula of the maxillary artery as a complication of Le Fort I osteotomy

INTRODUCTION

The Le Fort I osteotomy, one of the most common techniques used to correct dento-midfacial deformities, is generally considered to be operatively safe. However, sometimes this procedure can lead to fatal vascular complications.

MATERIALS AND METHODS

This article describes a fifty-year-old woman with a giant facial venous malformation. The patient underwent a Le Fort I osteotomy in order to correct an open bite. The surgery was complicated by the development of an arteriovenous fistula (AVF) between the maxillary artery and the venous malformation, the diagnosis of which was made by ultrasound doppler. Neuroradiological embolisation process of the maxillary artery was performed in order to close the AVF.

RESULTS

The total fistula obliteration and a Class I occlusion were obtained.

CONCLUSIONS

The reported case suggests the necessity of a multidisciplinary process (involving both maxillofacial and neuroradiology teams) for the treatment of dento-midfacial deformities in relation to vascular malformations. This modality is the only way to guarantee minimization of morbidity (according to patient's expectations).

Assessment of pterygomaxillary separation in Le Fort I Osteotomy in class III patients

PURPOSE

To examine the separation of the pterygomaxillary region at the posterior nasal spine level after Le Fort I osteotomy in Class III patients.

PATIENTS AND METHODS

The study group consisted of 37 Japanese patients with mandibular prognathism and asymmetry, with maxillary retrognathism or asymmetry. A total of 74 sides were examined. Le Fort I osteotomy was performed without a pterygoid osteotome, with an ultrasonic curette used to remove interference at the pterygomaxillary region. Postoperative computed tomography (CT) was analyzed for all patients. The separation of the pterygomaxillary region and the location of the descending palatine artery were assessed.

RESULTS

Although acceptable separation between the maxilla and pterygoid plates was achieved in all patients, an exact separation of the pterygomaxillary junction at the posterior nasal spine level was found in only 18 of 74 sides (24%). In 29 of 74 sides (39.2%), the separation occurred anterior to the descending palatine artery. In 29 of 74 sides (39.2%), complete separation between the maxilla and lateral and/or medial pterygoid plate was not achieved, but lower level separation of the maxilla and pterygoid plate was always complete. The maxillary segments could be moved to the postoperative ideal position in all cases.

CONCLUSION

Le Fort I osteotomy without an osteotome does not always induce an exact separation at the pterygomaxillary junction at the posterior nasal spine level, but the ultrasonic bone curette can remove the interference between maxillary segment and pterygoid plates more safely.