U-shaped Osteotomy Around the Descending Palatine Artery to Prevent Posterior Osseous Interference for Superior/Posterior Repositioning of the Maxilla in Le Fort I Osteotomy

Abstract

In maxillary orthognathic surgery, superior repositioning of the maxilla is sometimes difficult, and removal of bony interference, especially around the descending palatine artery (DPA), is very time-consuming in cases of severe maxillary impaction. Posterior repositioning of the maxilla for removal of bony interference between the posterior maxilla and the pterygoid process is also technically difficult. Because the most common site of hemorrhage in Le Fort I osteotomy is the posterior maxilla, this bone removal is a source of frustration for surgeons in DPA injury. When the DPA is injured during bone removal and ligation is performed, aseptic necrosis of the maxilla may occur. Therefore, a simple and safe method for maxillary superior/posterior repositioning is required to remove osseous interference around the DPA. The authors describe here U-shaped osteotomy around the DPA to prevent posterior osseous interference for superior/posterior repositioning of the maxilla in Le Fort I osteotomy.

Surgical procedures for correcting vertical maxillary excess: A review

“… Yoshioka et al [16] 2009 24.77 (18–31) M: 4, F: 15 Modified horseshoe – n.a. 7.6 Yoshioka et al [7] 2011 21 (19–25) M: 1, F: 9 Modified horseshoe – II 5.0 Shimo et al [20] 2013 34 F: 1 Conventional horseshoe – II 5.0 Omura et al [11] 2015 n.a. n.a.…”

“…After a bilateral U-shaped osteotomy, the posterior bone disturbances are removed. In the case of facial asymmetry, repositioning can be easily accomplished with a unilateral U-shaped osteotomy [11] .…”

“…The mean blood loss in the pyramidal osteotomy technique is much less than that in the conventional Le Fort I technique [10] . The risk of intraoperative complications with the U-shape and pyramidal osteotomy techniques is low because: (1) these techniques can be performed safely away from the descending palatine canal, (2) the risk of DPA injury is less than that posed by the conventional Le Fort I method, and (3) these techniques allow safe repositioning for superior and/or posterior movement of the maxilla [10] , [11] .…”

“…The degree of accuracy for repositioning the maxilla with either a conventional horseshoe, a modified horseshoe, or a pyramidal osteotomy was good. Nevertheless, impaction of the nasal base was reported only in cases in which a pyramidal osteotomy or U-shaped osteotomy was used [10] , [11] .…”

“…The pyramidal osteotomy technique is an improved form of the Le Fort I that involves the use of minimally invasive rotating instruments to eliminate bone interference over the DPA through a V-shaped osteotomy [9] , [10] . The U-shaped osteotomy is described as a technique that preserves the DPA to prevent posterior interference for the repositioning of the maxilla in a Le Fort I osteotomy [11] .…”