Anterior open bite correction by Le Fort I osteotomy

with or without anterior segmentation: which is

more stable?
(Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2017.02.1275)

FAISAL
PPDGS BEDAH MULUT DAN MAKSILOFASIAL
FAKULTAS KEDOKTERAN GIGI, UNIVERSITAS HASANUDDIN
Abstract
• A retrospective cohort study was conducted to analyze the relapse rate of
anterior open bite (AOB) correction comparing Le Fort I osteotomy with
and without anterior segmentation.
Abstract
• Lateral cephalograms obtained at six different times were analyzed. A total
of 81 patients with AOB were recruited.
Anterior open bite (AOB) correction patients
(Sample)
with anterior
segmentation (46
Le Fort I patients)
osteotomy
(81 patients) without anterior
segmentation (35
patients)
Independent • Le Fort I osteotomy with or
without anterior segmentation
variable
Dependent • Anterior open bite correction

Variable
 Materials and methods
• This was a retrospective study of patients with AOB treated by orthognathic
surgery
 Inclusion criteria
• Age 18 years and above
• Medically fit
• Presenting an anterior open bite (i.e., lack of vertical contact between the
incisors)
• Treated by bimaxillary orthognathic surgery, and
• At least 24 months of postoperative follow-up
 Exclusion criteria
• Patients who underwent single-jaw surgery,
• Had under-gone previous orthognathic surgery,
• Had pathological lesions in the oral and maxillofacial region such as fibrous
dysplasia and condylar resorption
• or who had syndromic diseases affecting the craniofacial region such as cleft
lip and palate
 Materials and methods
Patients in Group A
had a Le Fort I osteotomy without
anterior segmentation (i.e., in one
piece or two pieces with a midline
split)
Eligible patients were divided into
two groups depending on the
maxillary procedure they received Patients in Group B
had a Le Fort I osteotomy with
anterior segmentation (i.e., in four
pieces where the midline split is
followed by segmentation behind
the canines)
 Materials and methods
• The mandibular surgeries that the patients received were recorded. All
patients underwent pre-surgical and post-surgical orthodontic treatment.
 Surgical procedures

• A mucosal incision was made 5 mm above the attached gingiva from the
zygomatic buttress on one side to the other.
• A mucoperiosteal flap was raised to expose the lateral wall of the maxilla to
the infraorbital foramen superiorly, the piriform aperture, and the
pterygomaxillary fissure posteriorly.
• A retractor was placed to engage the pterygomaxillary fissure.
• The mucoperiosteum from the lateral nasal wall to the inferior turbinate
bone was raised and protected.
 Surgical procedures
• An osteotomy was performed along the lateral wall of the maxilla with a bur
and completed with an osteotome to reach the pterygoid process.
• A lateral nasal osteotomy was performed. The mucoperiosteum along the
nasal floor and lateroinferior surface was raised and the nasal septum
osteoto-mized.
• A posterior osteotomy was made through the tuberosity at the site of the
extraction sockets of the upper third molars or distal to the last molars.
• The maxilla was then down-fractured and mobilized.
 Surgical procedures
• For group A (without anterior segmen-tation), the maxilla was fitted into the
wafer in one piece, or was segmented at the midline into two pieces.
 Surgical procedures
• For group B (with anterior segmentation), a midline split followed by
osteotomies be-hind the canines (through extraction sockets of the first
premolars or spaces created orthodontically distal to the canines) were
performed to create a Le Fort I in four pieces. The segments were mobilized
to establish the occlusion with a surgical guide and a custom made arch bar.
Four titanium miniplates with 6 mm screws on each side were used for
fixation at the piriform rims and zygomatic buttresses on each side.
 Le Fort I osteotomy
• Without anterior segmentation • With anterior segmentation
 Study variables and data collection
• Standardized lateral cephalometric radiographs were taken pre-surgery (T1)
• Immediately postoperative (T2),
• Postoperatively at 7 weeks (T3)
• 6 months (T4)
• 12 months (T5)
• and 24 months (T6)
 Study variables and data collection
• Cephalometric tracings were performed on acetate paper by one examiner.
• The cephalometric tracings from the same patient at the different follow-up time points
were superimposed at the cranial base.
• Landmarks for tracing included sella (S), nasion (N), posterior nasal spine (PNS), anterior
nasal spine (ANS), incisal edge of the upper incisor (U1), upper incisor root apex (U1-A),
tip of the mesial cusp of the last fully erupted upper molar (UM) and lower molar (LM),
incisor edge of the lower incisor (L1), and root apex of the lower incisor (L1-A). A
reference frame was constructed using the SN line, x-axis, and y-axis for measurement of
the surgical movement and post-surgical changes.
 Study variables and data collection
• The anterior maxilla was represented by the ANS and U1, while the posterior
maxilla was represented by the PNS and UM. The occlusal plane (OP) was
made by joining a line from U1 to UM, and the upper incisor angle (UIA)
was made by a line joining the upper incisor edge (U1) to the root apex of
the upper central incisors. Overbite was measured as the vertical distance
between the incisal edges of the upper and lower incisors projected
perpendicular to the x-axis.
Skeletal and dental landmarks used in the
cephalometric analysis.
 Outcome measures

• The primary outcome of this study was the AOB relapse rate at different
follow-up time points. The secondary outcomes were the risk factors
contributing to the relapse of AOB based on surgical move-ments (T2 T1)
of the anterior maxilla (ANS), the posterior maxilla (PNS), the maxillary
occlusal plane (OP), and the upper incisor angulation, and also based on the
mandibular procedures.
 Statistical analyses

• All data were gathered and entered into statistical software (IBM SPSS Statistics version 23.0; IBM Corp., Armonk, NY,
USA)
• The intra-observer variations were analyzed using the paired t-test.
• Descriptive statistics, including frequencies, means and standard deviations (SD), were used to describe the demographic
data of the samples and the preoperative cephalo-metric features for both groups.
• The mean overbite was obtained at the different postoperative time points for each group.
• The proportions of patients who showed relapse at the different postoperative times in each group were compared using
the x2 test.
• Risk factors such as preoperative overbite, surgical changes at the anterior maxilla (ANS, U1), posterior maxilla (PNS, UM),
upper incisal angle (UIA), and the occlusal plane (OP), and the man-dibular procedures used were also tested with regard to
the relapse rate using the x2 test.
 Results
• A total of 81 patients (22 male, 59 female) with AOB were treated by bimaxillary
orthognathic surgery.
• The mean age of the patients was 24.3 years (SD 6.0 years).
• Thirty-five patients (43.2%) who had a Le Fort I osteotomy without anterior segmentation
for the maxillary procedure formed group A; 13 of these patients (37.1%) had a midline
split for sagittal plane segmentation.
• Group B con-sisted of 46 patients (56.8%) who had a Le Fort I osteotomy with anterior
segmenta-tion for the maxillary procedure.
•
 Discussion
• The key findings of this study comparing the relapse rates of AOB in Le Fort I
osteotomy were the following: (1) an over-all relapse rate of 8.6% at 7 weeks, 9.9%
at 6 months, 7.4% at 12 months, and 12.3% at 24 months postoperative; (2) Le Fort
I osteotomy with anterior segmentation had significantly more AOB relapse when
compared to those without anterior seg-mentation at 7 weeks postoperative (15.2%
vs. 0%, P = 0.016); (3) in the short-term (7 weeks postoperative), Le Fort I
osteotomy with anterior segmenta-tion had significantly more AOB relapse when
the AOB closure was 4 mm and when the anterior maxilla was positioned inferiorly
>2 mm; and (4) in the long term (2 years postoperative), AOB closure 4 mm and
IVRO as the mandibular pro-cedure were the factors identified as caus-ing more
AOB relapse following Le Fort I osteotomy with anterior segmentation.
 Discussion
• The challenges faced by clinicians in the treatment of AOB can be attributed
to the complexity of the deformity such deformities have multiple
aetiologies with various combinations of skeletal, dental, soft tissue, and
habitual components
 Conclusion
• Le Fort I osteotomy without anterior segmentation was found to be more
stable for the surgical correction of anterior open bite when compared to the
Le Fort I osteotomy with anterior segmentation. The relapse of anterior
open bite in Le Fort I osteotomies with anterior segmentation was
significantly higher during the early postoperative period (7 weeks) and again
during the late postoperative period (2 years). Anterior open bite closure 4
mm, inferior positioning of the anterior segment >2 mm, and IVRO as the
mandibular procedure were found to be risk factors for AOB relapse in
patients undergoing Le Fort I osteotomy with an-terior segmentation.
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