Int. J. Oral Mac~illofac. Surg.

1996; 25:264-267 Copyright © Munksgaard 1996

Printed in Denmark. All rights resen'ed lntcmationalJournal of
Oral&
MaxillofacialSurgery
ISSN 0901-5027

Aesthetic and reconstructive surgery

The stability of maxillary Peter D. Waite 1, Tinerfe d. Tejera 2,

Boonjira AnucuP
1Department of Oral and Maxillofacial Surgery,
University of Alabama School of Dentistry,
advancement using Le Fort l Birmingham, AL, USA; 2Department of Oral
and Maxillofacial Surgery, University of North
Carolina School of Dentistry, Chapel Hill, NC,
USA; 3Department of Surgery, School of
osteotomy with and without Dentistry, Mahidol University, Bangkok,
Thailand

genial bone grafting

P. D. Waite, T. J. Tejera, B. Almctd: Tile stability of ma.rillary advancement ushzg Le
Fort I osteotomy with and without genial bone grafthzg, hit. J. Oral Maxillofac.
Surg. 1996; 25: 264-267. © Munksgaard, 1996

Abstract. The purpose of ihis study was to determine whether better stability is
achieved with genial bone grafts and four-plate rigid fixation for large advancement
Le Fort I osteotomies of the maxilla than with nongrafted osteotomies. We analyzed
radiographic data on 22 patients with obstructive sleep apnea syndrome. All patients
underwent Le Fort I osteotomy for maxillary advancement, I 1 patients without bone
grafts and 11 patients with bone grafts harvested from the mandibular symphyseal
area. Bilateral sagittal split advancement osteotomies and genial tubercle advance-
ments were also performed in all patients. Patients in the genial bone-grafted group
had a mean advancement (surgical change) of 9.7 mm and a mean relapse (postsur-
gical change) of 0.7 mm (7%). Patients who had rigid fixation alone had a mean ad- Key words: sleep apnea syndrome; genial
vancement of 10 mm and a mean relapse of 1.8 mm (18%). It is concluded that the bone grafting; rigid fixation; Le Fort I
osteotomy.
stability with genial bone grafts to the lateral wall of the maxilla with four-plate rigid
fixation was better than in the nongrafted group. Accepted for publication 21 March 1996

One of the problems associated with Maxillary advancement via Le Fort I appears to have a number of advantages.
large advancement of the maxilla (>4 osteotomy (6-10 mm), in combination It eliminates the utilization of other do-
mm) is relapse 1'2. Louis et al. found a with bilateral sagittal split ramus osteo- nor sites, and it gives rise to little mor-
trend toward more relapse with larger tomy to advance the mandible, is a cur- bidity. The genial bone possesses a
maxillary advancement 7. Various surgi- rently accepted surgical treatment for dense cortical plate and can provide ad-
cal modifications, such as extension of obstructive sleep apnea syndrome 1°. ditional immediate stability. At present,
the fixation period, modification of the This patient group differs from the nor- there is no published report evaluating
osteotomy, utilization of miniplates, and mal group of patients undergoing or- and comparing the stability of large
lilac crest bone grafting have been re- thognathic surgery in that they are older maxillary advancements in obstructive
commended to improve maxillary and most patients have both multiple sleep apnea patients with bone grafts
stability 8"9. Bone grafting has been medical problems and chronic hypoxia and rigid fixation 7. The purpose of this
shown to be beneficial in some which may compromise normal healing. study was to compare the stability
studies 8'9"12. It is proposed that bone The amount of maxillary advancement achieved by the utilization of four mini-
grafting can accelerate osseous healing, in this patient group is also usually plates combined with bone grafts at the
act as a physical stop, and provide a ma- greater than that of nonobstructive sleep lateral wall of the maxilla versus four
trix for bone growth 4. There are no well- apnea patients. In large advancements, miniplates alone in patients who under-
controlled studies in which the maxilla there is usually minimal bone contact at went large maxillomandibular advance-
is advanced a large distance with and the lateral wall of the maxilla. ments for treatment of obstructive sleep
without bone grafting. Split thickness genial tubercle bone apnea.
 Genial bone grafthlg h~ maxillary advancements 265

Material and methods the posterior cortex in order to preserve the ment (surgical change) of the position of
profile of the chin. In 11 patients, the anterior these landmarks in the horizontal plane at T2
The patients involved in this study were cortex was reserved for grafting at the lateral and relapse (postsurgical change) at T3 were
evaluated and diagnosed to have obstructive wall of the maxilla at the time of the applica- recorded. From these data, postsurgical
sleep apnea syndrome. All patients under- tion of the miniplates (Fig. 2). The anterior changes from T2 to T3 in both groups
went maxillomandibular advancement via Le cortex, sectioned diagonally into two tri- (relapse) were then calculated and summa-
Fort I osteotomy and bilateral sagittal split angular pieces, was then wedged into the gap rized in Tables 1 and 2. Statistical calculation
advancement osteotomy while the genial between the osteotomy sites and fixed to the was done by a computerized program (Sta-
tubercle was advanced separately as an posterior miniplates at the lateral wall of the tistix Analytical Software). A two-tailed,
adjunctive procedure. No attempt was made maxilla (Fig. 3). Three bicortical position paired t-test at a significant level of P<0.05
to change the vertical position, and no screws, 2.7 mm in diameter, were used for was used to compare the postsurgical
patient had preoperative or postoperative the fixation of each bilateral sagittal split changes from T2 to T3 within each group.
orthodontic treatment. Patients with antici- osteotomy. A series of cephalometric radio- The two-tailed, unpaired t-test was used to
pated restorative needs, such as those who graphs, presurgical (T1) within 1 week, post- compare the postsurgical changes from T2 to
had severe periodontal disease, or who were surgical (T2), and at a minimum postsurgical T3 between the two groups.
partially dentate or edentulous, were not follow-up period of 6 months (T3) was
included, since these conditions might affect obtained for follow-up. The mean follow-up
the position of the upper incisor. Twenty-two period was 10.5 months. All lateral cephalo- Results
patients, 19 men and three women, who met metric radiographs were taken by techni-
these criteria were selected. The age of the cians on the same machine. Cephalometric The mean surgical change as measured
patients ranged from 32 to 54 years with a analysis was conducted by the Quick CephTM on the y-axis by UPI from the sella for
mean age of 43 years. The Le Fort I osteo- software computer program (Orthodontic the bone-grafted group was 0.5_+1.8 mm
tomies were rigidly fixed with four titanium Processing, Chula Vista, CA, USA). The with a relapse (postsurgical change) o f
miniplates. Bilateral fixation of the maxilla position and the orientation of the maxilla in
0.1_+0.8 mm. The non-bone-grafted
was achieved by using prebent OSA plates the horizontal plane at TI, T2, and T3 were
(Walter Lorenz Corporation, Jacksonville, recorded. The landmarks used for the refer- group had a mean surgical change of
FL, USA) placed on each side of the piriform ence points were the incisal edge of the 0.6_+1.2 m m and a mean relapse (post-
rim and standard L-shaped Wiirzburg plates upper incisor (UPI), the anterior nasal spine surgical change) of 0.4+1.0 mm. Verti-
(Walter Lorenz Corporation) on each side of (ANS), the A-point (APT), and the posterior cal relapse was not significant.
the zygomatic buttress (Fig. 1). The genial nasal spine (PNS). All points were identified The mean advancement, as measured
tubercles were advanced and rotated 90 °. as reliable indicators of maxiUary position 2. on the x-axis by UPI from the sella, for
The anterior cortex was routinely split from With TI as a reference position, advance-
the bone-grafted group was 9.7_+3.3 m m
with a relapse of 0.7_+0.6 m m (Table 1).
The non-bone-grafted group had a
mean advancement of 10-+3.2 m m and a
relapse of 1.8_+1.7 mm (Table 2). The
mean relapse at UPI was 7% for the
bone-grafted group, whereas the n o n -

1 /

I
/

Fig. 2. Bone harvest site after outer cortex

Fig. 1. Diagrammatic drawing of genial tubercle advancement and placement of bone graft at has been removed and genial tubercle ad-
lateral wall of maxilla. vancement completed.
266 W a i t e et al.

bone-grafted group had a greater relapse

value of 18%.
By using TI as a reference position,
the postsurgical changes of the position
of the maxilla at T2 and T3 were com-
pared within each group with a two-
tailed, paired t-test. Significant relapses
were demonstrated in both methods of
treatment. There were significant
changes of maxillary position between
T2 and T3 at UPI (P<0.0044), ANS
(P<0.0025), APT (P<0.007), and PNS
reference points (P<0.004) within the
bone-grafted rigid fixation group. The
patient group with rigid fixation alone
had significant changes of maxillary po-
sition between T2 and T3 at UPI
(P<0.0054), ANS (P<0.0031), APT
(P<0.0031), and PNS reference points
(P<0.0021).
Fig. 3. Genial bone graft at lateral wall of maxilla rigidly fixed by L-shaped miniplate and
Relapse was evident in all the pa-
bone screws.
tients except 2/11 patients in the bone-
grafted group (patients I and 2). A two-
Table 1. Maxillary advancement and relapse of bone-graft group, as measured (in mm) at UPI, tailed, unpaired t-test was used to com-
ANS, APT, and PNS pare the amount of relapse between
UPI ANS APT PNS groups. There was a statistical differ-
Patient Adv. Rel. Adv. Rel. Adv. Rel. Adv. Rel. ence between the amount of relapse of
the bone-grafted group and the n o n -
1 5.1 0 6.4 0.5 3.5 0.3 3.4 0.2
bone-grafted group at all reference
2 5.3 0.5 7.4 0.2 5 0 7.5 0. I
points. The patients in the group with
3 6.5 0.1 7.4 0.3 5.9 0.1 6.1 0.2
rigid fixation alone demonstrated more
4 9.0 0.2 5.3 0.1 8.8 0 9.8 1.1
relapse than the group that had addi-
5 9.1 0.7 12.2 0.8 12.3 0.6 9.0 1.1
tional bone grafts when measuring at
6 9.5 0.4 12.5 0.2 11.I 0.7 10.7 0.1
UPI (P<0.0016), ANS (P<0.0014), APT
7 9.6 0.3 I 1.2 0.9 9.6 0.4 8.7 0.1
(P<0.0389), and PNS reference points
8 11.1 !.5 10.1 0.8 12.7 1.8 10.0 1.1
(P<0.0080).
9 12.4 0.8 13.6 0.9 11.9 1.2 10.1 0.8
10 13.8 2.0 16.1 0.6 14.7 2.4 10.8 2
11 15.5 1.0 15.3 2.1 13.4 1.5 14.1 1.6 Discussion
Mean 9.7 0.7 10.7 0.7 9.9 0.8 9.1 0.7 The role of bone grafting in large maxil-
SD 3.3 0.6 3.7 0.6 3.7 0.8 2.8 0.7 lary advancements remains somewhat
questionable, although ARAUJO et al),
HORSTER5, and LUYK & X,VARD-BooTlls
Table 2. Maxillary advancement and relapse of non-bone-graft group, as measured (in mm) at
UPI, ANS, APT, and PNS reported that bone grafting was benefi-
cial. WILLMAR13, however, did not find
UPI ANS APT PNS
statistical significance when comparing
Patient Adv. Rel. Adv. Rel. Adv. Rel. Adv. Rel. grafted and nongrafted groups of the
1 4.0 0.3 7.6 0.5 5.6 0.7 3.8 0.3 patients.
2 6.8 0.1 7.8 0.3 5.6 0.2 4.6 0.4 Large advancement of the maxilla
3 7.4 0. I 11.1 0.9 8.2 0.7 7.9 0.8 (>4 mm) usually leaves a bone gap at
4 8.6 1.2 11 1.4 7.3 1 8.4 1.2 the lateral wall of the maxillary sinus.
5 9.6 2 11 2.4 7.3 1.8 11.3 3.2 The buccal soft tissue subsequently may
6 9.7 0.4 5.6 0.8 7.0 0.9 8.6 0.5 herniate into the bone gap, thereby com-
7 10.6 2.8 13.1 3.6 12.9 3.1 10.1 3.0 promising the bony union and poten-
8 11.8 4.8 17.3 4.0 11.5 4.1 14.1 4.5 tially decreasing the stability. In our ex-
9 12.1 1.1 12.0 1.0 10.8 1.2 11.2 1.1 perience of large advancements of the
I0 13.8 1.4 8.8 0.7 14 0.6 12.3 10.8 maxilla with only rigid fixation, non-
11 15.2 5.1 16.1 4.8 14.8 4.2 13.7 3.9 union occurred, resulting in malocclu-
sion and relapse. Patients also com-
glean 10.0 1.8 11 1.9 9.5 1.7 9.6 1.9
plained of sinus pain and dysfunction.
SD 3.2 1.7 3.6 1.6 3.4 1.4 3.4 1.5
When these patients were reoperated, fi-
 Genial bone grafthlg bz maxillary advancements 267

brous tissue ingrowth into the maxillary recommend that bone grafting and four- grafts. J Maxillofac Surg 1985: 13: 250-
sinus was noted, and no evidence of plate rigid fixation be routinely done for 3.
bony union of the osteotomy sites was large advancements of the maxilla by Le 9. OBWEGESERHL. Surgical correction of
small or retrodisplaced maxillae. The
seen. In general, the utilization of auto- Fort I osteotomy. "dish-face" deformity. Plast Reconstr
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erate bony union ~. I0. X,VAITEPD, WOOTENV, LACHNERJ, GuY-
The advantage of the genial bone graft References ETrE RF. MaxiIIomandibular advance-
is that this bone is harvested from an in- 1. ARAUJOA, SCHENDELSA, WOLFORDLM, ment surgery in 23 patients with ob-
traoral site. There is no need for a second EPr~ BN. Total maxillary advancement structive sleep apnea syndrome. J Oral
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Surg 1978: 36: 849-58.
tibial bone harvesting, a fact which im- stability following down graft and/or ad-
2. CARLO'VI'AE
I Jr, SCHENDELSA. An anal=
plies less morbidity6. The genial bone ysis of factors influencing stability of vancement procedures with stabiliza-
graft has a property of cortical bone surgical advancement of the maxilla by tion using rigid fixation and porous
which can provide an immediate physi- the Le Fort I osteotomy. J Oral Maxillo- block hydroxylapatite implants. J Oral
cal stop. It will function as a space main- fac Surg 1987: 45: 924-8. Maxillofac Surg 1984: 47: 336-42.
3. CttAMPYM. Surgical treatment of mid- 12. WELCHTB. Stability in the correction of
tainer and a matrix for ossification.
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Therefore, the graft may improve long- sive review. J Oral Maxillofac Surg
cialties Head Neck 1980: 2: 451-65.
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may be of benefit since only the first 3 24. follow-up study of 106 operated patients
months of initial stability are provided 5. HORSTERW. Experience with function- with maxillo-facial deformity. Scand J
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plants in combination with rigid fixation term skeletal stability following rigid Peter D. Waite, MPH, DDS, MD
fixation of Le .Fort I osteotomies with Department of Oral and Marillofacial
was not a guaranteed method of provid-
advancements. Int J Oral MaxiIlofac Surgery
ing long-term stability for maxillary Surg 1993: 22: 82-86. University of Alabama School of Dentistry
down grafts and advancements. 8. LUYKNH, WARD-BooTHRE The stabil- 1919 - 7th Avenue
On the basis of this clinical experi- ity of Le Fort I advancement osteo- South Birmingham, AL 35294
ence and the results of this study, we tomies using bone plates without bone USA