J Oral Maxillofac Surg

49:1089-1097, 1991

Modifieci
r-y-Zygoma ti
Basis, and
A. OMAR ABUBAKER, DMD, F%D,* AND
GEORGE C. SOTEREANOS, DMD, MS, FACDt

A modified version of the Le Fort I maxillary osteotomy is described. The

esthetic and anatomic basis, the surgical technique, and possible compli-
cations are discussed and two representative cases are shown. This tech-
nique has been used to treat 38 patients with various degrees of combined
maxillary-zygomatic deficiency in the last 3 years. Based on this experi-
ence, it is concluded that this procedure provides a predictable esthetic
result and excellent skeletal stability with few intraoperative and postop-
erative complications. Furthermore, the need for simultaneous bone graft-
ing or alloplastic implants, as in the conventional Le Fort 1, is virtually
eliminated using this osteotomy.

Since Wassmund performed the first maxillary Le Fort I osteotomy with Proplast implant or onlay
Le Fort I osteotomy for correction of skeletal open bone graft have been used.” Although good cos-
bite in 1927,’ several improvements and modifica- metic results were reported, the possibility of infec-
tions have been introduced to achieve better esthet- tion and of displacement and resorption of the graft
ics and more stable results with deficient midface arc potential complications of these procedures.
surgery. ‘-’ However, patients with maxillary- Other factors that have limited the popularity of
zygomatic deficiency combined with class III mal- such procedures are an additional operative site to
occlusion continue to present a special challenge to obtain the bone graft and extraoral incisions.
clinicians treating these deformities. When this con- To achieve correction of maxillary-zygomatic de-
dition is associated with deficient nasal-ethmoidal ficiency and class III skeletal malocclusion in pa-
projection, Le Fort II and Le Fort III osteotomies tients with normal nasal projections, we have
and their various modifications have been used for adopted a modification of the Le Fort I osteotomy
correction.8~‘0 When patients with maxillary- by which correction of these deficiencies is
zygomatic deficiency with class III skeletal maloc- achieved through an intraoral approach without
clusion exhibit a normal nasal-ethmoidal projection, need for bone grafting or alloplastic implants.
a modified Le Fort I osteotomy with bone graft’* or

Received from the Division of Plastic and Maxillofacial Sur-

gery, University of Pittsburgh, PA.
* Formerly Fellow, Oral-Maxillofacial~ Surgery; Currently, Idiopathic midfacial hypoplasia frequently has a
Assistant Professor, Department of Oral and Maxillofacial Sur- nasoethmoidal component, an orbital component, a
gery, Medical College of Virginia, Richmond. maxillary-mandibular disproportion component,
t Associate Professor, Division of Plastic and Maxillofacial
Surgery. and a zygomatico-paranasal deficiency component.
Presented in part at the 71st Annnaf Meeting of the American When the nasofrontal projection and position of the
Association of Oral and Maxihofacial Surgeons in San Francis- globe are normal, the major esthetic components to
co, CA, September 20-24, 1989.
Address correspondence and reprint requests to Dr Sotere- be addressed are the maxillary-mandibular dispro-
anos: Division of Plastic and Maxillofacial Surgery, University portion, the zygomatic bone, and the paranasal
of Pittsburgh, Pittsburgh, PA 15261.
area. Although combination of the Le Ford: I oste-
0 1991 American Association of Oral ahd Maxillofacial Sur- otomy and an augmentation procedure is frquently
geons used to correct these deformities, a more :ideal ap-
0278-239:191/491 Cl-0010$3.00/0 proach would be a one-unit osteotomy designed to
1090 MODIFIED &E FORT OSTEOTCHW

correct the maxillary-mandibular disproportion and the contralatera8 side. The mucoperiosteal flap is
malocclusion, the paranasal area, and the zygo- then reflected in the usual manner, but is extended
matic deficiency. Because the esthetic epicenter of over the zygomatic arch and raised superiorly ex-
the zygomatic bone is located in an area approxi- posing the infraorbital nerve and region. The ante-
mately 2 cm lateral and 1.5 cm inferior to the lateral rior attachment of the masseter muscle is released
canthus,13 the horizontal and posterior extent of from the zygomatic tuber&, exposing the inferior
such osteotomy in the zygoma should be placed and medial aspects of the zygoma. The nasal mu-
posterior and superior to such areas. The anterior coperiosteal reflection is performed along the later-
horizontal component of this osteotomy should also al aspect of the piriform rim and nasal floor, extend-
be placed superiorly enough to include the parana- ing posteriorly and superiorly to the inferior tur-
sal portion of the maxillary bone. This will place the binate. The naso-mucoperiosteum is also reflected
horizontal portion of the osteotomy high in the an- from the nasal floor to expose the maxillary rostrum
terior maxillary bone extending posteriorly through and its attachment to the nasal septum. The carti-
the zygoma to a point just anterior to the zygomat- laginous septum is sectioned by a chisel technique.
ice-temporal sutures and approximately 7 to 10 mm The maxillary osteotomy is then performed with an
from the inferior border of the anterior extent of the oscillating saw bilaterally from the piriform aper-
zygomatic arch. Placement of the superior and pos- ture approximately 10 to 12 mm above the bony
terior extent of the osteotomy at this level not only nasal floor (Pig I). The lateral maxillary osteotomy
will provide an esthetic basis for the osteotomy, but courses posteriorly to just below the infraorbital fo-
also will place the osteotomy in the dense cortical ramen, extending posterolateralky to the zygoma.
bone of the zygoma. This will provide a strong bony The horizontal osteotomy is extended across the
basis for adequate skeletal fixation, which increases maxillary-zygomatic suture toward the temporal
stability and minimizes postoperative relapse of the process of the zygoma for a distance approximately
procedure. Anatomic considerations for such a 18 to 20 mm posterior to the zygomatico-maxillary
modification should include knowledge of the suture line and 7 to 10 mm above the inferior aspect
course and opening of the nasolacrimal duct and the of the zygoma (Fig 2). Prom the distal end of the
infraorbital nerve. l4 horizontal osteotomy, a vertical through-an
through osteotomy is made to the inferior and deep
Surgical Technique aspect of the zygoma (Fig 3). Finally, the maxiha is
separated from the pterygoid process with an os-
Under nasoendotracheal anesthesia, the patient teotome or reciprocating saw. At this point, the
is prepared and draped, preferably with the infraor- maxilla can be downfractured using d&impaction
bital and malar areas left exposed. An intraoral forceps or manual pressure as in standard Le Fort %
maxillary vestibular incision is extended from the osteotomy. The maxilla is freed and mobilized until
fist molar region on one side to a similar area on passive anterior movement into the prefabricated

FIGURE I. Intraoperative
view showing leve1 of osteoto-
my in relation to lateral fiasal
aperture and the anterior max-
illa. Inset, Osteotomy in the
lateral nasal walls and in tbe
zygomatic bone.
ABUBAKER AND SOTEREANOS 1091

FIGURE 2. intraoperative
view and diagram showing su-
perior extent of the osteotomy
in paranasal areas and rela-
tionship of osteotomy to in-
fraorbital foramen and orbital
rim.

interocclusal splint is accomplished. After maxillo- plate or transosseous stamless steel wire fixation
mandibuhar fixation is completed, the cartilaginous (Fig 4). The nasal septum is sutured to a horizontal
nasal septum is exposed and any tear in the nasal hole made through the anterior nasal spine with a
mucosal floor is repaired. The maxillary- 2-O nylon figure-eight suture to keep the nasal sep-
mandibular complex is then moved as one unit su- tum in the midline. Similarly, a nasal cinch suture is
periorly until adequate areas of bony contact are placed to help controQ nasal width. The incision line
achieved. To achieve this, bone often must be re- is closed in two layers to approximate the perioste-
moved, especially from the posterior margin until urn or the attachment of the muscles of faci& ex-
the maxillary-mandibular complex can be passively pression or both. Often the maxillomandibular fix-
seated in the desired vertical position. After proper ation is released after complietion sf the skeletall fix-
seating of the condyles is assured, the maxilla is ation. Recently, with use of rigid fixation, all
stabilized in the achieved position using either bone patients were treated without postoperative maxil-

FIGURE 3. lntraoperative
view and diagram showing
posterior and superior exten-
sion of osteotomy and poste-
rior vertical portion of the os-
teotomy in the aygoma.
1092 MODIFIED EE PORT QSTEQTOMV

FIGURE 4. Intraoperative
view and d&gram qhow,iwg
plate fixation at osdeotomy
site.

lomandibular fixation (MMF) and only training elas-

tics were applied on the second or third postopera-
tive day.
Le Fsrt ILmaxillary osteotomy has long been pre-
ferred f&- correction of class III skeletal dispropor-
Report of Cases tion. When the anteroposterior relationship be-
tween the maxilla and mandible is acceptable skel-
etally and dentally but hypoplasia or deficiency
Case 1
exists in the zygomatic and/or paranasal areas, a
A 27-year-old white woman had class III skeletal mal- bone graft or alloplastic material has been used ex-
occlusion and a pronounced appearance of maxillary de- tensively. Although there is potential for infection
ficiency associated with zygomatic, infraorbital, and and displacement of the graft or implant, good re-
paranasal retrusion. Dentally, she manifested a reverse sults ‘have been reported. When the anteroposterior
overjet of 12 mm (Fig 5).
After completion of the preoperative orthodontics for
disproportion b&ween the maxilla and mandibl? is
leveling and alignment, the patient underwent a modified associated with zygomatic and paranasal defi-
Le Fort I maxillary-zygomatic osteotomy and advance- ciency, hbwever, and the chosen treatment is a si-
ment of 7 mm as previously described. Concomitantly, multaneous Le Fort I and grafti.ng or implant place-
the mandible was set back 5 mm with bilateral sagittal ment in the zygomatic and paranasd regions, the
split osteotomies. Intraosseous wire skeletal fixation with
2 weeks of maxillomandibular fixation was used. The pa-
latter are potentially more susceptible to infection
tient had an uneventful postoperative course. Eighteen and di$placenie@t. Our experience bas shown this to
months postoperatively, she continued to show correc- cause &,$gnificantly higher rate of infection than
tion of the dental malocclusion, good esthetic augmenta- with $ther pro&dun? performed alone. A separate
tion of the malar and paranasal areas, and good stability. second procedtife to atigment the zygoma or pqra-
nasal’ area in a’previously advanced maxilla is a less
Case 2 attractive alternative to both patient and sm-geon.
Based on this rationale, we adopted this modifica-
A 20-year-old white woman with a skeletal class III tion of the Le, Fort I osteotomy.
malocclusion associated with maxillary-zygomatic hy-
poplasia and infraorbital-paranasal deficiency presented
Varions other modifiications of the Le Fort I max-
for treatment (Fig 6). Dentally, she showed bilateral class illary osteotomy have been described. Some of
III canine and molar relationships. After preoperative these modiCc$tions were developed to achieve ce$-
orthodontics, the patient underwent a modified Le Fort I tain esthetic objectives, whereas others were di-
osteotomy and advancement. A genioplasty was per- rected to attain a stronger bony base for skelet$
formed at the same time. Skeletal miniplate fixation was
fixation:‘-’ Biemnett and Wolford devql~ped the
used without maxillomandibular fixation. One year later,
the patient showed good stability of the osteotomized seg- maxillary steIj osteotomy, which irnproped the ac-
ments and no evidence of relapse. curacy of measurement of the osteototiized seg-
ABUBARER AND SOTEREANOS

FIGURE 5. Frontal facial view of patient preoperatively (A) and 8 months postoperatively (B). Lateral facial profile before (C) and 8
months after operation (D).

meants alsng the Frankfwt horizontal plane.4 Later, zygomatic bone. These modiications led to greater
other modifications described by Kaminishi and stabilization along the osteotomy line.. Another
Davis’ and by Bell and colleagues7 involved the ex- modification described by Stringer and oyner6
tension of the horizontal portion of the osteotomy consisted of extending the horizontal osteetomy
into the rnaxiElary buttress and the thick root of the from the piriform aperture anteriorly to the buttress
FIGURE 5 (cont’~$
Cephalogram before
(Ei, and 8 months af-
ter operation (F).
Intraoral anterior
occhsi~n before (G)
and 8 months after
operation <Hj.
ABUBAKER AND SQTEREANOS

FIGURE 6. Frontal facial view of patient preoperatively (A) and 6 months postoperatively (B) Lateral facial profile before (C) and 6
months after operation (D).

region posteriorly. The posterior horizontal exten- deficient zygornatic areas3 In this modification, the
sion of the osteotomy is carried over to the dense superior osteotomy is carried anteriorly from the
bone of the zygomatic arch. Similarly, this moditi- base of the piriform aperture and posteriorly in the
cation improved the method of fixation by making a orbital floor or slightly inferior to the orbital rim TV
superior step osteotomy into the dense bone of the avoid transection of the orbital septa. This osteot-
zygoma. The authors noted undesirable fullness of omy is extended posteriorly in the zygoma to &be
the buttress areas, however, particularly when the anterior insertion of the massetcr mu&e. In their
maxilla was advanced and inferiorly positioned. technique, they reported a frequent need for bone
Brusati and coworkers used this feature in their de- grafting in the orbital floor, the paranasal area, and
sign of a maxihomalar osteotomy for maxillary ad- the zygomatic osteotomy.
vancement to achieve esthetic improvement in the Our modification, on the other hand, includes
 FIGURE 6 (cont’c& Cepha-
logram before (E) and 10
months after operation (a;). Hn-
traoral anterior occlusion be-
fore (G) and 6 months after op-
eration (I$).

placement of the anterior osteotomy high in the and also provides a strong bony base for the skeletal
maxilla, providing marked improvement of esthet- fixation. With this procedure, 38 patiefits wit& var-
its in the deficient paranasal areas. It also extends ious degrees of combined maxillary-mandibulsr dis-
far posteriorly in the zygoma to include a larger proportion and maxillary-zygomatic deficiency
portion of the zygomatic bone, both in the antero- have been treated with good esthetics, good func-
posterior and vertical dimension. This produces an tional results, and superior postoperative stability.
improvement of the esthetics in the malar region Although the morbidity of this technique is gen-
ABUBAKER AND SOTEREANOS

et-ally comparable to that of the conventional ke References

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