J Oral Maxillofac Surg

55:728-731, 1997

Segmental LeFort I Osteotomy for

Recent survey data show that only 9.4% of the US indications for the two procedures, particularly
population have a posterior crossbite,’ which is most whether SARPE can be justified as the first stage of
frequently caused by a narrow maxilla, but Proffit et two-stage surgical treatmenl in patients in whom a later
al2 have reported that 30% of adults seeking consulta- one-piece LeFort I osteotomy will be required, rather
tion for treatment of dentofacial deformity have a com- than doing a one-stage segmental LeFort I procedure.
ponent of transverse maxillary deficiency. No data ex-
ist to document how many patients have only
Pattern of Expansion: Similarities
transverse maxillary deficiency without accompanying
and Differences
vertical and anterior-posterior skeletal problems. How-
ever, it is clear that a narrow maxilla occurs frequently
in patients with excessive vertical development of the An important consideration is that the pattern of
maxilla, and that it occurs in both Class II and Class expansion with RPE, surgically-assisted or not, is dif-
III individuals. ferent from that with the segmented LeFort I osteot-
Palatal expansion can be achieved in the following omy. In rapid palatal expansion, force is used to sepa-
two ways: surgically-assisted rapid palatal expansion rate the mid-palatal suture and the maxilla opens as
(SARPE) or segmenting the maxilla from the down- if on a hinge posteriorly and superiorly. Because of
fractured position during the LeFort I osteotomy to resistance from the lateral and superior maxillary su-
achieve transverse expansion at the same time as the tures, the palate swings open more anteriorly as if
maxilla also is repositioned in the anteroposterior and hinged behind the palate, and rotates outward as if
vertical planes. hinged above the nose. In SARPE, the technique in-
In our view, the following three issues are particu- volves reducing the resistance to expansion by making
larly important in comparing the two procedures: 1) osteotomies in the lateral maxillary buttress (preferred
the similarities and dilferences between transverse method), in the palate, or in both. With the use of a
widening with surgically-assisted rapid palatal expan- jackscrew, the force is concentrated over the remaining
sion (RPE) versus segmental LeFort I osteotomy, 2) sutures. Micro-fractures then allow the same pattern
the relative stability of the two procedures, and 3) the of expansion as with traditional nonsurgical RPE. The
presence of a diastema between the central incisors is
evidence that space was created anteriorly. In segmen-
Received from the University of North Carolina School of Den-
tistry, Chapel Hill, NC. tal LeFort I osteotomy, the pattern of expansion can
* Associate Professor, Department of Orthodontics. be varied depending on the location of the transverse
t Dalton L. McMichael Professor, Department of Oral and Maxil- maxillary deficiency. When maximum expansion pos-
lofacial Surgery.
$ Kenan Professor and Chair, Department of Orthodontics. teriorly is desired, a two-segment osteotomy, with a
§ Professor and Chair. Department of Oral and Maxillofacial Sur- cut between the maxillary central incisors allows the
gery. maxilla to open as if hinged anteriorly, widening more
Supported in part by NIH grant no. DE-05215 from the National
Institute of Dental Research. posteriorly than anteriorly.3
Address correspondence and reprint requests to Dr Bailey: Depart- The inelasticity of the palatal mucosa is most often
ment of Orthodontics. School of Dentistry, University of North Caro- the factor limiting posterior expansion. Fortunately,
lina, Chapel Hill, NC 27599.7450.
few patients require posterior maxillary width changes
0 1997 American AssociaGon of Oral and Maxillofacial Surgeons greater than 6-7 mm, an outcome achievable by either
0278-2391/97/5507-0021$3.00/O SARPE or segmental LeFort I osteotomy. For greater

728
BAILEY ET AL 729

expansion than this across the first premolars and ca- to the completion of orthodontics. Pogrel et al7detailed
nines, RPE or orthodontic tooth movement may be the outcomes in 12 patients who had SARPE followed
needed. later by a one-piece LeFort I osteotomy. Only the mean
When widening of the anterior maxilla is desired, expansion at the first molars (7.5 mm) was reported,
two options exist. The maxilla can be segmented in with the width diminishing 1.5 mm or less from the
the maxillary midline between the central incisors or completion of arch expansion until presurgical orth-
bilaterally between the canines and lateral incisors, but odontics was completed.
the need to keep alveolar bone in contact to prevent In a retrospective review of 39 patients, Phillips et
subsequent periodontal defects limits the amount of al3provided stability data for expansion following seg-
expansion possible across the canines. SARPE usually mental LeFort I osteotomy. They used the model sur-
widens the maxilla more in the canine region than the gery castson which surgical splints were made to judge
segmental LeFort I osteotomy does. the amount of expansion at surgery. Mean first molar
There are two reasons for expanding the maxilla. width increased more in the two segment osteotomy
They are to produce proper occlusion, correcting a (4.7 mm) than in the three segment osteotomy (3.5
posterior crossbite caused by a skeletal width defi- mm). When sufficient numbers of patients are available
ciency, or to provide space for aligning crowded maxil- for study, frequency distributions provide more mean-
lary incisors. Opening the suture more anteriorly than ingful data to clinicians than mean values. In this study,
posteriorly provides more space for aligning the ante- frequency distributions comparing first molar position
rior teeth. Changing the dental arch form to provide indicated that 28% of these patients had constriction
more space for tooth alignment may or may not be an of 3 mm or more from the position of maximum expan-
appropriate goal of treatment, and that in itself is a sion immediately postsurgery to the completion of
controversial issue at present. The different pattern of orthodontics. A similar number of patients had mini-
expansion with RPE versus segmental LeFort I osteot- mal change. No crossbite was evident at completion
omy often means that dental arch expansion, especially of treatment in 71% of the patients. Fifteen patients
across the canines, is used to relieve crowding in pa- from the samplewho had two-jaw surgery had a greater
tients treated with RPE, whereas premolar extraction decreasein molar width at treatment completion. Pre-
to relieve crowding is more likely to accompany seg- sumably, mandibular molar position influenced maxil-
mental LeFort I procedures. lary molar change. No other predictors of postsurgery
change were detected.
Stability of Expansion: RPE These reports seemto indicate better transverse sta-
Versus Osteotomy bility with SARPE, but differences in study design
make comparisons almost impossible. Inclusion crite-
In 1990 Kuo and Will4 discussed the treatment of ria are not specific enough in any of the studies to
maxillary constriction and presented a series of 21 pa- determine if patients not analyzed had different out-
tients having surgically-assisted rapid palatal expan- comes from those studied. Only Phillips’ and Pogrel’s
sion with lateral maxillary osteotomy. Their data indi- articles provide data from the point of maximum
cated that both molar tipping and maxillary expansion expansion to the longest follow-up period, data crucial
occur with the procedure. Only 15 patients were avail- to any analysis comparing the two approaches.3,7The
able for long-term follow-up (mean, 17 months), but period of retention following expansion also differed
it appeared that maxillary width was maintained (13/ markedly between the techniques. Neither Bays nor
15 at 100% initial expansion) and molar width was not Racey mention retention,5’6 a critical factor in trans-
(7/15 at 100% initial expansion). These investigators verse stability. Pogrel indicated that after expansion,
concluded that more extensive data were needed. Un- retention was maintained for at least 3 months, a mini-
fortunately, good data from adequate samplesstill are mum time required before bony fill can be expected
not available. For SARPE, data are available from only in the gap created in the palate.7 Only a 6-week period
a few recent and relatively small case series, and only of retention was reported by Phillips3
one report of stability after segmentalLeFort I osteot- Retention of the bone/tooth segmentsmay be a ne-
omy has appeared. glected point of emphasis for both approaches. In
Bays and Greco’ reported on 19 patients after younger patients, a 6-month period of retention is typi-
SARPE. Net expansion of 4.4 mm was achieved at the cal after rapid palatal expansion without surgery.
canines and 5.8 mm at the molars. Minimal change Treatment time usually is not critical in theseorthodon-
was seen from the completion of orthodontics to the tic patients, who typically have expansion in the first
6-month follow-up period. In an invited critique of the months of prolonged comprehensive treatment. A min-
article, Racey6 reported similar results in 18 patients. imum period of width retention in adults should be 3
In both articles no data were reported indicating the months, with a longer time preferred if maintaining
changes from the point of maximum arch expansion arch width is essentialto achieving a satisfactory result.
730 SEGMENTAL LEFORT I EXPANSION

This may be difficult to accomplish in adult patients as an outpatient procedure. In the latter circumstance,
to whom treatment time is important. Today patients when an osteotomy is made on only one side, the dif-
frequently return to the orthodontist to resume treat- ferential anchorage created will produce more expan-
ment four weeks after segmental LeFort I osteotomy, sion on the osteotomy side as a means of correcting a
a phenomenon facilitated by rigid fixation. Often orth- severely asymmetric maxilla. The important consider-
odontic appliances are removed within 6 months after ation in both situations is that no other surgery on the
orthognathic surgery.8 After segmental LeFort I sur- maxilla should be necessary.
gery, retaining maxillary arch width is critical while In patients with anteroposterior and transverse max-
other orthodontic movement is attained. This is nor- illary deficiency, a frequent type of Class III problem,
mally accomplished with heavy buccal or palatal auxil- crowding and/or protrusion of the maxillary incisors
liary wires because light archwires are inadequate for often is severe, and extraction of maxillary but not
retention. A longer postsurgery orthodontic treatment mandibular premolars frequently is the treatment of
time may be required. choice. If a three-segment osteotomy is desired, the
extraction space is partially closed by the orthodontist
indications For Segmental Osteotomy Versus before the LeFort I osteotomy, leaving room for the
Surgically-Assisted RPE surgeon to cut through the alveolar process in that
area. If there is no reason to differentially expand the
Jacobs et al9 have discussed the differences between posterior segments, or no need for surgical levelling
relative and absolute transverse maxillary deficiency of the segments, the space can be closed orthodon-
and the options for treatment. All the cases presented tically and a two-piece osteotomy (with the interdental
in this report involved segmental osteotomy. More re- osteotomy between the central incisors) used for
cently Betts et aI” have reviewed the same topic with expansion. In patients with vertical maxillary excess,
emphasis on SARPE. Before any treatment begins it correction of the open bite is facilitated if the posterior
is important to decide what width changes are required maxillary segments are superiorly repositioned and
in the maxilla to achieve a satisfactory occlusal rela- brought forward at surgery. Premolar extraction often
tionship with the mandible, a more difficult task when is needed even if arch expansion has been carried out
orthodontic and skeletal changes are planned in both previously. With proper retention, long-term stability
jaws. Clearly, surgically shortening or lengthening of can be achieved with segmental expansion in both
the mandible and tooth alignment in the mandible in- types of cases.
fluence the change that must be made in the maxilla. Data from Phillips and Pogre13” allow a comparison
When a choice exists between the alternatives of of treatment times. In patients having segmental LeFort
SARPE and maxillary segmental osteotomy, it is im- I osteotomy, a mean total treatment time of approxi-
portant that guidelines be established to assist in mak- mately 24 months is expected, comparable to that re-
ing the appropriate decision. In our view, the most ported by Proffit and Miguel’ in their study of treat-
important guideline is that if the patient will require ment duration for orthognathic surgery patients in
additional maxillary surgery after transverse expansion university and outside settings. Extrapolating from Po-
has been achieved, there is little reason to perform grel’s data,’ it seems that at least another 6 months
surgery twice. Should this be the case (for example, could be added to total treatment time if both SARPE
the long-face patient with a narrow maxilla), then the and one-piece LeFort I osteotomy are planned for the
transverse problem should be dealt with by segmenting same patient (1 to 2 months for expansion and 4 to 6
the maxilla at the time of the LeFort I osteotomy. In months retention).
a case series of 61 long-face patients treated with supe- No data exist to indicate if adverse outcomes are
rior repositioning of the maxilla at UNC, 25 needed less with two-stage surgical treatment, justifying the
segmentation of the maxilla to allow posterior expan- longer duration of treatment. The following three as-
sion. No difference in the incidence of complications pects of the outcome must be considered: 1) stability,
and surgical problems was noted between the patients which has received the greatest attention; 2) morbidity,
who had one-piece and segmental osteotomies, and surgical risk, costs, and other factors related to objec-
there was no difference in vertical stability between tive evaluation of the treatment experience; and 3) the
the groups. l1 impact of one- versus two-stage surgical procedures on
SARPE, from that perspective, has the following psychosocial characteristics and the patient’s quality of
two primary indications: 1) in a patient with only a life. The psychosocial impact of surgery has been
transverse problem who is too old for the traditional largely disregarded in the evaluation of SARPE. For
RPE, and 2) when there is unilateral or asymmetric patients with other types of orthognathic surgery, pre-
narrowing of the maxilla. In the first situation, there vious studies have evaluated motives for treatment,”
is some advantage to the reduced morbidity associated personality characteristics before and after surgery, and
with the partial osteotomy, because it can be performed satisfaction with outcomes.‘3 These issues should be
BAILEY ET AL 731

explored in patients undergoing treatment involving 2. Proffit WR, Phillips C, Dann C IV: Who seeks surgical-or-
thodontic treatment? Int J Adult Orthod Orthognath Surg
surgical maxillary expansion. Important questions that 3:153, 1990
patient perceptions are needed to answer are such 3. Phillips C, Medland WH, Fields HW Jr, et al: Stability of surgi-
things as the following: Do patients perceive any ad- cal maxillary expansion. Int J Adult Orthognath Surg 5:139,
1992
vantages of esthetics, function, and/or stability with 4. Kuo PC, Will LW: Surgical-orthodontic treatment of maxillary
one-stage versus two-stage treatment? If so, do these constriction. Oral Maxillofac Clin North Am 2:75 1, 1990
outweigh the increased risk, cost, and morbidity of a 5. Bays RA, Greco JM: Surgically assisted rapid palatal expansion.
J Oral Maxillofac Surg 50:110, 1992
two-stage procedure? Does the difference in treatment 6. Racey GL: Surgically assisted rapid palatal expansion. J Oral
time and time away from work/school represent a sig- Maxillofac Surg 50: 114, 1992
nificant advantage of one-stage treatment? 7. Pogrel MA, Kaban LB, Vargervik K, et al: Surgically assisted
rapid maxillary expansion in adults. Int J Adult Orthod Or-
The best approach to this type of study would involve thognath Surg 7:37, 1992
a clinical trial in which patients for whom either proce- 8. Proffit WR, Miguel JA: The duration and sequencing of surgical-
dure could be justified would be randomly assigned to orthodontic treatment. Int 5 Adult Orthod Orthognath Surg
10:35, 1995
either of the treatment groups, and in which both objec- 9. Jacobs JD, Bell WH, Williams CE, et al: Control of the trans-
tive outcomes and patient perceptions would be evalu- verse dimension with surgery and orthodontics. Am J Orthod
ated. Even if a formal randomized clinical trial is not 77:284, 1980
10. Betts NJ, Vanarsdall RL, Barber HD, et al: Diagnosis and treat-
possible, important data of this type can be gathered in ment of transverse maxillary deficiency. Int J Adult Orthod
the context of existing patient care regimens. At this Orthognath Surg 10:75, 1995
point, data to justify the more extensive surgical inter- 11. Proffit WR, Phillips C, Turvey TA: Stability following superior
repositioning of the maxilla by LeFort I Osteotomy. Am J
vention of two-stage treatment do not exist. Orthod Dentofac Orthop 92:151, 1987
12. Phillips C, Broder HL, Bennett ME: Dentofacial disharmony:
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13. Kiyak HA, Hohl T, Bell R: Psychosocial considerations in sur-
1. Brunell JA, Bhat M, Lipton JA: Prevalence and distribution of gery and orthodontics, in Proffit WR: White RP (eds): Surgi-
selected occlusal characteristics in the US population, 19% cal Orthodontic Treatment, St Louis, MO, Mosby-Year Book,
1991. J Dent Res 75:706, 1996 1991