DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Vertical maxillary deficiency
2. Maxillary hypoplasia.
POSTOPERATIVE DIAGNOSES:
1. Vertical maxillary deficiency
2. Maxillary hypoplasia.
OPERATION PERFORMED: LeFort I osteotomy with application of osteodistractors.
ANESTHESIA: General via nasal endotracheal intubation.
DESCRIPTION OF OPERATION: The patient was placed on the operating room table in a supine position, and after induction of nasal endotracheal general anesthesia, the patient was prepped and draped in the usual fashion. The mouth was opened utilizing a Jackson bite block. An oropharyngeal toilet was performed, and an oropharyngeal packing was placed. Marcaine 0.5% with 1:200,000 epinephrine was then infiltrated along the maxillary vestibule from the malar buttress area to the anterior nasal spine. This was done bilaterally. Care was also taken to infiltrate the area of the retromolar tuberosity. This was done bilaterally.
In addition, solution was deposited at the greater palatine foramen and at the nasal palatine foramen. Approximately 10 mL of Marcaine was utilized for this procedure. This procedure was done bilaterally so that the area of the entire maxilla was anesthetized using Marcaine. Using a Colorado needle on an electrocautery knife, an incision was made approximately 1 cm above the mucogingival line of the maxilla. This incision was through the mucosa, the submucosa, the muscle layer, and the periosteum. We began just distal to the second molar roots and above the roots by approximately 1 cm. We continued around parallel to the mucogingival line, past the maxillary midline, to the first molar of the opposite side.
Next, using periosteal elevators, a full-thickness mucoperiosteal flap was created. The infraorbital nerves were identified. Using a marking pen, the height of the maxillary canine tooth was noted. An osteotomy site line was then drawn with a surgical pen so that we could define the intended osteotomy line of the LeFort I osteotomy on the lateral cortical plate on the right side. The KLS-Martin vertical distractors were then fashioned into place. They were placed just distal to the maxillary canines and parallel to the canine roots.
The Freer nasal dissector was then utilized to deflect the nasal periosteum from the lateral and inferior nasal walls. The mucosa was also freed over the crest of the maxilla. The distractors were temporarily fixed in place by replacing the distractors so that they were centered over the intended osteotomy site marked by the surgical pen. Two screws and the holes were then placed to identify this position. The screws were screwed into place through the footplate of the distractors. This was done both above the intended maxillary osteotomy line and below the maxillary osteotomy line. Two holes were placed in the superior footplates and two holes were placed for the inferior footplates. The 5 mm KLS-Martin screws were utilized for this procedure. The screws were then removed, and the distractors were removed and segregated labeled left and right side.
Next, again, the marking pen was utilized to mark the site of the intended maxillary osteotomy lines. Using an Osteomed reciprocal saw with a 0.4 mm blade, the osteotomy was made through the lateral piriform wall on the right, continuing posteriorly approximately 5 mm above the mucogingival line, so the osteotomy went posteriorly from the lateral piriform opening safely above the roots of the maxillary teeth to the pterygomaxillary suture line. A similar osteotomy was made on the patient’s opposite side.
Next, using the nasal vomer osteotome, the vertical attachment of the maxilla to the maxillary crest was detached. Finally, a curved osteotome was used at the pterygomaxillary suture line on each side to disconnect the pterygomaxillary suture line. This was done with a curved osteotome and mallet. With the nasal vomer attachment severed, with the pterygoid attachments severed, and with the lateral cortical plate and medial cortical plate of the maxilla severed, the maxilla was then down-fractured from its cranial base with digital pressure. It was down-fractured in one piece.
Next, using a bone file and a small rongeur, all the bony spurs of the osteotomy were smoothed down or removed. The areas of interference or of bony projections that required further smoothing were carefully observed. We began this process on the right lateral wall of the maxilla and continued to the medial sinus wall of the maxilla to the midline and then to the opposite side sinus wall and then to the lateral cortical plate on the left. Wherever necessary, bone was trimmed to allow for a minimal interference to the rotational movement of the distal fragment against its base.
Once the maxilla was freed and could be moved anteriorly, posteriorly, or in a rotation around the malar eminence, the maxilla was then mobilized against the maxilla with the use of Osteomed screws. Approximately six screws were placed in each footplate with a minimum of three screws placed above the osteotomy and three in the inferior footplate of the device. These devices were placed bilaterally.
It should be noted that the same sequence of events happened on both sides, that is opening of the incision, identification of the bony landmarks and the soft tissue landmarks, application of the 8 mm vertical maxillary splint, completion of the osteotomy, and finally fixing the splint in final position. The closure was done with 4-0 Vicryl in a continuous fashion. Estimated blood loss was 150 mL. The patient’s condition was improved.
