Le Fort III osteotomy for severe dentofacial deformity correction associated with hypoplasia of the midface

Abstract

The combination of orthodontic therapy and orthognathic surgery is a well-established treatment modality for the correction of dentofacial deformities. When these deformities are more severe, involving hypoplastic midface, surgical techniques not used routinely in the treatment of facial changes are required, such as the Le Fort III osteotomy or variations of this technique. Few studies have reported the use of this technique or its modifications in non-syndromic patients. This paper demonstrates the orthodontic-surgical resolution of a patient with dentofacial deformity with severe malocclusion Class III, involving midface hypoplasia, with a modification technique of a Le Fort III osteotomy associated with Le Fort I and sagittal of the rami osteotomies. After three years of postoperative follow-up, the patient demonstrates significant improvement in chewing ability, no functional complaints, and high satisfaction with the aesthetics and improved quality of life.

Full text

CLÍNICO |
CLINICAL
RGO, Rev Gaúch Odontol, Porto Alegre, v.64, n.4, p. 453-459, out./dez., 2016
http://dx.doi.org/10.1590/1981-8637201600030000143129
1 Universidade Federal do Paraná, Faculdade de Odontologia, Departamento de Estomatologia. Av. Lothário Meissner, 632, 80210-170, Jd. Botânico,
Curitiba, PR, Brasil. Correspondência para / Correspondence to: AM SEBASTIANI. E-mail: <sebastiani.aline@gmail.com>.
2 Universidade Federal do Paraná, Programa de Residência em Cirurgia e Traumatologia Buco-maxilo-faciais. Curitiba, PR, Brasil.
3 Universidade Federal do Paraná, Programa de Mestrado em Odontologia, Programa de Residência em Cirurgia e Traumatologia Buco-maxilo-faciais.
Curitiba, PR, Brasil.
4 Universidade do Extremo Sul Catarinense, Curso de Odontologia. Criciúma, SC, Brasil.
5 Universidade Positivo, Curso de Odontologia. Curitiba, PR, Brasil.
Le Fort III osteotomy for severe dentofacial deformity correction associated
with hypoplasia of the midface
Osteotomia Le Fort III para correção de deformidade dentofacial severa associada a hipoplasia de terço médio da face
Aline Monise SEBASTIANI1
Nelson Luis Barbosa REBELATTO2
Leandro Eduardo KLÜPPEL3
Delson João da COSTA3
Fernando ANTONINI4
Rafaela Scariot de MORAES5
ABSTRACT
The combination of orthodontic therapy and orthognathic surgery is a well-established treatment modality for the correction of dentofacial
deformities. When these deformities are more severe, involving hypoplastic midface, surgical techniques not used routinely in the treatment
of facial changes are required, such as the Le Fort III osteotomy or variations of this technique. Few studies have reported the use of this
technique or its modications in non-syndromic patients. This paper demonstrates the orthodontic-surgical resolution of a patient with
dentofacial deformity with severe malocclusion Class III, involving midface hypoplasia, with a modication technique of a Le Fort III osteotomy
associated with Le Fort I and sagittal of the rami osteotomies. After three years of postoperative follow-up, the patient demonstrates signicant
improvement in chewing ability, no functional complaints, and high satisfaction with the aesthetics and improved quality of life.
Indexing terms: Face. Malocclusion. Orthognathic surgery.
RESUMO
A combinação da terapia ortodôntica com a cirurgia ortognática é uma modalidade de tratamento bem estabelecida para a correção de
deformidades dentofaciais. Quando estas deformidades apresentam maior severidade, envolvendo a hipoplasia do terço médio da face,
exigem técnicas cirúrgicas não utilizadas como rotina no tratamento das alterações faciais, como a osteotomias Le Fort III ou as variações
destas técnicas. Poucos estudos relatam o uso desta técnica ou de suas modicações em pacientes não sindrômicos. Este trabalho tem como
objetivo demonstrar uma resolução ortodôntica-cirúrgica de um paciente apresentando deformidade de face com má-oclusão Classe III severa,
envolvendo hipoplasia do terço médio facial, com a realização de uma técnica modicada da osteotomia Le Fort III, associada as osteotomias Le
Fort I e osteotomia sagital dos ramos mandibulares. O paciente encontra-se com três anos de acompanhamento pós-operatório, com melhora
signicativa na sua habilidade mastigatória, sem queixas funcionais, relatando alta satisfação com a estética e melhora na qualidade de vida.
Termos de indexação: Face. Má oclusão. Cirurgia ortognática.
INTRODUCTION
The combination of orthodontic and orthognathic
surgery therapy is a well-established treatment modality
to correct moderate and severe dentofacial deformities1.
The most common surgery techniques are the bilateral
sagittal split osteotomy (BSSO) in mandible surgeries and
the Le Fort I osteotomy in surgeries involving the maxilla.
The correction in patients with Class III malocclusion is
usually performed with these two osteotomy techniques,
either isolated or combined. However, severe deformities
involving midface hypoplasia represent a more challenging
treatment for the surgeon, requiring surgery techniques
that are not routinely performed to treat facial alterations,
like the Le Fort II and Le Fort III2 osteotomies and variations
of these techniques.

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AM SEBASTIANI et al.
After the orthodontic-surgical planning, teeth
14 and 24 were extracted to enable the maxillary teeth
decompensation. After two years of orthodontic treatment,
he showed a 15-mm maxillo-mandible discrepancy (Figure
The Le Fort III osteotomy has been widely used in
dentofacial deformity treatment, primarily in syndromic
patients2-5. It was rst reported in 1950 by Gilles and
Harrison6, and after this, Tessier7 described the technique
in more rened way, making it more applicable and
predictable in craniofacial deformity treatment and
revolutionizing the management in patients with total
deciency of the midface.
Several modications of the technique were
realized with osteotomy alterations8 or Le Fort I osteotomy
association9-10. Fewer studies related the use of the
technique or one of its modications in non-syndromic
patients with midface hypoplasia10.
This paper reports the orthodontic-surgical
resolution in one non-syndromic patient with dentofacial
deformity and severe Class III malocclusion on which a Le
Fort III modied osteotomy associated with the Le Fort I
and BSSO osteotomies was performed.
CASE REPORT
A 23-year-old male patient with extensive
mandible prognathism associated with midface
hypoplasia was referred due to a functional complaint
with restriction in feeding, esthetic complaints and bad
quality of life. In the facial analysis, he exhibited a concave
prole with midface depression, a wide chin-cervical
distance and his lower face extended. The patient had a
mandible asymmetry and deviated septum, both on the
right side (Figure 1A, B).
Figure 1.
Figure 1. Photos in the preoperative period. A) Front view. B) Prole view. C) Occlusal view.
Figure 2.
Planning in semi-adjustable articulator and model surgery. A) Initial occlusion. B) Simulation of the midface advance. C) Simulation with the maxilla advancement. C)
Simulation with the mandibular setback.
1C).
The case planning was performed through
prediction tracings and mounting of models in the semi-
adjustable articulator to dene the drives for surgery:

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Le Fort III osteotomy for severe dentofacial deformity correction
4-mm midface advance, 5-mm maxilla advance and
7-mm mandible setback with medium line correction
and genioplasty to a 6-mm vertical reduction. The model
surgery was performed with the models repositioning in
three segments to make the surgery splints: intermediate
splint 1 (after midface reposition), intermediate splint 2
(midface and maxilla operated) and nal splint (Figure 2).
Figure 3.
A) Horizontal osteotomy below the fronto-nasal suture. B) Oblique osteotomy of the zygomatic bone (right side).
Figure 4.
Stable internal xation. A) In the fronto-nasal region. B) In oblique osteotomy.
Operative technique
The surgery was begun through bicoronal access;
the incision line was drawn with methylene blue through
the head vertex to the preauricular area bilaterally.
After subcutaneous inltration (bupivacaine 0.5% with
epinephrine 1:200.000 U.I.), the incision was begun until
the subgaleal plan. To control the bleeding, Raney clips
and electrocautery were used. The dissection followed
the subgaleal plan to 2 cm above the supraorbital area,
and then, a pericranium incision between the temporal

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AM SEBASTIANI et al.
lines was performed. The dissection continued under the
periosteum, and the supraorbital vascular-nervous bundle
was released from its foramen through an osteotomy with
the piezoelectric motor; the orbital content was moved
away to perform detachment of the orbital borders until
the inferior orbital ssure was identied. During periorbital
dissection, the cantal ligament remained intact, and the
dissection extended back to the lacrimal apparatus.
Sideways, the outer layer of the deep temporal fascia was
incised superiorly to the zygomatic arch and continuously
joined with the incision of the pericranium. The dissection
was then performed through the layer of fat to achieve
the zygomatic arch and extended back to the anterior
to expose the zygoma and the lateral wall of the orbit.
Afterwards, subperiosteal detachment was conducted
over the nasal bones.
Figure 5.
Photos in the postoperative period of 03 years. A) Front view. B) Prole view. C) Occlusal view.
Figure 6.
Postoperative CT.
A horizontal osteotomy was performed right
below the frontonasal suture, extending laterally through
the median orbital surface and posteriorly to the lacrimal
fossa (Figure 3A). On the basis of the tear duct, the
osteotomy was directed to the orbital oor. The lacrimal
sac was protected with tissue retractors. Then, the oblique

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Le Fort III osteotomy for severe dentofacial deformity correction
osteotomy was performed on the side of the orbita to
the zygomatic bone inferior area (Figure 3B). Through the
transconjunctival access bilaterally, a third osteotomy was
performed, joining the other two osteotomies through the
orbital oor carefully so as not to rupture the infraorbital
branch. All osteotomies were performed with the
piezoelectric motor and completed with chisels. The chisel
was introduced in the nasal bone, perpendicular to the
cribiform plate when the separation of the nasal septum
from the skull was performed.
In order, the maxilla, mandible and chin were
inltrated with a local anesthetic, and the maxilla was
incised bilaterally (Figure 4A, B). The detachment was
extended to expose the side walls in the nasal cavity, the
posterior area of the maxilla and the inferior area of the
zygoma. Using chisels, the osteotomy was completed in
the inferior area of the zygoma and posteriorly of the
maxilla tuberosity on both sides. A curved chisel was used
to promove the pterygoid plates’ disjunction.
Rowe forceps were used to mobilize the segment.
After the complete manipulation, the maxillo-mandible
block with the intermediate split 1 was performed,
promoting a 4-mm midface straightforward (including
the maxilla). The xation was performed with two plates
and monocortical screws in the frontonasal suture and
one straight plate in the oblique osteotomy in the zygoma
body bilaterally. A small undesirable fracture occurred in
the infraorbital rim on both sides and requiring xation
with miniplates and screws. The maxillo-mandible block
was removed, and intermediate occlusion, the symmetry
of the advance and the segment stability were checked.
This was followed by the Le Fort I osteotomy and
maxilla down fracture to 5 mm advance planned, using
as a reference intermediate splint 2, which was xed with
four L plates and screws. After the maxillo-mandible lock
was removed, the positioning of the maxilla, upper-incisor
exposure and new intermediate occlusion were checked. In
order, through BSSO, the mandible was set back to 7 mm,
correcting the midline deviation. The segments were xed
with a straight plate and monocortical screws bilaterally.
Finally, the genioplasty was held with a 6-mm vertical
reduction, and the xation was performed with plate and
monocortical screws. The blocking was removed, and the
nal occlusion was checked.
The intraoral and transconjunctival approaches
were sutured with continuous sutures and absorbable
thread. The bicoronal approach was repositioned, and
after suspensory sutures in the cantal lateral ligament and
temporal muscle with absorbable thread, the scalp was
closed in two layers, the deepest with absorbable sutures
and shallowest with nylon 3-0 with portovac drain suction
installation. The scalp was held using a compressive
bandage around the head and chin.
The patient was kept for the rst 48 hours in the
intensive care unit. The drain portovac was removed after
48 hours. After ve days, the patient was discharged from
the hospital.
Currently, after three years of postoperative
follow-up he shows signicant improvement in chewing
ability, denies respiratory and visual complaints and has no
pain or functional complaints. In addition, patient reports
high satisfaction with the aesthetics (Figure 5A, B, C).
Postoperative computed tomography demonstrates
the stability of xation (Figure 6).
DISCUSSION
Maxilla hypoplasia is a common diagnosis in the
spectrum of dentofacial deformities and is usually corrected
by a Le Fort I osteotomy to maxilla advance. However, when
we encounter a severe midface hypoplasia, we should
consider that facial appearance is heavily inuenced by
the periorbital area. This area includes the eyeballs, eyelids,
eyebrows and cheeks. The symmetry, form and position
of these components are extremely important because
little alterations in this area contribute signicantly to an
individual’s appearance11.
Depending on the extent of midface hypoplasia,
the surgical treatment of the deformity could be performed
by a quadrangular Le Fort I or by Le Fort II osteotomy.
However, these techniques do not properly correct the malar
hypoplasia that could be presenting10. Other approaches
have been used, such as the Le Fort I osteotomy with an
increased infraorbital region. Procedures like higher Le Fort
I osteotomies, without addressing the infraorbital region,
can lead to the patient having a sunken appearance in the
upper portion of the midface. The simultaneous increase
in the infraorbital area with alloplastic associated with Le
Fort I, leads to graft communication with the maxillary
sinus and may subsequently become infected. Bone grafts
used to increase the infraorbital rim are unpredictable in
their resorption rate and are uncomfortable to the patient.
Thus, for these cases, a Le Fort III osteotomy or one of its
modications is more appropriate12.
In non-syndromic cases, the conventional Le
Fort III osteotomy, though it will correct deformities at

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AM SEBASTIANI et al.
the naso-orbit-malar level, could result in enophthalmos,
and in cases of normal nasal projection, it can result in
an undesirable increase in nasal prominence. In addition,
even with the greatest advances, a deformity in the lateral
orbital arches can be found. To avoid this, modications in
the Le Fort III osteotomy were proposed. In 1971, Kufner13
proposed a modication to correct midface projection
deciencies without involving the nasal subunit. The
modication involves an osteotomy in the orbital lateral
border to the zygoma body, through the orbital oor,
through the inferior orbital ssure, and through the maxilla
to the side wall of the nasal cavity. Other advantages of this
modication include midface stabilization, avoiding the
need for bone grafting, facilitating the xing of the plates,
allowing greater bone interfacing and the postoperative
protection of the orbital sclera.
Cheung et al.10 described the application of an
oblique modied Le Fort III osteotomy that included the
bones in the nose in addition to a Le Fort I osteotomy with
segmentation for treatment of non-syndromic patients
with maxillar hypoplasia in three patients, obtaining
satisfactory results.
The patient with the midface deciency associated
with maxillary deciency has been well described in the
literature. Technical problems arise when the maxilla and
midface require different movements, when different
midline deviation presents or when the maxilla should be
segmented12. When the maxilla and midface movements
are confronted, it is necessary to perform the Le Fort I
associated with the Le Fort III osteotomy. Le Fort I osteotomy
association is also especially useful in cases in which there
is a difference in the extent of the midface hypoplasia
in the orbital region in relation to a maxillo-mandibular
discrepancy14.
The biggest advantage of simultaneous Le Fort III
and Le Fort I osteotomies is that both, midface deformity
and maxilla, can be addressed in a predictable manner and
simultaneously in separate segments, resulting in optimal
aesthetic results when the horizontal maxilla deciency
differs signicantly from the infraorbital areas12. In addition,
it minimizes the advancement in the Le Fort III osteotomy,
reducing the need for bone grafts14-15.
The patient in this report had midface hypoplasia
involving the nasal bones, zygoma, inferior orbital rims
and maxilla bone. His maxillo-mandibular discrepancy was
greater than his midface deciency, mainly due to its severe
mandibular prognathism. However, a very large mandibular
setback could damage the patient’s airway. Thus, for the
midface approach, the surgical technique was chosen
based on the modication performed by Cheung et al.10
with a Le Fort III osteotomy involving the nasal bones and
the Le Fort I osteotomy, allowing further advancement of
the maxillary alveolar segment.
The Le Fort III osteotomy is considered a complex
technique, representing a challenge to surgeons due to the
risk associated with several complications that could be a
mild recurrence and extending to blindness and death14.
Therefore, it should be considered only in specic cases in
which it is impossible to resolve the patient’s deformity and
complaints with other less complex techniques. In addition,
the patient must have be in good physical condition to
support the procedure due to prolonged operative time
and extensive blood loss.
The patient who will be subjected to these
extensive reconstructions should be aware of the possible
transoperative and postoperative complications. In the
preoperative period, the preparation for possible trans
operative complications should be performed, a bed
should be booked in the intensive care unit and erythrocyte
concentrates reservation. The patient should also be
accompanied by a multidisciplinary team including an
ophthalmologist, otolaryngologist, nutritionist, psychologist,
physiotherapist and speech therapist.
Moreover, it is important to clarify that dentofacial
deformities arise from skeletal defects involving the three
planes of space, and careful planning is required for the
correct three-dimensional positioning of all segments. Any
planning error can result in subsequent errors, preventing
proper correction of the deformity. Thus, both the surgeon
and orthodontist have a fundamental function in surgical
planning for the correct management before and after
the intervention, enabling occlusion, oral function and
appropriate aesthetic appearance.
Collaborators
AM SEBASTIANI was responsible for writing the
article. LE KLUPPEL was responsible for performing the
reported surgery and organizing the article. F ANTONINI
was responsible for the case and performing the
planning, clinical documentation and co-supervision of
the writing of the article. DJ COSTA, NLB REBELLATO
and RS MORAES were responsible for the planning and
execution of the treatment and writing the article.

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Le Fort III osteotomy for severe dentofacial deformity correction
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Received on: 16/3/2016
Final version resubmitted on: 23/6/2016
Approved on: 14/9/2016