Pearls and pitfalls in multipiece maxillary osteotomy

The Le Fort I is the workhorse osteotomy for addressing dentofacial deformities involving the maxilla. Segmentation of the maxilla is commonly used to address transverse discrepancies and multiplane occlusions. Original investigations by Bell et al. concluded that maxillary segmentation and pedicle stretch only exhibited transitory effects on revascularization and bone healing even after ligation of the descending palatal vessels. Therefore, the segmental Le Fort I osteotomy is generally a reliable and safe procedure when performed correctly. Still, there are a variety of pitfalls to this procedure that the surgeon should anticipate and attempt to mitigate. The ascending pharyngeal and ascending palatine arteries provide the blood supply to the down-fractured maxilla. The resulting soft tissue pedicle is comprised of the intact palatal and labial/buccal mucosa. The integrity of the palatal mucosa is critical to maintaining the vitality of the maxillary segments. With a conventional three-piece design, the anterior segment is particularly vulnerable to palatal disruptions because there is reduced collateral blood supply from the buccal tissue. Rarely, palatal perforations can result in postoperative fistulas, particularly in the setting of a large transverse expansions and/or unrepaired nasal floor tears overlying the defect. Although devascularization is one of the most feared complications of segmental surgery, injury to the neighboring teeth is much more frequently seen. Roots can be amputated, and the osteotomy can propagate through and violate the periodontal ligament. Disruptions to the periodontal ligament can cause ankylosis or, in the case of root delamination, reduced bony support. Finally, even afterward, there is a heightened risk of surgical relapse. Maxillary transverse expansion is considered an unstable movement as the elasticity of the palatal tissues works to pull the segments together. Likewise, the three-piece closure of an anterior open bite is prone to reopening. The purpose of this chapter is to review pearls and pitfalls in the multipiece maxillary osteotomy.