A more effective alar cinch technique

Changes in three-dimensional nasal morphology according to the direction of maxillary movement during Le Fort I osteotomy

BACKGROUND

Le Fort I (LFI) osteotomy is commonly performed by orthognathic surgeons; however, postoperative changes in nasolabial morphology are of concern. Several factors influence such changes, but it is difficult to accurately predict the postoperative results. This study evaluated the three-dimensional (3D) morphological changes in the nasal region according to the different directions of maxillary movement during LFI osteotomy.

MATERIALS AND METHODS

Forty-one patients who underwent LFI osteotomies were included. All patients were divided into maxilla-up (Group U: 20 patients) and maxilla-forward (Group F: 21 patients) groups. Soft tissue morphologies were determined preoperatively and 3 or 6 months postoperatively using an optical 3D scanner. All datasets were evaluated in terms of volume changes in nine subregions and changes in linear measurements around the nasal area.

RESULTS

Both groups exhibited increased nasal volumes after surgery in the order of the three upper, three central, and three lower subregions. The change in volume of the central nasal region tended to be greater in Group U than that in Group F.

CONCLUSION

We evaluated 3D morphological changes in the nasal region according to the direction of maxillary movement during LFI osteotomy. Group U exhibited a large change in the volume of the central nasal region.

Does Le Fort I Osteotomy Influence Nasal Septum Deviation?

BACKGROUND

Le Fort I osteotomy is a technique for surgically correcting the maxillary position. Le Fort I osteotomy may affect the nasolabial structures since a very close relationship exists between the maxilla and the nose.

PURPOSE

This study aimed to investigate the effect of different maxillary movements on the nasal septum after Le Fort I osteotomies with cone beam computed tomography (CBCT) images. We hypothesized that nasal septal angle changes after maxillary impaction and advancement movements.

STUDY DESIGN, SETTING, AND SAMPLE

This retrospective cohort study involved patients who underwent Le Fort I osteotomy to correct the maxillary position at Erciyes University, Oral and Maxillofacial Surgery Hospital. This study included patients who had CBCT images before (T0) and ≥12 months after (T1) surgery. Patients with a history of septoplasty or rhinoplasty before orthognathic surgery, congenital deformities, or posttraumatic deformities were excluded.

PREDICTOR VARIABLES

Its predictor variable was the direction and magnitude of the maxilla's vertical and horizontal movements.

MAIN OUTCOME VARIABLE

Change in septal deviation (in degrees) was the main outcome of the study.

COVARIATES

Age, sex, operation (Le Fort I alone or double jaw surgery), cartilage reduction, and anterior nasal spine reduction during surgery were covariates.

DATA ANALYSIS

Angle values were compared with independent samples t test or the Mann-Whitney U test in two-category variables. The Kruskal Wallis test was used to compare the angle values according to the movement. A P value of < .05 was considered statistically significant.

RESULTS

This study evaluated 154 CBCT images of 77 patients (44 [57.1%] females and 33 [42.9%] males), of which 68 (88.3%) had double jaw surgery and nine (11.7%) had single Le Fort I surgery. The average nasal septum angle was significantly smaller preoperatively (166.2° [157.1° to 172.15°]) than postoperatively (168.7° [131.5° to 180.0°]) across subjects (P = .031). The septal angle decreased in 28 patients, and the rate of postoperative angular change was higher in patients with both advancement and impaction during the surgery (P = .014).

CONCLUSION AND RELEVANCE

Septum deviation can occur in 37% of cases after Le Fort I surgery. Therefore, Le Fort osteotomies are associated with changes in nasal appearance.

The influence of tissue redraping after Le Fort I type osteotomy

Elongation of the upper lip, in particular the philtrum, and nose widening are common postoperative changes after a Le Fort I osteotomy. These changes can be induced by the transection of soft tissue and loosening of the underlying musculature. A methodology for soft tissue redraping was developed to limit these undesirable nasolabial changes. This study evaluates the effectiveness of the technique and influence of maxillary translocation on the nasolabial form. Anthropometric measurements, lip, philtrum length, and nose width, were taken two weeks prior to, and one year after, surgery. The mean postoperative changes were minimised to less than 1mm except for lip length in the extrusion groups, which was less than 1.5mm. Statistical analysis showed a stable result for lip length after maxillary advancement and/or intrusion as limited lengthening mainly occurred at the vermilion. Conversely, lip lengthening after extrusion mainly occurred at the philtrum. The mean nose width was maintained after maxillary advancement, decreased after extrusion, and increased after intrusion. The type of maxillary translocation only influenced the nasolabial soft tissue in case of intrusion and extrusion, not after advancement.

Comparison of two alar cinch base suture in orthognathic surgery: a randomized clinical trial

Le Fort I osteotomy is widely used in orthognathic surgery to correct maxillary deformities. However, this osteotomy may be related with the increase of alar base width. The aims of the present study were to compare two alar cinch suture after Le Fort I osteotomy and observe which type presents a better result in controlling the enlargement of the alar base after maxillary repositioning in orthognathic surgery. A randomized clinical trial was carried out with 40 patients randomly assigned in two intervention groups: group 1 - patients submitted to internal suture and group 2 - patients submitted to external suture. Of the 40 patients, 65% were female and 35% were male. The mean age of the patients was 30,25 in group I and 28,6 in group II. There was an increase in the alar base width in both groups, with significant difference between the means (P < 0,001). It was possible to compare the evolution of the means of the alar base width between group I and group II. Thus, it was observed that the external technique (group II) better controlled alar base width after Le Fort I osteotomy. It was not possible to relate the enlargement of the alar cinch with maxillary movement performed (P > 0,05). Overall, alar base cinch suture is an essential component of Le Fort osteotomies to control the alar base width. In this study, the external technique was more effective when compared to the internal technique in controlling the enlargement of the alar base width.

Alar cinch sutures in orthognathic surgery: scoping review and proposal of a classification

Orthognathic surgery and the Le Fort I osteotomy result in noticeable alterations to the nasal/nasolabial anatomy. The alar base cinch technique is a surgical technique to control lateralization of the base of the nose and is well described in the literature. The aim of this scoping review was to identify every unique alar cinch suture technique reported in orthognathic surgery and to propose a classification for the different techniques described. A search was conducted in the PubMed, Cochrane Library, and Scopus electronic databases covering the period May 1980 to July 2020, which identified 10 articles that were eligible for this review. Among these, there were several proposals for modifications to the technique, and different studies to show the effectiveness of one type among all others. Despite observing multiple techniques and variations of these while performing this review, the lack of a classification for alar cinch suture was noticed. Therefore, we propose a classification of the alar cinch suture that includes four types, which cover all of the cinching techniques described. It is believed that the use of a standardized classification may be useful to avoid duplicate publishing of techniques and to set a standard for further studies.

Quality of Life After Class III Repair Orthognathic Surgery: Five-Year Retrospective Study

OBJECTIVE

To evaluate the effect of orthognathic surgery on the long-term quality of life of patients with presurgical skeletal Class III and to identify its strongest effect-whether esthetic, social, or functional.

MATERIALS AND METHODS

In this retrospective cohort study, the subjects were patients after orthognathic surgery for repairing skeletal Class III. Fifty-five patients who had undergone orthognathic surgery from 2013 to 2018 in the oral and maxillofacial surgery department participated in this study. Each participant completed a modified questionnaire used to assess the patient's esthetic, social, and functional abilities after orthognathic surgery.

RESULTS

The rate of esthetic improvement in orthognathic surgery patients was 88%. More than four-fifths (81.8%) of the patients reported improvement in their personal and social self-esteem and confidence. Finally, 40.7% of the patients reported functional improvement. No significant differences between male and female patients were found. All but one of the patients recommended orthognathic surgery for patients with similar problems. One in six (17.3%) patients was dissatisfied with the nasal appearance after the surgical procedure, while almost a quarter (21.8%) reported worsening of their mouth opening, and 25.4% reported worsening of TMJ (Temporo-Mandibular Joint) symptoms. Analysis of the results revealed no statistically significant pattern connecting preoperative overjet or overbite measures with satisfaction rates.

CONCLUSIONS

In this study, patient satisfaction with the orthognathic surgical procedure was mostly a result of improvements in facial esthetics, followed by psychological well-being and functional abilities. Most dissatisfaction after the orthognathic surgical procedure was related to nasal appearance, mouth opening, and TMJ complaints.

Nostril Surgery: Indications, Surgical Procedures and Outcomes-A Systematic Review of Published Cases

INTRODUCTION

To achieve adequate nasal proportions, nostril surgery can be a complementary technique useful in facial surgery. To help surgeons with the decision to realize nostril surgery, we conducted a systematic review to summarize reported cases on surgical procedures with a specific interest on indications, surgical procedures and postoperative outcomes. A therapeutic algorithm is also proposed.

METHOD

We carried out this review in accordance with the PRISMA criteria. Twenty-two eligible studies were identified using Medical databases, including 1599 patients. A qualitative and quantitative analysis was carried out.

DISCUSSION

Excision techniques were realized on 728 patients (45.5%), followed by cinching sutures on 642 patients (40%) and combined techniques: excision techniques with flap advancement techniques in 189 cases (12%), excision techniques with flap advancement techniques and cinching suture in 40 patients (2.5%). When excessive alar flaring was present, alar wedge resection was preferred in the 92% of followed by alar and sill resection. Cinching sutures were realized when excessive alar flaring was associated with a vertical alar axis, in cases of wide alar base, of associated orthognathic surgery. When excessive alar flaring was associated with wide alar bases, indications changed basing on the associated deformities. In 795 patients, nostril surgery was conducted simultaneously with rhinoplasty.

CONCLUSION

Nostril surgery through excision techniques, cinching sutures or flaps advancement techniques, reveals good outcomes and can be complementary to rhinoplasty or orthognathic surgery. Through this systematic review, we tried to orient surgeons to find the best treatment for nostril base surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does the Nostril Shape Change After Le Fort I Advancement in Patients With Unilateral Complete Cleft Lip?

PURPOSE

Patients with unilateral cleft lip and palate (UCLP) may require Le Fort I advancement to correct maxillary hypoplasia after reaching skeletal maturity. The underlying cleft anatomy, previous operations, and scarring can affect nostril changes after maxillary advancement. The purpose of the present study was to determine whether Le Fort I advancement affects the nostril configuration (ie, width, axis, shape) in patients with UCLP. The specific aims were to (1) compare cleft and noncleft nostrils in patients with UCLP after maxillary advancement and (2) compare the changes in nostril configuration in patients with UCLP with those in noncleft controls after Le Fort advancement.

PATIENTS AND METHODS

A retrospective case-control study of nonsyndromic, skeletally mature patients with UCLP and a case-matched control group without UCLP who had undergone single-piece Le Fort I advancement with alar cinch suture from 2010 to 2014. Patients were included if they had undergone pre- and postoperative 3-dimensional photogrammetry without intervening nasal revision. Three-dimensional anthropometry was used to evaluate changes in nostril axis and width, soft triangle angle, columellar show, and nasal width after orthognathic correction.

RESULTS

The present study included 19 patients with UCLP (11 males; mean age, 18.0 years) and 19 noncleft controls (11 males; mean age, 18.7 years; P = .276). The mean sagittal advancement in the patients with UCLP and noncleft controls was 7.5 mm and 6.3 mm, respectively (P = .143). On average, the nostrils widened, the soft triangles flattened, and the columellar show increased. No significant difference was found in the changes to the nostril configuration between the cleft and noncleft sides in the patients with UCLP. No significant differences were found in the nostril changes between patients with UCLP and noncleft controls.

CONCLUSIONS

Baseline nostril asymmetry is not altered by Le Fort osteotomy in patients with UCLP because both nostrils respond similarly to the deforming forces of maxillary advancement. Similarly, no differences were found in the nostril changes between the cleft and noncleft controls. These findings can aid proper surgical planning for cleft nasal revisions.

Nasolabial soft tissue effects of segmented and non-segmented Le Fort I osteotomy using a modified alar cinch technique-a cone beam computed tomography evaluation

The aim of this study was to verify soft tissues changes and the effect of a minimally invasive surgical technique in the nasolabial region after segmented and non-segmented Le Fort I osteotomy, using cone beam computed tomography (CBCT) evaluation of three-dimensional (3D) volume surfaces. Two groups were evaluated: group 1, bimaxillary surgery with maxillary segmentation (n=40); group 2, bimaxillary surgery without maxillary segmentation (n=40). In both groups, a specific alar cinching technique was used to control nasal base broadening. CBCT evaluation was performed at three different treatment time points: T0, 1 month before surgery; T1, 1 month after surgery; T2, 1year after surgery. The results showed statistically significant differences in the nasolabial area (P<0.001). For group 1, the mean change in alar base width (Al_inf-Al_inf) was 1.31±1.40mm at T1 and 0.93±1.77mm at T2; for group 2 these values were 1.12±2.01mm at T1 and 0.54±1.54mm at T2. For group 1, the mean changes in inter-alar width (Al-Al) were 1.68±1.46mm at T1 and 1.49±1.33mm at T2; for group 2, they were 2.22±1.93mm at T1 and 1.34±1.79mm at T2. The alar cinch technique proposed here appears to be effective in controlling nasolabial soft tissue widening.

Nasal Soft Tissue Change Following Bimaxillary Orthognathic Surgery

OBJECTIVE

The purpose of this study is to identify the correlation between maxillary movement and nasal soft tissue changes on three-dimensional reconstructed cone beam computed tomography (CBCT) images after Le Fort I osteotomy.

MATERIALS AND METHODS

The authors also investigate the long-term change of alar base width (ABW) to determine the effect of cinch suture. The authors retrospectively studied 52 subjects (14 males and 38 females) who were treated by bimaxillary orthognathic surgery including Le Fort I osteotomy and mandibular ramus surgery. The landmarks and planes were established on three-dimensional reconstructed CBCT images. The authors measured each parameters preoperatively, 1 month postoperatively, and 1 year postoperatively.

RESULTS

There was no significant correlation between the horizontal movement of A-point and the widening of ABW (P < 0.038), nor was there a significant correlation between the vertical movement of A-point and the change of ABW (P < 0.61). There was no significant correlation between horizontal and vertical movement of anterior nasal spine and the widening of ABW, nor was there a significant correlation between the nasal tip length and the vector of maxillary movement.

CONCLUSION

There was no significant correlation between the ABW widening and the vector of surgical maxillary movement. The effect and stability of the alar base cinch suture is difficult to determine and require further investigation.

Complications associated with orthognathic surgery

While most patients undergo orthognathic surgery for aesthetic purposes, aesthetic improvements are most often followed by postoperative functional complications. Therefore, patients must carefully decide whether their purpose of undergoing orthognathic surgery lies on the aesthetic side or the functional side. There is a wide variety of complications associated with orthognathic surgery. There should be a clear distinction between malpractice and complications. Complications can be resolved without any serious problems if the cause is detected early and adequate treatment provided. Oral and maxillofacial surgeons must have a full understanding of the types, causes, and treatment of complications, and should deliver this information to patients who develop these complications.

Modified alar base cinch suture fixation at the bilateral lower border of the piriform rim after a maxillary Le Fort I osteotomy

Classic cinch suture narrowing of the nasal alar base by medially suturing the bilateral nasolabial soft tissue with one long suture has a limited effect. The modified cinch method described in the present study anchors non-absorbable sutures to the bilateral lower border of the piriform rim and provides optimal direction, position, and stability. The sutures can be shortened and the strength kept stable while the surgical wounds heal. Separate bilateral sutures can also reduce interference and distortion from nasotracheal intubation and make the nasolabial profile more symmetrical. Seventeen consecutive cases of maxillary Le Fort I osteotomy were analyzed. The nasal and alar base width changes were 0.4±1.2mm and 0.1±1.1mm, respectively, and the widening rate was only 1.1%. Compared with the results of other studies, postoperative nasal flaring was well controlled using the modified cinch suture anchored to the bilateral lower border of the piriform rim described in this study.

Three-dimensional evaluation of the alar cinch suture after Le Fort I osteotomy

Orthognathic surgery has an influence on the overlying soft tissues of the translated bony maxillomandibular complex. Improvements in both function and facial appearance are the goals of surgery. However, unwanted changes to the soft tissues, especially in the nose region, frequently occur. The most common secondary change in the nasolabial region is widening of the alar base. Various surgical techniques have been developed to minimize this effect. The purpose of this study was to evaluate the changes in the nasal region due to orthognathic surgery, especially the alar width and nasal volume, using combined cone beam computed tomography (CBCT) and three-dimensional (3D) stereophotogrammetry datasets. Twenty-six patients who underwent a Le Fort I advancement osteotomy between 2006 and 2013 were included. From 2006 to 2010, no alar base cinch sutures were performed. From 2010 onwards, alar base cinch sutures were used. Preoperative and postoperative documentation consisted of 3D stereophotogrammetry and CBCT scans. 3D measurements were performed on the combined datasets, and the alar base width and nose volume were analyzed. No difference in alar base width or nose volume was observed between patients who had undergone an alar cinch and those who had not. Postoperatively the nose widened and the volume increased in both groups.

Is the Pyriform Ligament Important for Alar Width Maintenance After Le Fort I Osteotomy?

PURPOSE

To determine whether identification and incorporation of the pyriform ligament in the alar cinch results in decreased alar base widening compared with standard alar cinch techniques.

MATERIALS AND METHODS

This was a retrospective case series and the sample was composed of patients undergoing Le Fort I osteotomy. Intraoperatively, the pyriform ligament was identified and incorporated in the alar cinch suture. Greatest alar width (GAW) measured immediately after closure was compared with GAW measured at least 5 months postoperatively. The change in alar base width was compared with that reported in the literature using other alar cinch techniques. Two case examples are reported.

RESULTS

The sample was composed of 15 patients (mean age, 27.1 yr; 27% female). The mean postoperative change in GAW was 1.0 ± 0.6 mm (2.59 ± 1.59%). Postoperative change in alar base width reported in the literature ranged from 0.5 to 10.8%.

CONCLUSION

The pyriform ligament is easily identified during exposure of the maxilla and pyriform aperture and can be used to control widening of the alar base after Le Fort I osteotomy.

Nasal changes after orthognathic surgery for patients with prognathism and Class III malocclusion: analysis using three-dimensional photogrammetry

BACKGROUND/PURPOSE

Orthognathic surgery alters the position of maxilla and mandible, and consequently changes the nasal shape. The nasal change remains a concern to Asian patients. The aim of this study was to measure the nasal changes using a novel three-dimensional photographic imaging method.

METHODS

A total of 38 patients with Class III malocclusion and prognathism were enrolled. All patients underwent two-jaw surgery with the standard technique. A nasal alar cinching suture was included at the end of procedure. Facial landmarks and nasal morphology were defined and measured from pre- and postoperative three-dimensional photographic images. Intra-rater errors on landmark identification were controlled. Patient's reports of perceptual nasal changes were recorded.

RESULTS

The average width of the alar base and subalare remained similar after surgery. Alar width was increased by 0.74 mm. Nasal height and length remained the same. Nasolabial angle increased significantly. The area of nostril show revealed a significant increase and was correlated with a decrease of columella inclination. Nasal tip projection decreased significantly, by 1.99 mm. Preoperative nasal morphology was different between patients with and without cleft lip/palate, but most nasal changes were concordant. In the self-perception, 37% of patients reported improved nasal appearance, 58% reported no change, and 5% were not satisfied with the nasal changes.

CONCLUSION

After the surgery, characteristic nasal changes occurred with an increase of nasolabial angle and nostril show, but a preserved nasal width. The majority of patients did not perceive adverse nasal changes.

Modified versus classic alar base sutures after LeFort I osteotomy: a systematic review

OBJECTIVE

The purpose of this systematic review is to evaluate the efficacy of a new modified alar base cinch suture by comparing it with the commonly used classic alar base suture after LeFort I osteotomy.

STUDY DESIGN

A comprehensive search strategy was performed to include interventional studies involving the comparisons of alar base suturing methods after LeFort I osteotomy. Data analyses were conducted using the random-effects model.

RESULTS

Three studies with 146 participants undergoing LeFort I maxillary osteotomy were included in this review. The results showed that, compared with the classic method, both modified transseptal alar base suture and modified reinsertion sutures significantly decreased postoperative alar and alar base widening.

CONCLUSIONS

The modified alar base cinch suture was more effective than the classic alar base suture in maintaining preoperative alar and alar base width after LeFort I osteotomy.

Subnasal modified Le Fort I osteotomy: indications and results

PURPOSE

To study the possible morphologic changes in the nose after subnasal modified Le Fort I maxillary osteotomy to correct class III dentofacial deformities in patients with considered normal nasal morphology.

MATERIAL AND METHODS

Fifteen patients (7 males, 8 females) requiring maxillary advancement to treat class III dentofacial deformities were studied prospectively between January 2004 and January 2011. All the patients had an adequate projection of the nasal tip preoperatively preventing a conventional Le Fort I osteotomy. Patients received preoperatively (T1), 6 months after surgery (T2), and 12 months after the initial surgical procedure (T3) lateral cephalograms, CT-3D studies and clinical nose analysis to measure different morphologic variables including: the alar/nose base width, nasal tip protrusion and nasal bridge length using a digital sliding caliper directly on the soft-tissue surface of the face.

RESULTS

Mean age was 26.2 years, range 20-36 years. A significant advancement of the maxilla was noted postoperatively (mean 7.5 mm). After surgery the different anthropometric variables of the nasal region analysed had not suffered any significant variation. No significant differences were found when comparing T2 with T3 measures. No significant complications were found.

CONCLUSION

The results indicated that maxillary advancement using a subnasal modified Le Fort I osteotomy can prevent undesirable soft tissue changes of the nose when anterior repositioning of the maxilla is indicated in patients with preoperatively normal nasal morphology.

Comparison between the classical and a modified trans-septal technique of alar cinching for Le Fort I osteotomies: a prospective randomized controlled trial

The aim of this prospective randomized control trial was to analyse the efficacy of a new trans-septal alar base cinch suture in controlling alar width in patients undergoing maxillary intrusion and setback by comparing it with the traditional cinch suture. Statistical evaluation was carried out in 62 of 76 patients. Group I (31 patients) received the traditional alar base cinch suture, and group II (31 patients) received the alar base cinch suture with an anchoring bite taken through the nasal septum 10mm behind its anterior edge. In both groups the accurate identification of alar fibroareolar tissue was facilitated by an 18 gauge green needle passed extra orally. Alar base width was measured before and 6 months after surgery using Vernier callipers. Preoperative alar base width for group I was 29.76 mm (1.901SD) and for group II 29.79 mm (3.141SD); the postoperative values were 32.42 mm (1.858SD) and 29.94 mm (2.568SD), respectively. Mean alar base widening was 2.661 mm (0.800SD) in group I and 0.145 mm (2.050) in group II. The difference in alar widening was statistically significant (p<0.001). In conclusion, the trans-septal modified alar cinch suture offers better control of alar base architecture in maxillary intrusion and setback.

Nasolabial changes after maxillary advancement

BACKGROUND

Improving facial aesthetics has been shown to be a strong motivating factor in patients who decide to undergo orthognathic surgery. The nasolabial region is a keystone of facial aesthetics and thus is of central importance in planning and execution of orthognathic surgery. This article was performed to study modifications of nasolabial area after maxillary advancement.

METHODS

Forty-two patients undergoing orthognathic surgery were considered. In those patients, after Le Fort I osteotomy, only maxillary advancement was performed.

RESULTS

For each patient, several points in the nasolabial area were marked, and the distances between these landmarks were measured before and 6 months after surgery.

CONCLUSIONS

The outcomes of this study show a general trend in the widening of the alar base with an associated shortening of the columellar length and lengthening of the base of the nose.

The stability of an alar cinch suture after Le Fort I and mandibular osteotomies in Japanese patients with Class III malocclusions

We previously reported a modified technique for the placement of symmetrical cinch sutures after switching from a nasal to an oral endotracheal tube. We undertook a study to assess the effectiveness of our technique and the stability of changes in the nasolabial morphology after bimaxillary surgery. The study group comprised 30 patients aged 17-36 years who had skeletal Class III malocclusion. All patients had bimaxillary surgery with an alar base cinch suture and V-Y closure. The nasal region was measured directly or on cephalograms before, and 1 week and 1 year after operation. The suture did not alter the width of the alar base, but the nasolabial angle and projection of the tip increased significantly. The length of the upper lip did not change significantly.

Comparative analysis of two different alar base sutures after Le Fort I osteotomy: randomized double-blind controlled trial

OBJECTIVE

The aim of this prospective study was to analyze the efficacy of a new alar base cinch suture by comparing it with the commonly used cinch suture described by Schendel and Delaire in Dr. William Bell's book.

STUDY DESIGN

Thirty-five patients submitted to maxillary impaction and/or advancements of ≥ 3 mm were randomly divided into 2 groups. Group 1 received an extra oral alar base cinch suture, and patients from group 2 received the classic intraoral suture. Alar and alar base width were measured before and after surgery in digital photographs, with the patient's head in a submental oblique view. Data were reported as means and standard deviations, and difference between groups were determined using Welch t test. A P value of <.05 was considered to be statistically significant.

RESULTS

Mean alar base widening was 1.38 mm in group 1 and 2.5 mm in group 2, and mean alar widening was 1.40 mm in group 1 and 2.31 mm in group 2. The difference was statistically significant (P < .05).

CONCLUSION

Extraoral alar base cinch suture was more effective in maintaining preoperative Alar and alar base width compared with classic intraoral nasal suture.

Incomplete mobilization of the maxilla resulting in failed maxillary distraction: a case report

Maxillary distraction osteogenesis has become an accepted alternative method in the treatment of patients with severe maxillary hypoplasia in craniofacial syndromes and cleft-related deformities. Insufficient distraction, undesirable soft tissue changes, and occurrence of defective distraction vectors are among the potential complications of intraoral maxillary distraction osteogenesis. A 2-stage procedure combining maxillary advancement by distraction technique with genioplasty and mandibular setback surgery was planned to correct jaw deformities in a 22-year-old patient with severe maxillary retrusion, mandibular prognathism, and excessive lower facial height. In the first stage, osteotomies were performed and maxilla was lightly mobilized after down-fracture. Distractors were placed to the maxilla intraorally. During activation period, the maxilla rotated in a clockwise direction, producing a discrepancy between the planned and the actual vectors. Complete distraction was unsatisfactory and the complication was due to surgical technique. This case report presents the failure of maxillary distraction due to incomplete mobilization of the maxilla. Treatment of the case was achieved by the conventional osteotomy techniques at final operation. The maxilla was successfully advanced to the desired position producing good occlusion and an improved facial profile.

A simple technique to facilitate the Le Fort I osteotomy downfracture

In order to mobilize and reposition the maxilla when treating dentofacial deformities, the Le Fort I maxillary osteotomy is commonly used. Like other surgical procedures, this procedure is not without inherent difficulties. At times, it may be difficult to initially mobilize the maxilla after performing the osteotomies. Techniques used to help in the initial mobilization and downfracture of the maxilla from the pterygoid plates include digital pressure to the dentoalveolus, disimpaction forceps, spreaders, and other instruments. These techniques are similar in that they all apply a unidirectional downward vector of force on the maxilla and have various drawbacks. We present a technique that uses a 0.5-mm stainless steel traction wire to facilitate Le Fort I maxillary downfracturing by applying a forward and downward vector of force simultaneously. After vertical downfracture of the maxilla, lateral traction on the wire can be used to complete the pterygomaxillary disjunction. This technique has several advantages and is atraumatic, and requires no special instrumentation; thus, downfracturing of the maxilla is done with relatively little effort and minimal risk.