Int. J. Oral Maxillofac. Surg.

2009; 38: 1250–1255

doi:10.1016/j.ijom.2009.07.003, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Postoperative skeletal stability I. Yoshioka, A. Khanal, M. Kodama,

N. Furuta, K. Tominaga
Division of Maxillofacial Diagnostic and

and accuracy of a new Surgical Science, Department of Oral and

Maxillofacial Surgery, Kyushu Dental College,
Kitakyushu, 803-8580, Japan

combined Le Fort I and

horseshoe osteotomy for
superior repositioning of the
maxilla
I. Yoshioka, A. Khanal, M. Kodama, N. Furuta, K. Tominaga: Postoperative skeletal
stability and accuracy of a new combined Le Fort I and horseshoe osteotomy for
superior repositioning of the maxilla. Int. J. Oral Maxillofac. Surg. 2009; 38: 1250–
1255. # 2009 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. Postoperative skeletal stability and accuracy were evaluated in a

combination of Le Fort I and horseshoe osteotomies for superior repositioning of
maxilla in bi-maxillary surgeries in 19 consecutive patients. 9 underwent Le Fort I
osteotomy alone (preoperative planned superior movement <3.5 mm). 10
underwent Le Fort I and horseshoe osteotomy (combination group) (preoperative
planned superior movement >3.5 mm). The maxilla was osteotomized and fixed
with 4 titanium Le Fort plates followed by bilateral sagittal split ramus osteotomy of
the mandible, fixed with 2 semi-rigid titanium miniplates. Maxillomandibular
fixation was performed for 1 week. Lateral cephalograms were obtained
preoperatively, 1 week postoperatively, 3, 6, 12 months later. The changes in point
A, point of maxillary tuberosity, and upper molar mesial cusp tip were examined.
Discrepancy between the planned and measured superior movement of the maxilla
in the Le Fort I and combination groups was 0.30 and 0.23 mm, respectively. The
Keywords: Le Fort I osteotomy; horseshoe
maxillae in both groups were repositioned close to their planned positions during
osteotomy; superior repositioning of maxilla;
surgery. 1 year later, both groups showed skeletal stability with no significant stability.
postoperative changes. When high superior repositioning of the maxilla is indicated,
horseshoe osteotomy combined with Le Fort I is reliable and useful for accuracy and Accepted for publication 7 July 2009
postoperative stability. Available online 6 August 2009

0901-5027/1201250 + 06 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Superior repositioning of the maxilla is
often required when treating maxillofacial
deformities with vertical maxillary excess,
for example in cases of long face or open
bite. Impacting the maxilla superiorly as a
single segment after Le Fort I osteotomy is
sometimes difficult for high impactions
owing to the presence of bone around
the descending palatine artery (DPA)
and nasal concha. Bone around this vessel
can be trimmed equally for superior repo-
sitioning of the maxilla, but there is always
a potential risk of damaging or cutting it,
which may lead to severe hemorrhage.
Controversy exists regarding the manage-
ment of the DPA during Le Fort I osteot-
omy. Some surgeons advocate preserving
the DPA while others ligate the vessels.
LANIGAN et al.15 have reported cases of
avascular necrosis of the maxilla after
ligating the DPA. DODSON et al.6 using
laser Doppler flowmetry have shown that
mean maxillary gingival blood flow in the
DPA-ligated or the DPA-preserved group
to be similar.
In 1975, HALL and RODDY11 described
horseshoe osteotomy, which was initially
called ‘total maxillary alveolar osteotomy’.
Later in the same year, WOLFORD and
EPKER22, and WEST and McNEIL21 described
similar maxillary osteotomies with some
modifications, which were not combined
with a Le Fort I osteotomy. In 1977, BELL
and McBRIDE2 introduced horseshoe palatal
osteotomy in combination with Le Fort I
osteotomy. The biggest advantage of this
technique was that it allows high superior
repositioning of the maxilla, especially in
the posterior region while safeguarding the
DPA because there is no need for bone
trimming around the vessel and this helps
to maintain the nasal chamber volume.
Horseshoe combined with Le Fort I
osteotomy is indicated in multi-segment
maxillary osteotomies and in high impac-
tion cases. There are few reports about the
stability of the maxilla after combined
horseshoe and Le Fort I osteotomy2,12.
The objective of this study was to evaluate
the postoperative stability of the maxilla
treated with combined Le Fort I and horse-
shoe osteotomy and its accuracy in bimax-
illary surgeries. The authors have also
tried to introduce a new technique of
further dividing the palate into multi seg-
ments to facilitate higher impaction of the
maxilla.
Patients and Methods
Patient Selection
19 consecutive patients referred for surgi-
cal correction of dentofacial deformity
Horseshoe osteotomy in maxilla 1251
from 2003 to 2005 were studied in this Surgical Procedure
prospective study. The exclusion criteria
were: single jaw surgery; periodontal dis- All surgery was performed by a single
ease judged severe by the surgeon; pre- surgeon (K.T). Soft tissue dissection was
vious maxillo-mandibular surgery; any performed in the standard fashion, as pre-
history of trauma and craniofacial syn- viously described3. The Le Fort I osteot-
dromes; and inability to follow-up for omy technique followed was that of BELL
the study protocol. et al3. After the Le Fort I osteotomy and
The patients were divided into 2 groups down fracture, horseshoe osteotomy was
depending on the amount of superior repo- performed from the superior surface of the
sitioning of the maxilla proposed after down fractured maxilla. Using a round bur
preoperative planning from cephalometric (0.05 mm), guiding holes were made from
and model analysis, and from clinical the superior surface of the down fractured
evaluation of the patients’ facial profiles. maxilla through the anterior nasal floor
From the authors’ previous experience, and the maxillary sinus into the oral cavity
superior repositioning of the maxilla (Fig. 1a). The holes were drilled in a
>3.5 mm in the posterior region as a horseshoe form so as to divide the maxilla
single Le Fort I segment is difficult to into dentoalveolar and palatal compo-
achieve, so horseshoe osteotomy was per- nents. The bur was drilled carefully from
formed in cases where preoperative super- the lateral side of the palate directed medi-
ior movement of the maxilla was ally to avoid injury to the dental roots.
>3.5 mm. 9 patients (2 male, 7 female; Using an osteotome, the guiding holes
age range: 18–31 years, average 24.4 were joined and the down fractured max-
years) underwent Le Fort I osteotomy in illa was separated into two parts; the den-
which superior repositioning of the max- toalveolar and the palatal components.
illa was <3.5 mm. The remaining 10 Palatal mucosa and periosteum were pre-
patients (2 male, 8 female; age range: served (Fig. 1 b, c).
19–31 years, average 25.11 years) under- Sometimes, even after performing
went Le Fort I and horseshoe combination horseshoe osteotomy, it is difficult to repo-
osteotomy in which superior repositioning sition the maxilla superiorly due to the
of the maxilla was >3.5 mm. All patients bony interferences between the palatal and
received pre- and postoperative orthodon- the dentoalveolar components. The proxi-
tic treatment. mity to the dental roots on one side and the
Fig. 1. (a) Guiding drills made by a small round bur (0.05 mm) from the superior aspect of the
down fractured maxilla. (b) The guiding holes are joined using an osteotome that separates the
down fractured maxilla into 2 portions. (c) The down fractured maxilla after horseshoe
osteotomy with dentoalveolar and palatal component. Mucoperisoteum and palatine vessels
are preserved. (d) Cross-section after horseshoe osteotomy at first molar teeth. Even after
performing the horseshoe osteotomy, the desired impaction cannot be achieved due to bilateral
undercuts as seen here. The proximity of dental roots in the dentoalveolar component and the
descending palatine artery (DPA) along with palatine vessels in the palatal component makes
further trimming almost impossible.
1252 Yoshioka et al.
Fig. 2. (a) To achieve greater superior impaction of the dentoalveolar component, the palatal
portion can be further divided into 3 pieces as seen here. (b) Completed 3 piece horseshoe
osteotomy. (c) Cross section of the 3 piece horseshoe osteotomy, which allows more superior
impaction as there are no undercut hindrances.
DPA on the other makes further trimming
of the dentoalveolar or the palatal compo-
nent almost impossible (Fig. 1d).
To overcome this problem, the authors
have developed a new technique of further
dividing the palatal component into 3 parts
through 2 sagittal osteotomies. At first,
guiding holes were made using the same
round bur (0.05 mm) over the intended
2 parallel osteotomy lines, which were
later joined by an osteotome to divide it
into 3 equal segments. The periosteum
and the palatal mucosa were preserved
(Fig. 2 a, b).
Osteotomizing the palatal component
into 3 parts allows greater flexibility for
higher superior impaction of the dentoal-
veolar component. This technique main-
tains the posterior nasal chamber volume
while the anterior aspect of the nasal floor
in the dentoalveolar component can be
shaved easily using round burs to maintain
the anterior nasal airway volume, thus
eliminating the need for procedures such
as turbinectomies. The DPA and anterior
palatine vessels are safeguarded (Fig. 2 c).
This new technique of dividing the palatal
component into multiple segments was
carried out in all patients in the combina-
tion group (n=10).
A double splint technique was applied
to achieve the planned position of the
dentoalveolar component intraoperatively
and fixed with 4 titanium 5-hole Le Fort
plates in both groups. No bony fixation
was performed for the palatal component
in the combination group. No iliac bone or
synthetic bone was grafted along the lat-
eral or posterior maxillary walls. In all 19
cases, bilateral sagittal split ramus osteot-
omy was performed following Trauner/
Obwegeser’s technique19 and fixed with
2 semi-rigid 4-hole titanium miniplates at
the anterior mandibular ramus. Maxillo-
mandibular fixation (MMF) with steel
wires (0.03 mm) was released 1 week
postoperatively.
Fig. 3. Method of analysing lateral cephalograms for superior movement of the maxilla using
upper molar cusp tip (UMT) in relation to Frankfort horizontal plane (FH).
Method of Analysis
The subjects were evaluated 2 weeks
before surgery (T0) and at 1 week (T1),
3 months (T2), 6 months (T3), and 1 year
(T4) after surgery. Lateral cephalograms
were taken with the patient oriented to the
Frankfort horizontal plane with teeth in
centric occlusion. The reliability of super-
ior repositioning was assessed on lateral
cephalograms 1 week postoperatively
(Fig. 3). Operative changes of the upper
first molar cusp tip (UMT) from the Frank-
fort horizontal plane were measured. Dis-
crepancy between prediction and actual
superior movement of UMT were exam-
ined. Postoperative changes of the A point
and point of maxillary tuberosity (PMT)
were measured. The linear measures on
lateral cephalograms used in this study are
illustrated in Fig. 4. X and Y coordinate
measurements were obtained by using a
line parallel to the Frankfort horizontal
plane at the nasion for the X coordinate.
A perpendicular line was drawn intersect-
ing the first line at the nasion. These X-
and Y-coordinated axes were transcribed
onto each successive radiograph by super-
imposition on the ‘best fit’ of sella, nasion,
anterior and posterior cranial base land-
marks.
The relevant points were indicated on
the X and Y axes. Movements of these
points were represented as linear measure-
ments in millimeters on both the axes. On
the X-axis, anterior movement was indi-
cated as a positive value, and posterior
movement as a negative value. On the Y-
axis, superior movement was indicated as
a positive value, and inferior movement as
a negative value. Statistical analysis was
performed with the paired t-test for inde-
pendent samples to compare the groups.
All cephalometric evaluation was car-
ried out by one of the author, who was
unaware of the cephalograms being exam-
ined, to maintain impartiality.
 Horseshoe osteotomy in maxilla 1253

of point A and PMT were small

(<0.5 mm) at any examination interval.

Fig. 4. Method of analysing lateral cephalograms for postoperative changes of point A (A) and
point of maxillary tuberosity (PMT) with the construction of x and y axes.
Results
No injury to the DPA or the anterior
palatine vessels was encountered during
these procedures. There were no compli-
cations such as non-union or vascular
compromise to the maxilla in any of the
cases 1 year postoperatively. In the com-
bination group, a few patients experienced
slightly abnormal contouring of the palate,
which resolved to its normal morphology
about 3 months postoperatively. No cut-
ting or tearing through the oral mucosa
was experienced. No patient complained
of any remarkable change in their voice.
Accuracy for superior repositioning of
the maxilla
Table 1 shows the reliability of superior
repositioning of the maxilla in both the
groups obtained by measuring the UMT 1
week after surgery (T1). The mean super-
ior prediction for the combination group
was 5.05 mm (range 4.0–7.0 mm), the
mean actual position was 4.84 mm,
accounting for 0.30 mm as a discrepancy
value between the planned and actual
maxillary positioning. In the Le Fort I
group, the mean superior prediction was
3.06 mm (2.5–3.5 mm) and the mean
actual position 2.82 mm with a discre-
pancy value of 0.23 mm. This shows that
the maxillae in both groups were reposi-
tioned nearly to their planned positions
during surgery.
Postoperative stability
Table 2 shows the postoperative changes
of point A and PMT with no significant
differences between the two groups in
horizontal and vertical stability 1 year
after surgery. Overall, the skeletal changes
Discussion
When high superior repositioning of the
maxilla is indicated, for example in cases
of vertical maxillary excess with long face
or open bite, the bone around the descend-
ing palatine artery or the inferior nasal
concha is a barrier to achieve the planned
superior repositioning using Le Fort I
osteotomy. BELL et al2,4 and EPKER
et al.7 suggested dissecting the inferior
nasal concha or turbinectomy when super-
ior repositioning of the maxilla was >6 or
8 mm. Dissection of the inferior nasal
concha potentially causes atrophic rhini-
tis5. Bone around the DPA can be trimmed
for superior repositioning of the maxilla,
but there is always a risk of damaging the
vessels, leading to haemorrhage and vas-
cular compromise of the maxilla. Maxil-
lary superior impaction is easier after
ligating the DPA, but LANIGAN et al.15 have
reported a few cases of avascular necrosis
of the maxilla following it. Some studies
have shown that the blood supply to the
maxilla is only temporarily decreased and
does not cause long-term vascular com-
promise6,9.
The combination of Le Fort I and horse-
shoe osteotomy allows high superior
impaction of the maxilla making it suita-
ble for procedures such as facial height
reduction in cases with vertical maxillary
excess. The present cases showed that
when superior repositioning of the maxilla
was >3.5 mm on the first molar, combina-
tion osteotomy was indicated. Superior
movement of the posterior maxilla
>3.5 mm was determined as the criterion
for horseshoe osteotomy, based on past
experience in single segment Le Fort I
osteotomies. Considering the proximity
of the infra-orbital foramen, length of

Table 1. Reliability of superior repositioning.

Combination of Le Fort I and horseshoe osteotomy Le Fort I osteotomy
prediction actual discrepancy Case prprediction actual discrepancy
Case No (mm) (mm) (mm) No (mm) (mm) (mm)
1. 5.0 4.23 0.77 1. 3.5 3.10 0.40
2. 5.0 4.58 0.42 2. 3.0 2.84 0.16
3. 4.0 4.14 0.14 3. 3.0 2.60 0.40
4. 7.5 7.61 0.11 4. 3.0 2.56 0.44
5. 4.0 4.04 0.04 5. 3.0 2.94 0.06
6. 4.0 3.75 0.25 6. 2.5 2.40 0.10
7. 6.0 5.45 0.55 7. 3.0 2.91 0.09
8. 6.0 5.79 0.21 8. 3.5 3.38 0.12
9. 4.0 3.65 0.35 9. 3.0 2.69 0.31
10. 5.0 5.12 0.17
mean 5.05 4.84 0.30 3.06 2.82 0.23
SD 1.11 1.49 0.21 0.28 0.28 0.15
1254 Yoshioka et al.
Table 2. Postoperative changes (mm) of point A and PMT from immediate post-surgery (mm).
procedure
point A X Combination
Le Fort I
Y Combination Le Fort I
PMT X Combination Le Fort I
Y Combination Le Fort I
Data are mean  SD.
X: (+)indicated anterior movement,( )indicated posterior movement
Y: (+)indicated inferior movement,( )indicated superior movement
T1, 1-week postoperative; T2, 3-month postoperative;
T3, 6-month postoperative; T4, 1-year postoperative, respectively.
Statistical analysis was performed with the paired t test for independent samples to compare between the both groups.
PMT : point of maxillary tuberosity
roots and stiffness of the palatal mucosa,
the authors achieved the highest superior
repositioning of 7.6 mm using combina-
tion osteotomy with high accuracy of the
planned superior maxillary movement.
The accuracy rate of the Le Fort I group
was equally high during superior reposi-
tioning of the maxilla. This procedure also
decreases the risk of injury to the DPA,
which avoids the potential risk of haemor-
rhage in the posterior maxilla. The com-
bination of Le Fort I and horseshoe
osteotomy also maintains the chamber size
of the nasal cavity during superior impac-
tion of the maxilla.
Various studies have shown good post-
operative stability after superior reposi-
tioning of the
maxilla1,7,8,10,13,14,16,18,20,22. PROFFIT
et al.17 reported that superior repositioning
of the maxilla was the most stable surgical
procedure of the maxilla. All these proce-
dures were performed as a single maxil-
lary segment without horseshoe
osteotomy. There are few papers on super-
ior repositioning of the maxilla in the
current literature. BELL and McBRIDE2
and HARADA et al.12 have shown good
postoperative stability with Le Fort I com-
bined with horseshoe osteotomy during
superior positioning of the maxilla. The
authors results have also shown that the
maxillae were repositioned nearly to their
planned positions in both groups. This
suggests that combining Le Fort I with
horseshoe osteotomy is a reliable method
for high superior repositioning of the max-
illa. In addition, postoperative changes of
point A and PMT were very small
(<0.5 mm) at any examination interval
showing postoperative stability of the
superiorly repositioned maxilla.
This new surgical modification of com-
bining horseshoe osteotomy with Le Fort I
osteotomy for superior repositioning of
the maxilla has several advantages, such
as high and reliable superior repositioning
of the maxilla, decreased risk of damaging
n T2-T1
10 0.21  0.13 0.24  0.12
9 0.26  0.10 0.24  0.09
10 9 0.28  0.10 0.23  0.08 0.32  0.07 0.24  0.11
10 9 0.18  0.13 0.28  0.07 0.22  0.13 0.26  0.08
10 9 0.35  0.09 0.33  0.05 0.32  0.07 0.35  0.06
or cutting the DPA and maintaining the
functional nasal airway. Complications
include: cutting or injury to the anterior
palatine vessels; tearing the oral (palatal)
mucosa; necrosis of palatal bone segments
if detached from the palatal soft tissues
and periosteum; abnormal contour of the
palate temporarily; and damage to the
tooth roots.
The authors conclude that the combina-
tion of horseshoe osteotomy with le Fort I
osteotomy is a useful technique for reli-
able superior repositioning of the maxilla
with good postoperative accuracy and sta-
bility.
Competing interests
None declared
Funding
None
Ethical approval
Not required
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