Int. J. Oral Mac~illofac. Surg.

1996; 25:264-267 Copyright © Munksgaard 1996

Printed in Denmark. All rights resen'ed lntcmationalJournal of
Oral&
MaxillofacialSurgery
ISSN 0901-5027

Aesthetic and reconstructive surgery

The stability of maxillary Peter D. Waite 1, Tinerfe d. Tejera 2,

Boonjira AnucuP
1Department of Oral and Maxillofacial Surgery,
University of Alabama School of Dentistry,
advancement using Le Fort l Birmingham, AL, USA; 2Department of Oral
and Maxillofacial Surgery, University of North
Carolina School of Dentistry, Chapel Hill, NC,
USA; 3Department of Surgery, School of
osteotomy with and without Dentistry, Mahidol University, Bangkok,
Thailand

genial bone grafting

P. D. Waite, T. J. Tejera, B. Almctd: Tile stability of ma.rillary advancement ushzg Le
Fort I osteotomy with and without genial bone grafthzg, hit. J. Oral Maxillofac.
Surg. 1996; 25: 264-267. © Munksgaard, 1996

Abstract. The purpose of ihis study was to determine whether better stability is
achieved with genial bone grafts and four-plate rigid fixation for large advancement
Le Fort I osteotomies of the maxilla than with nongrafted osteotomies. We analyzed
radiographic data on 22 patients with obstructive sleep apnea syndrome. All patients
underwent Le Fort I osteotomy for maxillary advancement, I 1 patients without bone
grafts and 11 patients with bone grafts harvested from the mandibular symphyseal
area. Bilateral sagittal split advancement osteotomies and genial tubercle advance-
ments were also performed in all patients. Patients in the genial bone-grafted group
had a mean advancement (surgical change) of 9.7 mm and a mean relapse (postsur-
gical change) of 0.7 mm (7%). Patients who had rigid fixation alone had a mean ad- Key words: sleep apnea syndrome; genial
vancement of 10 mm and a mean relapse of 1.8 mm (18%). It is concluded that the bone grafting; rigid fixation; Le Fort I
osteotomy.
stability with genial bone grafts to the lateral wall of the maxilla with four-plate rigid
fixation was better than in the nongrafted group. Accepted for publication 21 March 1996

One of the problems associated with
large advancement of the maxilla (>4
mm) is relapse 1'2. Louis et al. found a
trend toward more relapse with larger
maxillary advancement 7. Various surgi-
cal modifications, such as extension of
the fixation period, modification of the
osteotomy, utilization of miniplates, and
lilac crest bone grafting have been re-
commended to improve maxillary
stability 8"9. Bone grafting has been
shown to be beneficial in some
studies 8'9"12. It is proposed that bone
grafting can accelerate osseous healing,
act as a physical stop, and provide a ma-
trix for bone growth 4. There are no well-
controlled studies in which the maxilla
is advanced a large distance with and
without bone grafting.
Maxillary advancement via Le Fort I
osteotomy (6-10 mm), in combination
with bilateral sagittal split ramus osteo-
tomy to advance the mandible, is a cur-
rently accepted surgical treatment for
obstructive sleep apnea syndrome 1°.
This patient group differs from the nor-
mal group of patients undergoing or-
thognathic surgery in that they are older
and most patients have both multiple
medical problems and chronic hypoxia
which may compromise normal healing.
The amount of maxillary advancement
in this patient group is also usually
greater than that of nonobstructive sleep
apnea patients. In large advancements,
there is usually minimal bone contact at
the lateral wall of the maxilla.
Split thickness genial tubercle bone
appears to have a number of advantages.
It eliminates the utilization of other do-
nor sites, and it gives rise to little mor-
bidity. The genial bone possesses a
dense cortical plate and can provide ad-
ditional immediate stability. At present,
there is no published report evaluating
and comparing the stability of large
maxillary advancements in obstructive
sleep apnea patients with bone grafts
and rigid fixation 7. The purpose of this
study was to compare the stability
achieved by the utilization of four mini-
plates combined with bone grafts at the
lateral wall of the maxilla versus four
miniplates alone in patients who under-
went large maxillomandibular advance-
ments for treatment of obstructive sleep
apnea.

Material and methods
The patients involved in this study were
evaluated and diagnosed to have obstructive
sleep apnea syndrome. All patients under-
went maxillomandibular advancement via Le
Fort I osteotomy and bilateral sagittal split
advancement osteotomy while the genial
tubercle was advanced separately as an
adjunctive procedure. No attempt was made
to change the vertical position, and no
patient had preoperative or postoperative
orthodontic treatment. Patients with antici-
pated restorative needs, such as those who
had severe periodontal disease, or who were
partially dentate or edentulous, were not
included, since these conditions might affect
the position of the upper incisor. Twenty-two
patients, 19 men and three women, who met
these criteria were selected. The age of the
patients ranged from 32 to 54 years with a
mean age of 43 years. The Le Fort I osteo-
tomies were rigidly fixed with four titanium
miniplates. Bilateral fixation of the maxilla
was achieved by using prebent OSA plates
(Walter Lorenz Corporation, Jacksonville,
FL, USA) placed on each side of the piriform
rim and standard L-shaped Wiirzburg plates
(Walter Lorenz Corporation) on each side of
the zygomatic buttress (Fig. 1). The genial
tubercles were advanced and rotated 90 °.
The anterior cortex was routinely split from
Fig. 1. Diagrammatic drawing of genial tubercle advancement and placement of bone graft at
lateral wall of maxilla.
Genial bone grafthlg h~ maxillary advancements
the posterior cortex in order to preserve the
profile of the chin. In 11 patients, the anterior
cortex was reserved for grafting at the lateral
wall of the maxilla at the time of the applica-
tion of the miniplates (Fig. 2). The anterior
cortex, sectioned diagonally into two tri-
angular pieces, was then wedged into the gap
between the osteotomy sites and fixed to the
posterior miniplates at the lateral wall of the
maxilla (Fig. 3). Three bicortical position
screws, 2.7 mm in diameter, were used for
the fixation of each bilateral sagittal split
osteotomy. A series of cephalometric radio-
graphs, presurgical (T1) within 1 week, post-
surgical (T2), and at a minimum postsurgical
follow-up period of 6 months (T3) was
obtained for follow-up. The mean follow-up
period was 10.5 months. All lateral cephalo-
metric radiographs were taken by techni-
cians on the same machine. Cephalometric
analysis was conducted by the Quick CephTM
software computer program (Orthodontic
Processing, Chula Vista, CA, USA). The
position and the orientation of the maxilla in
the horizontal plane at TI, T2, and T3 were
recorded. The landmarks used for the refer-
ence points were the incisal edge of the
upper incisor (UPI), the anterior nasal spine
(ANS), the A-point (APT), and the posterior
nasal spine (PNS). All points were identified
as reliable indicators of maxiUary position 2.
With TI as a reference position, advance-
1 /
I
/
265
ment (surgical change) of the position of
these landmarks in the horizontal plane at T2
and relapse (postsurgical change) at T3 were
recorded. From these data, postsurgical
changes from T2 to T3 in both groups
(relapse) were then calculated and summa-
rized in Tables 1 and 2. Statistical calculation
was done by a computerized program (Sta-
tistix Analytical Software). A two-tailed,
paired t-test at a significant level of P<0.05
was used to compare the postsurgical
changes from T2 to T3 within each group.
The two-tailed, unpaired t-test was used to
compare the postsurgical changes from T2 to
T3 between the two groups.
Results
The mean surgical change as measured
on the y-axis by UPI from the sella for
the bone-grafted group was 0.5_+1.8 mm
with a relapse (postsurgical change) o f
0.1_+0.8 mm. The non-bone-grafted
group had a mean surgical change of
0.6_+1.2 m m and a mean relapse (post-
surgical change) of 0.4+1.0 mm. Verti-
cal relapse was not significant.
The mean advancement, as measured
on the x-axis by UPI from the sella, for
the bone-grafted group was 9.7_+3.3 m m
with a relapse of 0.7_+0.6 m m (Table 1).
The non-bone-grafted group had a
mean advancement of 10-+3.2 m m and a
relapse of 1.8_+1.7 mm (Table 2). The
mean relapse at UPI was 7% for the
bone-grafted group, whereas the n o n -
Fig. 2. Bone harvest site after outer cortex
has been removed and genial tubercle ad-
vancement completed.
266 W a i t e et al.

bone-grafted group had a greater relapse

value of 18%.
By using TI as a reference position,
the postsurgical changes of the position
of the maxilla at T2 and T3 were com-
pared within each group with a two-
tailed, paired t-test. Significant relapses
were demonstrated in both methods of
treatment. There were significant
changes of maxillary position between
T2 and T3 at UPI (P<0.0044), ANS
(P<0.0025), APT (P<0.007), and PNS
reference points (P<0.004) within the
bone-grafted rigid fixation group. The
patient group with rigid fixation alone
had significant changes of maxillary po-
sition between T2 and T3 at UPI
(P<0.0054), ANS (P<0.0031), APT
(P<0.0031), and PNS reference points
(P<0.0021).
Fig. 3. Genial bone graft at lateral wall of maxilla rigidly fixed by L-shaped miniplate and
Relapse was evident in all the pa-
bone screws.
tients except 2/11 patients in the bone-
grafted group (patients I and 2). A two-
Table 1. Maxillary advancement and relapse of bone-graft group, as measured (in mm) at UPI, tailed, unpaired t-test was used to com-
ANS, APT, and PNS pare the amount of relapse between
UPI ANS APT PNS groups. There was a statistical differ-
Patient Adv. Rel. Adv. Rel. Adv. Rel. Adv. Rel. ence between the amount of relapse of
the bone-grafted group and the n o n -
1 5.1 0 6.4 0.5 3.5 0.3 3.4 0.2
bone-grafted group at all reference
2 5.3 0.5 7.4 0.2 5 0 7.5 0. I
points. The patients in the group with
3 6.5 0.1 7.4 0.3 5.9 0.1 6.1 0.2
rigid fixation alone demonstrated more
4 9.0 0.2 5.3 0.1 8.8 0 9.8 1.1
relapse than the group that had addi-
5 9.1 0.7 12.2 0.8 12.3 0.6 9.0 1.1
tional bone grafts when measuring at
6 9.5 0.4 12.5 0.2 11.I 0.7 10.7 0.1
UPI (P<0.0016), ANS (P<0.0014), APT
7 9.6 0.3 I 1.2 0.9 9.6 0.4 8.7 0.1
(P<0.0389), and PNS reference points
8 11.1 !.5 10.1 0.8 12.7 1.8 10.0 1.1
(P<0.0080).
9 12.4 0.8 13.6 0.9 11.9 1.2 10.1 0.8
10 13.8 2.0 16.1 0.6 14.7 2.4 10.8 2
11 15.5 1.0 15.3 2.1 13.4 1.5 14.1 1.6 Discussion
Mean 9.7 0.7 10.7 0.7 9.9 0.8 9.1 0.7 The role of bone grafting in large maxil-
SD 3.3 0.6 3.7 0.6 3.7 0.8 2.8 0.7 lary advancements remains somewhat
questionable, although ARAUJO et al),
HORSTER5, and LUYK & X,VARD-BooTlls
Table 2. Maxillary advancement and relapse of non-bone-graft group, as measured (in mm) at
UPI, ANS, APT, and PNS reported that bone grafting was benefi-
cial. WILLMAR13, however, did not find
UPI ANS APT PNS
statistical significance when comparing
Patient Adv. Rel. Adv. Rel. Adv. Rel. Adv. Rel. grafted and nongrafted groups of the
1 4.0 0.3 7.6 0.5 5.6 0.7 3.8 0.3 patients.
2 6.8 0.1 7.8 0.3 5.6 0.2 4.6 0.4 Large advancement of the maxilla
3 7.4 0. I 11.1 0.9 8.2 0.7 7.9 0.8 (>4 mm) usually leaves a bone gap at
4 8.6 1.2 11 1.4 7.3 1 8.4 1.2 the lateral wall of the maxillary sinus.
5 9.6 2 11 2.4 7.3 1.8 11.3 3.2 The buccal soft tissue subsequently may
6 9.7 0.4 5.6 0.8 7.0 0.9 8.6 0.5 herniate into the bone gap, thereby com-
7 10.6 2.8 13.1 3.6 12.9 3.1 10.1 3.0 promising the bony union and poten-
8 11.8 4.8 17.3 4.0 11.5 4.1 14.1 4.5 tially decreasing the stability. In our ex-
9 12.1 1.1 12.0 1.0 10.8 1.2 11.2 1.1 perience of large advancements of the
I0 13.8 1.4 8.8 0.7 14 0.6 12.3 10.8 maxilla with only rigid fixation, non-
11 15.2 5.1 16.1 4.8 14.8 4.2 13.7 3.9 union occurred, resulting in malocclu-
sion and relapse. Patients also com-
glean 10.0 1.8 11 1.9 9.5 1.7 9.6 1.9
plained of sinus pain and dysfunction.
SD 3.2 1.7 3.6 1.6 3.4 1.4 3.4 1.5
When these patients were reoperated, fi-

brous tissue ingrowth into the maxillary
sinus was noted, and no evidence of
bony union of the osteotomy sites was
seen. In general, the utilization of auto-
genous bone grafts is believed to accel-
erate bony union ~.
The advantage of the genial bone graft
is that this bone is harvested from an in-
traoral site. There is no need for a second
surgical site, as in cranial, iliae crest, or
tibial bone harvesting, a fact which im-
plies less morbidity6. The genial bone
graft has a property of cortical bone
which can provide an immediate physi-
cal stop. It will function as a space main-
tainer and a matrix for ossification.
Therefore, the graft may improve long-
term stability through a better quality of
bony healing at the osteotomy site. This
may be of benefit since only the first 3
months of initial stability are provided
by internal rigid fixation3. Alloplastic al-
ternatives, such as PBHA (porous block
hydroxyapatite) interpositional implants
have been advocated. WARDROP &
WOLFORDu found that this material gen-
erally worked very well, yet they
stressed that the utilization of PBHA im-
plants in combination with rigid fixation
was not a guaranteed method of provid-
ing long-term stability for maxillary
down grafts and advancements.
On the basis of this clinical experi-
ence and the results of this study, we
Genial bone grafthlg bz maxillary advancements
recommend that bone grafting and four-
plate rigid fixation be routinely done for
large advancements of the maxilla by Le
Fort I osteotomy.
References
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Address:
Peter D. Waite, MPH, DDS, MD
Department of Oral and Marillofacial
Surgery
University of Alabama School of Dentistry
1919 - 7th Avenue
South Birmingham, AL 35294
USA