CASE REPORT:

Blindness After Lefort I Osteotomy: A Possible Complication

Associated With Pterygomaxillary Separation

Antonio Augusto Cruz, Antonio Santos

Journal Of Cranio- Maxillofacial Surgery, 34, 2006

Dr. Gireesha
III MDS
 INTRODUCTION

• Lefort I osteotomy is a standard technique for the surgical

management of dentofacial anomalies and for providing access for
other surgical preocedures
• Key step- Pterygomaxillary disjunction
• Transection of this suture - intra & extra cranial complications
• Visual loss after Lefort I osteotomy is a devastating complication, the
mechanism of which is not known
 HISTORY

• 1859, Germany, Von Langenbach- 1st maxillary osteotomy

▫ At the level of fracture line described by Le Fort in 1901
▫ Performed to access nasopharyngeal polyp
• 1867, Chever- mobilisation of maxilla along Le Fort line using bone
chisels
▫ For eradicating nasal obstruction caused by recurrent epistaxis
• 1927, Wassmund- 1st to use Le Fort osteotomy for orthodontic
correction
▫ Post- traumatic malocclusion and midfacial deformities
• Schuchardt- Pterygomaxillary disjunction for mobilisation of maxilla
▫ He noticed that incomplete osteotomy was insufficient for anterior
repositioning and recommended # at pterygomaxillary junction

• 1960, Obwegeser- precision of the operative technique

2 technical issues were addressed by him
▫ Complete mobilisation of maxilla without tissue resistance
▫ Use of bone graft between the pterygoid plates and the maxillary
tuberosity
SURGICAL ANATOMY
8 and 20 mm
10 to 12 mm from nasal floor

10 to 14 mm
Infra orbital artery- 32mm
Descinding palatine
Artery- 25 mm
PSA- 15 mm
 SURGICAL TECHNIQUE
• Surgical exposure of maxilla
1. Anterior – to expose the piriform rim
2. Superior- lateral- to expose the infraorbital neurovascular bundle
3. Posterior- carried to the zygomatic suture, zygomatic buttress, and
zygomaticomaxillary suture

• Lateral Osteotomy cuts

• Nasal septal osteotomy
• Pterygomaxillary dysjunction
• In summary Le Fort I osteotomy cuts are made in
▫ Lateral wall of maxilla
▫ Medial sinus wall
▫ Nasal septum
▫ Pterygomaxillary junction
 CASE REPORT

• 22 year female, presented with vision loss in the right eye

• Lefort I osteotomy for occlusal correction 1 week before
• Immediate post-op period
▫ Swelling of the right upper
and lower eye lids
▫ Absence of perception of light
▫ Inconclusive MR imaging

• Administration of high dose steroids- no improvement

• 1 week post-operatively
▫ Complete blepharoptosis on the right side
▫ Intense chemosis
▫ Loss of abduction
▫ Pupillary dilatation
▫ Normal occular fundus but absence of light perception
• CT scan examination
▫ Complex fractures of the pterygoid plates on both sides
▫ On right side- comminuted fracture of the medial and lateral walls of the
maxillary sinus, greater wing of the sphenoid, lateral and anterior walls of
the sphenoid sinus
▫ Fractures involving the superior and inferior orbital fissures with the bone
fragment extending from the superior orbital fissure to the orbital apex
 DISCUSSION

• Pterygomaxillary dysjunction involves separation between

▫ Maxillary tuberosity
▫ Pyramidal process of the palatine bone
▫ Pterygoid plates of the sphenoid bone
• Complexity of sutures between these three bones increases with age
▫ In adults this region is charecterised by heavily interdigitated osseous
structures
▫ Disarticulated easily during childhood
• Comprehensive literature review

• Disclosed 25 reports of ophthalmic and neurologic complications

Skull Base Complications Associated With Lefort I Osteotomy

AUTHORS DIAGNOSIS COMPLICATION

Tomasetti et al 1976 Retruded maxilla Dry eye
Brady et al 1981 Hemifacial microsomia Internal carotid thrombosis
Newhouse et al VME Traumati arterio-venous fistula
1982 on right side
Watts 1984 Retruded maxilla 6th nerve palsy
Habal 1986 Retruded maxilla Carotid cavernous fistula
Carr & Gillbert 1986 CLP 3rd nerve palsy
Lanigan & Tubman VME Carotid cavernous fistula
1987
Reiner et al 1988 Retruded maxilla 6th nerve palsy
Hes & Man 1988 Maxillary hypoplasia Carotid cavernous fistula
Skull Base Complications Associated With Lefort I Osteotomy
AUTHORS DIAGNOSIS COMPLICATION
Lanigan 1993 Malocclusion 3rd nerve palsy, bllindness
Midfacial retrusion Orbital haemorrhage
VME, apertognathia Blindness
VME Dryness
VME Dryness, ipsilateral
hyposthesia, dryness f
turbinates
Bendor- Samuel et Maxillary hypoplasia Carotid cavernous fistula, 3rd
al 1995 secondary to CLP nerve palsy
Maxillary hypoplasia Blindness
secondary to CLP
Girotto et al 1998 Congenital hemifacial Blindness, 6th nerve palsy
atrophy
Maxillary hypoplasia CSF leak, superior orbital
fissure syndrome
Unilateral CLP Blindness
Skull Base Complications Associated With Lefort I Osteotomy

AUTHORS DIAGNOSIS COMPLICATION

Wilson et al 2000 Maxillary hypoplasia CSF, superior orbital fissure
syndrome
Maxillary hypoplasia Blindness & 6th nerve palsy
Loe et al 2002 Retruded maxilla Aneurysym at the junction of
secondary to CLP basilar artery & posterior
cerebral artery, blindness
Cleft of lip and alveolus Mydriasis, 6th nerve parexis,
blindness
• Overall complications can be grouped into four categories
▫ Loss of function of lacrimal gland
▫ Cranial nerve palsies
▫ Damage to internal carotid artery
▫ Loss of vision
• 4 cases of impaired lacrimal gland function
▫ Damage to the greater superficial petrosal, sphenopalatine ganglion or
maxillary nerve during its path to the orbit through inferior orbital
fissure
• Full recovery occurred over a period of 8- 24 months
• 6 cases of isolated cranial nerve palsies
▫ Only 2 cases had a permanent sequel
▫ All the cases recovered within 2-18 months after surgery

• 7 patients had vascular accidents related to ICA

• 1 patient had acute orbital haemorrhage from unknown source
▫ Four patients had permanent neurological complications
• There are 8 case reports of blindness
▫ 4 cases- 3rd/ 6th nerve palsies
▫ 1 case- intracranial vascular aneurysm
▫ 3 cases- blindness appearing as an isolated complication
• The data summerised that different types of complications may occur
in one patient hence may be linked to a common mechanism
• Postoperative CT scans were performed in 17 cases
▫ 10 cases- no evidence of skull base fractures
 Hence speculated the blindness is due to hypoperfusion and hypotension of
the optic nerve

▫ 7 cases- atypical # of sphenoid bone, with bone fragment close to the

orbita apex in the superior orbital fissure

Radiological findings of the case described follow this pattern

• Conclusion……

“Adverse transmission of forces via the sphenoid bone to the base of

the skull during separation of the pterygomaxillary junction”

• Instances of rare complications reported with Le Fort I are as follows:
▫ Blindness: 3 cases, 2 of which were permanent
▫ Nasolacrimal obstruction or injury: 3 cases treated with
dacrocystorhinostomy or turbinectomy/septoplasty
▫ Postoperative hemorrhage that required intervention: 21 cases
▫ Intraoperative hemorrhage that required special intervention: 18 cases
▫ Orbital compartment syndrome: 1 case
▫ Avascular necrosis: 36 cases (most of which were segmental)
▫ False aneurysm of sphenopalatine artery: 2 cases

Complications of orthognathic surgery

R.A. Bays, G.F. Bouloux, Oral Maxillofacial Surg Clin N Am, 2003
• Instances of rare complications reported with Le Fort I are as follows:
▫ False aneurysm of maxillary artery: 1 case
▫ Carotid-cavernous sinus fistula: 1 case
▫ Vomerosphenoidal dysarticulation: 1 case
▫ Cranial nerve III palsy: 1 case, which spontaneously resolved
▫ Maxillary sinusitis: 4 cases
▫ Keratitis: 3 cases

Complications of orthognathic surgery

R.A. Bays, G.F. Bouloux, Oral Maxillofacial Surg Clin N Am, 2003
• Transection of pterygomaxillary junction is the most critical step in
Lefort I osteotomies
• Surgeons must be aware of the skull base complications due to
concussion and counter coupe injuries
• Must avoid any mobilisation of maxilla until being sure that a
complete separation of this bone from pterygoid plates has been
achieved
 REFERENCES

• Case Report:
Blindness After Le Fort I Osteotomy: A Possible Complication
Associated With Pterygomaxillary Seperation, Antonio Auguto Et Al,
Journal Of Cranio- Maxillofacial Surgery, 2006
• Complications Of Orthognathic Surgery, R.A. Bays, G.F. Bouloux,
Oral Maxillofacial Surg Clin N Am, 2003
• Gray’s Anatomy- 39th Edition
• Timothy A. Turvey- Oral & Maxillofacial Surgery, 2nd Edition, Vol III