Surgical Modifications to Reduce Morbidity of Intraoral Quadrangular Le Fort Ii Osteotomy (Ioqlfiio)

Objectives: IOQLFIIO is a well-described method for correction of midfacial deficiency in skeletal class III patients. Although the indication is not uncommon many surgeons are reluctant from using the technique described by Keller et al. presumably because of higher morbidity compared with standard Le Fort I or high Le fort I osteotomies.

Methods: We present 3 surgical modifications to previous reports: 1. inferior orbital rim osteotomy by angulated piezosurgical instruments thereby avoiding the use of chisels in the orbital region, 2. osteosynthetic fixation only laterally at the zygomatic buttress with 2 L-shaped miniplates thus avoiding paranasal osteosynthesis and 3. advancement step camouflage in the lateral infraorbital region with a compound mass of autologous bone chips and fibrin glue with the intention to reduce bone bloc associated side effects.

Results: 13 consecutive patients presenting with midfacial deficiency and class III malocclusion were treated by means of IQLFIIO and mandibular osteotomies. In all cases osteotomy and consecutive downfracture could be conducted as planned by using the piezotome, sinus lift instruments and reposition forceps of Rowe. No atypical fractures were encountered. There were no cases of infraorbital nerve anesthesia. Midfacial hypesthesia was found in 54% of operated sides after 3 months, after 6 months in 23%, after 12 months in 13%. Postoperative 3D scans revealed osseous healing at the infraorbital advancement step.

Conclusion: Our results suggest that IQLFIIO can fully be conducted without chisels in the orbital region. Implementation of piezosurgery in IQLFIIO allows safe bone cutting in the orbital region. Two miniplates and step camouflage with fibrin glue-stabilized bone chips are sufficient for osseous healing.