Early Surgery: Le Fort I Advancement in a 6-Year-Old Patient-A Therapeutic Approach Using a Modified Le Fort I Osteotomy

Abstract

Orthognathic surgery in young patients before completion of skeletal growth is still sharply discussed today. In the following case report of a 6-year-old patient, however, there was a vital indication for treatment. The main clinical symptoms were characterized by impaired hearing as a result of constantly recurring seromucotympanum and adenoids, persistent rhinorrhea and otorrhea, chronic tonsillitis and chronic otitis media. ENT interventions such as the partial C-tonsillectomy, paracentesis with tympanic drainage, adenotomy and tube dilation with balloon catheter did not bring lasting success. Despite antibiotic therapy with aminopenicillins and cephalosporins in ß-hemolytic streptococci, no improvement in the symptoms could ultimately be achieved, so that there was a life-threatening risk of endocarditis with previous pulmonary valve replacement. In our orthognathic consultation, a maxillary retrognathism with a frontal crossbite was diagnosed. With an interdisciplinary consideration of the risks and side effects, an early surgical treatment in the sense of an upper jaw advancement with dilatation of the airways and evacuation of the maxillary sinuses was carried out. The operative challenge consisted of determining an ideal osteotomy line so as not to damage permanent tooth structures. Furthermore, the patient and his family had to understand the expected outcomes, potential risks, and possible complications that might arise from early surgical interventions, such as a subsequent maxillary growth discrepancy. After successful surgery the patient could already be discharged on the 2nd postoperative day and soon no longer showed any complaints or symptoms with regard to the tube ventilation disorder and the seromucotympanum-also no dental or skeletal recurrence has been evident up to now. With 25 years of experience in "Early surgery," we have learned that orthognathic operations in children and adolescents might have decisive effects on life quality.

Fig. 1

Preoperative 3D surface reconstruction of a CBCT showing the infraorbital nerves (orange), deciduous teeth and dental buds (white)

Fig. 2

a Intraoperative picture showing micro-osteosynthesis plates fixed with microscrews on the zygomaticoalveolar crest and piriform aperture of the upper jaw. b Intraoperative picture showing the position of elastics on the self-tapping set TADs in class III position

Fig. 3

a Preoperative photodocumentation. b Photodocumentation 1 week after operation. c Follow-up photodocumentation 3 years and 1 month after operation

Fig. 4

a Preoperative intraoral scan. b Follow-up intraoral scan 3 years and 1 month postoperative

Fig. 5

a X-ray images generated from a cbct scan 1 month and 7 days preoperatively. b X-ray images generated from a cbct scan 1 year and 5 months postoperatively

Fig. 6

Prof Dr Jean Delaire (http://www.estmjs.org/members/jean-delaire/)