Comparison of skeletal stability with rigid and wire fixation in patients who have undergone Le Fort I and Anterior Segmental Maxillary Osteotomy

INTRODUCTION

Orthognathic surgery is performed to reorganize the facial skeleton, correcting deformities to achieve harmoniously alignment with the skull base for perfect dental occlusion. Le Fort I osteotomy addresses various maxillary issues, including anteroposterior hypoplasia or hyperplasia, vertical excess or deficiency, anterior open bite, and transverse discrepancies. Skeletal stability post-surgery depends on factors such as orthodontics, scar retraction, nasal septum interference, fixation type, and occlusion quality. Ongoing discussions are exploring the intriguing balance between the skeletal stability and occlusal harmony of wire osteosynthesis versus rigid internal fixation.

In 1859, Von Langenbeck pioneered maxillary osteotomy. Subsequently, in 1868, David Williams Cheever of Boston executed a groundbreaking procedure, known as a Le Fort I osteotomy, to eliminate a sizable nasopharyngeal polyp. This technique, involving bilateral osteotomies, was later recognized as Cheever’s “double operation,” representing a significant milestone in the field.[^1-3] The Le Fort I osteotomy, first introduced by Wassmund[^4,5] in 1927, addressed anterior open bite. William Bell[⁶] further substantiated the biological foundation for the safety provided by Le Fort I downfracture osteotomy. Gunther Cohn-Stock,[^7,8] known as the father of maxillary orthognathic surgery, introduced the anterior segmental maxillary osteotomy in 1921. This diversified the techniques, leading to modified designs of AMO with the downfracture methods gaining prominence, employed by Wassmund[⁴] and Wunderer.[⁹] The Wassmund method ensures optimal vascularity,[⁴] and Wunderer combined palatal flap elevation with labial pedicle preservation, and down-fracture utilizes circum-vestibular incision. Esthetic and functional success outcomes of orthognathic surgery hinge on long-term stability, with fixation methods such as rigid fixation and wire osteosynthesis playing crucial roles. Surgical directions, such as superior maxillary repositioning, impact post-surgical stability, emphasizing the multifaceted considerations in orthognathic procedures.

MATERIALS AND METHODS

Sampling method

Surgical procedure

Patients in Group I were treated with wire fixation using 26-gauge stainless steel wire [Figure 1], and Group II received rigid internal fixation using titanium plates and screws [Figure 2]. Both groups underwent Le Fort I and anterior maxillary osteotomy to correct maxillary excess in the vertical and anteroposterior directions. Fourteen patients had underwent concurrent genioplasty for correction of chin deficiency.

Figure 1: Maxilla stabilized with wire osteosynthesis

Figure 2: Maxilla stabilized with rigid fixation

Materials and measurements

a. The skeletal stability for both Group I [Figures 3–5] and Group II [Figures 6–8] was measured at three different periods; preoperative (T₁), 1-week postoperative(T₂), and 6-month postoperative (T₃) using a lateral cephalogram and analyzed using cephalometric analysis. The cephalometric analysis was carried out considering the following points[⁴] [Figure 9].

Figure 3: Preoperative lateral cephalogram and orthopantamogram-group I

Figure 4: 1-week postoperative lateral cephalogram and orthopantamogram- Group I

Figure 5: 6-month postoperative lateral cephalogram and orthopantamogram- Group I

Figure 6: Preoperative lateral cephalogram and orthopantamogram-Group II

Figure 7: 1-week postoperative lateral cephalogram and orthopantamogram- Group II

Figure 8: 6-month postoperative lateral cephalogram and orthopantamogram- Group II

Figure 9: Cephalometric landmarks

The vertical and sagittal plane measurements were made from the following reference points.

Statistical analysis

Statistical Analysis SPSS (Windows version 22.0) was conducted using inferential statistics, such as an independent t test, to compare changes in occlusion between Group I (patients who underwent wire osteosynthesis) and Group II (patients who underwent rigid fixation) in the preoperative and 6-month postoperative period and skeletal changes in Group I (wire osteosynthesis) and Group II (rigid fixation), in the preoperative, 1-week, and 6-month postoperative periods. A paired t test was conducted to evaluate the changes in occlusion between Group I (wire osteosynthesis) and Group II (rigid fixation) during the preoperative and 6-month postoperative periods. ANOVA (analysis of variance) was used to assess the skeletal changes within Group I (wire osteosynthesis) and Group II (rigid fixation) in the preoperative, 1-week postoperative, and 6-month postoperative periods.

Ethical considerations

Ethical clearance was obtained from the Institutional Ethical Committee IEC/01/2011/MNDC, as well as informed consents were obtained from individual participants before the surgical procedure.

RESULTS

Skeletal stability comparison: Group I and Group II

1. Comparison of posterior vertical measurement PNS-PNS₁ between Group I (wire osteosynthesis) and Group II (rigid fixation) [Table 1].

   There was a significant difference in the posterior vertical measurement (PNS-PNS₁) between Group I and Group II during the T1 (P = 0.006), T2 (P = 0.018), and T3 (P = 0.008) periods.

2. Comparison of anterior vertical measurement M-M’ between Group I (wire osteosynthesis) and Group II (rigid fixation) [Table 2].

   There was no significant difference in the anterior vertical measurement (M-M₁₎ between Group I and Group II in the T1 (P = 0.185), T2 (P = 0.184), and T3 (P = 0.116).

3. Comparison of posterior sagittal measurement (PNS₁-N₁) total between Group I (wire osteosynthesis) and Group II (rigid fixation) [Table 3].

   There was no significant difference in the posterior sagittal measurement (PNS₁-N₁) between Group I and Group II in the T1 (P = 0.107), T2 (P = 0.095), and T3 (P = 0.065).

4. Comparison of anterior sagittal measurement M₁-N₁ total between Group I (wire osteosynthesis) and Group II (rigid fixation) [Table 4].

   There was no significant difference in the anterior sagittal measurement M₁-N₁ between Group I and Group II in the T1 (P = 0.064), T2 (P = 0.128), and T3 (P = 0.239) [Graphs 1–4].

Table 1: Comparison of posterior vertical measurement between Groups I and II

Stage	Group	Mean ± SD	N	t	P
T1	Rigid fixation	24.8 ± 1.5	8	3.23*	0.006
	Wire osteosynthesis	30.6 ± 4.9	8
T2	Rigid fixation	23.0 ± 1.5	8	2.69*	0.018
	Wire osteosynthesis	27.4 ± 4.3	8
T3	Rigid fixation	23.5 ± 1.3	8	3.07*	0.008
	Wire osteosynthesis	28.8 ± 4.7	8

T1 = Preoperative, T2 = 1-week postoperative, T3 = 6-month postoperative

* Significant at P < 0.05

 

Table 2: Comparison of anterior vertical measurement between Groups I and II

Stage	Group	Mean ± SD	N	t	P
T1	Rigid fixation	31.8 ± 1.3	8	1.4	0.185
	Wire osteosynthesis	34.1 ± 4.5	8
T2	Rigid fixation	26.0 ± 1.3	8	1.4	0.184
	Wire osteosynthesis	28.9 ± 5.7	8
T3	Rigid fixation	26.4 ± 1.3	8	1.67	0.116
	Wire osteosynthesis	29.8 ± 5.5	8

T1 = Preoperative, T2 = 1-week postoperative, T3 = 6-month postoperative

*Significant atP < 0.05

 

Table 3: Comparison of posterior sagittal measurement between Groups I and II

Stage	Group	Mean ±SD	N	t	P
T1	Rigid fixation	53.1 ± 5.0	8	1.72	0.107
	Wire osteosynthesis	57.5 ± 5.1	8
T2	Rigid fixation	49.9 ± 5.3	8	1.79	0.095
	Wire osteosynthesis	54.7 ± 5.5	8
T3	Rigid fixation	50.0 ± 5.2	8	2.01	0.065
	Wire osteosynthesis	55.4 ± 5.6	8

T1 = Preoperative, T2 = 1-week postoperative, T3 = 6-month postoperative

*Significant atP < 0.05

 

Table 4: Comparison of anterior sagittal measurement between Groups I and II

Stage	Group	Mean± SD	N	t	P
T1	Rigid fixation	10.7 ± 2.8	8	2.01	0.064
	Wire osteosynthesis	8.0 ± 2.5	8
T2	Rigid fixation	6.9 ± 2.6	8	1.62	0.128
	Wire osteosynthesis	5.0 ± 2.0	8
T3	Rigid fixation	7.0 ± 2.4	8	1.23	0.239
	Wire osteosynthesis	5.6 ± 2.1	8

T1 = Preoperative, T2 = 1-week postoperative, T3 = 6-month postoperative

*Significant atP < 0.05

 

Graph 1: Comparison of posterior vertical measurement between the Group I and II

 

Graph 2: Comparison of anterior vertical measurement between the Group I and II

 

Graph 3: Comparison of posterior sagittal measurement between the Group I and II

 

Graph 4: Comparison of anterior sagittal measurement between Group I and II

 

DISCUSSION

Orthognathic surgery is a highly intricate surgical procedure that aims to rectify facial deformities, which can have a profound impact on a patient’s dental occlusion and overall facial aesthetics. This demanding procedure necessitates a seamless collaboration between a maxillofacial surgeon and an orthodontist to achieve optimal outcomes for the patient. The surgical team must be well-trained in facial analysis and have a strong understanding of the maxillofacial skeleton to achieve excellent surgical outcomes. Treating maxillofacial anomalies is a unique endeavor that requires particularly trained surgeons with significant knowledge of both anatomy and surgical techniques. This is essential in achieving successful bony reconstruction and attaining excellent surgical results. This study compares the skeletal stability in patients undergoing Le Fort I and anterior segmental maxillary osteotomy, with wire or rigid fixation, for maxillary excess correction. Sickels et al., Proffit et al., and Vijay et al. stated that maxillary superior repositioning is a stable procedure.[^10-12] Our study conclusively demonstrates that there is no significant difference in skeletal stability between rigid and wire fixation, except in the posterior maxillary region, which is not clinically significant. Furthermore, similar to previous studies, we found no significant difference in the anterior maxilla after segmentation in both groups I and II. In our study, similar to the findings of Turvey et al.,[¹³] Winfried et al.,[¹⁴] and Kato et al.,[¹⁵] we observed no significant difference in the anterior maxilla after segmentation, both in the vertical and sagittal planes postoperatively in both groups I and II.

According to Kerkmanov et al.[¹⁶] and Fischer et al.,[¹⁷] there is no significant difference in the skeletal stability with or without maxillo-mandibular fixation in wire fixation. In our study, the maximum superior repositioning in Group I (wire fixation) was found to be 7 mm, and no postoperative maxillo-mandibular fixation was necessary. Fourteen patients from both Group I (wire fixation) and Group II (rigid fixation) underwent genioplasty performed by a single surgeon, resulting in stable postoperative outcomes without the need for maxillo-mandibular fixation.

In our study, there was no significant difference in skeletal stability between Group I (wire fixation) and Group II (rigid fixation), except in the posterior maxilla. Christopher et al.[¹⁸] in their study of 20 patients who had undergone Le Fort I down-fracture with rigid fixation reported a vertical relapse of 0.38 ± 1.01 mm at the posterior maxilla and vertical relapse of 0.69 ± 0.89 mm at the anterior maxilla. Haers et al.[¹⁹] reported a vertical relapse of 0.2 ± 1.0 mm at the posterior maxilla and 0.4 ± 1.3 mm vertical relapse in the anterior maxilla during the 1-year postoperative period, in their study of 19 cases of maxillary intrusion and fixation with wire osteosynthesis. In their comparative study, Murray et al.[²⁰] reported a vertical relapse of 0.67 ± 0.75 mm and 0.78 ± 1.13 mm over 1 year at the posterior maxilla for both 2-plate and 4-plate rigid fixation, demonstrating the potential differences in outcomes between the two fixation methods. In the anterior maxilla, a vertical replacement of 0.54 ±0.89 mm and 0.56 ± 0.68 mm was reported. In our study, we found the vertical relapse in Group I (wire fixation) was 1.38 ± 0.3 mm and 0.5 ± 0.2 mm in Group II (rigid fixation) at the posterior maxilla, and in the anterior maxilla, the vertical relapse was 0.88 ± 0.3 mm in the Group I (wire fixation) and Group II (rigid fixation) 0.38 ± 0.00 mm during the 6-month postoperative period (T3). In our study on the sagittal plane, a vertical relapse of 0.38 ± 0.1 mm posteriorly and 0.38 ± 0.1 mm anteriorly in Group I (wire osteosynthesis) and 0.13 ± 0.1 mm posteriorly and 0.13 ± 0.2 mm anteriorly in Group II (rigid fixation) were noted. Christopher et al.[¹⁸] reported a relapse of 0.38 ± 0.61 mm posteriorly and 0.41 ± 0.59 mm anteriorly, in the sagittal plane. Murray et al.[²⁰] reported a relapse of 0.68 ± 0.65 mm and 1.03 ± 0.99 mm at the anterior maxilla at the sagittal plane in their comparative study of 2- and 4-plate fixations. Haers et al.[¹⁹] reported a relapse of 1.0 ± 0.9 mm at the anterior maxilla in the sagittal plane for maxillary intrusion and fixation with wire osteosynthesis.

In order to draw a statistically significant conclusion regarding the potential superiority of wire osteosynthesis or rigid fixation in terms of postoperative stability, it is imperative to conduct further data collection and prospective research involving a more extensive sample size with participants exhibiting diverse facial characteristics. This will help confirm any true differences between the interventions Kloukos et al.[²¹] Ueki et al.[²²] said that the results showed that stability did not depend on the use or otherwise of Biopex(®). The intragroup analysis showed no statistically significant difference in skeletal stability between Groups I (Wire) and II (Rigid) in both vertical and sagittal directions. There was a relapse in both Groups I (wire) and II (rigid). In our study, the relapse was less than 2 mm in both Groups I and II. Profit et al.[²³] stated in their study of 28 patients that changes in the postoperative period of vertical relapse between 2 and 4 mm are considered to be significant.

Based on the research by Anyanechi et al.[²⁴] and Will et al.[²⁵] it has been suggested that wire osteosynthesis is capable of sustaining forces and movements during the wire fixation period, facilitating the alignment of the callus and enabling the teeth to accommodate minor skeletal changes. This indicates that in current practice, this method may continue to be valuable, especially in settings with limited access to rigid internal fixation equipment. Van Sickels[²⁶] reported that in rigid fixation, there are more occlusion-related problems as compared with those with wire osteosynthesis. The comparison of the two groups I (wire fixation, Figure 10) and II (rigid fixation, Figure 11) revealed that skeletally both groups I and II had a relapse in the 6-month postoperative period but not to a significant level. Group I had more relapse than Group II in the posterior maxilla.

Figure 10: Group I (wire osteosynthesis) preoperative and postoperative

Figure 11: Group II (rigid osteosynthesis) preoperative and postoperative

CONCLUSION

In orthognathic surgery, minor post-surgical relapse is anticipated as the bone and soft tissues adapt to their new position. Comparing the results of the skeletal stability for both wire and rigid fixation revealed similar results, except in the posterior maxilla. As the occlusal stability is supposed to be achieved more easily with wire osteosynthesis, wire osteosynthesis can be considered a better stable form of fixation than rigid fixation for stabilization of superior repositioning of the maxilla using Le Fort I and anterior maxillary osteotomy for correction of vertical and anteroposterior maxillary excess.

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