British Journal of Oral and Maxillofacial Surgery 45 (2007) 412414

Short communication

The identication and protection of the descending palatine artery in Le Fort I osteotomy: A forgotten technique?
Barry O. Regan 1 , Girish Bharadwaj
Maxillofacial Unit, Queen Margaret Hospital, Dunfermline, Fife KY12 0SU, UK Accepted 19 December 2005 Available online 9 March 2006

Abstract We describe the advantages of a simple technique of identication and preservation of the descending palatine artery during Le Fort I osteotomy. 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Le Fort I osteotomy; Pterygomaxillary separation; Vascular complications; Tuberosity osteotomy; Descending palatine artery

Introduction The most common site of haemorrhage in the Le Fort I osteotomy is the posterior maxilla, and the vessel most often involved in major postoperative arterial haemorrhage is the descending palatine artery,1 but it is not routinely identied and protected during operation despite the existence of a safe and reliable manoeuvre. Venous bleeding after Le Fort I osteotomy usually comes from the pterygoid venous plexus. The basis for the preservation of blood supply to the maxilla has been explored extensively in the past in primates.2 Epker has discussed the problems with these studies which limit their usefulness when extrapolated to clinical situations.3 Bays et al. reported that the incidence of aseptic necrosis of the maxilla after Le Fort I osteotomy was low (0.7%) after routine bilateral ligation of the descending palatine artery in 149 patients.4 They justied such routine ligation because it reduces the risk of postoperative haemorrhage after intraoperative damage to the vessel. The experimental evidence, however, suggests that the blood supply to the maxilla is better when the vessels are preserved.2 Lanigan
Corresponding author. Tel.: +44 7930 501910. E-mail addresses: Barry.oregan@faht.scot.nhs.uk (B.O. Regan), drgirishb@yahoo.com (G. Bharadwaj). 1 Tel.: +44 1383 623623x6637.

et al. advised against routine ligation and recommended that the descending palatine artery should be preserved whenever possible to minimise the risk of postoperative haemorrhage and aseptic necrosis.5 A number of techniques have been described to prevent neural and vascular injury during pterygomaxillary separation.68 From a recent survey of oral and maxillofacial surgeons in the UK, it transpired that the most widely adopted techniques are leverage alone and (less commonly) osteotomy of the tuberosity.9 Johnson and Arnett reported the use of a rotary drill for pyramidal release of bone around the descending palatine canal to facilitate maxillary impaction.10 We have used a modied technique of bony release of the pyramidal process of the palatine bone using spatula osteotomes around the descending palatine artery in 20 consecutive patients who had Le Fort I osteotomies.

Method A Le Fort I osteotomy was done by a single surgeon in 20 consecutive patients who required bimaxillary osteotomy. There were 3 men and 17 women and their ages ranged from 16 to 36 years. An osteotomy of the tuberosity was done to achieve maxillary separation and mobilisation before identication of the descending palatine artery.

0266-4356/$ see front matter 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2005.12.016

B.O. Regan, G. Bharadwaj / British Journal of Oral and Maxillofacial Surgery 45 (2007) 412414

413

behind the second maxillary molar (Fig. 1). After early mobilisation of the maxilla, a horizontal bone cut using a spatula osteotome is made along the lateral base of the pyramidal process of the exposed palatine bone (Fig. 2ac). This allows the lateral bony segment to be dislodged gently, so exposing the vessel and giving safe and direct access to the smaller posteromedial segment. This segment can then be fractured off easily with a spatula osteotome or a curved Warwick James elevator. Careful use of the spatula osteotome avoids damage to the vessel. The bony segments are gently raised from the canal, fully exposing the vessel and allowing preservation during further maxillary mobilisation and xation. The dimensions of the lateral bony segment vary in size, usually 710 mm in height depending on the site of the bony cut on the base.

Fig. 1. Axial view at LFI level showing descending palatine artery location.

Results The descending palatine artery was identied on both sides in all 20 patients. The integrity of the vessel was preserved in 39 of 40 operations. Peroperative bleeding from one artery was arrested by cautery. We had no undue difculty in mobilisation of the maxilla, no mechanical obstruction during maxillary impaction, and no postoperative haemorrhage in any patient.

Technique Anterior access to the perpendicular plate of the palatine bone is achieved with a straight osteotome placed along the medial antral wall to the point of change in timbre, as in a conventional Le Fort I osteotomy. The posterolateral access is achieved by a vertical osteotomy of the tuberosity 23 mm

Fig. 2. Exposure of right descending palatine artery. (a) Axial view (LFI level); (b) right palatine bone (coronal plane as shown by dotted line in (a)); (c) right palatine bone (lateral segment removed).

414

B.O. Regan, G. Bharadwaj / British Journal of Oral and Maxillofacial Surgery 45 (2007) 412414

Discussion The descending palatine artery is one of the terminal branches of the maxillary artery. It lies within the greater palatine canal, which is located in the perpendicular plate of the palatine bone and traverses in an anteroinferomedial direction with a mean angulation of 60 to the sagittal plane. The incidence of serious haemorrhage in a standard Le Fort I osteotomy is low and can be reduced further by careful operative technique and appropriate instruments. A number of techniques have been used to achieve pterygomaxillary separation. A curved Obwegeser osteotome is often used through a blind approach to the pterygomaxillary ssure. Leverage alone is commonly used to avoid the use of osteotomes for pterygomaxillary disarticulation.7 These techniques include the use of Tessiers spreaders combined with digital manipulation to achieve pterygomaxillary separation. Further maxillary mobilisation is by Smiths 3-prong spreaders or Turveys maxillary expanders to reduce the risk of damage to the descending palatine vessels.7 An osteotomy of the tuberosity has also been advocated in an attempt to reduce the risk of vascular complications.8 The advantages of identication and protection of the descending palatine artery include reduction of peroperative and postoperative haemorrhage, protection of the blood supply to the maxilla particularly in segmental osteotomies, removal of mechanical bony obstruction particularly in impaction and setback movements, and preservation of sensory function of the palatine nerves. The use of a rotary drill

when visual access is poor, as described by Johnson and Arnett,10 carries a risk of inadvertent injury to the vessel. This risk can be reduced by the use of spatula osteotomes, as our results indicate.

References
1. Lanigan DT, Hey JH, West RA. Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort I osteotomies. J Oral Maxillofac Surg 1990;48:56173. 2. Bell WH, Fonseca RJ, Kennedy JW, Levy BM. Bone healing and revascularization after total maxillary osteotomy. J Oral Surg 1975;33:25360. 3. Epker BN. Vascular considerations in orthognathic surgery II. Maxillary osteotomies. Oral Surg Oral Med Oral Pathol 1984;57:4738. 4. Bays RA, Reinkingh MR, Maron R. Descending palatine artery ligation in Le Fort osteotomies. J Oral Maxillofac Surg 1993;51(Suppl. 3):142. 5. Lanigan DT, Hey JH, West RA. Aseptic necrosis following maxillary osteotomies: report of 36 cases. J Oral Maxillofac Surg 1990;48:142. 6. Lanigan DT, Guest P. Alternative approaches to pterygomaxillary separation. Int J Oral Maxillofac Surg 1993;22:1318. 7. Precious DS, Morrison A, Ricard D. Pterygomaxillary separation without the use of an osteotome. J Oral Maxillofac Surg 1991;49:989. 8. Trimble LD, Tideman H, Stoelinga PJW. A modication of the pterygoid plate separation in low level maxillary osteotomies. J Oral Maxillofac Surg 1983;41:5446. 9. ORegan MB, Bharadwaj G. Pterygomaxillary separation in Le Fort I osteotomy: UK OMFS consultant survey. Br J Oral Maxillofac Surg 2006;44:203. 10. Johnson LM, Arnett GW. Pyramidal osseous release around descending palatine artery: a surgical technique. J Oral Maxillofac Surg 1991;49:13568.