2. • Le Fort I osteotomies are one of the most common procedures
performed by oral and maxillofacial surgeons, due to their
versatility in correcting facial deformity and asymmetry
3. COMPLICATIONS
• Bleeding (dissecting of descending palatine artery )
• intraoral and extra oral sensory deficits of the branches of the
maxillary nerve
• dental injury
• maxillary sinusitis
• malocclusion
4. RARE COMPLICATIONS
• avascular necrosis of the maxilla
• ophthalmic complications (diplopia and visual impairment)
• cranial nerve injuries
• unfavorable fractures involving the skull base (sphenoid sinus)
5. • A retrospective study by Ferri et al.6 that investigated 5025
orthognathic surgery cases over a 25-year period, showed that
there was a 0.197% risk of skull base fracture secondary to a Le
Fort I osteotomy
7. • A 32-year-old female, with no previous medical history, was
referred for correction of her facial deformity
• She presented with a Class III dentofacial deformity with
midfacial hypoplasia and vertical maxillary excess
8. TREATMENT PLAN
1. pre-surgical orthodontics, involving decompensation
and arch alignment
2. Virtual surgical planning utilized the following
movements:
i. maxillary impaction and anticlockwise rotation(3 mm
anteriorly, 1 mm posteriorly)
ii. maxillary rotation for midline correction (3 mm to the right)
iii. and maxillary advancement (6.5 mm).
16. COMPLICATIONS
• The early postoperative course was uneventful, with no
complications identified by the patient or surgeons
• Then Two days after discharge , patient present with :
i. headaches
ii. large volume vomits and altered level of consciousness over a
period of 6 h
iii. On arrival to the emergency department, her Glasgow Coma
Scale (GCS) score was 12 (eyes 3, voice 3, motor 6), which
rapidly deteriorated to 8 (eyes 3, voice1, motor 4) over the
course of the following 30 min.
17. INITIAL EXAMINATION :
• Swelling
• trismus (mouth opening of 1 cm)
• and blood in the bilateral nares
• Her pupils were equal and reactive to light
• neck was supple
• BP=145/ 95 mmHg , HR=65 B/M , BT 37.2 °C , Her oxygen
saturation remained at 98% on room
• However, there was generalized hypotonicity and weakness in
the bilateral upper and lower limbs
18. RADIOGRAPHY
• Computed tomography (CT) of the head/neck showed a skull
base fracture at the level of the right sphenoid sinus (roof and
posterior wall), with features of raised intracranial pressure
(ICP) represented by tonsillar descent of 5 mm
19.
20. • CT head, sagittal view, showing signs of increased intracranial
pressure by means of tonsillar descent by 5 mm.
21.
22.
23. •She has diagnosed that she has
encephalomeningities with basilar fracture of
the skull
24.
25. • Meningitis should be suspected in patients with skull base
defects when it is associated with symptoms such as
photophobia, phonophobia, severe headache, neck stiffness,
and nausea/vomiting.
• Encephalitis involves changes in neurological function, which
may include reduced level of consciousness, focal neurological
deficits, and behavioural changes
26.
27. It is believed that the two most likely aspects of the Le Fort I osteotomy
to result in iatrogenic skull base fractures unfavorable:
1. oblique fracture patterns through the pterygoid plates , which can
occur during pterygomaxillary dysjunction
2. uncontrolled down-fracture of the maxilla when osteotomy is not
completed.
28. CONCLUSION
• Post Le Fort I osteotomy, if a patient presents acutely unwell
with neurological symptoms, the following management
principles should be applied:
• Firstly, securing the airway is crucial , As with head injury
protocols, a GCS of 8 or lower requires urgent intubation and
ventilation
29. • Secondly, a CT of the brain may help identify evidence of a skull
base fracture, which would increase the likelihood of meningitis
• Thirdly, acutely unwell patient, this warrants an urgent lumbar
puncture to measure ICP and collect fluid for MCS
30. Forthly, Empirical antibiotic therapy should be commenced in
these patients, with more targeted antibiotic regimens
commenced
i. Vancomycin
ii. meropenem
iii. selected third-generation cephalosporins (cefotaxime and
ceftriaxone) are preferred due to their penetration through the
blood–brain barrier.11
31. Fifthly, strategies to reduce ICP need to be applied:
• First-line therapies for elevated ICP include conservative
measures such as elevation of the head above 30 degrees,
maintaining the neck midline to facilitate venous drainage, bed
rest, regular stool softeners, antiemetics, and antitussives.
• Second-line therapies may involve the use of controlled
hyperventilation to reduce serum CO2 which in turn reduces
cerebral blood flow
• Third-line therapies include the use of drugs such as mannitol as
an osmotic agent, which can be used to create an osmotic
gradient across the blood, thereby drawing fluid intravascularly
and decreasing cerebral oedema
• Acetazolamide is a carbonic anhydrase inhibitor that reduces the
production ofCSF and hence will help to lower ICP.
32. • In the setting of CSF rhinorrhoea , reduction of ICP are
considered first-line management , these may facilitate
spontaneous closure of a small defect
• In circumstances of persistent or larger defects, the surgeon
needs to consider CSF diversion techniques or surgical closure
33. • CSF diversion
• can be facilitated by means of a continuous lumbar drain. This
lumbar drain can remain in situ for several days to facilitate
mucosal coverage of the skull base defect
• skull base surgery, repair is commonly done via a transnasal
endoscopic approach utilizing a nasal septal flap
