Endoscopic Approaches to Maxillary Orthognathic Surgery

Endoscopically assisted surgery has become an essential component in many fields of surgical specialties. The implementation of this technique to craniofacial and maxillofacial surgery is a recent development. Endoscopic approach to subcondylar mandible fractures has been established as reliable surgical method [1–4]. The endoscopic repair of midfacial and malar fractures, of traumatic arch injury, of frontal sinus fracture, and of orbital fractures is described in the recent literature also [5–10]. The use of endoscopic techniques in the field of orthognathic surgery must be addressed separately for the sagittal split osteotomy and the Le Fort l osteotomy. Troulis and colleagues [11,12] have described the endoscopic vertical ramus osteotomy followed by rigid fixation for treating mandibular prognathism. There are only a few articles published that present endoscopic approaches to the midface and Le Fort l level with regard to orthognathic surgery [13–15]. What could be the benefit of an endoscopically assisted Le Fort l osteotomy? First, there is need to describe the commonly used technique with an open approach. Through a horizontal incision of the mucosal soft tissue in the Le Fort l plane, the osteotomy is performed using an oscillating saw. The pterygomaxillary junction, the lateral nasal wall, and the nasal septum can be osteotomized using different chisels. The downfracture of the Le Fort l plane completes this procedure after an average operation time of about 30 minutes. In most of the cases, the le Fort I osteotomy as mono-segment or multi-segment procedure is performed to correct congenital and acquired deformities of the jaws. The overall complication rate of Le Fort l osteotomies varies between 6% and 9% [16,17]. Hemorrhage, infection, and maxillary necrosis represent the majority of these complications. Some authors reported ischemic problems because of the decreased vascularization of mostly anterior maxillary segments [18,19]. Different cadaveric studies showed that the commonly performed le Fort l osteotomy carries the risk of injury to the descending palatal artery [20,21]. Only the ascending palatal artery and the pharyngeal branch arising from the ascending pharyngeal artery can be preserved routinely. Quejada and colleagues [22] could show in an animal study that the maintenance of vascular pedicles to the palate and labiobuccal area was sufficient to support total maxillary osteotomy despite trans-section of both descending palatinal vessels. Lanigan and colleagues [23,24], however, suggested total maxillary osteotomy using vertical incisions from the buccal approach with tun-