Does the use of a pterygoid osteotome affect pterygomaxillary fracture patterns in Le Fort I osteotomy?

OBJECTIVES

Safe separation of the pterygomaxillary junction (PMJ) is a critical step during Le Fort I (LF-I) osteotomy. The use of a pterygoid osteotome remains controversial due to its potential association with unfavorable fracture patterns and serious complications. This study aimed to evaluate the effect of pterygoid osteotome use on PMJ fracture patterns in horizontal and vertical planes using computed tomography (CT).

MATERIALS AND

METHODS

This retrospective study included 83 patients who underwent LF-I osteotomy between 2022 and 2025 and had postoperative CT imaging within the first postoperative month. A total of 166 PMJs were evaluated by analyzing the right and left sides separately. Patients were divided into two groups according to pterygoid osteotome use. Preoperative cone-beam CT was used for anatomical measurements, while postoperative CT images were assessed to classify PMJ separation patterns in horizontal and vertical planes. Fracture patterns were compared between groups.

RESULTS

When analyzed separately by side, a statistically significant difference was observed only in left-sided horizontal fracture patterns, with a higher incidence of posterior maxillary sinus wall fractures (Type 3) in the osteotome-positive group (p < 0.05). When all PMJs were evaluated together, significant differences were found in both horizontal and vertical fracture patterns between groups (p < 0.05). Ideal separation along the pterygomaxillary fissure (Type 1) was more frequent in the osteotome-negative group (63.9%), whereas pterygoid plate fractures (Type 4) were more common in the osteotome-positive group (19.1%) (p = 0.002). High-level vertical fractures near the skull base were also significantly more frequent in the osteotome-positive group (14.9% vs. 5.6%, p = 0.049).

CONCLUSIONS

Osteotomeless pterygomaxillary separation during down-fracture was associated with more ideal and complication-free fracture patterns in both horizontal and vertical planes. In contrast, pterygoid osteotome use was associated with an increased incidence of unfavorable fracture patterns. These findings support the consideration of osteotome-free techniques as a safe and effective alternative during LF-I osteotomy.