European Journal of Cardiovascular Medicine

Maxillary hypoplasia is a common dentofacial deformity encountered in orthognathic surgery and may present as a component of skeletal Class III malocclusion, cleft-related deformities, or syndromic craniofacial anomalies [1,2]. Le Fort I osteotomy remains the cornerstone procedure for maxillary advancement, offering predictable correction of occlusal, esthetic, and functional deficits [3].

Beyond skeletal realignment, the primary objectives of maxillary advancement include restoration of masticatory efficiency, improvement of speech articulation, optimization of nasal airflow, and enhancement of patient-perceived quality of life [4]. While advancements of limited magnitude often heal satisfactorily with rigid fixation alone, larger advancements raise concerns regarding stability, relapse, and compromised bone healing [5].

Interpositional bone grafting has traditionally been advocated to fill osteotomy gaps, enhance bony union, and improve postoperative stability, especially in advancements exceeding 5–7 mm [6]. Autogenous grafts from iliac crest, calvarium, or mandibular sites have been most commonly employed [7]. However, graft harvesting increases operative time, donor-site morbidity, and postoperative discomfort [8].

Recent advances in rigid internal fixation and surgical technique have prompted reconsideration of routine bone graft use. Several authors have reported satisfactory outcomes without grafting, citing adequate stability and reduced morbidity [9–11]. Nevertheless, the functional implications of graft omission remain inadequately explored, particularly in terms of patient-centered outcomes.

Given the limited comparative evidence focusing specifically on postoperative functional performance, this study aimed to evaluate and compare functional outcomes following maxillary advancement performed with and without bone grafts.

Study Design and Setting A prospective comparative clinical study was conducted in a tertiary-care maxillofacial surgery center over a 24-month period. Institutional ethical clearance was obtained, and all participants provided informed consent. Study Population Patients aged 18–40 years diagnosed with maxillary hypoplasia requiring Le Fort I advancement were included. Exclusion criteria comprised syndromic craniofacial anomalies, cleft lip and palate, systemic bone disorders, previous orthognathic surgery, and patients requiring segmental osteotomy. Group Allocation Participants were allocated into two groups: • Group A (Grafted Group): Maxillary advancement with interpositional bone grafts • Group B (Non-Grafted Group): Maxillary advancement without bone grafts Allocation was based on surgeon preference and advancement magnitude. Surgical Technique Standard Le Fort I osteotomy was performed under general anesthesia. Rigid fixation was achieved using titanium miniplates and screws. Autogenous cancellous bone grafts were placed in Group A patients at the osteotomy site. Postoperative protocols were standardized across groups. Outcome Measures Functional outcomes were evaluated preoperatively and at 3, 6, and 12 months postoperatively: • Masticatory efficiency (chewing performance score) • Speech articulation (speech pathologist assessment) • Nasal airflow (patient-reported nasal breathing scale) • Quality of life (validated questionnaire) Statistical Analysis Data were analyzed using SPSS software. Continuous variables were compared using independent t-tests, while categorical variables were analyzed using chi-square tests. A p-value < 0.05 was considered statistically significant.

Table 1. Demographic and Clinical Characteristics

The demographic and baseline clinical characteristics of patients in both groups were comparable. The mean age distribution did not differ significantly between the grafted and non-grafted groups, indicating adequate age matching. Gender distribution was also similar across both cohorts, minimizing gender-related bias in functional outcome assessment. The mean magnitude of maxillary advancement was slightly higher in the grafted group; however, this difference was not statistically significant. Overall, baseline homogeneity between the two groups ensured that postoperative functional outcomes could be attributed primarily to the surgical intervention rather than confounding demographic variables.

Table 2. Masticatory Efficiency Outcomes

Preoperatively, both groups demonstrated reduced masticatory efficiency scores, consistent with compromised occlusion and maxillary deficiency. At the 12-month postoperative evaluation, a statistically significant improvement in masticatory efficiency was observed in both groups. The grafted group demonstrated higher mean masticatory efficiency scores compared to the non-grafted group, and this difference reached statistical significance. These findings suggested that interpositional bone grafting may have contributed to improved functional stability and occlusal load transfer during mastication. Nevertheless, the non-grafted group also exhibited clinically meaningful improvement, indicating that acceptable masticatory function could be achieved without grafting in selected cases.

Table 3. Speech and Nasal Function Outcomes

Postoperative assessment revealed marked improvement in speech articulation and nasal breathing in both groups. The proportion of patients reporting improved speech clarity was slightly higher in the grafted group; however, the difference between groups was not statistically significant. Similarly, subjective improvement in nasal airflow was reported by the majority of patients in both cohorts, with no significant intergroup variation. These findings indicated that maxillary advancement itself played a dominant role in enhancing speech and nasal function, while the use of bone grafts did not exert a measurable additional influence on these parameters.

Table 4. Postoperative Complications

Postoperative complications were infrequent in both groups. Minor surgical site infections were rare and resolved with conservative management. Skeletal relapse exceeding 2 mm was observed more frequently in the non-grafted group; however, this difference was not statistically significant. Donor-site morbidity, including transient pain and discomfort, was observed exclusively in the grafted group. No cases of non-union or fixation failure were recorded. These findings suggested that while bone grafting may offer marginal benefits in skeletal stability, it also introduced additional morbidity related to graft harvesting.

Table 1. Demographic and Clinical Characteristics of Study Groups

Table 2. Comparison of Masticatory Efficiency Scores

T

able 3. Speech and Nasal Function Outcomes at 12 Months

Table 4. Postoperative Complications

The present study evaluated functional outcomes following maxillary advancement with and without interpositional bone grafts. The findings demonstrate that both surgical approaches yield significant functional improvement, although grafting provided marginal advantages in postoperative stability and masticatory efficiency.

Masticatory performance improved substantially in both cohorts, reflecting enhanced occlusal relationships and muscle coordination following maxillary repositioning. The superior scores observed in the grafted group at 12 months may be attributed to enhanced skeletal stability and more predictable bone healing at the osteotomy interface. Previous biomechanical and clinical studies have suggested that bone grafts may contribute to improved load distribution and resistance to micromovement, particularly in advancements exceeding 6 mm [1,5].

Speech articulation outcomes were comparable between groups, indicating that maxillary repositioning itself—rather than grafting—plays the dominant role in correcting velopharyngeal and articulatory disturbances. These findings align with earlier reports that speech improvements following orthognathic surgery are primarily related to skeletal realignment and neuromuscular adaptation rather than interpositional graft presence [6,17].

Nasal airflow improvement was also similar in both groups. Maxillary advancement increases the nasopharyngeal airway volume, contributing to subjective improvements in nasal breathing. The lack of difference between groups suggests that bone grafts do not significantly influence airway outcomes, consistent with previously published airway assessment studies [7,18].

Postoperative complications were infrequent and comparable. Although relapse was marginally higher in the non-grafted group, the difference was not statistically significant. Modern rigid fixation techniques likely play a critical role in maintaining stability, potentially reducing the necessity for routine grafting. However, donor-site morbidity remains a notable disadvantage of graft use, as observed in this study and widely documented in the literature [8,19].

From a clinical standpoint, these findings support a selective approach to bone grafting during maxillary advancement. Patients requiring large advancements or presenting with compromised bone quality may benefit from graft placement, whereas smaller advancements can be managed successfully without grafts, reducing operative morbidity and patient burden.

The study’s strengths include its prospective design, standardized surgical technique, and comprehensive functional assessment. Limitations include modest sample size and single-center setting, which may limit generalizability. Longer follow-up periods would further clarify long-term stability differences.

Overall, the evidence suggests that while bone grafting may confer incremental benefits in specific functional domains, its routine use in all maxillary advancements may not be mandatory.

Maxillary advancement surgery results in significant postoperative functional improvement irrespective of bone graft use. Interpositional bone grafting offers marginal advantages in masticatory efficiency and skeletal stability but is associated with donor-site morbidity. A tailored, case-specific approach to graft utilization is recommended to optimize outcomes while minimizing surgical morbidity.

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