Q: I am a 35 year-old man with a facial condition known as Binder’s syndrome, you may be familiar with it as a craniofacial plastic surgeon. My whole midface is back and I think I need a combined LeFort III and LeFort I osteotomy. My upper teeth are a bit forward of my lower teeth so it is a bit of an overbite. My thought is that the LeFort III would bring out all the backset midface bones and then at the same time a LeFort I could be done to bring my teeth back into place. I am not contemplating having any orthodontic treatment before surgery. I have attached some pictures of my face for you to see. What do you think of this plan?
A: I am very familiar with Binder’s syndrome, also known as nasomaxillary hypoplasia. You definitely have a rather severe manifestation of it with the entire midface quite retruded. Your basic thoughts on the need for midface advancement is correct but what it is not obvious to you is how one’s bite relationship controls whether and how any type of orthognathic surgery is done.
Let me give you some clarification on your LeFort concepts as they are understandably not accurate. You can’t separate or differentiate different levels of a LeFort osteotomy regardless of type. You either have to do a LeFort III or do a LeFort I, you can’t do both at the same time. That make look like it would work on drawings or on paper, but it does not work that way in practical application. The bottom line is while your facial deformity would ideally benefit from a LeFort III advancement, your bite does not support that facial skeletal change. That would put your upper teeth (provided that the bone would actually move that far which I doubt without external distraction) greater than 10 mms in front of your lower teeth. (and no you can’t do a LeFort I setback later as a secondary procedure) The irony is that your bite, for whatever reason, is simply too close to normal to support any of these LeFort procedures even though your facial skeleton could use it.Your bite with the amount of midfacial deficiency that you have should show a severe Class III malocclusion (underbite) which it does not. I have never seen such a combination of severe midfacial hypoplasia with a relatively normal bite before.
This leaves your only practical treatment solution as an augmentative or camouflage approach, which is actually much easier on you. The midface can be brought forward through infraorbital rim-malar and paranasal implants combined with a rib graft rhinoplasty. This concept builds on top of the existing midfacial skeleton rather than trying to move it forward. As an additional benefit, the brow bones/supraorbital rims can be set back as they have a large amount of bossing. The combination of all these facial procedures does a pretty good job of improving your facial balance. I have attached some imaging which shows those changes.
Dr. Barry Eppley