Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical review and update

SARPE (2 stage) vs Le Fort 1
(single stage) Approach to
Complex Maxillary Deformities:
A Critical Review and Update
AO North America
12 th Annual Symposium

Wahsington, DC

samedi 17 mars 2012 1

Based on

Short- and Long-Term Stability of SARPE Revisited
AJODO 2011; 138:815-22


SARPE

Samson Assisted Rapid Palatal Expansion


Stability of SARPE
Numerous published studies
• Dental Cast • P-A ceph (+ dental cast)
★ Northway & Meade AO '97 ★ Byloff & Mossaz, EJO '04

★ Bays and Greco, JOMS '92 ★ Berger et al, AJODO '98

★ Stromberg & Holm, JCS '95 ★ Koudstaal et al, IJOMS '09

★ Antilla et al, EJO '04 ★ Hino et al, JCS '09 (P-A only)

★ Pogrel et al, IJAOOS <92 ★ Kuo & Will, OMS CNA '90 (P-A only)


Stability of SARPE

Conclusions about stability depend on
★ What was measured?
★ When measurements were made?

Especially whether there were measurements
during the sequence as well as before/after?

©Dr Sylvain Chamberland


Goal of This Presentation

• Present further longitudinal data for short-
and long-term stability
• Follow-up previous reports
★ (Angke east 2006 Scientiﬁc Meeting)

★Closer Look at the Stability of SARPE
✓ JOMS 2008; 66:1895-1900



Goal of This Presentation

•Larger sample + 2-years stability data
• Data obtained at 6 time points
★ The only study with PA ceph and models at multiple
time points



Methods

• Prospective and observational
study of SARPE outcomes
• Consecutively treated cases
Looking ahead

• Approved by Laval University
Ethic Committee



Experimental sample
Distribution

9
9 9 # cas

7

•
7

# of patients
N = 38 5 5
6

★ 19, 19
2
★ Mean age : 24.9 ± 9,7 2

(range 15,1: 53,7) 0
-,17] (17, 20] (20,25] (25,30] (30,35] (35, +
Âge



Observation Time Point N Mean time S-D Min. Max.
(months)
Dental cast + PA ceph

T1-T2 (Distraction completed) 38 0,68 0,23 0,46 1,81

T2-T3 (Expander retention) 38 5,95 0,68 4,21 7,13

T1-T4 (Start to 2nd surgery) 32 15,27 3,99 9,40 24,28
T2-T5 (End expansion to
37 21,59 5,28 12,88 41,69
deband)
T3-T5 (Expander out to
37 15,64 5,09 7,79 35,19
deband)
D1-T5 (Total treatment time) 37 23,57 5,27 15,41 43,07

T5-T6 (Post ortho treatment)
©Dr Sylvain Chamberland 23 25,35 4,49 20,96 39,49

• Of the 38 who completed the distraction phase

• 32 had a 2nd surgical phase planned

• 4 of them did not need it after reassessment

• 1 was over-expanded and needed constriction of the maxilla
at the 2 nd surgical phase to achieve arch coordination

✦ His data were removed at T5

• 23 patients have returned for records 2-years after the end
of orthodontic treatment


Tooth-borne Expansion Device

•Superscrew™
• Banded; N = 21
A

• Bonded; N = 17

B



Our SARPE Technique
Mid-palatal suture
Zygomaticomaxillary
Piriform rim
Pterygomaxillary junction

Zygomatic buttress

Piriform rim

Widening of the osteotomy cut:
→ lateral rotation hemimaxillae

Our SARPE Technique
Midpalatal suture
Zygomaticomaxillary buttress
Piriform rim
Pterygomaxillary junction

Separation of the
pterygoid junction

Separation with osteotome
of the midpalatal suture

Per-op diastema of 1 to 1,5 mm

Treatment modality
• Appliance cementation: 1 day to 1 week prior to
surgery
• Latency period: 7 days
• Distraction period: 0,25 mm bid
★ 14 to 21 days; monitored twice a week

• Tx initiated in the mandibular arch 1 week to 2
months before SAPRE


Treatment modality

• Brackets bonded in maxillary arch 2 months
after expansion is stopped
• Expander removal: 6 months after expansion is
stopped
• No other retention except the main arch wire
• At debonding: bonded lingual wire 3-3 only, ↑&↓


Outcome Measures
• Standardized PA ceph • Study cast
• DPI set to obtain 1:1

• Screw width in situ vs screw width on the ceph

★ T1: r = 0,99164

★ T2: r = 0,98955

• Nasal cavity width • Dental width changes
• Mx width: Jr-Jl • Screw width
©Dr Sylvain Chamberland • Screw changes • Diastema

Statistics Refer to the
article for more
• Paired 2-samples T-tests details about stats

✓ Bonferroni method: α = 0.05/6

• Repeated measures ANOVA
• Unpaired 2 samples T-tests
• Pearson's correlation coefficients

• Shrout and Fleiss's intraclass correlation
coefficient of fidelity
= 0,99


Results


"

Changes in Canine

arch
dimensions 1st premolar

• Signiﬁcant: p < 0.001 2nd premolar

★ Expansion T3-T1
1st molar
★ Relapse T5-T3

★ Net expansion T5-T1
2nd molar

★ 2-years recall T6T1
1st lower molar, Non exo subgroup

1st lower molar, Exo subgroup
Maximal expansion T3-T1
Relapse T5-T3
Net expansion T5-T1 -4 -3 -1 1 2 4 5 7 8
Long term relapse T6-T5

Net changes T6-T1 Changes (mm)

∆ 1st Molar
∆ Nasal Cavity
∆ Mx
% ∆ Mx/∆ M1 Changes in skeletal width Changes over time post SARPE

8,00 80 80

• Signiﬁcant skeletal expansion 7,00
65
69

6,00
★ Mx & Nasal cavity (p < 0.0001) 56 57

% Skeletal expansion
Expansion (mm)
5,00

• Changes T5T3: NS (p=0,1166) 41
4,00
46 46

• Skeletal changes = STABLE
34
3,00

23
2,00

1,00 11

0 0
0,68 6,632 15,27 23,57 48,92
Time point (months)


Other outcomes
• Type of expansion device: Bonded vs 2-bands
★ Same efﬁcacy for skeletal & dental expansion (No difference: p=0,2727)

★ Same dental relapse (No difference: p=0,5052)

• Effect of phase 2 surgery on transverse relapse
at the 1st molar

★ No signiﬁcant effect of any phase 2 surgery (No difference: p=0,6637)

★ Or any combination of phase 2 surgery



Effect of time on relapse after appliance removal
Time point comparison Relapse (mm) Error T or F value DF P value

T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001

T3 vs T4 (9,5 ± 3,2 m) -1,05 0,30 3,53 (T) 125 0,0006

T4 vs T5 (5,7 ± 1,5 m) -0,79 0,30 2,62 (T) 125 0,0098

T3 vs T5 (15,2 ± 5,1 m) -1,85 0,29 6,43 (T) 125 <.0001

T5 vs T6 (24,7 ± 3,1 m) -1,09 0,34 3,23 (T) 125 0,0016

• Signiﬁcant relationship between the amount of
relapse seen after SARPE and the time the post
treatment observation was made


Effect of time on relapse after appliance removal
Time point comparison Relapse (mm) Error T or F value DF P value

T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001

T3 vs T4 (9,5 ± 3,2 m) -1,05 0,30 3,53 (T) 125 0,0006

T4 vs T5 (5,7 ± 1,5 m) -0,79 0,30 2,62 (T) 125 0,0098

T3 vs T5 (15,2 ± 5,1 m) -1,85 0,29 6,43 (T) 125 <.0001

T5 vs T6 (24,7 ± 3,1 m) -1,09 0,34 3,23 (T) 125 0,0016

• 57% of the total relapse occurred during the 1st 9 months
after expander removal
• 43% occurred in the following 6 months
• Another 1 mm or so occurred 2 years after debonding

Correlation between variables
• 2 variables are signiﬁcantly correlated with the amount of
expansion of 1st molar at T3
★ Diastema at the end of expansion (r2 = 0,41; p < .0001)

★ Change in length of the screw during expansion (r2 = 0,88; p < .0001)

• Dental changes are not correlated with
skeletal changes (r 2 = 0,11; p = 0.0381) (supported by Goldenberg et al)



Discussion


Short term stability
• Expansion of 1st molar = 7,6 ± 1,57 mm
★ Similar to other reports measuring to the maximum
expansion point
✓ Pogrel et al, Byloff and Mossaz, Koudstaal et al, de Freitas et al

• Signiﬁcant relapse for all teeth (canine to 2nd

molar)
• Mean relapse at 1st molar = 1,83 ± 1,83 mm
★ 24% of the maximum expansion; large std. dev.

Short term stability

• Post treatment retention is an important
factor
• In this study: expansion device maintained 6
months



Comparison to Other Short-Term
-0,99
Experimentals (n=38; 37;23) 24% -1,83
5,73
7,60
4,57
-3,16
Byloff and Mossaz, (n = 14) 36%
5,54
8,70

18% -1,48
de Freitas et al, 2008 (n = 20) 7,12
8,06
≠Pterygoid + T2 = before Phase2 surgery
-0,50
Koudstaal et al, 2009 (n = 19) T-B 11% 6,30
12 months study 6,80

period 4,60 ≅Exp.
Koudstaal et al, 2009 (n =23) B-B 11% -0,60
5,20

17.5% -1,01
Berger et al, 1998 (n=28) 4,77
5,78

Pogrel et al, 1992 (n=12) 12% -0,88
6,62
7,50

-4,00 -3,00 -2,00 -1,00 0 1,00 2,00 3,00 4,00 5,00 6,00 7,00 8,00 9,00
mm
Long Term Relapse Short Term Relapse Net expansion
©Dr Sylvain Chamberland Maximum expansion Long term exp


Those 12 months study period

•Concluded that expansion was stable
• But all their patients were still in
orthodontic treatment



Our Study = 49 Months
• Data at T4 were collected 15 months post-
SARPE, prior to 2nd surgical phase for those who

needed one
• Relapse at T4 = 57% of the relapse we found
• Therefore, any inferences about the stability of
SARPE is questionable if arch form coordination
or ﬁnal AP or vertical relationships have not
achieved at the time of measurements


In Our Study
SARPE: Post-Tx changes
50,0 %
First Molar
45,0 % First Premolar
42%
40,0 %

• 42% of the patients have a 35,0 %

relapse of 2 mm
% of patients
30,0 %

25,0 %

• 22 % of a relapse > 3 mm 20,0 %
22%

• This is similar to 15,0 %

multisegmented Le Fort 1 10,0 %

5,0 %

0%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
Relapse (mm)

Net changes T6-T1

Long term stability
"

•
Canine

Data at T6 = 24,7 ± 3 m
•
1st premolar
Relapse NS
•
2nd premolar
Relapse S : 1 st Molar
1st molar
★ = 0,99± 1,1 mm; p= 0.0003
★ 17% of net expansion at T5 that 2nd molar

adds to relapse T5T3 -4 -3 -1 1 2 4 5 7 8
Changes (mm)


Net changes T6-T1

Long term stability
"

• Cannot be explained by type 1 Canine

error (α = 0.05/6)

• Cannot be explained by the effect
1st premolar

of a bonded vs banded appliance 2nd premolar

• Post treatment arch form 1st molar
adjustment may be the explanation
since on the average, lower molar
2nd molar
distance was expanded and
constricted modestly and a large -4 -3 -1 1 2 4 5 7 8

std dev was noted (-0,18 ± 1,5 mm)
Changes (mm)


Comparison to Other Long-Term
Studies 17% -0,99
-1,83
Experimentals (n=38; 37;23) 5,73
7,60
2y 4,57

-1,30
22%
Antilla et al, 2004 (n=20; 13) 7,20
6y 5,9

8.3%-1,20
Stromberg & Holms, 1995 (n=20) 8,30
3,5 y

-0,22
≅Exp.
6%
Nortway & Meade, 1997 (n=16) 5,50
5y

-0,45
7%
Bays & Greco, 1992 (n=19) 5,78
2,4 y

-2,25 0 2,25 4,50 6,75 9,00
mm
Long Term Relapse Short Term Relapse Net expansion
©Dr Sylvain Chamberland Maximum expansion Long term exp


Skeletal Expansion & Stability

• Immediately after SARPE about half (46%) of the expansion was
skeletal

• This is more than Byloff & Mossaz, Berger et al
★ Appliance was removed after 3 months instead of 6 months

• Hino et al (JCS 2008) reported larger skeletal expansion (~ 6,3
to 6,9 mm) but used landmark closer to the teeth



CBCT study
• Skeletal expansion ranging from 1,3 to 7 mm
✦ Loddi et al, Landes et al, Goldenberg et al, Tausche et al, Zemann et al, Lagravere et
al

✦ Koudstaal et al (IJOMS 2009) obtained 3,1 ± 2 mm of
expansion at alveolar crest and 2,6 ± 1,8 mm at nasal level

✦ Lagravere et al (AJODO 2010) CBCT study

✓ BAME = 1,3± 1,4 mm vs TAME = 1,83± 1,69 mm at the
outer cortex of alveolar bone

• There was no difference between TB and BB appliances (12 month study
©Dr Sylvain Chamberland period)

SARPE: Post-Tx changes

50,0 % First Molar
First Premolar
40,0 %

Stability?

% of patients
30,0 %

20,0 %

10,0 %

0%

•
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]

If one look at skeletal changes, it should Relapse (mm)

rank high in the hierarchy
• But if one looks at dental changes
★ 64% of the patients have > 2 mm change
★ 22% have > 3 mm changes



Stability?

• This could be attributed to
★ The device itself
★ The surgical technique
★ The timing of observation



Stability?
• For all other surgery
★ Presurgical orthodontic preparation is done
★ Few if any dental movements need to be accomplish
after surgery

• This is not the case for SARPE
★ Many dental movement are done after expander
removal including correction of overexpansion


SARPE and other surgical
procedure

• It is appropriate to focus on skeletal, not dental
stability— which has not been clearly reported
previously because appropriate P-A ceph were
not available at multiple time point



Related variables

• Correlation between the width of the diastema
at the end of distraction (T2) and the amount of
1 st molar expansion at T3 indicates that the

adequate molar expansion is occurring
• If no diastema appears ➙ no separation of the
hemimaxillae and tipping of buccal segment is
occurring



Related variabless
• Dental changes are not correlated with skeletal
changes (r2 = 0,11; p = 0.0381) (supported by Goldenberg et al)

• In frontal view, rotation of the hemimaxillae occurs
★ Teeth expands more widely than the bone
★ Palatal depth decrease

• No signiﬁcant relationship between the amount of
expansion and the amount of relapse (r2 = 0,07; p =
0.1186)


Before Expansion

After Expansion
A
B

C
C



lAs the appliance is activated,
note that the hemimaxilla move inward
relatively to the upper part
lThis may explain why CBCT study
may ﬁnd less skeletal expansion than
PA ceph because of the precision of
the landmarks


Phase 2 surgery

• A classic study of the stability of transverse expansion
obtained with segmented Le Fort 1 reported that patients
who had concurrent mandibular surgery had signiﬁcantly
greater relapse at the 1st and 2nd molar

• Our data show no signiﬁcant effect of any phase 2 surgery
on dental relapse

• This might be an important decision factor if large
transverse changes are necessary along with vertical and AP
changes


Conclusion
• Skeletal change were modest (3-4 mm) but
stable
• Relapse in dental expansion was almost
totally attributed to lingual movement of
posterior teeth



Conclusion
• Phase 2 surgery did not affect dental relapse
• Diastema at the end of distraction is a
predictor that adequate molar expansion is
occurring
• Bonded expanders show the same efﬁcacy
as banded expanders.



Conclusion
• Doing 2 phase surgery (SARPE + Bimax surgery)
thinking that the transverse changes will be more
stable than Le Fort 1 changes is not warranted
• When maxilla need to be repositioned AP or
vertically in a 2 nd phase

★ Decision should be based on the risk, morbidity & cost of 2
surgery versus risk, morbidity & cost of 1 stage segmental Le
Fort 1 for large expansion along with vertical and AP changes



Conclusion
• Most of the transverse change of 5-6 mm the
maxilla can be corrected by a segmented Le Fort 1

• Expansion greater than 6-7 mm is an indication for
SARPE



Le Fort 1 Morbidity
A

• Pulpal necrosis

B

• Periodontal defects



Le Fort 1 Morbidity
• Aseptic necrosis
★ Most likely to occur with Le Fort 1
osteotomies done in multiple
segments in conjonction with
superior repositioning and
transverse expansion Courtesy of Dr Brian Alpert

Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990



SARPE Morbidity
•
A B

Nasopalatal cyst

•
A B

Fibrous healing



SARPE Morbidity
• Asymmetric fracture of interdental septum + gingival defect

Cureton SL, Cuenin M, AJODO, 1999

• Non-separation of the pterygoid junction or attempting too much
expansion (3mm) intraoperatively may lead to aberrant fracture that
can run to the base of the skull, orbit and pterygopalatine fossa
Lanigan DT, Mintz SM, J Oral Maxillofac Surg 60: 104-110, 2002



Clinical Implications
• If only transverse changes are needed
★ SARPE = Choice # 1

MC; tx:18m Ka.Ri. Tx: 103w


SARPE may be indicated
• For very large transverse (>6 mm), AP and vertical
changes or periodontally compromised patients

©Dr Sylvain Chamberland (Personal opinion)


Retrospective look

Ka.Tr.271107

• This case would have had an excellent outcome
with exo of 5's/5's and 1 phase surgery that
would include segmented Le Fort 1 & BSSO

• Nevertheless, a non extraction 2 phase surgery
was done

Ka.Tr.210909

Retrospective look
• 2 years post treatment
✦ Some bite opening occured

✓ As the transverse relapse, Mx incisors may procline to accomodate

• Therefore, we can not conclude that 2 phase
surgery was any better than 1 phase surgery for
this particular case

Ka.Tr.120911


Case 1
• Class I ( cl III tendency)

• Mx constriction

• Moderate to severe crowding

• Heavily restored teeth

©Dr Sylvain Chamberland Ka.La.270510


• Moderate apnea, severe snoring

• Orthodontic Tx plan: exo 5's/5's

• Surgical Tx plan = Mx & Md advancement



Progess reports
• Reassessment of bracket position

• Mx: 3 segments

• Md: ﬁnishing space closure

• Surgery in May

Ka.La.120312



• Decompensation of the dentition is done

• Surgical tx plan will focus on skeletal changes



Case 2
• Class III

• Severe Mx constriction Ω

• Could this case be treated 37,12

in 1 phase surgery?
✦ YES. (exo 15, 24 / non ex) 33,52

St.Gi.191009



• Retrusive maxilla

• Retroclined /1

• Md laterodeviation to the left



• Pre-surgical
✦ Segmented Le Fort 1: to constrict!

✦ Md set back and laterodeviation 41,26

✦ Surgery tomorrow...
43,85

St.Gi.221111



St.Gi.221111

• /1: proclined by 12°

• 1/: retroclined by 10°



29 days post surgery
St.Gi.211211;

St.Gi.061211;

14 days post surgery



St.Gi.130212

St.Gi.120312

• Finishing stages

• Tooth mass discrepancy may help to explain the cl II canine
relationship

• Signiﬁcant arch width improvement
St.Gi.191009 St.Gi.221111 St.Gi.130212

43,85 40,07
33,52



Case 3
• Class III

• Mutilated dentition

• Moderate Mx constriction

• Overerupted UL6

Hé.Ar.030909



• Retrusive maxilla

• Proclined 1/

• Retroclined /1



• TADs
✦ Mx: to intrude UL6

✦ Md: to get some protraction of LL8



Pre-Surgical
• Edentulous space prepared

• Surg. Plan:
✦ Mx: Le Fort 1 advancement

✦ Bone graft at implant site

Hé.Ar.171111



• Mx: Le Fort 1 to advance

• Md: Genioplasty to correct the chin
déviation



• 17 days post surgery

Hé.Ar.160511



At 121 weeks

• Crowns are scheduled next month

• Operative dentistry will follow

Hé.Ar.250112


• Bridge and crown placed today

• Total Tx time 128 weeks

Hé.Ar.120312



Class 4
• Anterior open bite

• Moderate crowding

Ma-Je.Be210808



Ma-Je.Be210808

• Slight vertical maxillary excess

• Bimaxillary protrusion

• Lip incompetency



Tx Plan
• Would you do SARPE?

• Would you plan a non extraction approach?

• Would you extract?

• Would you plan a segmented Le Fort 1?

• Would you plan a 1 piece Le Fort 1?

• My plan:
✦ Exo of 5's

✦ Bimaxillary surgery


At 85 weeks
• Normal OJ & OB

• Class I molar and canine relationship

• Midline coincident

Ma-Je.Be300410



• Retracting and uprighting the incisors helped to
close the bite

• Slight maxillary excess



Ma-Je.Be210808
At 109 weeks
20 weeks post surgery

• Class I occlusion is achieved

Ma-Je.Be131010



• Mx: Le Fort 1: superior
repositionning &
advancement

• Md: BSSO & genio



Case 5
• Narrow maxillary arch

• Cl II div 1, open bite

• Avulsion 22, fractured 11, 21

• Exfoliation 74, missing 35

Lu.Mo.030708



• Retrognathic mandible

• Bimaxillary protrusion

• Lip incompetency



Tx Plan
• Would you do SARPE?

• Would you plan a non extraction approach?

• Would you extract?

• Would you plan a segmented Le Fort 1?

• Would you plan a 1 piece Le Fort 1?



Tx Plan

• Exo of 5's & E

• Mx Le Fort 1
✦ Impaction, advancement, expansion

• Md: BSSO

• Genio advancement



Lu.Mo.200409

At 36 weeks
Mx: Step distal to the canine. Prothetic tooth bonded to a bracket
Md: En masse retraction

Lu.Mo.010410

At 85 weeks
Mx: 3 segments
Md: Spaces closed
•Surgery in June


• Incisors were retracted, no extrusion



Presurgical models
• Selective grinding to maximize toot contact

• Left posterior Xbite noted
✦ Expansion needed



• Surgery at 96 weeks Lu.Mo.010710

✦ Le Fort 1: advancement 3,5 mm, impaction 3,5 mm, expansion 1,6 mm

✦ BSSO: advancement 8 mm; genio: advancement 6 mm, vertical reduction
2,5 mm

• At the removal of the surgical splint
✦ Note lack of posterior occlusal contact


Osteotomy half way between
apices of the teeth and
infraorbital nerve

Osteotomy sites ﬁlled
with bone from the
slice removed at the
symphysis

Rigid ﬁxation to the piriform
rim & zygomatic buttress
buttress

DL 130312
Courtesy Dr Carl Bouchard

• Tx time = 123 weeks

• Implant #22 was placed

Lu.Mo.201210


• Nice proﬁle

• Lips are competent



Lu.Mo.070711

• At 28 weeks into retention
✦ Crown is placed on #22

Lu.Mo.130112

• At 60 weeks into retention
✦ Note some midline deviation to the right and slight cl II



• Recall at 60 weeks



Why I don't like rigid fixation
for a genioplasty
Lu.Mo.010710 Lu.Mo.130212
Apposition zone Screw Embed

Screw in the
resorptive zone
Screw
Poor contact between distal prominent
Note bone formation over superior
& proximal segment portion of fixation device and
resorption in area of inferior
portion of fixation device


Why do I prefer
osteosynthesis?
Apposition
zone

R: Remodeling
A: Apposition Courtesy Dr Dany Morais
Resorptive
Note complete coverage of ﬁxation
zone
wires by bone and smooth labial Resorptive zone
Improved contact between proximal and cortical bone of anterior manbible
distal segment

De.Le060608 De.Le130410
Precious D., Armstrong J., Morais D., Anatomic placement of ﬁxation device in genioplasty, OOO 1992,; 73-2-8

Why I don't like posterior
openbite after orthognathic
surgery?
Pressure Condyle resorb

• Lack of posterior occlusion
may increase pressure at the
condyle and cause
non-physiologic remodeling
or condylar resorption

Screwed Setting Jam-packed Slight progressive
occlusion retrusion The bite open


Distinguished Attendees
Thank you
www.slideshare.net/sylvainchamberland
www.sylvainchamberland.com


• Mx: segmented Le Fort 1
✦ Advancement

✦ Anterior elongation

✦ Expansion

• Md: BSSO + genio



Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical review and update

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Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical review and update