Response to Pitak-Arnnop “Letter to the Editor”

Historical Accuracy and Terminology

 In their response, Pitak-Arnnop states that describing our cohort as having undergone “replacement of a bony lid following a Caldwell Luc approach” may be “inaccurate and potentially misleading.” We seek to clarify a few points.

Contemporary usage of the “Caldwell-Luc” eponym may refer to an anterior maxillary antrostomy through a sublabial approach. As indicated by Pitak-Arnnop, this approach was reported by Caldwell (1893), Spicer (1894), and Luc (1897) independently in the last decade of the 20th century, to address pathology (often infectious) of the maxillary sinus. However, approaches via the canine fossa were described even earlier by Heath of London (1889) and Robertson of Newcastle-on-Tyne (1892). ² One innovation introduced by Caldwell and Luc was fenestration through either the inferior or middle meatus to allow for counter-drainage through the nose.^2,3

The sublabial approach offers benefit in various clinical scenarios, as described in our manuscript. Dr. Lindorf modified this approach to include re-apposition of the anterior maxillary sinus wall in osteoplastic fashion. ⁴ Abello had previously described a hinged bony window for a similar purpose. ⁵ Lindorf clarifies that he always preserved the maxillary sinus mucosa, in contrast to the classical Caldwell-Luc which entailed removal of the sinus mucosa. ⁴

In our patients, the maxillary sinonasal mucosa was not always preserved, similar to the Caldwell-Luc approach. However, nasal counter-drainage was typically not surgically created as pathology was predominantly neoplastic in nature rather than infectious due to obstructed nasal drainage. The re-apposition of the bony flap was indeed very similar to Lindorf’s, whose work we referenced in our introduction and discussion. We could describe our cohort as having undergone a “Heath,” “Robertson,” or “modified Lindorf” approach, however these might not carry significant meaning to contemporary readers. Limited space for publication required some brevity in historical discussion.

As for the benefits of such a bony lid, we agree that further research will be required to establish definitive advantages. One retrospective German cohort suggested expedited healing and improved radiologic findings with use of a maxillary bone lid compared to surgery without lid replacement. ⁶ Other cohorts have suggested similar advantages.^7,8

Fixation of the Osteoplastic Window

 Pitak-Arnnop proposes that titanium miniplates may be susceptible to infection. They point to Purbo et al.’s study of 10 midfacial titanium plates removed due to infection (erythema and purulence), which demonstrated microbial biofilms on scanning electron microscopy. ⁹ Importantly, those plates were used to treat open midfacial fractures, with bone exposed to oral flora for a longer period. In our cohort, osteotomy was performed under controlled surgical conditions and closed promptly with a watertight closure, akin to orthognathic surgery. None of our patients demonstrated signs of infection.

Need for plate removal is a valid concern, and possibly more common for mandibular rather than maxillary plates. ¹⁰ Posnick et al ’s study showed a 1.1% rate of maxillary hardware removal for Lefort 1 osteotomies for orthognathic surgery. ¹¹ Indeed, one of our patients did request subsequent plate removal as described in our manuscript. Other avenues for fixation include suture, wire, resorbable plates, or fibrin glue. ¹² In his original report of the approach, Lindorf described a beveled cut less than 0.2 mm wide that allowed the osteoplastic flap to be replaced without additional fixation. ⁴

Pathological Classification

 Patient 3 had undergone extraction of tooth #14 by an outside provider 1 year before presenting. Ideally, cyst removal could have been performed via a transalveolar approach at the time of extraction, but this did not occur. When we saw her, there was no oroantral fistula at site of tooth #14. Removal via the previous extraction site would have destroyed the alveolus and been quite difficult given the size and bony encapsulation of the cyst. Removal via the anterior maxillary wall prevented destruction of the alveolus and a likely OA communication that would likely require subsequent closure. Pathological classification revealed a residual cyst.

Injury to the Anterior Superior Alveolar Nerve

 The anterior superior alveolar nerve (ASAN) runs across the anterior maxillary wall below the infraorbital foramen (IOF). ¹³ We make superior bony cuts across the anterior maxillary wall at a level 5 mm below the IOF. Although the mean vertical height from the IOF to the ASAN is 5.5 mm, it ranges from 1 to 11 mm, increasing more as the nerve courses medially. We disagree that the risk to the nerve is negligible, especially when approaching pathology requiring a larger window, or in patients with decreased vertical height of the midface or longer tooth roots. We would recommend discussing this risk with patients when obtaining informed consent.