The Le Fort I osteotomy is a surgical procedure to realign the upper jaw (

maxilla In vertebrates, the maxilla (: maxillae ) is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The two maxil ...

). This procedure is a type of

orthognathic surgery Orthognathic surgery (), also known as corrective jaw surgery or simply jaw surgery, is surgery designed to correct conditions of the jaw and lower face related to structure, growth, airway issues including sleep apnea, TMJ disorders, malocclusio ...

that is primarily performed to fix deformities of the face and jaw, improve facial aesthetics, treat

malocclusion In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855–1 ...

s (misaligned teeth), and treat certain medical conditions, such as

obstructive sleep apnea Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial airway obstruction, obstruction of the respiratory tract#Upper respiratory tract, upper airway lea ...

. The surgery involves separating the maxilla from the rest of the skull and then repositioning it.

History

The Le Fort I osteotomy is named after René Le Fort's 1901 description of midface fracture patterns resulting from trauma, is a surgical procedure used to correct dentofacial deformities and, in some cases, facilitate tumor removal or complex fracture reduction. The procedure involves a horizontal

osteotomy An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It i ...

of the maxilla, separating it from the skull base at the level of the Le Fort I fracture line. Unlike the fracture, the osteotomy preserves the pterygoid plates by cutting at the pterygomaxillary junction. This allowed for controlled movement of the tooth-bearing portion of the maxilla in multiple directions (anteroposteriorly, vertically, rotationally) and permitted segmentation or expansion. Early maxillary osteotomies, performed in the 1860s, primarily aimed to improve surgical access for nasopharyngeal tumor removal through temporary maxillary mobilization. The application of this technique to correct dentofacial deformities developed later. In the early 1900s, procedures using postoperative traction for maxillary repositioning were described. The 1930s saw further refinement with the introduction of intraoperative mobilization, especially for correcting open bites. Separating the pterygomaxillary junction also became a technique for achieving anterior repositioning. Subsequent developments in surgical techniques, understanding of revascularization, and the integration of

orthodontics Orthodontics (also referred to as orthodontia) is a dentistry specialty that addresses the diagnosis, prevention, management, and correction of mal-positioned teeth and jaws, as well as misaligned bite patterns. It may also address the modificati ...

and fixation methods have influenced the use of the Le Fort I osteotomy. Collaboration between surgeons and orthodontists, along with techniques such as complete mobilization and bone grafting, have been incorporated into practice. The Le Fort I osteotomy is now used in orthognathic surgery and may be performed in conjunction with mandibular osteotomies in combined jaw procedures such as

maxillomandibular advancement Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (Bi-Max), or maxillomandibular osteotomy (MMO), is a surgical procedure or sleep surgery which moves the upper jaw (maxilla) and the lower j ...

Maxillary anatomy

The maxilla is a paired bone that forms a significant portion of the midface. It articulates with the frontal, zygomatic,

palatine bone In anatomy, the palatine bones (; derived from the Latin ''palatum'') are two irregular bones of the facial skeleton in many animal species, located above the uvula in the throat. Together with the maxilla, they comprise the hard palate. Stru ...

, and sphenoid bones. The Le Fort I segment, the portion of the maxilla mobilized during the osteotomy, receives its blood supply primarily from the

ascending palatine artery The ascending palatine artery is an artery is a branch of the facial artery which ascends along the neck before splitting into two terminal branches; one branch supplies the soft palate, and the other supplies the palatine tonsil and pharyngotympa ...

(a branch of the

facial artery The facial artery, formerly called the external maxillary artery, is a branch of the external carotid artery that supplies blood to superficial structures of the medial regions of the face. Structure The facial artery arises in the carotid t ...

) and the anterior branch of the

ascending pharyngeal artery The ascending pharyngeal artery is an artery of the neck that supplies the pharynx. Its named branches are the inferior tympanic artery, pharyngeal artery, and posterior meningeal artery. inferior tympanic artery, and the meningeal branches (i ...

(from the

external carotid artery The external carotid artery is the major artery of the head and upper neck. It arises from the common carotid artery. It terminates by splitting into the superficial temporal and maxillary artery within the parotid gland. Structure Origin T ...

). The descending palatine arteries, located posterior to the

pyramidal process of the palatine bone The pyramidal process of the palatine bone projects backward and lateralward from the junction of the horizontal and vertical parts, and is received into the angular interval between the lower extremities of the pterygoid plates. On its posterior ...

, are at risk of injury, particularly during the lateral nasal osteotomy. The

maxillary nerve In neuroanatomy, the maxillary nerve (V) is one of the three branches or divisions of the trigeminal nerve, the fifth (CN V) cranial nerve. It comprises the principal functions of Sense, sensation from the maxilla, nasal cavity, Sinus (anatomy ...

(cranial nerve V) provides sensory innervation to the maxilla. The

infraorbital nerve The infraorbital nerve is a branch of the maxillary nerve (itself a branch of the trigeminal nerve (CN V)). It arises in the pterygopalatine fossa. It passes through the inferior orbital fissure to enter the orbit. It travels through the orbit, ...

, a terminal branch of the maxillary nerve, innervates midface soft tissues and anterior maxillary teeth and is identified and preserved during the osteotomy.

Indications

The Le Fort I osteotomy is indicated for a variety of conditions related to skeletal discrepancies of the midface. These include maxillomandibular deformities such as maxillary hypoplasia (underdevelopment of the bones of the upper jaw) and

mandibular hyperplasia Condylar hyperplasia (mandibular hyperplasia) is over-enlargement of the mandible bone in the skull. It was first described by Robert Adams in 1836 who related it to the overdevelopment of mandible. In humans, the mandibular bone has two condyl ...

(overdevelopment of the mandible) as well as facial asymmetries. It is commonly used to correct malocclusion, specifically Angle's Class II (overbite) and Class III (underbite) malocclusions, improving the patient's bite and chewing function. The procedure can also address vertical discrepancies, such as

vertical maxillary excess A jaw abnormality is a disorder in the formation, shape and/or size of the jaw. In general abnormalities arise within the jaw when there is a disturbance or fault in the fusion of the mandibular processes. The mandible in particular has the most d ...

(long face syndrome) or deficiency, which affect facial height and the amount of gingival display when smiling. Certain cases of an

open bite malocclusion Open bite is a type of orthodontic malocclusion which has been estimated to occur in 0.6% of the people in the United States. This type of malocclusion has no vertical overlap or contact between the anterior incisors.Shapiro PA. Stability of open ...

(apertognathia), a condition where the front teeth do not meet when the jaw is closed, can also be corrected with this procedure. Le Fort I osteotomy is also used to treat certain cases of

by increasing the volume of the upper airway, thus alleviating breathing difficulties during sleep. In cases of severe maxillary atrophy, often seen in patients who have lost teeth and experienced bone resorption, the osteotomy can be combined with bone grafting to create a suitable foundation for dental implants. The Le Fort I osteotomy can also be used to gain surgical access for the removal of tumors in the midface or skull base or to facilitate the reduction of complex midfacial fractures.

Procedure

Preoperative planning for the Le Fort I osteotomy is performed and typically involves detailed facial analysis, imaging, and often the creation of surgical splints. Orthodontic treatment may be necessary before and after surgery to optimize dental alignment. The surgery begins by placing the patient under

general anesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analgesi ...

, injecting a local anesthetic containing epinephrine into the planned incision line, and then placing a throat pack. An incision in the maxillary vestibule (the area between the upper lip and gum), extending from the first molar on one side to the first molar on the other, is made. The soft tissues are carefully dissected to expose the maxilla. Key anatomical structures, such as the infraorbital nerves, are identified and protected. The osteotomy itself is performed using a combination of specialized instruments, including saws, burs, and

osteotome An osteotome is an instrument used for cutting or preparing bone. Osteotomes are similar to a chisel but bevelled on both sides. They are used today in plastic surgery, orthopedic surgery and dental implantation. The chain osteotome, origina ...

s. The horizontal cut is made above the roots of the teeth, extending from the lateral maxillary buttress (the bony prominence on the side of the maxilla) to the piriform rims (near the opening of the nasal cavity). Additional cuts are made to separate the maxilla from the

nasal septum The nasal septum () separates the left and right airways of the Human nose, nasal cavity, dividing the two nostrils. It is Depression (kinesiology), depressed by the depressor septi nasi muscle. Structure The fleshy external end of the nasal s ...

and the pterygomaxillary junction. These cuts allow the maxilla to be mobilized as a single unit. Once the osteotomy is complete, the maxilla is gently sperated by down-fracturing using finger pressure and repositioned according to the preoperative plan. This repositioning can involve moving the maxilla forward (advancement), backward (retraction), upward (impaction), downward (down-grafting), or rotating it. In some cases, the maxilla may be segmented and/or expanded transversely to allow for more complex movements. After repositioning, the maxilla is stabilized using plates and screws. These fixation devices hold the bone segments in their new position, allowing for healing. Surgical splints, fabricated preoperatively, are used to guide the correct positioning of the jaws and ensure proper occlusion (bite). The surgical site is then irrigated, and the soft tissues are closed with sutures. In some cases, additional procedures, such as a nasal or alar cinch suture (to prevent widening of the nostrils) or a V-to-Y closure (to prevent lip shortening), may be performed. Postoperatively, maxillomandibular fixation (wiring the jaws together) may be used for a period to aid in healing.

Complications

The Le Fort I osteotomy, while generally considered a technically straightforward surgery, carries a risk of complications, albeit infrequent. Reported complication rates from various studies range between 6.7% and 8.77%. These complications can be broadly classified into several categories: anatomical, septic, ischemic, vascular, neurologic, and otologic. Anatomical complications include

nasal septum deviation Nasal septum deviation is a physical disorder of the nose, involving a displacement of the nasal septum. Some displacement is common, affecting 80% of people, mostly without their knowledge. Signs and symptoms The nasal septum is the bone and ...

(a shift in the nasal septum), nonunion (failure of the bone to heal properly), and malposition of the maxilla. Vascular complications primarily involve hemorrhage (bleeding). Ischemic complications, such as avascular necrosis (bone death due to lack of blood supply), can also occur and are more likely with large advancements or segmental osteotomies. Neurologic complications can include nerve damage leading to sensory deficits in the midface, although these are usually temporary. Rare but more serious neurological complications such as unilateral blindness and oculomotor nerve palsy have been reported. Otologic complications, such as middle ear problems, are also possible but are not common. Infections, such as abscesses and maxillary sinusitis, can also occur.

References