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Le Fort I Osteotomy: Steven M. Sullivan, DDS
Le Fort I Osteotomy: Steven M. Sullivan, DDS
KEYWORDS
Le Fort I osteotomy Maxillary segmentation Le Fort I geometry modifications
KEY POINTS
The osteotomy design in a Le Fort I significantly impacts the ability to reposition the maxilla 3-dimensionally.
The surgical technique presented allows for efficiency in completion of the osteotomies.
Sequencing for segmentation as well as segmentation schemes will be presented so that 3-dimensional problems in the
maxilla can be individually addressed.
Control of the vertical dimension in the Le Fort I is critical to ensure accurate transposition of the surgical treatment plan
to the executed surgical procedure.
Fig. 4 (A) A minimum of 5 mm of mucosa above the attached gingiva is essential for appropriate closure. (B) The periosteum is incised to
facilitate a clean reflection.
Fig. 6 (A) The nasal septum is disarticulated easily with a notched right angle retractor by engaging the caudal edge and applying firm
upward pressure. (B) The disarticulate also initiates the reflection of the nasal mucosa and facilitate its further reflection from the nasal
cavity and septum.
4 Sullivan
Fig. 9 (A) Nasal mucosa retractor. (B) The nasal mucosa retractor is inserted to the depth of the nasal cavity to protect the turbinates.
Le Fort I Osteotomy 5
Fig. 10 (A) A reciprocating saw is used to make a horizontal osteotomy parallel to the maxillary occlusal plane. (B) The lateral nasal wall
can be cut simultaneously by sweeping the saw medially after the saw penetrates the anterior maxillary wall.
Fig. 11 The buttress is osteotomized by angling the saw 90 to the buttress, 45 to the horizontal osteotomy, and 45 inferiorly toward
the lower third of the pterygoid plates as shown in Fig. 8.
Fig. 15 (A, B) A curved Burton osteotome is inserted low on the maxilla at the ptyeromaxillary junction. The assistant surgeons index
finger is placed intraorally in the region of the hamulus. The osteotome is advanced with a mallet until the posterior maxilla is separated.
The assistant will feel the separation and preclude perforation of the osteotome intraorally.
this has been accomplished bilaterally and the arch wire cut, a
small oscillating saw with a rounded end blade can then be
used to complete the cut through lateral piriform rim, joining
the horseshoe osteotomy in the nasal cavity in a converging
direction (Fig. 26).
A periotome is used to initiate the segmentation between
the teeth and to create an initial osteotomy in the bone, which
is not full thickness in nature. Because of its flexibility, it will
minimize the possibility of root damage. The periotome
osteotomy extends from the coronal one-third of the root su-
periorly to the full-thickness osteotomy, which is above the
apices of the root. A spatula osteotome is then used to facili-
tate splitting of the alveolus from the mid root are superiorly to
the full thicken osteotomy (Fig. 27) and is completed with a
wood handle osteotome gently mobilizing the anterior segment
to ensure that they have been separated appropriately
(Fig. 28).
A Turvey palatal spreader is then used to ensure that the
posterior dentoalveolar components have been separated from
Fig. 16 The maxilla can be down fractured with digital pressure. the nasal floor (Fig. 29). Once it is verified that the segmen-
tation is complete Fig. 30, a prefabricated palatal splint is
inserted and secured with circumdental 24-gauge wires to
maintain the width.
Fig. 17 (A, B) The maxilla must be completely mobilized. Rowe disimpaction forceps are being used in this case.
Le Fort I Osteotomy 7
Fig. 18 (A, B) A hole is drilled the anterior nasal spine to facilitate placement of a retraction wire and later to anchor the nasal septum
and alar cinch.
Fig. 19 A double bladed Burton palatal retractor greatly enhances visualization for bony reductions and segmentation.
Fig. 20 (AeC) The nasal septum and lateral nasal walls are reduced carefully.
Fig. 23 (A, B) Segmentation between the lateral and canine is most often done because it has the least impact on the nasal base and
addresses the 3-dimensional changes that may be needed. It also gives the surgeon control over the incisor position.
Fig. 24 (A, B) A horseshoe osteotomy is used for most segmentation requiring 5 mm or less of transverse change.
Fig. 25 (AeC) The initial interdental osteotomies are done after identifying the roots and near or above the root apices. Angular
orientation is better with the maxilla down fractured.
Fig. 26 (A, B) An oscillating saw is used to complete the osteotomy, and joins the palatal horseshoe osteotomy and should converge
posteriorly.
Le Fort I Osteotomy 9
Fig. 27 (A, B) A periotome is used to initiate the segmentation between the roots and is only 2 to 3 mm in depth. A spatula osteotome is
then used to complete the segmentation.
Fig. 28 A wood handled osteotome is used to gently complete Fig. 29 A Turvey palatal spreader is used to ensure complete
the separation. separation of the posterior segments.
Fig. 30 The segmentation will allow for the segments to move 3-dimensionally without interference.
Fig. 31 (A, B) Larger width changes can be accomplished with a midline osteotomy and maintained with a block graft.
10 Sullivan
Fig. 32 Interferences in repositioning the maxilla are usually posterior near the pterygoid plates and passive repositioning is essential.
If greater than 5 mm is required, I will often perform a careful to feel if there are any interferences posteriorly.
palatal releasing incision with reflection of the palatal tissue Oftentimes, they will be adjacent to the separation of the
such that a midline osteotomy from the nasal side can be pterygoid plates on the medial side of the maxilla (Fig. 32). If
accomplished without injuring the palatal tissue. The palatal the treatment plan will permit, I often will include 2 mm of
tissue reflection allows the posterior segments to freely slide maxillary advancement, because it is undetectable from a
transversely. Bone grafting can be done from the nasal side. My clinical standpoint but can minimize the possibility of ptery-
preference is freeze dried bone or porous hydroxyapatite goid interference during repositioning. If there are in-
blocks (Fig. 31). terferences that are detected, they should be identified and
The maxilla is then placed into occlusion with the mandible. removed. The bevel created at the buttress osteotomy often-
Maximum interdigitation with tooth-to-tooth contact is times will allow it to slide upon itself so minimal reduction is
preferred and secured with 28-gauge wire. I have found that often the case (Fig. 33). Any bony interferences should be
heavier gauge wire tends to cause bracket separation. The removed judiciously so as to facilitate as much bone-to-bone
preference to not use a splint between the teeth is founded on contact as possible.
my observation that the splint tends to result in intrusion of the When the maxilla is repositioned passively into its planned
teeth during the first few weeks postoperatively. When it is position and the vertical measurement of the planned final
removed, the interdigitation is often less than planned and position verified, rigid fixation can then be applied (Fig. 34).
additional elastic therapy is needed. Monitoring the occlusion One has the option to put a posterior buttress wire to help hold
when there is tooth-to-tooth contact is far easier than when the maxilla in position, and even at times, if good bone-to-
the teeth are obscured by a splint. bone contact is present, this may be all that is necessary for
With the mobilized maxilla now in its final max- posterior fixation.
illaemandibular occlusion, it is important that any detectable It is my preference to use a plate design that specifically fa-
interference as the maxilla is repositioned vertically is cilitates the use of segmental osteotomies, because well over
accounted for. There should be upward, and ever so slightly 90% of my maxillary surgery is segmented. Bone plates are
forward, pressure at the angles. adapted along the piriform rim and nasal cavity with the
The maxilla should be rotated gently superiorly with extended L incorporating the anterior 4-tooth segment and
appropriate retractors, such as Obwegeser toe-out retractors, the segment containing the canine and posterior teeth. It is my
which are placed in the buttress region so interferences can be preference to use a 1.5-mm screw with plates that have a slightly
felt then visualized. It is important that the retractors have no thicker profile but still maintain a 1.5-mm footprint. This, I find,
contact with the maxillomandibular complex as it is rotated to be tremendously flexible and more than adequate, because I
into its final position. As the maxilla is gently rotated superiorly am often able to treatment plan these cases with significant
with upward pressure to seat the condyles, one should be bone-to-bone contact, so a heavier plate is unnecessary. An L-
Fig. 33 (A, B) The bevel created by the angular nature of the posterior maxillary osteotomy creates excellent bone contact.
Le Fort I Osteotomy 11
plate is then placed at the buttresses (Fig. 35). Once this has
been accomplished, the release of the maxillomandibular fixa-
tion to verify that the planned occlusion is obtained.
If there are midline shifts or creation of an open bite ten-
dency, this signifies a posterior interference. This results in
condylar displacement. The displacement can be in the form of
inferior condylar distraction, in which case an open bite or
open bite tendency will be noticed. In the case of condylar
torque, the midline will often shift. If this is the case, the
superior screws of the bone plates can be removed and addi-
Fig. 34 With the maxilla in occlusion and repositioned, the
tional inspection can take place to identify the source of the
planned vertical change is verified.
interference. If it is found and relieved, the maxilla can again
be passively repositioned, the vertical dimension verified using
Fig. 36 (AeC) Grafting of defects can be done with nonstructural grafting material, such as tricalcium phosphateecollagen sponges or
structural grafts such as porous hydroxyapatite blocks.
Fig. 37 (AeC) The nasal septum is reapproximated to the anterior nasal spine. The suture is passed through the anterior nasal spine hole
and tied.
12 Sullivan
Fig. 39 (AeC) An alar base suture is passed from left to right and symmetry is verified with gentle traction. (D, E) The cinch suture is
anchored by passing through the anterior nasal spine hole and snugly tying it.
Fig. 40 (A) Suture through the approximate location of the elevated zygomaticus muscles bilaterally and sutured at the midline (B) adds
definition to the nasal labial folds and bolsters the alar base (C).
Le Fort I Osteotomy 13
redefine the nasolabial folds and evert the lateral vermillion Nonunion of the maxilla is extremely rare with an occur-
(Fig. 40). rence of 0.33% to 0.8%. This is most often related to inade-
The closure of the mucosa can be done using a variety of quate bony contact owing to large surgical movements, and
techniques: VY closure, double VY closure, or linearly. This will failure of fixation owing to parafunction. Nonunions are best
need to be based on the needs of the patient. If the lip length treated when first recognized by removal of intervening fibrous
is extremely long, oftentimes a linear suture line will be tissue in the osteotomy sites, reapplication of bone plates, and
adequate, in that any shortening may either be desirable or grafting with autogenous, allogenenic, or alloplastic grafts,
unnoticed. A double V-Y closure can be used if there are con- which provide structural support.
cerns about loss of lateral vermilion height, however, if the lips
are full and symmetric. A conventional VY can be accom- Summary
plished. This is done with a fast resorbing 5-0 Vicryl suture.
With the depth of the vestibule being approximated with dig-
The technique described is very efficient and relies on few
ital pressure to ascertain the length of the leg of the Y-
instruments to accomplish the operation. The surgical design
component of the suture line, additional interrupted sutures
and geometry facilitate excellent bone contact and thicker
are used to close the terminal component of the incision.
bone for application of fixation.
Corner tacking sutures at the base of the Y and the midline are
then accomplished, followed by a simple running suture line
for the vestibular incisions (Fig. 41). References
The nasal trumpet is then removed to ensure that there
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compromise of the maxillary artery is a far more remote stability with modified Le Fort I technique. J Oral Maxillofac Surg
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not unusual and has been discussed. Fortunately, with the use 914e6.
of rigid fixation maxillary malpositioning is easy to diagnose 10. Reyneke J. Essentials of orthognathic surgery. Hanover Park (IL):
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