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.

Introduction posterior maxillary osteotomies parallel to one another with

The desire to mobilize the maxilla through an osteotomy dates
back to more than 150 years ago. Von Langenbeck1 discussed
the utilization of a maxillary osteotomy to facilitate nasal
polyp removal in 1859. Cheever2 in 1876 similarly discussed
down fracture of the hemi maxilla for clearing the nasal cavity
of an obstructing lesion. The concept or desire for movement
and repositioning of the maxilla was not Von Langenbecks or
Cheevers goal; however, the thought process of freeing the
maxilla from a fixed position was described.
In 1901, Le Fort3 helped to bring clarity to the natural
cleavage planes of the facial skeleton. By defining the level I
cleavage plane of the maxilla from the cranial base, predict-
able manipulation of the maxilla could be planned for treat-
ment of a malpositioned maxilla. In fact, in 1927 Wassmund4
discussed the technique for mobilization of the maxilla but did
not include separation of the pterygoid plates. Schuchardt5 in
1942 reported the successful advancement of the maxilla via
separation from the pterygoid plates and complete down
fracture after an unsatisfactory attempt without pterygoid
plate separation.
By the late1960s and early 1970s, Bell6 capitalized on the
ability to mobilize the maxilla and discussed segmentalization
for the facilitation of orthodontic treatment goals as well as
described the vascular supply, which permitted these surgical
movements. In the 1980s, continued refinement of the Le Fort I
osteotomy procedure focused on techniques to facilitate
postoperative stability. Kaminishi and colleagues7 discussed
carrying the osteotomy cut high into the dense cortical bone of
the zygomaticomaxillary buttress to facilitate postoperative
stability and internal fixation. Bennett and Wolford8 further
advocated the step osteotomy of the maxilla to avoid un-
wanted vertical movement from an angulated nonstepped
osteotomy of the maxilla. Their design kept the anterior and
Department of Oral and Maxillofacial Surgery, University of Okla-
homa College of Dentistry, 1201 North Stonewall, Oklahoma City, OK
73117, USA
E-mail address: Steven-Sullivan@ouhsc.edu
the step at a right angle near the buttress. Reyenke and
Masuriek,9,10 somewhat conversely, advocated a sloped
osteotomy for inferior anterior maxillary repositioning with is
goal being improved bony contact during inferior repositioning
of the maxilla.
The versatility of the Le Fort I osteotomy to correct maxil-
lary deformities is unquestioned. As a result, the osteotomy
design has undergone modification to enhance the ability of
the surgeon to accurately reposition the maxilla and to
improve bony contact and logically the initial stability of the
mobilized jaw. The technique I will describe further enhances
bony contact by increasing bony surface area while decreasing
osteotomy gaps along the buttress and posterior maxilla.
Surgical technique
Preoperative planning
Execution of the surgical procedure is best done with
controlled hypotension, the use of local anesthesia with
vasoconstrictor and nasotracheal intubation. It is important
that the smallest endotracheal tube, which meets the neces-
sary length requirement to pass through the vocal cords
without impingement of the balloon on the cords, should be
used. It is important, especially at the termination of the case
when closing, that there is the ability to have control of the
diameter of the nares as well as the alar base.
The endotracheal tube should be secured passively in such a
way that there is no upward or cephalad traction on the nose
causing any distortion that would impact the ability to get an
appropriate recapitulation of the nasal base or enhance it in
cases where it is excessively wide, narrow, or asymmetric.
Establishment of a preoperative vertical dimension is
essential whether the maxilla is to be moved superiorly or
inferiorly any vertical changes can be accounted for. Errors will
impact the patients tooth-to-lip display. External markers
have shown to be the most effective in controlling the vertical
dimension. I prefer a .04500 Steinmann pin, which is inserted in
the nasal bridge at soft tissue nasion (Fig. 1).

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2 Sullivan
Fig. 1 External reference pin place in the bridge of the nose.
The measurement of the vertical dimension is made from
the pin to the arch wire. This will ensure that maximum control
intraoperatively can be obtained so that your planned vertical
change can be accurately obtained. A Marshac caliper, or Boley
gauge, will suffice in recording this measurement (Fig. 2).
Incisions for a Le Fort I osteotomy should be made using
complete vestibular retraction with an appropriate retractor
that will fit across the entire arch (Fig. 3). Whether one uses
electrocautery or scalpel can be left to the surgeons prefer-
ence; however, I find that the Colorado tip provides for good
hemostasis, minimal thermal damage, and surgical precision.
The initial incision should be placed at a minimum of 5 mm
above the mucogingival junction, leaving an adequate amount
of movable mucosa for final closure.
Fig. 2 Preoperative measurement is recorded. External mea-
surements are more accurate then internal measurements and
more reproducible.
Fig. 3 Good vestibular retraction is essential for making the
mucosal incision.
Keep in mind that the soft tissue will retract somewhat, so a
generous collar of soft tissue should be accounted for. It is my
preference to make an incision from the embrasure of the first
molar to embrasure of the opposite first molar through mucosa
and muscle with the periosteum being incised with a #15 blade
(Fig. 4). Once this has been accomplished, the entire maxilla is
exposed with a mucoperiosteal elevator and Obwegeser curved
out right angle retractors being inserted behind the buttress
and engaging the pterygomaxillary juncture (Fig. 5).
An adequate amount of reflection must take place to allow
for placement of your rigid fixation once the maxilla has been
repositioned. To facilitate reflection of the nasal mucosa, I find
that disarticulation of the septum from the anterior nasal spine
is most helpful. The nasal septum can be easily disarticulated
by use of a right angle notched retractor by engaging septum at
the junction of the anterior nasal spine. Using cephalad and
slight posterior traction the septum will disarticulate from the
maxillary crest and anterior nasal spine and initiate the
elevation of the mucoperiosteum from the anterior floor of the
nasal cavity (Fig. 6).
A nasal freer is then used to complete the remaining reflec-
tion of the nasal mucosa. It is important that the mucoper-
iosteum be reflected from the entire lateral nasal wall, nasal
floor, and off the septum bilaterally. This will minimize tears to
the nasal mucosa during the osteotomies. Using this technique
oftentimes will preclude the need for any nasal mucosa repair
following down fracture (Fig. 7). The proposed geometry of the
Le Fort I osteotomy now can be clearly visualized and even
premarked using a sterile pencil so that there is symmetry,
appropriateness in the height bilaterally, and location of the
buttress cut such that tooth roots can be avoided (Fig. 8).
A nasal mucosa retractor is then inserted at the piriform rim
between the base of the rim and the inferior turbinate to
protect the turbinate from the reciprocating saw, which is used
to make the anterior maxillary wall and the lateral nasal wall
cut (Fig. 9). A reciprocating saw will easily pass through the
thin maxillary bone. As it is swept medially and then superiorly,
the lateral nasal wall will also be osteotomized. Many times
this method precludes the use of other osteotomes before
down fracture (Fig. 10).
The buttress cut has been modified from how it has been
described in the literature. Historically, a right angle stepped
buttress cut has been used; however, that leaves a very
Le Fort I Osteotomy
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. 5 The maxilla is degloved to facilitate complete
visualization.
precarious area of the thin bone at the buttress, which makes
it challenging to place bone plates along the lines of force
distribution. With this in mind, I have modified the osteotomy
to be done at a 45 angle to the anterior maxillary cut, beveling
45 from lateral to medial and making the terminus of the cut
at the lower one-third of the pterygoid plates (Fig. 11). This
creates an osteotomy angled in all 3 dimensions. The resulting
sagittal bevel through the buttress facilitates excellent bone-
to-bone contact. The 45 -angle cut to the anterior maxillary
osteotomy facilitates bone plates being placed 90 to the
buttress and parallel to the direction of force distribution. The
contralateral osteotomies are then completed (Fig. 12).
If the maxilla is being impacted, this is an appropriate time
to estimate the amount of anterior maxillary bone removal
that will be required to facilitate the superior repositioning.
With impactions of greater than 4 mm, I will often remove this
at the time of the initial anterior maxillary osteotomy with a
lesser amount being removed at the buttress (Fig. 13). A
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.
3
double guarded osteotome is then used to separate the nasal
septum from the maxilla (Fig. 14).
A curved Burton osteotome is then inserted to the pter-
ygomaxillary juncture with the orientation of the osteotome
being inferomedial. The assistant places a finger inside the
mouth in the area of the hamulus, and the osteotome is then
malleted until such time as the separation is felt (Fig. 15).
Once this is accomplished on the opposite side, the down
fracture can be often accomplished using digital downward
pressure (Fig. 16). It is imperative that that the maxilla be
generously mobilized to facilitate any movements that are
desired and permit the maxilla to be passively repositioned. I
prefer Rowe disimpaction forceps for this maneuver (Fig. 17).
After complete mobilization, a 1.5-mm wire passing bur is
used to make a hole at the base of the anterior nasal spine, and
then a 24-gauge wire is passed and tightened to facilitate
downward traction (Fig. 18). This hole will also be used at the
time of closure so that there is anchoring of the soft tissues.
This will be described elsewhere in this paper. The use of a
double-bladed, palatal retractor facilitates visualization of the
down fractured maxilla and enhances visibility during instru-
mentation (Fig. 19). Double action rongeurs are then used to
remove residual components of the nasal septum and lateral
nasal wall, with great care being taken to minimize trauma to
the descending palatine vessels (Fig. 20).
I do not find it necessary or advantageous to immediately
ligate or cauterize the descending palatine vessels. Often, in
the tuberosity region at the terminus of the buttress cut, there
will be a small triangle of bone that needs to be removed. Once
this interference has been completed, it is essential that any
potential bony interference around the greater palatine ves-
sels and pterygoid plates be removed so that passive reposi-
tioning of the maxilla, especially if it is moving superiorly, can
be accomplished (Fig. 21). The maxillary crest is reduced and a
4 Sullivan

Fig. 7 The nasal mucosa should be reflected completely from

the nasal cavity and septum to preclude damage to the turbinates
and maintain the nasal mucosal integrity during osteotomy and
down fracture.

septal groove is placed to allow the cartilaginous septum to fit

passively into it (Fig. 22).
Using the technique described, it is unusual for the nasal
mucosa to tear; however, if turbinectomies or tears to the
nasal mucosa are noted, a 4.0 chromic suture can be used to
repair the mucosa at this time. If the decision to segment the
maxilla has been made preoperatively, segmentation can be
effected very quickly with the maxilla in a down fracture po-
sition. It is rare that segmentation takes place anywhere other
than between the lateral and canine teeth. The rationale for
this is the 3-dimensional changes in the dentition typically are
in the posterior teeth, and inclusion of the canine allows one to
alter canine width, account for Bolton discrepancies with the
segmentation, as well as effect changes in the pitch and roll of Fig. 8 The osteotomy design is a modification of the Ben-
the posterior segments independent of one another. The 4- netteWolford design and facilitates the application of fixation and
tooth anterior segment is considered the esthetic unit, and is angular in nature to improve bone contact.
vertical changes that are skeletal in nature can then be
accomplished, such as partial closure of open bites and
improvement of the smile line. Reangulation of the incisors accomplished with a #702 bur with the anterior aspect of the
skeletally rather than orthodontically can also be done osteotomy coming forward to no closer than about 15 mm from
(Fig. 23). the piriform rim. This is done to ensure a good bony pedicle for
Although some surgeons prefer to segment before down the anterior segment (Fig. 24).
fracture, I find that the orientation of the osteotomy cuts are Width changes of greater than 5 mm will be accomplished
far easier to visualize in the down fractured state and can be with a midline osteotomy after a palatal releasing incision. It is
accomplished very quickly and efficiently, often requiring less my preference to use a sterile pencil to mark the roots of the
than 10 minutes. Changes in width of the maxilla will dictate teeth and then draw out the proposed interdental osteotomies
the osteotomy design that I use for the palatal cut. If there is directly on bone. A #701 bur is then used to make a cortical
less than 5 mm in width change, a horseshoe osteotomy is kerf in the bone above the apices of the teeth (Fig. 25). Once

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. 13 Anterior bone removal can be done before down frac-

ture if large impactions are being done or judicially and incre-
Fig. 12 The completed osteotomies should be symmetric. mentally removed as the maxilla is being repositioned.

Fig. 14 (A, B) The septum is osteotomized using a double guarded osteotome.

6 Sullivan

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. 21 It is important that the posterior maxilla be free of interferences.

Fig. 22 (A, B) A groove is developed on the maxillary crest to facilitate positioning of the septum when the maxilla is repositioned.

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
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
palatal releasing incision with reflection of the palatal tissue
such that a midline osteotomy from the nasal side can be
accomplished without injuring the palatal tissue. The palatal
tissue reflection allows the posterior segments to freely slide
transversely. Bone grafting can be done from the nasal side. My
preference is freeze dried bone or porous hydroxyapatite
blocks (Fig. 31).
The maxilla is then placed into occlusion with the mandible.
Maximum interdigitation with tooth-to-tooth contact is
preferred and secured with 28-gauge wire. I have found that
heavier gauge wire tends to cause bracket separation. The
preference to not use a splint between the teeth is founded on
my observation that the splint tends to result in intrusion of the
teeth during the first few weeks postoperatively. When it is
removed, the interdigitation is often less than planned and
additional elastic therapy is needed. Monitoring the occlusion
when there is tooth-to-tooth contact is far easier than when
the teeth are obscured by a splint.
With the mobilized maxilla now in its final max-
illaemandibular occlusion, it is important that any detectable
interference as the maxilla is repositioned vertically is
accounted for. There should be upward, and ever so slightly
forward, pressure at the angles.
The maxilla should be rotated gently superiorly with
appropriate retractors, such as Obwegeser toe-out retractors,
which are placed in the buttress region so interferences can be
felt then visualized. It is important that the retractors have no
contact with the maxillomandibular complex as it is rotated
into its final position. As the maxilla is gently rotated superiorly
with upward pressure to seat the condyles, one should be
Fig. 33 (A, B) The bevel created by the angular nature of the posterior maxillary osteotomy creates excellent bone contact.
Sullivan
careful to feel if there are any interferences posteriorly.
Oftentimes, they will be adjacent to the separation of the
pterygoid plates on the medial side of the maxilla (Fig. 32). If
the treatment plan will permit, I often will include 2 mm of
maxillary advancement, because it is undetectable from a
clinical standpoint but can minimize the possibility of ptery-
goid interference during repositioning. If there are in-
terferences that are detected, they should be identified and
removed. The bevel created at the buttress osteotomy often-
times will allow it to slide upon itself so minimal reduction is
often the case (Fig. 33). Any bony interferences should be
removed judiciously so as to facilitate as much bone-to-bone
contact as possible.
When the maxilla is repositioned passively into its planned
position and the vertical measurement of the planned final
position verified, rigid fixation can then be applied (Fig. 34).
One has the option to put a posterior buttress wire to help hold
the maxilla in position, and even at times, if good bone-to-
bone contact is present, this may be all that is necessary for
posterior fixation.
It is my preference to use a plate design that specifically fa-
cilitates the use of segmental osteotomies, because well over
90% of my maxillary surgery is segmented. Bone plates are
adapted along the piriform rim and nasal cavity with the
extended L incorporating the anterior 4-tooth segment and
the segment containing the canine and posterior teeth. It is my
preference to use a 1.5-mm screw with plates that have a slightly
thicker profile but still maintain a 1.5-mm footprint. This, I find,
to be tremendously flexible and more than adequate, because I
am often able to treatment plan these cases with significant
bone-to-bone contact, so a heavier plate is unnecessary. An L-
Le Fort I Osteotomy 11

Fig. 35 The maxilla is plated with 1.5 mm system. A specially

designed anterior segmental plate is used to secure the incisor and
posterior segments. Posterior plates are placed 90 to the buttress
osteotomy as a result of the osteotomy geometry.

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
Fig. 38 A nasal trumpet similarly sized to the endotracheal tube
helps to maintain nasal base shape and nares symmetry.
the external reference, and new holes drilled. In most in-
stances where there has been condylar distraction, the ante-
rior plates will not change their overall position; however, the
plates on the buttresses tend to move more medial, signifying
some additional superior repositioning of the posterior maxilla.
Once the maxilla has been replated, the occlusion is verified
and, if satisfactory, any necessary bone grafting can be done. I
tend to use a tricalcium phosphateecollagen sponge that is
saturated with autogenous blood for noneload-bearing defects
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).
Sullivan
and with hydroxyapatite or allogeneic bone blocks for load-
bearing defects (Fig. 36).
Closure of the maxilla is extremely important to ensure
appropriate soft tissue esthetics. The nasal septum is verified
to be free of interferences, and then a suture is passed through
the caudal edge and the suture then passed through the
anterior nasal spine hole, securing it in position such that it
minimizes the possibility of displacement when the endotra-
cheal tube is removed (Fig. 37). I find it helpful to place nasal
trumpet of the same size as the endotracheal tube in the
unintubated nares to help form the alar base and to ensure
that the diameters are as close to one another as possible
(Fig. 38).
An alar base cinch, which I find to be critically important, is
typically initiated from the left side with the needle being
passed parallel to the alar base bilaterally from a posterior to
anterior direction. Its symmetric insertion is verified by inferior
and cross-suture traction (Fig. 39AeC).
The alar base should retract inferiorly and adapt nicely to
the piriform rims with a bit of pouting of the philtrum. The alar
cinch suture is then passed through the anterior nasal spine
hole and the cinch suture tightened to equal or slightly over-
correct the preoperative alar base width (Fig. 39D, E).
An additional suture is then used to reorient the zygomati-
cus musculature. It is a very simple mattress suture inserted in
the first and second premolar region and brought across the
midline either under the nasal spine or through the anterior
nasal spine hole. Once this has been tied, the vestibular inci-
sion often lays perfectly adapted. This suture tends to help
Le Fort I Osteotomy
Fig. 41 (AeC) V-Y closure.
redefine the nasolabial folds and evert the lateral vermillion
(Fig. 40).
The closure of the mucosa can be done using a variety of
techniques: VY closure, double VY closure, or linearly. This will
need to be based on the needs of the patient. If the lip length
is extremely long, oftentimes a linear suture line will be
adequate, in that any shortening may either be desirable or
unnoticed. A double V-Y closure can be used if there are con-
cerns about loss of lateral vermilion height, however, if the lips
are full and symmetric. A conventional VY can be accom-
plished. This is done with a fast resorbing 5-0 Vicryl suture.
With the depth of the vestibule being approximated with dig-
ital pressure to ascertain the length of the leg of the Y-
component of the suture line, additional interrupted sutures
are used to close the terminal component of the incision.
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).
The nasal trumpet is then removed to ensure that there
have not been any fundamental changes in the base of the nose
and the nasal septum has maintained its midline position. A
nasogastric tube is typically passed and left in place until such
time that the patient is awake and not having issues with
nausea. Light elastics are placed on the orthodontic brackets
with the direction of pull corresponding to the direction of the
correction.
Complications
The most concerning intraoperative complication is posterior
maxillary bleeding. This is often from direct injury to the
palatine vessels. Posterior maxillary bleeding is often managed
with electrocautery or placing vascular clips on the vessels. I
do not feel it is necessary to ligate these vessels prophylacti-
cally because the incidence of bleeding is low and leads to an
unnecessary loss of palatal blood supply. Fortunately,
compromise of the maxillary artery is a far more remote
complication and if control of bleeding cannot be managed
with direct compression, cautery, or ligation, then emboliza-
tion may be needed.
Maxillary malpositioning owing to posterior interferences is
not unusual and has been discussed. Fortunately, with the use
of rigid fixation maxillary malpositioning is easy to diagnose
and remedy.
13
Nonunion of the maxilla is extremely rare with an occur-
rence of 0.33% to 0.8%. This is most often related to inade-
quate bony contact owing to large surgical movements, and
failure of fixation owing to parafunction. Nonunions are best
treated when first recognized by removal of intervening fibrous
tissue in the osteotomy sites, reapplication of bone plates, and
grafting with autogenous, allogenenic, or alloplastic grafts,
which provide structural support.
Summary
The technique described is very efficient and relies on few
instruments to accomplish the operation. The surgical design
and geometry facilitate excellent bone contact and thicker
bone for application of fixation.
References
1. Langenbeck BV. Beitrage zur osteoplastik e die osteoplastische
resektion des oberkeifers. In: Goshen A, editor. Deutche klinik.
Berlin: Reimer; 1859.
2. Cheever DW. Naso-pharyngeal polypus, attached to the basilar
process of the occipital and body of the sphenoid bone successfully
removed by a section, displacement, and subsequent replacement
and reunion of the superior maxillary bone. Boston Med Surg J
1867;8:162.
3. Le Fort R. Fractures de la machoire superieure. Rev Chir 1901;4:
360.
4. Wassmund M. Frakturen und Luxationen des Gesichtsschadels.
Leipzig (Germany): Meusser; 1927.
5. Schuchardt K. Ein Beitrag zur chirurgischen Kieferorthopade unter
Berucksichtgung iher Bedeutung fur die Behandlung angeborener
und erworbner Kieferdeformitaten bei Soldaten. Dtch. Zahn-Mund-
un. Kieferheilk 1942;9:73.
6. Bell WH. Le Fort I osteotomy for the correction of dentofacial
deformities. J Oral Surg 1975;33:412.
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