Le Fort I osteotomy |
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The Le Fort I osteotomy is a surgical procedure to realign the upper jaw (maxilla). This procedure is a type of orthognathic surgery that is primarily performed to fix deformities of the face and jaw, improve facial aesthetics, treat malocclusions (misaligned teeth), and treat certain medical conditions, such as obstructive sleep apnea. The surgery involves separating the maxilla from the rest of the skull and then repositioning it. [1] [2] [3]
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 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 permited segmentation or expansion. [1] [2] [4]
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. [1] [2] [4]
Subsequent developments in surgical techniques, understanding of revascularization, and the integration of orthodontics 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. [1] [2] [4]
The maxilla is a paired bone that forms a significant portion of the midface. It articulates with the frontal, zygomatic, palatine bone, 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 (a branch of the facial artery) and the anterior branch of the ascending pharyngeal artery (from the external carotid artery). The descending palatine arteries, located posterior to the pyramidal process of the palatine bone, are at risk of injury, particularly during the lateral nasal osteotomy. The maxillary nerve (cranial nerve V2) provides sensory innervation to the maxilla. The infraorbital nerve, a terminal branch of the maxillary nerve, innervates midface soft tissues and anterior maxillary teeth and is identified and preserved during the osteotomy. [1] [2]
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 (overdevelopment of the mandible) as well as facial asymmetries. [1] [2]
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 (long face syndrome) or deficiency, which affect facial height and the amount of gingival display when smiling. Certain cases of an open bite malocclusion (apertognathia), a condition where the front teeth do not meet when the jaw is closed, can also be corrected with this procedure. [1] [2] [3]
Le Fort I osteotomy is also used to treat certain cases of obstructive sleep apnea 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. [1] [2]
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. [1] [2] [3]
The surgery begins by placing the patient under general anesthesia, 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. [1] [2] [3]
The osteotomy itself is performed using a combination of specialized instruments, including saws, burs, and osteotomes. 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 and the pterygomaxillary junction. These cuts allow the maxilla to be mobilized as a single unit. [2]
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. [1] [2]
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. [2]
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. [2]
Anatomical complications include nasal septum deviation (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. [1] [2]
In vertebrates, the maxilla is the upper fixed 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 maxillary bones are fused at the intermaxillary suture, forming the anterior nasal spine. This is similar to the mandible, which is also a fusion of two mandibular bones at the mandibular symphysis. The mandible is the movable part of the jaw.
Rhinoplasty, commonly called nose job, medically called nasal reconstruction, is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.
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 is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.
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, malocclusion problems primarily arising from skeletal disharmonies, and other orthodontic dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics and self-esteem.
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 (1855–1930), the "father of modern orthodontics", popularised it. The word derives from mal- 'incorrect' and occlusion 'the manner in which opposing teeth meet'.
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 jaw (mandible) forward. The procedure was first used to correct deformities of the facial skeleton to include malocclusion. In the late 1970s advancement of the lower jaw was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with obstructive sleep apnea.
Hypertelorism is an abnormally increased distance between two organs or bodily parts, usually referring to an increased distance between the orbits (eyes), or orbital hypertelorism. In this condition the distance between the inner eye corners as well as the distance between the pupils is greater than normal. Hypertelorism should not be confused with telecanthus, in which the distance between the inner eye corners is increased but the distances between the outer eye corners and the pupils remain unchanged.
The human nose is the first organ of the respiratory system. It is also the principal organ in the olfactory system. The shape of the nose is determined by the nasal bones and the nasal cartilages, including the nasal septum, which separates the nostrils and divides the nasal cavity into two.
The Le Fortfractures are a pattern of midface fractures originally described by the French surgeon, René Le Fort, in the early 1900s. He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning. Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat. Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.
Bone segment navigation is a surgical method used to find the anatomical position of displaced bone fragments in fractures, or to position surgically created fragments in craniofacial surgery. Such fragments are later fixed in position by osteosynthesis. It has been developed for use in craniofacial and oral and maxillofacial surgery.
Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.
Mandibular fracture, also known as fracture of the jaw, is a break through the mandibular bone. In about 60% of cases the break occurs in two places. It may result in a decreased ability to fully open the mouth. Often the teeth will not feel properly aligned or there may be bleeding of the gums. Mandibular fractures occur most commonly among males in their 30s.
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 differential typical growth anomalies than any other bone in the human skeleton. This is due to variants in the complex symmetrical growth pattern which formulates the mandible.
Maxillary hypoplasia, or maxillary deficiency, is an underdevelopment of the bones of the upper jaw. It is associated with Crouzon syndrome, Angelman syndrome, as well as Fetal alcohol syndrome. It can also be associated with Cleft lip and cleft palate. Some people could develop it due to poor dental extractions.
A facial cleft is an opening or gap in the face, or a malformation of a part of the face. Facial clefts is a collective term for all sorts of clefts. All structures like bone, soft tissue, skin etc. can be affected. Facial clefts are extremely rare congenital anomalies. There are many variations of a type of clefting and classifications are needed to describe and classify all types of clefting. Facial clefts hardly ever occur isolated; most of the time there is an overlap of adjacent facial clefts.
The zygomaticomaxillary complex fracture, also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture, has four components, three of which are directly related to connections between the zygoma and the face, and the fourth being the orbital floor. Its specific locations are the lateral orbital wall, separation of the maxilla and zygoma at the anterior maxilla, the zygomatic arch, and the orbital floor near the infraorbital canal.
Surgically assisted rapid palatal expansion (SARPE), also known as surgically assisted rapid maxillary expansion(SARME), is a technique in the field of orthodontics which is used to expand the maxillary arch. This technique is a combination of both Oral and Maxillofacial Surgery and Orthodontics. This procedure is primarily done in adult patients whose maxillary sutures are fused and cannot be expanded via other techniques.
Hugo Obwegeser was an Austrian Oral and Maxillo-Facial Surgeon and Plastic Surgeon who is known as the father of the modern orthognathic surgery. In his publication of 1970, he was the first surgeon to describe the simultaneous procedure which involved surgeries of both Maxilla and Mandible involving Le Fort I and Bilateral Sagittal Split Osteotomy technique.
A Le Fort osteotomy is the name for three types of osteotomies of the jaw and face. They are based on the analogous bone fractures described by the French surgeon and physician René Le Fort.
Mandibular setback surgery is a surgical procedure performed along the occlusal plane to prevent bite opening on the anterior or posterior teeth and retract the lower jaw for both functional and aesthetic effects in patients with mandibular prognathism. It is an orthodontic surgery that is a form of reconstructive plastic surgery. There are three main types of procedures for mandibular setback surgery: Bilateral Sagittal Split Osteotomy (BSSO), Intraoral Vertical Ramus Osteotomy (IVRO) and Extraoral Ramus Osteotomy (EVRO), depending on the magnitude of mandibular setback for each patient. Postoperative care aims to minimise postoperative complications, complications includes bite changes, relapse and nerve injury.