LeFort I Osteotomy
Oleh :
• The LeFort I osteotomy is commonly used for the
correction of malocclusion and maxillomandibular
deformities class II and III malocclusions, as
I N D I C AT I O N S well dentofacial asymmetries.
• Class III malocclusion is one of the most common
reasons for performing a LeFort I osteotomy.
Class III malocclusion associated with maxillary
hypoplasia commonly found in patients with orofacial
clefts, obstructive sleep apnea (OSA), and maxillary atrophy.
LeFort 1 osteotomy with horizontal advancement is used
for the majority of patients to correct their malocclusion.
If left untreated, the maxillary hypoplasia can lead to
superior rotation of the mandible, reducing the facial
height and upwardly tilting the occlusal plane.
I N D I C AT I O N S
I N D I C AT I O N S
• Severe class II deformities due to • LeFort I osteotomy + bilateral sagittal split
mandibular retrognathism LeFort 1 osteotomy (BSSO) secondary maxillary
osteotomy and repositioning + mandibular effects seen in asymmetrical mandibular
advancement and osseous genioplasty. deformities, attributed to unilateral
mandibular condylar hyperplasia.
• Patients with vertical maxillary excess (VME) or
deficiency osteotomy by decreasing the vertical
position of the maxilla and the amount of gingival
show.
INDICATIONS
• LeFort I osteotomy maxillary atrophy and OSA.
Autogenous iliac bone grafts + LeFort 1 osteotomies
rehabilitate the atrophied, edentulous mandible
for osteointegrated implants.
TECHNIQUE
The patient is placed in a supine position This is commonly done via a tattoo at the
with a shoulder roll for a neutral head level of the medial canthus or a K-wire
position. Nasotracheal intubation is preferred. placed at the level of the nasofrontal junction.
The tube is usually secured with a 2.0 silk Preoperative measurements of the maxilla
suture to either the membranous portion of from the teeth or orthodontic brackets should
the caudal septum or the anterior scalp. be obtained on both the left and right.
External facial landmarks are important to Local anesthesia injected into the
establish prior to beginning the procedure. gingivobuccal sulcus of the upper lip to help
with hemostasis.
• The incision is made with the purpose of leaving
a healthy cuff of sliding gingiva. The cuff will
always appear shorter after it is cut avoid the
TECHNIQUE embarrassing complication.
• Once through the mucosa and into the loose
areolar tissue in the submucosal plane,
dissection should proceed directly to bone.
• The incision is made from first molar to first
molar, to expose both the lateral and medial
buttresses of the maxilla.
TECHNIQUE
• When the periosteum is identified, it should be
scored with electrocautery for the entire length
of the incision. Subperiosteal dissection with an
elevator is performed.
TECHNIQUE
• After the maxilla is exposed, • The osteotomy should then be • The same osteotomy is
reference points should be made marked on the maxilla with a performed on the contralateral
on the maxilla to help achieve sterile pencil or with a high- side.
the preoperative plan. speed bur.
• A thin osteotome is then used to
• The aesthetic needs of the • The osteotomy is made with a complete the posterior
patient will help determine where reciprocating saw at the lateral osteotomies of the lateral and
the medial and lateral maxillary buttress and directed to medial maxillary buttresses.
osteotomies are made. the ipsilateral piriform rim.
TECHNIQUE
• Once the osteotomies are • Downfracturing the maxilla • Now that the maxilla is free,
completed, the downfracture will allow for further the soft tissue should be
is performed with digital dissection of the nasal floor stretched to allow for
pressure. and nasal mucosa. greater range of motion.
TECHNIQUE
Once downfracture and mobilization are complete, the
aesthetic needs and preoperative planning will determine
the new position of the maxilla.
The patient is released from MMF, then the
occlusion is checked.
If impaction is planned, the appropriate amount of anterior
maxillary bone, septum, and vomer should be reduced to
provide for a stable base and prevent nasal septal
deviation.
TECHNIQUE
The maxillary midline is checked in relation to the external
reference points and the central incisors are checked in
relation to the mandibular incisors.
It is then used to position the maxilla by placing the patient
in maxillomandibular fixation (MMF).
The desired movements are made in relation to the
external reference points measured preoperatively. If a
surgical splint has been fashioned preoperatively,
TECHNIQUE
After ensuring proper occlusion, the incision is
closed with an absorbable suture with a 3.0 or
4.0 Vicryl suture in a horizontal mattress-type
fashion to ensure a watertight closure.
A V-Y advancement of the mucosa
tissue prevent a flat upper lip
recreate the upper-lip pout especially
after a large horizontal movement.
TECHNIQUE
Postoperatively, NG tube is kept in for 24
hours to help prevent nausea. The patient is
placed in a heads-up position and given a
handheld suction.
At 24 hours, the NG tube is removed
and the patient is discharged if he or
she is tolerating liquids, ambulating,
and pain is controlled. The patient will spend one night
in the hospital to help with pain
and nausea.
Segmenting the
Maxilla
If the transverse dimension of the maxilla needs to be
changed or if there are steps in the occlusion, a segmental
LeFort 1 osteotomy can be performed.
The sequence of this procedure commences after
downfracturing the LeFort 1 segment. The most common
segmentation is the paramedian osteotomy.
This osteotomy avoids the midline to avoid the thicker
bone and thinner mucosa of the maxilla.
Segmenting the
Maxilla
The technique involves the surgeon placing his or her
finger on the palatal mucosa and using the reciprocating
saw to make the osteotomy through the maxilla.
Once the osteotomy is completed, the segments are
mobilized and a prefashioned splint is used to position the
maxilla in the appropriate place.
Leave these patients in their occlusal splint for 4 to 6 weeks to
provide the maxilla with extra support while healing
LeFort 1 Distraction Osteogenesis
Distraction osteogenesis + LeFort 1 osteotomy patients
with significant maxillary hypoplasia and class III
malocclusion >1 cm and a normal mandibular position.
If distraction osteogenesis is decided, the LeFort 1
osteotomy is performed as described above differs
once the downfracture has been completed.
The same amount of mobilization of the maxilla is not
required.
LeFort 1 Distraction Osteogenesis
Distraction can be achieved via an internal or an
external approach.
The internal distraction systems are buried underneath
the mucosa and are less cumbersome after surgery.
The external distraction system provides for a greater
degree of versatility because it is secured to the cranium
and can be adjusted during the activation period.
C O M P L I C AT I O N S
Patients with major anatomical irregularities, such
as cleft lip and palate, were more likely to
experience complications. These patients,
representing 11.5% of the population, experienced
nearly half the complications.
O U T C O M E S D ATA
• A study of LeFort I maxillary • The biggest risk factor in • One meta-analysis the average
advancement without additional predicting relapse distance of distance of relapse 25 to 30% of
surgeries or associated syndromes maxillary movement. the total movement.
14% of patients had clinically
significant relapse (> 2 mm).
• Horizontal relapse rates after • As a result of the gradual movement
maxillary advancement 37% and progressive bone generation,
• VME patients similar relapse of the overall movement, vertical distraction osteogenesis more
rate which occur during the first 6 relapse rates 65%. stable with a relapse rate of 8.24% of
months. the total movement.
• The LeFort I osteotomy of the maxilla core
procedure in orthognathic surgery for the
management of facial skeletal deformities
low technical difficulty and dependable results.
CONCLUSIONS
• An emphasis should be placed on proper
presurgical orthodontics and solid presurgical
planning to ensure predictable and stable
results.
THANK YOU!
ANY QUESTIONS?
