1. Le Fort I Maxillary Osteotomy
Dr Jameel Kifayatullah
Oral and maxillofacial surgeon
Khyber college of dentistry
jamilkifayatullah@yahoo.com

2. Treatment /Reconstructive Goals
• To establish proper function and esthetics
through establishment of the appropriate
form and position of the jaws, a Class I
occlusion with appropriate bucco-lingual
relationship and appropriate overlap and
overjet with aesthetic vertical and soft tissue
relationships

3. Indications
• Correction of maxillary
Hypoplasia and Hyperplasia
Vertical excess and deficiency
Asymmetry
Transverse anomalies
Occlusal plane abnormalities
• Obstructive sleep Apnoea
• Access to pharynx and base of skull for tumor
resection

4. Contraindications
• Major medical comorbidities with poor operative tolerance
• Cardiac disease with inability to tolerate hypotensive anesthesia
• Presence of active dentoalveolar infection
• Maxillary posterior repositioning in the presence of constricted airway
anatomy or obstructive sleep apnea
• A patient in active growth phase
• Possible need for postoperative maxillomandibular fixation in the
presence of underlying substance abuse, psychiatric illness, or
uncontrolled seizure disorders
• Need for presurgical orthodontic treatment
• Major discordance between patient’s and surgeon’s goals and
expectations
• Poorly compliant patient with toxic habits including, but not limited to,
incessant smoking, substance abuse, or poor personal and oral hygiene
• Questionable blood supply to the maxilla as seen in multiply operated
patients (e.g. cleft palate) or patients with a history of radiation therapy to
the region

5. The important surgical bony
landmarks
• piriform nasal apertures
• the lateral nasal walls/medial sinus walls
• the nasal septum and vomer,
• the anterior nasal spine,
• the infraorbital foramen and neurovascular bundle
• the lateral maxillary wall,
• the maxillary tooth apices,
• the zygomaticomaxillary buttresses,
• the pterygomaxillary fissure and pterygoid plates.

6. Vascular landmarks
• The internal maxillary artery enters the pterygopalatine
fossa approximately 16.6 mm above the nasal floor and
gives off the descending palatine artery. The descending
palatine artery travels a short distance within the
pterygopalatine fossa and then enters the greater palatine
canal. It travels approximately 10 mm within the canal in an
inferior, anterior, and slightly medial direction to exit the
greater palatine foramen in the region of the second and
third molars.
• The osteotomized maxilla depends on the rich collateral
circulation provided by the ascending pharyngeal artery
and the ascending palatine branch of the facial artery.

7. VASCULAR LANDMARKS

8. Patient positioning and draping
• The patient is positioned on the
operating table supine with the
head in a head holder.
• For corrective bone surgery, the
whole face including the lower
part of the forehead and eye
brows, the auricles and the
superior part of the neck need to
be visible, and not covered with
drapes. The nasal anaesthetic
tube is covered with sterile
adhesive tape and the cranium
covered with two sterile drapes
as illustrated. The eyes are
protected with a bland eye
ointment and the lips are
lubricated.

9. Anaesthesia considerations
• Execution of the
surgical procedure is
best done with
controlled hypotension,
the use of local
anesthesia with
vasoconstrictor and
nasotracheal intubation

10. Vertical reference Point
• A screw inserted into the
glabella (the root of the bridge
of the nose) provides a good
vertical reference point.
• The procedure starts with the
insertion of a 12-14 mm long
screw with a cruciform head
into a 6-8 mm hole drilled into
the glabella. The distance
between the middle of the
cruciform head and the arch
wire is measured with a
caliper and recorded. All
vertical changes are then
measured against this
reference distance.

11. Reference point in posterior region
• Place reference hole in buttress region to
allow for accurate posterior/superior
positioning

12. Incision

14. Circumvestibular Incision
• Incisions are made in the vestibule above the
apices of the teeth from the upper right to the
upper left first molar(parotid papilla identified
and protected).
• The incision is made through the mucosa,
submucosa, underlying facial muscles and
periosteum

15. Exposure of surgical site
• The maxilla is exposed from the anterior nasal spine to
the tuberosity and pterygoid plates
• Subperiosteal dissection carried out superiorly and
posteriorly to expose piriform rim,infraorbital
foramen,zygomatic buttress and posterior maxilla
• Sharp periosteal elevators are used to strip the soft
tissues in the subperiosteal plane to expose the
anterior maxillary wall, pyriform rims and nasal
apertures, and zygomatico-maxillary buttresses.
The periosteal dissection is performed in a systematic
fashion.

16. Subperiosteal Dissection

17. Dissection

18. Exposure gained

19. OSTEOTOMY CUTS
• Roots of the canine and upper first molar is
marked for guidance
• Bone cut 5 mm above canine root is marked
• Cuts are made with a thin reciprocating saw
blade or piezo‐surgical saw from the lateral
nasal aperture to the junction of the posterior
maxilla and the pterygoid plates.

20. Nasal septal separation
• The nasal septum and vomer is separated with
a nasal septal osteotome(guarded nasal
osteotome)

21. Release of Lateral nasal walls
• the bone attachments of the lateral nasal
walls are also released with an osteotome.
• Osteotomy is performed on the other side
using the same steps

22. RELEASE OF LATERAL NASAL WALLS

23. Pterygomaxillary dysjunction
• The attachment of the maxilla to the
pterygoid plates are then osteotomised and
this allows the maxilla to be ‘down‐fractured’
• Content of pterygomaxillary fissure and soft
palate is protected by keeping index finger at
hamulus to feel osteotome during pterygoid
osteotomy

24. Pterygomaxillary dysjunction
• A curved pterygoid chisel is
placed with the curvature
pointing medially and
inferiorly between the
tuberosity and the
pterygoid plates.
• A mallet is used to drive the
osteotome medially to
complete the
pterygomaxillary
dysjunction. The position of
the tip of the osteotome
can be checked with a
palpating finger.

25. Pterygomaxillary dysjunction
• An upward and
posteriorly oriented
osteotome will not
reliably separate the
maxilla from the
pterygoid plates. It is also
associated with increased
risk of bleeding from the
pterygoid plexus and
internal maxillary artery.

26. DOWNFRACTURING
• The maxilla is
downfractured
anteriorly, with the help
of a bone hook or
manually

27. Removal of bone
• The downfracture maneuver
allows for a complete
visualization of the osteotomy
lines. Remaining bony bridges
at the posterior aspect of the
maxilla can be transected
under direct vision. To
minimize bleeding when
trimming bone close to the
posterior maxilla, meticulous
soft tissue protection should
be employed.
• The downfracture technique
allows good access to the
nasal septum for septal
corrections when indicated

28. Maxilla repositioning
• . The upper jaw can then be separated and
mobilized and moved to the new planned
position.
• Maxillary repositioning may involve
movements in superior, inferior, differential,
asymmetric, anterior, and posterior directions

29. Mobilisation of maxilla
• It may be useful to use Tessier
mobilizers or curved
osteotomes which are inserted
behind the maxilla on each
side in order to pull the maxilla
forwards. Rowe disimpaction
forceps can also be used for
this purpose.
• At this point the mobilized
maxilla should be free and
able to be moved by the
surgeon's hand more than is
actually required.

30. Anterior movements
• Anterior movements
can be facilitated with
traction using a wire
directly attached to the
maxilla or to a bone
screw in the maxilla.

31. Positioning of the maxilla
Mandibulo-maxillary
fixation
Once the desired mobility is
accomplished, the maxillary and
mandibular teeth are wired together
with or without a wafer splint. With
the maxilla and mandible attached
together and the condyles properly
seated in the glenoid fossas,the
complex is passively closed in the
desired vertical dimension using the
external reference point

32. Control of vertical height
The preplanned vertical
position of the maxilla is
then established against the
fixed reference marker in
the nasofrontal junction.
When necessary, maxillary
bone is removed with a drill
until that vertical
relationship is achieved
passively. If the nasal
septum or the inferior
turbinates are preventing
upward movement of the
maxilla, they are reduced at
this stage.

33. Internal fixation
• Internal fixation is
performed with four
miniplates, usually L- or
reversed L-shaped, along
the pyriform aperture and
the zygomaticomaxillary
buttress.
• Care must be taken to
passively adapt the plates
to the bone surfaces. The
screws in the mobilized
maxillary segment must
avoid the tooth roots.

34. ALAR CINCH SUTURE
• Extensive anterior
movements of the maxilla
will stretch the soft tissue
envelope of the face and
will lead to bilateral
widening of the alar base
and the nasal vestibules.
This can be prevented by
performing an alar cinch
suture, which engages both
alar bases in an attempt to
approximate them towards
the midline immediately
before wound closure.

35. Posterior movement (backward)
• Posterior movements
are rarely indicated. If
needed, a segment of
bone must be removed
usually from the
posterior aspect of the
maxilla. This is usually
performed under direct
vision from a
downfracture approach.

36. Superior (upward) movement
• Superior movement
(shortening) of the maxilla
requires an ostectomy of a
bone segment.
• In an upward movement of
the maxilla the septum needs
to be vertically trimmed to
avoid septal buckling
deviation, which may lead to
impaired airway flow and
nasal deformation. In large
impactions, the inferior
turbinates should be trimmed
to avoid airway obstruction

37. Inferior (downward) movement
• Inferior movement
(lengthening) of the
maxilla is possible, but
results in a gap and a
non-contact situation
between the upper and
lower part of the
maxilla.

38. Downgrafting
• The gaps need to be bone
grafted, usually with free
bone grafts from the iliac
crest or the outer table of
the skull, or allogeneic
bone.
• The amount of
lengthening is checked
against the vertical
reference mark at the
naso-frontal junction.

39. Asymmetric movement/rotations
• Asymmetric movements
and rotations are also
possible. In this case a
bone gap may occur on
one side and bone may
need to be trimmed on
the contralateral side.

40. Need for bone grafts
• After osteosynthesis,
the need for bone grafts
(eg. by rotational
movements) should be
evaluated and if
required, they should
be placed at this time

41. Control of position
• After completion of
osteosynthesis on both
sides, the MMF is released
and the resulting occlusion
is checked against the pre-
planned position. The splint
may be fixed to the
maxillary teeth with a few
thin wires (especially when
the maxilla is segmented)
and left in place during the
healing phase to allow for
neuromuscular adaption
and position control.

42. SEGMENTAL LEFORT I OSTEOTOMY
• 2 piece maxillary surgery required for
surgically assisted maxillary expansion
procedure
• 3 piece maxillary osteotomy most commonly
used procedure

43. Two piece segmental maxillary
osteotomy
• In the two pieces maxillary segmentation
interdental osteotomy performed between
the central incisors roots, under finger control
by the palatal side

44. Two piece segmental maxillary
osteotomy

45. Advantages of segmentalisation
• For gaining width
• Allows for vertical changes
• Adjustment of angulations of posterior
maxillary segments

46. Most common sites of
segmentalisation
• Between Central incisors
• Between the canine and lateral incisors
• Between the canine and premolar teeth

47. TECHNIQUE
• Conservative tunneling from the standard
circumvestibular incision can be made inferiorly
to alveolar crest on buccal surface of maxilla with
a woodsen elevator
• Interdental osteotomy made with a thin cement
spatula osteotome prior to performing horizontal
osteotomy
• The osteotomy can be carried superiorly to the
level of planned horizontal maxillary osteotomy

48. Technique
• Following horizontal osteotomy and down
fracture the maxilla is segmentalized by
making two parasagittal cuts that join across
the midline and connect with interdental
osteotomies using round end cutting
bur(Steiger Bur)

49. Segmetal maxillary osteotomy

50. Segmental Lefort I maxillary
osteotomy