Outcome Studies
Intra- and Perioperative Complications
of the LeFort I Osteotomy: A Prospective
Evaluation of 1000 Patients
Franz-Josef Kramer, MD, DMD,* Carola Baethge, DMD,† Gwen Swennen, MD, DMD,*
Thomas Teltzrow, MD, DMD,* Andrea Schulze, DMD,‡ Johannes Berten, DMD,§
Peter Brachvogel, MD, DMD*
Hannover, Germany
The LeFort I osteotomy has become a routine pro-
cedure in elective orthognathic surgery. The au-
thors report the occurrence of intra- or periopera-
tive complications in a series of 1000 consecutive
LeFort I osteotomies performed within a 20-year
period. In total, 64 (6.4%) patients experienced com-
plications. Anatomical complications affected 26
(2.6%), patients, including 16 (1.6%) with a devia-
tion of the nasal septum and 10 (1.0%) with non-
union of the osteotomy gap. Extensive bleeding
that required blood transfusion occurred in 11
(1.1%) patients exclusively after bimaxillary correc-
tions; in 1 patient a ligation of the external carotid
artery became necessary. Significant infections
such as abscesses or maxillary sinusitis occurred in
11 (1.1%) patients. No patient experienced an
osteomyelitis. Ischemic complications affected 10
(1.0%) patients, including 2 (0.2%) who experienced
an aseptic necrosis of the alveolar process and 8
(0.8%) who, under critical revision, were affected
by retractions of the gingiva. Five (0.5%) patients
experienced an insufficient fixation of the osteo-
synthesis material. The risk and the extent of com-
plications was enhanced in patients with anatomi-
cal irregularities (eg, in patients with craniofacial
dysplasias, orofacial clefts, or vascular anomalies).
The risk of ischemic complications was enhanced
in extensive dislocations or transversal segmenta-
tion of the maxilla. The authors conclude that
patients with major anatomical irregularities
From the Departments of *Oral and Maxillofacial Surgery and §
Orthodontics, Medical University of Hannover, Hannover, Ger-
many; the †Department of Orthodontics, Charitè, Campus Ben-
jamin Franklin, Berlin, Germany; and ‡Private Practice Bremen,
Germany.
Address correspondence to Dr. Franz-Josef Kramer, Klinik und
Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Medizinische
Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Ger-
many; e-mail: Kramer.Franz@MH-Hannover.de
should be informed about an enhanced risk of Le-
Fort I osteotomies. Preoperative planning avoiding
transversal segmentation or extensive dislocations
of the maxilla should reduce the occurrence of com-
plications. For healthy individuals, the risk of com-
plications with the LeFort I osteotomy is consid-
ered low.
Key Words: Complications, Le Fort I osteotomy, or-
thognathic surgery, skeletal dysgnathia
ince the early reports of Wassmund,1 Ob-
S
wegeser,2 Bell,3 and others, osteotomies of
the maxilla at the LeFort I level have become
a widely used routine procedure of elective
orthognathic surgery to mobilize the maxilla in all
dimensions. In addition, the procedure is known to
tolerate several segmentations modifying the length,
width, and height of the maxilla and the occlusal
plane.4 However, as with every surgical procedure,
the LeFort I osteotomy is related to a variety of com-
plications. A quantitative assessment of complica-
tions might be helpful for the patient, the orthodon-
tist, and the surgeon to estimate the benefit of an
elective operation versus its immanent risks. Knowl-
edge of complications also might help to prevent
their occurrence and facilitate their management.
The aim of this study was to report the types and
frequencies of intra- and perioperative complications
that were related to LeFort I osteotomies.
Patients and Methods
n a prospective study, 1000 consecutive patients,
I who underwent a LeFort I osteotomy because of
skeletal dysgnathia for maxillary or mandibulo-
maxillary correction, were assessed for the occur-
rence of intraoperative and perioperative complica-
tions. All patients were surgically treated at the
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Hannover Medical University between 1983 and
2002. The average patient’s age was 24.4 years (mini-
mum, 15 years; maximum, 47 years); 65% were fe-
males and 35% males. One hundred thirteen (11.3%)
patients underwent surgery because of skeletal
Angle class II malocclusion and 597 (59.7%) because
of skeletal Angle class III malocclusion. Two hun-
dred ninety (29.0%) patients had no sagittal but ver-
tical or transversal skeletal anomalies. One hundred
fifteen (11.5%) patients had major anatomical irregu-
larities, most often orofacial clefts, vascular malfor-
mations, or congenital craniofacial dysplasias. All
patients received orthodontic treatment before and
after the LeFort I osteotomy.
Typical risks of LeFort I osteotomy that all pa-
tients were informed of included reversible disorders
of sensibility at the upper jaw and the possibility of
impaired wound healing. The decision of when to
perform orthognathic surgery was an interdiscipli-
nary one, made by both the patient’s orthodontist
and the surgeon. After completion of preoperative
orthodontic treatment, the surgeon planned the in-
dividual procedure, defining the direction and extent
of maxillary mobilization and the necessity of split-
ting. A model operation with articulated cast models
was performed in each case, and an individual oc-
clusal splint was created, defining the new sagittal
and transversal position of the maxilla. The vertical
position of the maxilla was assessed individually by
both functional and aesthetic aspects.
All patients were asked for autogenous blood
donation 6 weeks before surgery. In general, for a
LeFort I osteotomy, 500 mL and for a bimaxillary
procedure 1000 mL of autogenous erythrocyte con-
centrates were collected.
The operation was performed as described by
Epker and Fish.5 Preoperative medications included
a single shot of Penicillin (10 Mio international units
IV) and Prednisolone (500 mg IV) immediately be-
fore surgery. All patients were operated on under
general anesthesia with nasal intubation. Until
implementation of miniplate osteosynthesis in 1988,
all patients had to tolerate a postoperative man-
dibulo-maxillary immobilization for 3 weeks to sta-
bilize the osteotomized fragments and to advance
bone healing. Since 1988, the down fractured maxilla
was stabilized by four L-shaped osteosynthesis mini-
plates (1.5 System, Martin GmbH, Tuttlingen, Ger-
many) that were located at the vestibular surface of
the crista zygomatico-alveolaris maxillae and lateral
to the foramen piriformis. In cases of segmentation of
the maxilla, additional osteosynthesis miniplates
were applied. In more than 90% of the patients, the
972
osteosynthesis material was removed 9 to 12 months
after the LeFort I osteotomy.
Because of the educational mission of our center,
the osteotomies were performed either by experi-
enced surgeons or by inexperienced surgeons under
supervision of an experienced surgeon.
Each patient’s operative course and outcome
was documented prospectively at three defined
stages of treatment. Immediately after surgery, the
intraoperative course of the procedure was analyzed
and recognized intraoperative complications were
documented. An analysis of perioperative complica-
tions was performed 10 days after surgery, when the
sutures were removed. Finally, in 90% of the pa-
tients, a third investigation was performed when the
osteosynthesis material was removed. The investiga-
tions included an interview with the performing sur-
geon immediately after the osteotomy and both clini-
cal and radiographic examinations of the patient that
were performed during the early postoperative pe-
riod and, in about 90% of the patients, before re-
moval of the osteosynthesis plates. The results were
documented in a PC-based databank and analyzed
by descriptive and analytic statistics (Mann-
Whitney-U test; SPSS Version 10.0., SPSS, Chicago,
IL, USA).
RESULTS
n total, 64 (6.4%) of the 1000 patients experienced
I intra- or perioperative complications completely
or partially related to the LeFort I osteotomy (Ta-
ble 1).
Twenty-nine complications occurred in patients
with major anatomical irregularities, such as cleft lip
and palate, craniofacial dysplasias, or vascular mal-
formations (n = 115). This represents 45.3% of all
observed complications. The cumulative risk of com-
plications in this group of patients was 25.2%.
Table 1. Complications of LeFort I Osteotomy
Patients Without Patients With
Major Anatomic Major Anatomic
Type of All Patients Irregularities Irregularities*
Complication (n = 1000) (n = 885) (n = 115)
Anatomic 26 (2.6%) 21 (2.4%) 5 (4.3%)
Hemorrhagic 11 (1.1%) 5 (0.6%) 6 (5.2%)
Septic 11 (1.1%) 4 (0.5%) 7 (6.1%)
Ischemic 10 (1.0%) 4 (0.5%) 6 (5.2%)
Insufficient osteosynthesis 5 (0.5%) 0 5 (4.3%)
Other 1 (1.0%) 1 (0.1%) 0
Total 64 (6.4%) 35 (3.9%) 29 (25.2%)
*Patients with major anatomic irregularities include cleft lip palate, cranio-
facial dysplasias, and vascular malformations.
 COMPLICATIONS OF THE LeFort I OSTEOTOMY / Kramer et al

In patients without major anatomical irregulari- that had to be incised and drained externally, result-
ties (n = 885) 35 intra- or perioperative complications ing in rapid recovery. Six (0.6%) patients experienced
were found. This represents 54.7% of all observed sinusitis maxillaris that could be controlled easily by
complications. The cumulative risk of complications medications. No patient experienced an osteomyeli-
in this group of patients was 3.9%. This is signifi- tis. All patients with septic complications had under-
cantly lower than in patients with major anatomical gone mandibulo-maxillary procedures; seven pa-
irregularities (P < 0.05). Interestingly, 29 of the 35 tients with septic complications had anatomical
patients (82.9%) without major anatomical irregulari- irregularities.
ties who experienced complications had either a
transversal segmentation of the maxilla or an exten- Mechanical Complications
sive anterior dislocation of the maxilla exceeding
9 mm. In five (0.5%) patients, an insufficient fixation of the
The types of complications that were found osteosynthesis material at the maxilla was found, re-
most often were related to anatomical problems sulting in a nonunion of the osteotomy gap. All af-
(2.6%), followed by hemorrhage (1.1%) and septic fected patients had mandibulo-maxillary surgery
complications (1.1%). Five (0.5%) patients experi- and major anatomical irregularities.
enced insufficient osteosynthesis. In one (0.1%) pa-
tient, a cerebral hypoxia occurred after surgery. In 10 Rare Complications
(1.0%) patients, ischemic complications of the maxilla
During the early era of postoperative mandibulo-
or gingiva were observed.
maxillary wire fixation, in one patient a cerebral hyp-
Anatomical Complications oxia was observed after elective LeFort I osteotomy.
Although the course of the operation in the 29-year-
In 16 (1.6%) patients, a deviation of the nasal septum old healthy male patient was uneventful, the patient
was observed. The deviation was caused by an in-
sufficient reduction of the nasal septum before ver-
tical elevation of the maxilla. In eight (0.8%) other
patients, despite sufficient osteosynthesis, a non-
union of the osteotomy gap was observed, resulting
in a prolonged mobility of the maxilla. In two (0.2%)
patients, a malposition of the maxilla was observed
after surgery. Those two patients presented with par-
ticularly difficult anatomical relationships that re-
quired an extensive mobilization of the maxilla.
Hemorrhage
Hemorrhage as a severe complication of LeFort I os-
teotomies was documented when transfusions of
erythrocyte concentrates of foreign donors were re-
quired after the autogenous blood donation already
had been given. In 11 (1.1%) patients, a severe hem-
orrhage was observed. In one patient, the ligation of
the external carotid artery via a submandibular inci-
sion was required. All 11 affected patients under-
went mandibulo-maxillary surgery for orthognathic
correction. Hemorrhage during LeFort I osteotomy
was caused by lacerations of branches of the A or V
maxillaris, most often caused by irregular fractures
of the pterygoid or during down fracture of the max-
illa. Six of the patients with hemorrhage as a com-
plication had an irregular anatomy.
Septic Complications
Fig 1 Margin of the gingiva (A) before and (B) after Le-
Eleven (1.1%) patients experienced septic complica- Fort I osteotomy. Significant retractions were found at the
tions. In five (0.5%) patients, an abscess developed canine and the lateral incisor.

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THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 15, NUMBER 6 November 2004
vomited during the first postoperative night and suf-
focated because of mandibulo-maxillary fixation. Al-
though the fixation was opened quickly and imme-
diate intensive care was provided, a cerebral hypoxia
could not be avoided, resulting in slight persisting
cerebral damage. Other rare complications were not
observed.
Ischemic Complications
Under critical observation in eight (0.8%) patients
after LeFort I osteotomy postoperative retractions of
the gingiva were found (Fig 1 A, B). In two (0.2%)
more patients, a partial necrosis of the maxilla was
observed (Fig 2 A–C). In one case the maxilla was
mobilized 9 mm anteriorly after transversal segmen-
tation; in another patient an anterior displacement of
10 mm resulted in a subtotal aseptic necrosis of the
maxillary alveolar process (Fig 3 A–D). All patients
who experienced ischemic complications underwent
maxillary anterior dislocations exceeding 9 mm (n =
4) or transversal maxillary segmentations (n = 2) or
had major anatomical irregularities (n = 6).
DISCUSSION
uring the last decades, the LeFort I osteotomy
D has become an increasingly applied procedure
in elective orthognathic surgery, usually resulting in
a high level of patient satisfaction.6,7 Although the
experiences with this procedure resulted in better
results, minimized operation times, and improved
comfort for the patients,6,8 a permanent awareness
974
regarding the occurrence of intra- or postoperative
complications is essential. In this investigation, 64 of
1000 (6.4%) patients were found to have complica-
tions attributed to the mono- or multisegmented Le-
Fort I osteotomy. This percentage is similar to those
of other reports of an occurrence of 9% of complica-
tions in 410 LeFort I osteotomies and in 6.1% of 146
patients several years ago.9,10
The reported spectrum of severity in complica-
tions associated with the LeFort I osteotomy varies to
a great extent between barely notable symptoms and
(rare) catastrophic courses. In agreement with the
findings of other studies, we found that life-
threatening complications occurred very sel-
dom.9,11,12 In addition to the reported single case of a
postoperative cerebral hypoxia after vomiting under
mandibulo-maxillary fixation, we observed no com-
plications of airway management.13 Modern osteo-
synthesis materials provide usually sufficient rigid-
ity for an immediate postoperative mobilization of
the jaws, thus avoiding mandibulo-maxillary fixation
and the potential compression of the peripheral oro-
pharyngeal airway.
In contrast to the findings of van de Perre et al,14
who reported in a retrospective analysis of 2049 pa-
tients with various orthopaedic procedures that ex-
cessive blood loss was the most frequently observed
complication in maxillary surgery, we found that
1.1% of our patients experienced severe hemor-
rhage. Usually, hemorrhagic complications arise
from bleeding of the A and V maxillaris and their
branches.15,16 Because of the proximity of the vessels
Fig 2 (A–C) Aseptic necrosis of
the alveolar process after LeFort I
osteotomy.
 COMPLICATIONS OF THE LeFort I OSTEOTOMY / Kramer et al
Fig 3 (A) Significant Angle class III malocclusion before
surgery. (B, C) Aseptic necrosis after extensive dislocation
of the maxilla (10 mm). (D) Situation after 3 months.
to the pterygoid osteotomy site, a risk of laceration
always has to be considered. Usually, severe bleed-
ing during the osteotomy was treated immediately
by local compression and, after exploration of the
defect, by ligation or coagulation. In one patient with
an orofacial cleft, the ligation of the external carotid
artery via a submandibular approach became neces-
sary. Embolization17 was never applied.
However, vascular trauma during LeFort I oste-
otomies can result in the delayed formation of an
AV-fistula or a pseudoaneurysm,18 most likely in the
A maxillaris or the sphenopalatinal branch.19 In none
of our patients was this complication observed. Al-
though a mild epistaxis was found quite often during
the early postoperative period, a life-threatening ep-
istaxis20 was never seen. The average blood loss dur-
ing LeFort I osteotomy was reported by Panula et al,8
with about 700 mL. To avoid an intra- or postopera-
tive relevant anemia in the patients (hemoglobin be-
low 8 mg/dL) and to prevent the necessity of foreign
blood donation, we recommend (in contrast to the
recommendation of other authors21) the routine col-
lection of autogenous erythrocyte concentrates for
elective orthognathic surgery.
The observed occurrence of septic complications
in 1.1% of the patients has to be considered low when
compared with other reports8,9,12; rare septic compli-
cations such as actinomycosis of the maxillary si-
nus22 or brain abscess23 were not found. The preop-
erative prophylactic single-shot application of
antibiotics to avoid septic complications as applied in
this study was recommended previously in several
reports.24,25
One of the most relevant problems of the LeFort
I osteotomy is the occurrence of ischemic complica-
tions. Although the biologic basis of maxillary oste-
otomies in animal studies is well documented,3,4,26
several consequences of an insufficient vasculariza-
tion after maxillary orthognathic surgery can occur,
including loss of tooth vitality, periodontal defects,
loss of tooth, or loss of segments of or the entire
maxilla. In 1990, Lanigan et al27 described 36 cases of
aseptic necrosis of the maxilla after maxillary osteot-
omies. Although segmentation of the maxilla,
stretching of the vascular pedicle by extensive ante-
rior dislocation of the maxilla, and transsection of the
descending palatine vessels have been shown to ex-
hibit no relevant effect on revascularization or bone
healing,3,4,28 we found in our clinical investigation
that a small number of patients without intraopera-
tively recognized damage to the palatinal vessels ex-
hibited ischemic complications. All patients with
documented ischemic complications had anatomical
irregularities,29 transversal segmentations, or exten-
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THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 15, NUMBER 6 November 2004
Fig 4 (A) Schematic display of a extensive Angle skeletal
class III malocclusion. (B) To avoid an extensive anterior
dislocation of the maxilla, the retroposition of the mandible
might be used. In our experience, no satisfying aesthetic
result can be achieved with that alternative. (C) A slight
counterclockwise rotation of the maxillo-mandibular block
helps to circumvent the problems of extreme anterior dis-
placement of the maxilla (resulting in a high risk of aseptic
necrosis) and mandibular retroposition (resulting in an
aesthetically unfavorable result). No functional complica-
tions related to this concept were observed.
sive dislocations anteriorly of 9 mm or more. As a
consequence of these unacceptable results of elective
surgery in otherwise young and healthy subjects, we
decided to avoid any transversal osteotomy of the
maxilla for segmentation. In addition, we generally
976
intend to minimize the distances of maxillary dislo-
cation. In patients with class III malocclusion, ante-
rior dislocations of the maxilla of more than 8 mm in
the sagittal plane are to be circumvented. In patients
that require an immense anterior displacement of the
maxillary complex, the extent of dislocation and the
risk of ischemic complications can be reduced by a
combined mandibulo-maxillary approach (Fig 4A–
C). Although a compensatory posterior dislocation of
the mandible would lead to an aesthetically unfavor-
able result and should be avoided (Fig 4B), a coun-
terclockwise rotation of the mandibulo-maxillary
block can help to reduce the distance of maxillary
dislocation (Fig 4A, C) and usually preserves accept-
able functional and aesthetic outcomes.
Usually, the sensory recovery after LeFort I os-
teotomy is incomplete but strong enough to mask
any subjective alterations of sensory function.30
Other rare complications, such as of the visual31–35 or
auditory systems,36,37 were not observed in this in-
vestigation.
In conclusion, the results of this study demon-
strate that the LeFort I osteotomy is a safe procedure
with a low incidence of complications. Intra-and
perioperative complications affected 6.4% of the ex-
amined patients. The occurrence of complications
was significantly greater patients who presented
with an irregular anatomy (25.2%, P < 0.05). Patients
with major anatomical alternations are particular
at risk when extensive dislocations or transversal
segmentations are intended. Preoperative planning,
including a rotation of the mandibulo-maxillary
complex, can help to reduce the amount of anterior
dislocation of the maxilla and the risk of ischemic
complications. Patients with anatomical irregulari-
ties should be informed about an increased risk of
intra- and perioperative complications.
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