Lefort 1 osteotomy

Amal ramesh
Contents

 Introduction
 Indications
 Important surgical bony landmarks
 Surgical technique
 Modifications
Introduction

 In 1972, Martin Wassmund introduced a surgical pro- cedure for moving the entire maxilla. This operation,
which has been since called Le Fort I osteotomy or total maxillary osteotomy, was first used to correct open
bite.
Indications

 Vertical maxillary excess

 Vertical maxillary deficiency
 Anterior-posterior maxillary deficieny(maxillary hypoplasia)
 Facial asymmetry
Important surgical bony landmarks

Piriform nasal apertures

 lateral nasal walls/medial sinus wall
 nasal septum and vomer,
 anterior nasal spine,
 infraorbital foramen and neurovascular bundle
 lateral maxillary wall,
 maxillary tooth apices,
 zygomaticomaxillary buttresses,
 pterygomaxillary fissure and pterygoid plates.
Surgical technique

 The procedure is performed under general anaesthesia with 1:100,000 epinphrine is

infiltrated into the mucosal tissues of the upper lip.
 A horizontal maxillary incision is made in the maxillary vestibule from the 2 nd molar re- gion of one side to
the same area on the opposite side.
 A mucoperiosteal flap is raised to expose the anterior nasal floor, pyriform aperture, lateral walls of the
maxilla, zygomatic crests and pterygomaxillary junction.A nasoseptalosteotome is used to separate the nasal
septum from the maxilla.
 The bone is sectioned 4-5 mm above the apices of teeth extending from the lateral part of the pyriform rim
posteriorly across the canine fossa and through the zygomatic maxillary crest.
 The anterior, posterior and inferior parts of the lateral nasal wall can be sectioned transantrally under direct
vision. Posterior aspect of the lateral maxilla and the posterolateral antral wall is cut by malleting a spatula
osteotome posteriorly until contact is made with the dense perpendicular plate of the palatine bone.
 Final step then involves pterygomaxillary disjunction by using a sharp curved osteotome medially and
anteriorly into the pterygomaxillary suture to separate the maxillary tuberosity from the pterygoid plates.
 The maxilla is down fractured by inferior pressure against the anterior portion of maxilla and forward
pressure against the tuberosity. This can be facilitated by use of Tessier's mobilisers or disimpaction forceps.
 The maxilla is then wired into occlusion by using a splint with intermaxillary fixation. Stabi- lisation of the
maxilla is then achieved by interosse- ous wires or miniplate done at the nasal and zygomaticomaxillary
buttresses of the proximal and distal segments.
 When large osseous gaps are created at the ostec- tomy sites, bone grafts are laid across them for added
stability and rapid union.repositioning. Autogenous corticocancellous bone harvested from the iliac is most
commonly used.
Modifications

TWO-PIECE LEFORT 1 OSTEOTOMY

Indications:
 Extreme vertical and anteroposterior excess
 Transverse horizontal maxillary deficieny
TECHNIQUE:
 In case of extreme vertical and anteroposterior excess, a classical Le Fort I in combination with
anterior max- illary osteotomy may be required.
 In cases of transverse horizontal maxillary deficien- cy, maxillary expansion can be achieved by
segment- ing the maxilla after a conventional Le Fort I osteotomy,With the maxilla in the down
fractured position,the midpalatal bone or parasagittal palatal bone can be osteotomised through
appropriate interdent space transpalatally.
 First, the thick part of the anterior maxilla is sectioned with a fissure bur, then the palatal cuts are completed.
The bone is then completely see tioned by the use of an osteotome.
 Arterior maxilla may be divided by malleting an osteotome between the central incisors and then directed
posteriorly as ittransects the deeper portion of the mid-palatal suture and splits the interseptal bone. This step
is done in ease of midline diastema (Fig. 35.38A-D). The maxilla is then divided into two segments and can
be moved laterally to correct the horizontal deficiency.
Quadrangular Le Fort I osteotomy

Indications:
 Maxillary zygomatic horizontal deficiency
 class III skeletal malocclusion
 normal nasal projection
 Coexisting vertical maxillary excess or deficiency or maxillary transverse deficiency can be treated
TECHNIQUE:
 The incision is same as that done in for a conventional Le Fort I osteotomy. The maxillary exposure is done
superiorly to visualise the infraorbi- e moved tal nerve and infraorbital rim, the lacrimal fossa medially and
lateral orbital rim laterally.
 Septal cartilage is detached from the maxillary crest anteriorly and the vomer is detached from the palatal
midline posteriorly with a fine chisel. The bone cuts are then made starting from the pyriform rim at the level
of the infraorbital nerve and extending laterally just inferior to the infraorbi- tal foramen to the zygoma body.
At this point the cut makes a right angle and proceeds inferiorly through the buttress and lateral antral wall to
the pterygopalatinepterygopalatinePosterior fissure.Posterior osteotomy cut is completed jusanterior to the
pterygoid plate with a fine chisel. The same line of osteotomy cut is performed on the other side and all bone
cuts are checked for completeness.
 The maxilla is then down fractured with finger pressure on the anterior maxilla and forward pressure on the
tuberosity region. The mobilised maxilla is then secured to the mandible with a prefabricated splint and
intermaxillary wires.
the