Overview of Le Fort Osteotomy

The LeFort I osteotomy is a surgical operation used mainly to fix deformities in the middle part of the face. It’s a way for surgeons to adjust the part of your upper jaw (maxilla) that holds your teeth. The operation can shift this part forwards or backwards, up or down, turn it, or even split it or enlarge it.

Besides fixing deformities, the LeFort I procedure can also make it simpler for surgeons to remove tumors or repair complicated fractures in the middle part of your face. The name of the procedure comes from Rene LeFort, who first identified this type of fracture in 1901.

The very first uses of a similar operation were to get better sight of the area when removing certain types of growths from the throat. However, the LeFort I procedure as we know it today was first proposed by Wassmund in 1921. He used it to fix abnormalities in the jaw or face, but unlike today’s surgeries, the jaw was not immediately adjusted during the operation. Then, in 1934, Auxhausen took things a step further by adjusting the patient’s jaw during the operation itself to fix gaps between the upper and lower teeth when the mouth is closed.

The approach of this surgery has continuously improved. It now includes understanding the benefits of surgery under lower blood pressure to lessen bleeding, the use of braces before and after surgery, the importance of not straining the jaw after surgery, and the use of computer simulations for surgery planning. As a result of these advancements, the LeFort I osteotomy is now considered a safe and reliable procedure that almost always leads to the desired results.

Anatomy and Physiology of Le Fort Osteotomy

The maxilla, or the upper jawbone, is formed by two maxillary bones joined together at the middle. This bone connects with various other bones in your skull: the frontal bone (forehead) at the top, the teeth sockets at the bottom, the cheekbone on the sides, the palate towards the back, and a part of the sphenoid bone at the back corner. The sphenoid bone is near your temples and has a butterfly shape.

The LeFort I segment of the maxilla, which is a certain section of the upper jaw, gets its blood supply from two specific arteries. One of these is the ascending palatine artery, a branch of the facial artery. The second one is the anterior branch of the ascending pharyngeal artery, which comes straight from the external carotid artery in your neck. During a surgical procedure on this part of the upper jaw (LeFort I osteotomy), the surgeon needs to be careful not to damage these arteries, especially while making an incision on the bone near the nose and separating another part of the jaw. This is because accidentally hitting these blood vessels can cause considerable bleeding.

The maxilla is served by the maxillary division of the trigeminal nerve. This nerve starts from a network of nerves in the skull (trigeminal ganglion), goes out through an opening (foramen rotundum), and enters a small cavity near the jaw (pterygopalatine fossa). It then splits into many smaller branches. One of these branches, the infraorbital nerve, provides feeling to the middle of the face, including lower eyelid, cheek, nose, upper lip, and upper front teeth. This nerve is usually encountered during the LeFort I osteotomy, and the surgeon should be cautious to avoid damaging it.

Why do People Need Le Fort Osteotomy

The LeFort I osteotomy is a medical procedure commonly used to change the position of the upper jaw that holds the teeth. This operation might be necessary if you have one of these conditions:

1. Disproportionate jaw sizes: This happens when the jaw that holds your upper teeth (maxilla) is too small (maxillary hypoplasia) or if your lower jaw (mandibular) is too big (mandibular hyperplasia).

2. Overly large upper jaw: This is also known as a Vertical maxillary excess.

3. Incorrect bite alignment: The term used by doctors for this problem is either Angle’s class II or class III malocclusion.

4. Misaligned teeth: This can occur if you’ve midline discrepancies or asymmetries.

5. Open bite: This situation, medically referred to as apertognathia, is when some teeth don’t touch when the mouth is closed.

6. Problems with the shape or alignment of your jawbones that make it hard to bite properly: This can be due to an absolute transverse arch discrepancy or dual or multiplanar occlusion.

7. Severe shrinkage of the upper jaw: This condition, known as severe maxillary atrophy, often occurs alongside bone grafting.

8. Obstructive sleep apnea: This is a condition where your throat muscles block the airway during sleep, causing breathing to start and stop repeatedly.

9. Need to reach and remove skull base tumors.

10. Helping set hard-to-realign fractures back into place.

In some instances, the procedure may need to be performed in sections or multiple pieces, especially for cases involving problems with the shape or alignment of your jawbones or dual or multiplanar occlusion. However, the details for this process are not covered here.

When a Person Should Avoid Le Fort Osteotomy

There are several circumstances in which a type of jaw surgery called LeFort I osteotomy may not be suitable:

– If a person’s skeleton is still growing, they may not be suitable for this surgery.
– If a person has severe gum disease that’s not under control, they may not be a good candidate.
– Certain dental and facial growth disorders, like overgrowth of the jaw joint (condylar hyperplasia) or loss of jaw joint (idiopathic condylar resorption), might make the surgery less effective or more risky.
– If a person has bone or joint diseases like osteoporosis (weakening of the bones) or osteopenia (low bone mass), this surgery may not be right for them.
– People with certain medical conditions, like uncontrolled diabetes or a weakened immune system, might be at higher risk of complications.
– If a person has poor nutrition, for example, if they have low levels of a protein called albumin in their blood, this could make their recovery more difficult.

However, sometimes a situation that usually makes surgery less suitable, could in fact make the surgery more necessary for a patient. Because of this, the doctor will always do a thorough check before surgery, and discuss the risks and benefits with the patient, or their parent or guardian, to make sure they fully understand what the surgery could involve.

Equipment used for Le Fort Osteotomy

If your doctor needs to perform a procedure called a LeFort osteotomy, they will need certain tools and materials. Let’s break it down:

  • 15 blade: A small surgical knife used for making precise cuts.
  • Monopolar or bipolar electrocautery: This is a device that uses electricity to heat tissue to stop bleeding or to cut through tissue.
  • Assorted retractors: These are tools used to hold back your tissues or organs so the doctor can see better.
  • Marking pen: A special pen used to mark the areas where cuts will be made.
  • Local anesthetic with epinephrine: A medicine used to numb the area where the surgery will be done. Epinephrine is added to make the numbing effect last longer.
  • Kirschner or K-wire: A type of thin metal wire used to hold pieces of bone together.
  • Gauge or caliper: A tool for measuring the thickness or distance between things carefully.
  • Assorted periosteal elevators: Various tools used to lift a specific layer of tissue that surrounds bones.
  • Reciprocating saw: A powerful tool used for cutting through bone.
  • Straight tapered fissure bur (701 or 702): A type of drill bit specifically designed to create precise incisions in bone.
  • U-shaped or double-guarded straight osteotome: Special tools used to cut or shape bone.
  • Single guarded osteotome: Similar to before, but with a safety guard to prevent going too deep.
  • Cruciform or large curved osteotome: These are also tools for cutting or shaping bone, but they have different shapes for different needs.
  • Turvey spreaders: Tools used to gently separate bone sections.
  • Rowe dis-impaction forceps: A specialized tool used to free bone fragments.
  • Rongeur: A tool for removing chunks of bone or tissue.
  • Bone-eating bur or reciprocating rasp: A tool for smoothing rough edges on bone.
  • Small single-pronged skin hook: A tool for lifting and holding skin during surgery.
  • Sutures: These are the stitches used to close up wounds after surgery.
  • Assorted 24- to 28-gauge wires: Various sizes of wire that can be used to fix broken bones or secure other structures in the body.

These tools help ensure your doctor can perform the surgery effectively and safely.

Who is needed to perform Le Fort Osteotomy?

The surgery team includes various professionals each with a specific role. This team includes:

1) The Surgeon: This is a doctor who specializes in doing operations.

2) The Surgical Assistant: This person aids the surgeon during the operation, such as holding tools or controlling bleeding if needed.

3) The Surgical Technician: They’re responsible for all the equipment needed for the surgery, making sure that everything is working correctly and is ready to use.

4) The Perioperative Nurse: This nurse takes care of you before, during, and after surgery. For example, they help prepare you for the operation and care for you afterward as you recover.

5) The Anesthesiologist or Nurse Anesthetist: They are doctors or nurses who specialize in giving anesthesia. Anesthesia is the medicine that makes you sleep and not feel pain during the surgery.

6) The Postanesthesia Care Unit Nurse: This is a nurse who monitors you after the operation to make sure you wake up safely from the anesthesia and manage your pain or discomfort.

These professionals work together to make sure your surgery goes as smoothly and safely as possible.

Preparing for Le Fort Osteotomy

Before a LeFort osteotomy (a specific type of facial surgery), the doctors make sure to go through detailed checks and preparation processes. These include collecting your health history, doing a complete physical examination, and carefully analyzing your facial structure. They might also use digital or traditional model surgery to plan the operation in a very precise way. In some cases, they might use special mouthpieces known as occlusal splints.

If necessary, braces (a form of orthodontics) might be applied to your teeth before the surgery to adjust their position and orientation. This helps the surgeon get a better working area for the surgery. After the surgery, braces might be needed again to finalize the alignment of the teeth. All these steps are taken to ensure the best possible results from your surgery.

How is Le Fort Osteotomy performed

The medical procedure that we’re discussing is performed while you are fully asleep under general anesthesia, lying on your back. In the operation, an endotracheal tube (a tube placed through your throat into the windpipe to assist with breathing) is gently, but securely inserted. Before the surgery begins, surgeons take measurements and use markers for reference to guide the movements during surgery. This can be done using a thin metal wire or marking pen.

After that, a local anesthesia containing a substance called epinephrine is injected along the area where the surgery will take place. This anesthesia aims to reduce bleeding during the surgery and help with pain relief afterwards. An object called a “throat pack” is then placed in your throat to prevent blood or other fluids from going down your windpipe.

The surgeons also use plastic instruments to expose the surgery area for better visualization and convenience. The actual cut is strategically planned beforehand to ensure enough gum tissue is left for stitching after the surgery. The incision, about 5 millimeters above the meeting point of your gums and your inner cheek or lip, is made with precision tools. The layer of tissue covering your facial bones is then carefully separated from the bone itself, using medical tools like periosteal elevators, until it reaches around the natural openings of your nasal cavity. This dissection continues towards the back of this cavity and upwards to the nerves located beneath the eye sockets, which are carefully identified and prevented from getting damaged.

The planned bone cut, also known as an osteotomy, is marked once the area is fully exposed. The cut is carefully made to avoid the roots of the teeth and the lower part of the nasal cavity. Tools like a surgical saw and a bur, which is a drill used for cutting hard tissues, are used for the bone cut under continuous irrigation, meaning water is constantly flowing over it to keep the area clean and cool.

The bone cut is then mirrored on the other side of the face, a process that requires care due to the thickness differences of the bones in the area. Once that is done, lateral (side to side) nasal bone cuts are made with a chisel-like instrument or a specially guarded osteotome (which is a tool used for cutting or preparing bone). Once this is done, the section of bone connecting your upper jaw with the rest of your skull is carefully separated with other special osteotomes.

Note that the medical team will ensure the appropriate management of your blood pressure during this stage of the surgery since there is a risk of significant bleeding if the tools are not properly positioned. Once the osteotomes have finished their job, the newly cut upper jaw bone, called the maxilla, is gently pushed downwards with fingers. If necessary, remaining nasal tissues may be managed.

Before moving forward, the surgical team will make sure to control any active bleeding from the recent bone cuts. The team will then proceed with the surgery according to the pre-surgery plan, adjusting the tissues, if needed, in order to bring the upper jaw to the desired position.

Possible Complications of Le Fort Osteotomy

A LeFort I osteotomy is a type of surgery usually associated with fixing facial deformities. Although it’s generally straightforward, there can occasionally be complications. These complications occur at a rate of roughly 6.7% to 8.77%, according to various studies. They can be grouped into different types, including complications related to: the body’s anatomy, infections, blood supply disruptions, blood vessel problems, nerve disorders, and ear complications.

In a study that looked at 1,000 patients, it was discovered that folks with major irregularities in their anatomy, such as facial abnormalities, cleft palate, and abnormal blood vessels, had a higher chance of complications. Also, patients who had more complex types of surgeries or considerable changes were at a higher risk of having complications.

The most frequent complications have to do with anatomy. Examples of this are when the wall dividing the two nostrils is bent due to improper reduction during the surgery, when the bone doesn’t heal properly, or when the upper jaw is moved incorrectly. Common infection-related complications include abscesses and sinus infections, which are usually managed with simple treatments.

A significant blood vessel-related complication is heavy bleeding. This typically happens due to injuries to the branches of the facial artery, which can occur due to an unfavorable fracture during the surgery. Careful surgical techniques and proper instrument placement can help avoid this problem. In some cases, a medication called Tranexamic acid is used 30 minutes before the anesthesia is given to reduce blood loss.

Complications resulting from insufficient blood supply, such as the death of bone tissue, occur frequently with extensive changes, complex surgeries, and major anatomical abnormalities. When a significant change is planned, doctors might consider performing surgeries on both jaws to avoid excessive movements in one jaw.

Teeth or root damage is another potential complication but is often related to the surgeon’s experience and improper placement of the surgical cut. Temporary nerve sensitivity changes are common but typically resolve over time. Most patients regain full feeling within two months, though all regain it within six months. More serious complications, like one-sided blindness and eye muscle paralysis, have been reported but these are extremely rare.

What Else Should I Know About Le Fort Osteotomy?

The LeFort I osteotomy is a common and useful procedure in facial surgery due to its relative safety, versatility, and straightforwardness. It can be used for various reasons, including reconstruction, addressing injuries, dealing with physical diseases, and improving sleep disorders.

This type of surgery can enhance the middle part of your face and can also help improve your nasal passageways. It can help with conditions like maxillary hypoplasia, which occurs when the upper jaw doesn’t develop fully. It can also improve how your teeth line up and look.

In addition, the LeFort I procedure can adjust the upper jawbone for cosmetic reasons. For instance, it can manage how much of your teeth are visible when you smile.

Frequently asked questions

1. What specific deformity or condition is the Le Fort Osteotomy being used to address in my case? 2. What are the potential risks and complications associated with the Le Fort Osteotomy procedure? 3. How long is the recovery period after the Le Fort Osteotomy surgery? 4. Are there any alternative treatments or procedures that could be considered for my condition? 5. What is the success rate of the Le Fort Osteotomy in achieving the desired results for my specific case?

Le Fort Osteotomy is a surgical procedure that involves making incisions in the upper jawbone to reposition it. During this procedure, the surgeon needs to be careful not to damage the blood vessels and nerves in the area, as this can cause bleeding and affect sensation in the face. It is important to consult with a medical professional to understand how Le Fort Osteotomy may specifically affect you.

There could be several reasons why someone may need Le Fort Osteotomy. Some possible reasons include: 1. Correcting facial deformities: Le Fort Osteotomy is commonly used to correct severe facial deformities, such as a misaligned upper jaw or a significantly protruding or recessed jaw. This surgery can help improve the overall facial balance and appearance. 2. Correcting bite problems: If a person has a severe malocclusion (misalignment of the teeth and jaws), Le Fort Osteotomy may be necessary to reposition the upper jaw and align it properly with the lower jaw. This can improve the bite and chewing function. 3. Treating obstructive sleep apnea: In some cases, Le Fort Osteotomy may be recommended as part of the treatment for obstructive sleep apnea. By repositioning the upper jaw, the surgery can help open up the airway and improve breathing during sleep. 4. Addressing TMJ disorders: Temporomandibular joint (TMJ) disorders can cause pain, difficulty in jaw movement, and other symptoms. In certain cases, Le Fort Osteotomy may be performed to correct underlying structural issues in the jaw joint and alleviate TMJ-related problems. It is important to note that the decision to undergo Le Fort Osteotomy is made after a thorough evaluation by a healthcare professional. They will assess the individual's specific condition and determine if this surgery is the most appropriate treatment option.

A person should not get LeFort I osteotomy if their skeleton is still growing, if they have severe gum disease, if they have certain dental and facial growth disorders, if they have bone or joint diseases, if they have certain medical conditions, or if they have poor nutrition. It is important for the doctor to thoroughly assess the patient's suitability for the surgery and discuss the risks and benefits before proceeding.

The recovery time for Le Fort Osteotomy can vary depending on the individual and the complexity of the surgery, but it generally takes several weeks to months. During this time, patients may experience swelling, bruising, and discomfort in the face and jaw. It is important to follow post-operative instructions, including a soft diet and avoiding strenuous activities, to promote proper healing.

To prepare for Le Fort Osteotomy, the patient should undergo a thorough check-up, including collecting their health history, physical examination, and analysis of their facial structure. The doctors may also use digital or traditional model surgery to plan the operation precisely. In some cases, braces may be applied to adjust the position and orientation of the teeth before the surgery.

The complications of Le Fort Osteotomy include complications related to the body's anatomy, infections, blood supply disruptions, blood vessel problems, nerve disorders, and ear complications. Some specific complications include improper reduction of the wall dividing the nostrils, improper healing of the bone, incorrect movement of the upper jaw, abscesses, sinus infections, heavy bleeding, death of bone tissue due to insufficient blood supply, teeth or root damage, temporary nerve sensitivity changes, and rare complications such as one-sided blindness and eye muscle paralysis.

Symptoms that require Le Fort Osteotomy include disproportionate jaw sizes, overly large upper jaw, incorrect bite alignment, misaligned teeth, open bite, problems with the shape or alignment of jawbones, severe shrinkage of the upper jaw, obstructive sleep apnea, the need to reach and remove skull base tumors, and helping set hard-to-realign fractures back into place.

There is no specific information provided in the given text about the safety of Le Fort Osteotomy in pregnancy. It is recommended to consult with a healthcare professional for personalized advice regarding the safety of any surgical procedure during pregnancy.

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