The Le Fort procedure is a specialized type of orthognathic or corrective jaw surgery focused primarily on the midface and upper jaw, known as the maxilla. This operation involves surgically separating and repositioning the bone structure to correct functional and aesthetic issues. The procedure takes its name from René Le Fort, a French surgeon who first characterized the three distinct patterns of midface fractures at the turn of the 20th century. A Le Fort procedure is technically an osteotomy, the precise cutting of bone to allow for controlled movement and stable fixation.
Indications for Maxillofacial Reconstruction
Patients often require a Le Fort procedure to correct skeletal discrepancies that affect both function and facial harmony. One common reason is the correction of severe malocclusion, specifically Class II or Class III bite relationships where the upper jaw is underdeveloped or overdeveloped relative to the lower jaw. Since this misalignment cannot be fully corrected by orthodontics alone, surgical intervention is necessary to properly align the dental arches.
The procedure is also used to repair complex facial trauma, particularly fractures involving the middle third of the face that result in bone displacement. The surgery aims to restore the correct pre-injury anatomy and stabilize the fractured segments. Congenital deformities, such as those related to a cleft lip and palate, often lead to maxillary hypoplasia, which the Le Fort procedure addresses by advancing the upper jaw.
Certain medical conditions like obstructive sleep apnea may be treated with a Le Fort advancement, often in conjunction with lower jaw surgery. Repositioning the maxilla forward increases the volume of the upper airway, alleviating breathing difficulties during sleep. The goal is to establish a stable bite, improve chewing function, and enhance the overall balance of the facial profile.
Classifying the Procedures
The Le Fort procedures are classified into three distinct levels, determined by the anatomical plane of the osteotomy across the facial skeleton. The most common is the Le Fort I osteotomy, which involves a horizontal cut made high above the roots of the upper teeth. This separation isolates the tooth-bearing portion of the maxilla from the rest of the facial skeleton, allowing it to be moved in multiple dimensions.
The Le Fort II procedure is a higher, more complex, pyramidal cut that extends superiorly into the nasal bones and the lower portion of the eye sockets, or orbital floors. This procedure mobilizes the entire central midface, including the nose and upper jaw, necessary for correcting more extensive midfacial deficiencies. The fracture line typically starts near the nasal bridge and extends down and back toward the pterygoid plates.
The highest and most involved level is the Le Fort III osteotomy, often referred to as craniofacial disjunction. This transverse cut separates the entire midface, including the cheekbones (zygomatic arches) and the lateral orbital walls, from the base of the skull. A Le Fort III is reserved for correcting severe midfacial hypoplasia seen in certain craniofacial syndromes, as it allows for the entire orbital-maxillary complex to be advanced.
Steps in Performing the Surgery
The surgical process begins with meticulous pre-operative planning, often utilizing three-dimensional computed tomography (CT) scans to create a virtual surgical plan. This digital blueprint allows the surgeon to map out the exact cuts and the final position of the bone segments. The procedure is performed under general anesthesia, accessed through an incision made entirely inside the mouth, in the gum tissue above the upper teeth.
Using specialized surgical instruments, the surgeon performs the osteotomy along the planned line, carefully cutting the bone while preserving the soft tissues and blood supply. Once the bone is cut, the maxilla is separated from its attachments—a process called mobilization—which may involve using instruments like Rowe disimpaction forceps to ensure free movement. This allows the segment to be moved to its new, predetermined position.
After the maxilla is correctly positioned, it is permanently secured using small, biocompatible titanium plates and screws. This rigid internal fixation provides immediate stability for the bone to heal in its new alignment. The intraoral incision is then closed with dissolving sutures, ensuring no visible external scars are left.
Post-Operative Care and Healing
The initial recovery period is characterized by significant facial swelling, which typically peaks around two to three days after the operation. Managing this swelling with cold compresses and keeping the head elevated is a primary focus. Patients commonly experience numbness in the upper lip and cheeks, a temporary symptom resulting from nerve manipulation that gradually resolves over several weeks or months.
Pain management is achieved through prescribed oral medications, as discomfort is often related more to the pressure from swelling than the bone manipulation itself. A strictly modified diet is mandated for bone consolidation, starting with clear liquids and advancing to a non-chewing soft diet for four to six weeks. Eating anything hard or crunchy too early risks displacing the newly positioned jaw segment.
Patients will also use orthodontic elastics to guide the bite and maintain the new occlusion. These elastics are often managed by the orthodontist, who plays a continuing role in the post-surgical phase. Final bone healing takes several months, but the patient will continue with orthodontic treatment to achieve the final alignment of the teeth.