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The LeFort I osteotomy is a procedure utilized extensively within the field of oral and maxillofacial surgery when maxilla repositioning is required to correct dentofacial abnormalities or facilitate surgical access. This procedure facilitates horizontal and vertical movement and allows for transverse expansion when performed as a segmental osteotomy. This procedure has various applications. The LeFort I osteotomy improves facial harmony and aesthetics by addressing maxillary asymmetry and protrusion. The technique also enhances dental occlusion and chewing function by correcting malocclusion. The LeFort I osteotomy may also alleviate symptoms of obstructive sleep apnea by enlarging the upper airway. Proper technique helps optimize patient outcomes and reduce morbidity. This activity for healthcare professionals is designed to enhance learners' proficiency in identifying patients with indications for the LeFort I osteotomy and performing the procedure with precision and care. Participants gain a deeper understanding of the procedure's origins, indications, limitations, contraindications, potential complications, and clinical significance. Greater competence equips learners to collaborate more effectively within an interprofessional team caring for patients with dentofacial abnormalities. Objectives: Identify pertinent anatomical structures associated with the LeFort I osteotomy. Describe the different indications for the LeFort I osteotomy. Implement the proper surgical techniques for the LeFort I osteotomy. Implement effective collaboration and communication practices among interprofessional team members to improve outcomes and treatment efficacy for patients who might benefit from a LeFort I osteotomy. Access free multiple choice questions on this topic.

The LeFort I osteotomy is a horizontal maxillary osteotomy utilized to correct midface deformities, allowing movement of the dentition-bearing portion of the maxilla anteroposteriorly, vertically, rotationally, and with segmentation or expansion. The procedure may also be used to facilitate surgical access for tumor removal and the reduction of complex midfacial fractures. This surgery is named after the LeFort I horizontal fracture pattern described by Rene LeFort in 1901.[1] The earliest maxillary osteotomies were utilized to facilitate exposure during nasopharyngeal polyp removal. The first LeFort I osteotomy for dentofacial deformity correction was described by Wassmund in 1921, utilizing orthopedic traction rather than intraoperative mobilization. Auxhausen first described the osteotomy with intraoperative mobilization in 1934 to close an open bite. [2] Schuchardt separated the pterygomaxillary junction, allowing anterior repositioning. Bell’s research demonstrated the revascularization phenomenon, the ability to sacrifice the descending palatine arteries without compromising blood supply, and the ability for osseous healing from a complete maxillary osteotomy, thus providing the biological basis for a complete down-fracture. The technique has continued to evolve, incorporating and recognizing the roles of hypotensive anesthesia, orthodontics, tension-free stability, and virtual surgical planning. Consequently, the LeFort I osteotomy has become widely accepted as a reliable, predictable, and safe procedure.[3]

While a technically simple and versatile procedure, rare but serious complications can occur during or after a LeFort I osteotomy. Complication rates vary, and the incidence has been reported in several studies to be between 6.7% and 8.77%. Complications can broadly be categorized as anatomic, septic, ischemic, vascular, neurologic, and otologic. In a prospective study of 1,000 patients, Kramer et al found that patients with major anatomic irregularities, such as craniofacial anomalies, cleft palate, and vascular abnormalities, were at increased risk of complications and accounted for a disproportionate number of observed cases. Patients who underwent segmental osteotomies or large advancements were also shown to have an increased risk of complications.[16] A smaller study excluding segmental osteotomies and patients with major anatomic irregularities demonstrated increased complications associated with maxillary setbacks relative to other movements. The most commonly encountered complications are anatomic and include nasal septal deviation resulting from an inadequate reduction of the cartilaginous septum when performing a maxillary impaction, nonunion of the osteotomy gap, and improper positioning of the maxilla.[17] Common septic complications include abscesses and maxillary sinusitis, both of which are readily controlled by conservative therapies. The primary vascular complication of concern is hemorrhage, which typically results from damage to branches of the maxillary artery, most often due to an unfavorable fracture of the pterygoid plates.[18] This complication may be avoided by careful surgical technique and osteotome placement or consideration of alternatives to the traditional pterygomaxillary osteotomy. Tranexamic acid at 10 mg/kg 30 minutes before general anesthesia induction is also advocated to reduce blood loss.[19] Ischemic complications, including avascular necrosis, are associated with large advancements, segmental osteotomies, and major anatomic irregularities. Consideration should be given to 2-jaw surgery if a significant advancement is anticipated, as it can help limit extensive anteroposterior movements within a single jaw.

Ischemic complications, including avascular necrosis, are associated with large advancements, segmental osteotomies, and major anatomic irregularities. Consideration should be given to 2-jaw surgery if a significant advancement is anticipated, as it can help limit extensive anteroposterior movements within a single jaw. Damage to teeth or root amputation is another complication that may be encountered but is related to the surgeon's experience and failure to initiate the osteotomy apical to the roots of the teeth. Neurosensory deficits in the infraorbital nerve are frequently seen after surgery secondary to compression or retraction, but symptoms typically resolve. Most patients regain full sensation within 2 months, and all regain sensation within 6 months. Other more serious neurologic complications have been reported, such as unilateral blindness and oculomotor nerve palsy. However, these complications are exceedingly rare.

Although oral and maxillofacial surgeons or head and neck surgeons typically perform the LeFort I osteotomy, the crucial role of an interdisciplinary team throughout all stages—preoperatively, perioperatively, intraoperatively, and postoperatively—cannot be overstated. Successful outcomes are contingent upon comprehensive interprofessional care and support. Preoperatively and postoperatively, the orthodontist plays a critical role in preparing the patient for orthognathic surgery and providing input and expertise relative to the surgical treatment plan and the anticipated need for postsurgical orthodontics. Preoperative optimization is essential for patients with medical comorbidities to have a safe and successful surgery. Depending upon the patient’s medical conditions, preoperative optimization may involve care coordination and planning by physicians and caregivers from multiple disciplines. Intraoperatively, the anesthesia provider facilitates safe surgery and emergence from general anesthesia. The surgeon and anesthesia provider coordinate and discuss the preferred intubation technique and the risks, benefits, and timing of hypotensive anesthesia. The surgeon and anesthesia provider also plan for potential airway challenges due to maxillomandibular fixation and postoperative edema. Hypotensive anesthesia has been shown to reduce blood loss, provide better surgical field visualization, and shorten the length of hospital stay.[20][21] In the immediate postoperative period, the nursing team is vital in educating patients, providing psychosocial support, and ensuring that patients meet immediate postoperative milestones. The pharmacist and pharmacy team determine the appropriate postoperative medications for the patient, balancing adequate pain control with minimizing deleterious side effects. The pharmacist also devises appropriate and effective pain control regimens for patients at risk for overnarcotization or respiratory depression, as is the case in patients with obstructive sleep apnea or morbid obesity. Proper nutrition is critical for wound healing. Thus, nutritionists and registered dieticians are pivotal in determining appropriate caloric needs, supporting and facilitating a dietary regimen, ultimately minimizing postoperative complications and decreasing patient morbidity.[22]