Upper jaw surgery
The Le Fort I osteotomy is the osteotomy for spatial repositioning of the upper jaw. This procedure is performed under general anaesthesia and with lowered blood pressure. Surgery time is about one and a half hours. The operation is carried out entirely inside the mouth. A ‘U-shaped’ incision is made through the gums above the upper teeth to gain access to the jawbone. The upper jaw incisions are made with specialised tools (burs and/or reciprocating saws), which allow for a controlled parting of the bone. Additional bone can be removed if the upper jaw is to be shortened. Bone can be added, if necessary, to lower the jaw and make the upper jaw longer. This includes a bone graft. The upper jawbone is then moved into its final position (planned prior to your surgery) and secured in place with tiny titanium plates and screws, which are left in place permanently. The gums are stitched back in place with dissolvable stitches. These stitches may take three to four weeks to dissolve, or can be taken out. The jawbones heal together and fuse again soon after surgery. After one month, the jaw regains its normal strength.
Some setting of the bite is often mandatory after surgery. This is achieved with two elastic bands on brackets just to guide and set the bite.
Facial swelling is variable and is controlled with intravenous steroid injections during the anaesthesia. Patients require a light diet for some days. Spaghetti and hamburgers are possible after a few days.
The upper jaw may be too narrow, too long, too short, or too far forwards or backwards to fit the lower jaw properly. Upper jaw surgery is the only way to correct those abnormalities. In maxillary surgery, the upper jaw can be positioned forward, backward, or it can be raised or lowered (with a bone graft). Asymmetries between different sides of the face can also be corrected by rotation or translation of the upper jaw, particularly if the dental midlines are off centre. Widening of the upper jaw is also possible by a surgical split in the midline followed by distraction.
The critical aspect of where to place the maxilla in the anteroposterior position is determined clinically and worked out further by computer analysis, i.e. 3D i-cat analysis and computer software (Maxilim). This illustrates the movement architecturally, taking into account the skeletal and soft tissue environment. The position of the maxilla in the vertical plane is determined by the amount of upper incisor tooth visible below the upper lip at rest and when the patient smiles.
Occasionally, bone grafts are required in the Le Fort I osteotomy to ensure bone healing and union across the bone cuts (extrusions and major advancements). The graft is frequently reaped from the anterior hip region (incision two cm in the underwear region – surgery takes half an hour). Bone graft material may also be reaped from the chin or lower jaw in bi-maxillary cases, but this is not always possible.
The operation is frequently carried out together with the Mandibular Sagittal Split Osteotomy (roughly 40% of the cases). This is called a Bi-Maxillary Osteotomy (M&M). Bi-maxillary osteotomies take around three to three and a half hours to complete and may be carried out in conjunction with chin surgery (45 minutes) and liposuction/liposculpture (60 to 75 minutes).
Frequently asked questions
- Is it necessary to wire the jaws together?
No, not at all. The healing of the jaws goes through the screws and plates, which are necessary to keep the ‘voluntary fracture’ immobile. After surgery, some elastics can be used for a couple of weeks just to guide the occlusion. This is certainly the final tuning.
- What about postoperative facial swelling?
This is highly variable. During surgery, you are given intravenous steroids. The tendency for swelling varies from person to person. Younger patients usually experience more swelling. Blond people are more likely to experience swelling than people with dark hair. After one week, 1/3 of the swelling has gone, and after three weeks, at least 2/3 has gone. After three weeks, there is still some puffing around the cheeks, but this swelling is merely lymph oedema. This takes some more time to resorb.
- Is there a cure to speed up the resorption of the swelling?
Yes, there is. After a few days you can apply a lymph drainage massage carried out by a specialised physiotherapist. This is substantially helpful after a Le Fort I.
- What about facial bruising?
Facial bruising is possible as well. Your face will gradually show all the colours of the rainbow, from blue to yellow, and by gravity it sinks from your face to your clavicle. However, this is nothing to worry about, since it disappears in a couple of weeks.
- What about diet?
Patients require a light diet for some days. Spaghetti and hamburgers are possible after a few days. We recommend making a quality broth soup with meat. You can add mixed potatoes and vegetables to the broth soup. We advise you to eat small quantities but frequently. It is best to eat six to eight times a day for the first few days, rather than just three times!! The most important thing is to drink a lot of fluid. At least half a litre a day.
- Is there sensory nerve damage?
There is sometimes sensory nerve damage in the upper lip and cheeks, but there is almost always a recovery after some weeks. This is caused by the retraction of the soft tissues towards the cheeks. A degree of permanent altered sensation is rare after upper jaw surgery. Sensibility of anterior gingiva and palate is often affected for some time (weeks to months.), but this will eventually resolve itself, and sensation returns gradually from posterior to anterior.
- What about motor nerves?
This is almost impossible, so it is therefore an extremely rare complication.
- What about a relapse?
Long-term complications include relapse. It can be related to your age. Most relapses are unnoticed by the patient. It is very rare for relapse to adversely affect the cosmetic improvement achieved, but it can compromise the occlusion.
- What about elastics?
Some setting of the bite is often mandatory after surgery. This is usually achieved with two elastic bands on brackets just to guide and set the bite.
- What about blood transfusion?
No blood transfusion is required.
- Is there a hospital stay?
Usually one night.
- Can I sneeze or blow through my nose?
You should sneeze with your mouth open. Do not blow through the nose, since air can slip through the bone cuts. The sinuses are momentarily open through the overlaying soft tissues and you can blow air into the cheeks through the nose, then the sinuses, then the bone cuts, and then the soft cheek areas.
- What will happen to the shape of my nose?
When the upper jaw is advanced or impacted superiorly, you might have a ‘turned up nose’ for some weeks, but this will return to normal within weeks to months. Sometimes, the nose flares out a bit and widens, but there are ways of working around this during surgery.
- Do I need to worry about some nose bleeding?
Slight nose bleedings are possible postoperatively, but this disappears in the course of the healing.