Le Fort 1 Osteotomy: Upper Jaw Surgery Steps and Recovery

A Le Fort I osteotomy is a surgical procedure that separates the entire upper jaw from the rest of the skull so it can be repositioned. The cut runs horizontally through the maxilla, roughly at the level of the nose floor, allowing the surgeon to move the jaw forward, backward, up, down, or rotate it to correct problems with bite alignment, facial symmetry, and breathing. It is one of the most widely used operations in orthognathic (jaw-correcting) surgery, valued for its ability to make changes in all three dimensions and for its track record of reliable long-term results with a relatively low rate of serious complications.¹

Who Needs This Surgery and Why

The most common reason for a Le Fort I osteotomy is a significant skeletal discrepancy between the upper and lower jaws that braces alone cannot fix. If the upper jaw sits too far back relative to the lower jaw (a “Class III” relationship) or too far forward (a “Class II” relationship), the bite is off in a way that only moving bone can correct. The procedure is also used for facial asymmetry where one side of the midface is vertically longer or shorter than the other, for a “gummy smile” caused by excess vertical height of the upper jaw, and for severe maxillary atrophy where the jaw has lost bone over time.²

Less intuitively, the surgery is sometimes part of the treatment plan for obstructive sleep apnea. When the upper jaw is advanced, it pulls the soft palate and surrounding tissues forward, which can open up the airway behind the palate. In many sleep apnea cases, however, both jaws are advanced together (a procedure called maxillomandibular advancement) rather than moving the upper jaw alone.

The operation is frequently performed alongside mandibular surgery. A patient whose upper jaw needs to come forward and whose lower jaw needs to move back, for instance, will have a Le Fort I combined with a bilateral sagittal split osteotomy of the mandible during the same session. This combination, sometimes called bimaxillary surgery, lets the surgeon fine-tune the relationship between both jaws in a single operation.

How the Bone Is Cut and Moved

The surgery is performed entirely through incisions inside the mouth, so there are no visible scars on the face. The surgeon makes a cut in the gum tissue above the upper teeth to expose the front and sides of the maxilla. Using a small reciprocating saw, the bone is cut horizontally from the base of the nasal opening across to each side, extending back toward the junction where the maxilla meets the pterygoid plates of the skull base. The nasal septum is also separated from the upper jaw.

One of the trickiest steps is freeing the back of the maxilla from the pterygoid plates, a junction called the pterygomaxillary suture. Traditionally, surgeons use a curved chisel (osteotome) to crack through this connection, but that carries risk of injuring nearby blood vessels. A systematic review found no strong clinical or anatomical evidence that an osteotome is actually necessary for this step, and reported that digital pressure alone (using the surgeon’s hands to “downfracture” the maxilla) produced no serious complications across 138 consecutive cases.³

Once freed, the maxilla “downfractures,” meaning it drops down on its soft-tissue hinge. The surgeon can then see inside the nose and sinuses, remove any bony interferences, and reposition the jaw in its planned location. Titanium mini-plates and screws lock everything in place. A thin acrylic wafer, made from pre-surgical models or digital planning, fits between the upper and lower teeth to guide the maxilla into the exact position that was planned.

Why the Bone Survives After Being Detached

A natural question is how a completely separated piece of bone stays alive. The answer lies in the soft-tissue pedicle that remains attached along the palate. Even though the horizontal bone cut severs the descending palatine arteries (the vessels that drop down through canals in the hard palate), the maxilla is never truly “loose.” It stays connected to the soft tissue of the palate and the back of the throat, and those tissues carry their own blood supply.

Cadaver studies have shown that after the osteotomy, blood reaches the maxilla primarily through the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal artery, both of which travel within the soft-tissue pedicle that remains intact.⁴ A rich network of small vessels in the gum tissue overlying the bone also helps perfuse the segment. In about 90% of people, both the ascending palatine and ascending pharyngeal arteries contribute to the blood supply. In roughly 10% of specimens studied, the ascending palatine artery is absent, and the ascending pharyngeal artery alone takes over the entire supply.⁵ That anatomic variation is clinically relevant because it means the surgeon has less redundancy to work with if something goes wrong with the pedicle.

What Happens to Your Face Afterward

Because the Le Fort I moves bone underneath the skin, the soft tissue of the face drapes over a new framework. Patients and surgeons both want to predict how the lips, nose, and cheeks will look after healing, but soft tissue does not move in a perfectly predictable one-to-one ratio with the bone beneath it.

When the maxilla is advanced (moved forward), the upper lip follows roughly 80 to 85% of the bone movement. So if the jaw is moved forward by 5 mm, the lip moves forward by about 4 mm.⁶ The nose is less predictable. The nasal tip tends to elevate slightly with advancement, but the ratio of bone-to-tip movement is much smaller, around 5:1, meaning a large forward movement of the jaw produces only a modest upward shift of the nose tip.

The direction the maxilla moves matters for different parts of the face. Advancement and upward movement (intrusion) tend to leave lip length stable, with any small increase in length happening at the red part of the lip (the vermilion). Downward movement (extrusion) lengthens the lip more at the skin portion above it (the philtrum). Nose width tends to stay the same after pure advancement, may narrow after extrusion, and can widen after intrusion.⁷ Some surgeons perform an alar cinch suture, a stitch that narrows the nostrils, at the end of the procedure to control nasal widening. Whether to trim the anterior nasal spine (the small bony projection at the base of the nose) during advancement is also debated, with at least one ongoing clinical trial investigating how that step affects the nasal profile.⁸

Nerve Sensation and Recovery Timeline

Numbness of the upper lip, cheeks, and gums is almost universal in the first days after surgery. The infraorbital nerve, which provides sensation to the midface, runs close to the osteotomy line and is stretched or bruised during the procedure. One study found that about 82% of patients had measurable sensory deficits two weeks after surgery. That number dropped steadily: roughly 60% at six weeks, 39% at three months, 20% at six months, and under 8% at one year. By two years, only about 3% still had any residual deficit.⁹

A separate retrospective study put immediate postoperative nerve disturbance at about 48% of patients, with complete resolution in all cases within six months.¹⁰ The difference in reported rates between studies likely reflects when and how sensation was tested, but the pattern is consistent: numbness is common early and resolves over months. Subjective severity also improves with time, meaning even patients who still test abnormally on a clinical exam often feel that the numbness has become mild enough to stop noticing.

Effects on the Teeth

Teeth sit directly in the bone that is being cut and moved, so it is reasonable to worry about their health. The blood supply to the roots of the upper front teeth can be temporarily disrupted during surgery. If the osteotomy is performed correctly and the palatal pedicle is preserved, this disruption is usually reversible. A study following 42 patients for up to five years found that about 91% of upper front teeth remained responsive to cold testing and roughly 89% to electrical pulp testing, meaning the vast majority of teeth stayed alive.¹¹ About 3% of teeth eventually needed root canal treatment because they lost vitality and developed infections at the root tip.

The risk to teeth increases when the procedure involves cutting the jaw into segments (more on that below), because the saw passes between tooth roots. Teeth immediately next to those interdental cuts face the greatest chance of blood supply disruption. Protecting the descending palatine artery during surgery is considered key to maintaining the highest possible blood flow to both the teeth and the gums.¹² Tooth discoloration can sometimes occur after surgery, but it does not always mean the tooth is dead.

Airway Changes

Moving the upper jaw changes the shape of the airway behind it, but the direction and magnitude of that change depend entirely on which way the jaw moves. Advancing the maxilla tends to open the space behind the soft palate. One study with six months of follow-up found that a Le Fort I osteotomy expanded the lower portion of the space behind the palate by roughly 17%, though the right maxillary sinus volume decreased by a similar amount.¹³ The correlation between the magnitude of surgical movement and the airway change was moderate, meaning bigger movements did not always translate proportionally into bigger airway gains.

When a Le Fort I advancement is combined with a mandibular setback (moving the lower jaw backward) to correct a Class III bite, the net effect on the airway can actually be negative. One study of that specific combination found that the posterior airway space shrank to about 75% of its original volume, and the distance between the lower jaw and the hyoid bone (a small bone in the throat) increased by a third, both signs of increased upper airway resistance during sleep.¹⁴ This is worth discussing with your surgeon if you already have any tendency toward snoring or sleep apnea, because the combination of advancing one jaw and setting back the other does not automatically help breathing the way a pure forward movement might.

How Stable Is the Result Over Time

One of the biggest concerns for anyone undergoing jaw surgery is whether the bones will stay where they are placed. The maxilla is typically held in its new position with titanium mini-plates screwed into the bone at the junction between the moved segment and the stable skull above it. Whether surgeons use two plates or four plates does not appear to make a meaningful difference in long-term stability; a comparison of the two approaches found no significant difference in vertical or horizontal relapse.¹⁵ Custom-manufactured patient-specific implants, which are designed from CT scans before surgery, also show stability comparable to standard mini-plates.¹⁶

The direction of movement matters for relapse risk. Upward movements (shortening the face) tend to be highly stable because the bone is being impacted into a shorter position. Downward movements (lengthening the face) carry the greatest relapse risk because gravity and muscle forces work against the new position. Advancements fall somewhere in between. In general, though, the Le Fort I osteotomy is considered one of the more stable orthognathic procedures when properly fixated.

Segmental and Multi-Piece Versions

Sometimes the upper jaw needs more than a single-piece repositioning. If a patient has a narrow arch or a gap between the front teeth that requires widening in addition to forward or vertical correction, the surgeon can cut the maxilla into two or three pieces and spread them apart. This is called a segmental Le Fort I osteotomy. A two-piece version splits the jaw down the midline; a three-piece version separates the front segment from two back segments.

A systematic review comparing segmental Le Fort I osteotomy to surgically assisted rapid maxillary expansion (where only the palatal suture is loosened and a device slowly widens the arch) found that both approaches increased jaw width significantly, but the segmental osteotomy produced a more parallel, even expansion without tilting the segments. The expansion-device approach showed higher dental relapse, particularly in the back of the arch.¹⁷ A clinical study of three-piece Le Fort I osteotomies reported an average expansion of about 6 mm at the canine teeth and about 4 mm at the back molars, with only minimal relapse of around 0.4 mm or less over time.¹⁸

The trade-off is that cutting the jaw into pieces introduces more interdental cuts, which raises the risk of compromising blood supply to adjacent teeth, as discussed above.

Special Considerations for Cleft Patients

Patients born with cleft lip and palate often have an underdeveloped upper jaw because scar tissue from prior repairs restricts growth. A Le Fort I advancement is one of the most common operations to correct this midface deficiency once the patient is old enough, typically after the mid-teens. However, the extensive scarring in cleft patients makes the surgery more challenging and increases the tendency for the jaw to relapse backward.

An alternative for cleft patients is distraction osteogenesis, where the bone is cut but then slowly pulled forward using an external or internal device over several weeks. A Cochrane systematic review comparing Le Fort I osteotomy to distraction osteogenesis in cleft patients found that both methods improved hard and soft tissue positions, but the distraction group achieved more forward movement and experienced less horizontal relapse. Five years after surgery, the distraction group had maintained a net forward movement, while the conventional osteotomy group had actually drifted backward.¹⁹ Neither approach worsened speech or velopharyngeal function compared to the other.²⁰

Custom patient-specific implants may help in cleft cases. An early series of 12 cleft patients undergoing wafer-free Le Fort I osteotomy with custom-designed titanium implants reported that the implants fitted precisely to pre-drilled holes and planned bone contours in 10 of 12 cases, achieving an average advancement of about 6 mm.²¹

Newer Instruments and Digital Planning

Traditional Le Fort I osteotomies use reciprocating saws and rotating burs to make the bone cuts. Piezosurgery, which uses ultrasonic vibrations to cut hard tissue while sparing soft tissue, has gained popularity as an alternative. A meta-analysis found that piezosurgery reduced intraoperative blood loss by roughly 80 mL compared to conventional methods.²² In one bimaxillary study, average blood loss dropped from about 770 mL with conventional instruments to about 540 mL with piezosurgery.²³ The downside is that piezosurgery is slower, and in that same study, auxiliary chisels were still needed for the nasal septum in every case and for the pterygoid plates in nearly half.

Blood loss management extends to the anesthesia side as well. Controlled low blood pressure during surgery (hypotensive anesthesia) significantly reduces bleeding compared to normal blood pressure. A randomized trial comparing hypotensive anesthesia to a blood-dilution technique found that none of the patients in the hypotensive group required a transfusion, whereas patients in the other groups did.²⁴

Recovery and Quality of Life

The first week or two after surgery are uncomfortable. The face swells substantially, the jaws may be guided with elastics (rubber bands connecting braces on the upper and lower teeth), and the diet is restricted to liquids and then soft foods for several weeks. Oral-health-related quality of life actually drops below its pre-surgical level in the immediate postoperative period before climbing back. By one year, it tends to be significantly better than before surgery.²⁵

Patient satisfaction surveys paint a broadly positive picture. In one large survey, over 90% of patients reported improvements in facial appearance, the look of their teeth, and biting ability, and quality-of-life scores rose from about 73 out of 100 before surgery to about 94 out of 100 after.²⁶ Enhanced recovery protocols, which use strategies like preemptive pain management and reduced opioid reliance, are also being adopted for orthognathic surgery. A retrospective comparison found that patients on such a protocol reported lower peak pain scores and used substantially less morphine-equivalent medication during their hospital stay than patients on a standard protocol.

Operating on Growing Patients

Orthognathic surgery is generally deferred until skeletal growth is complete, usually around 16 to 18 years of age for the upper jaw. Operating earlier risks the surgery being “outgrown,” with the jaw discrepancy returning as the face continues to develop. In rare cases involving severe functional or psychosocial problems, an early Le Fort I can be performed in a growing child, as reported in a case involving a six-year-old patient. Families in those situations are counseled that a second corrective surgery will likely be needed once growth is finished.²⁷

A cephalometric comparison of growing versus non-growing cleft patients who underwent Le Fort I osteotomy confirmed this pattern: early osteotomy in growing patients should generally be considered a two-stage approach because secondary correction after growth is complete is often necessary.²⁸ For most patients, the takeaway is straightforward: waiting until the mid-to-late teens gives the best chance of a single, stable correction.

The Jaw Joint After Surgery

The temporomandibular joint (TMJ) does not sit in the upper jaw, but it is affected by Le Fort I osteotomy because any change to how the teeth come together alters the forces on the jaw joints. When the surgery is combined with mandibular repositioning, the condyle (the ball at the top of the lower jaw) shifts in its socket. Research has shown that the position of the condyle within the joint space changes over time after bimaxillary surgery, and that patients who already have anterior disc displacement of the TMJ may follow a different trajectory of joint-space change than patients with healthy joints.²⁹

If you already have TMJ clicking, locking, or pain, this is worth bringing up during your surgical consultation. Pre-existing disc displacement does not automatically disqualify you from surgery, but it may influence the surgical plan and the postoperative monitoring schedule. Some patients find that their TMJ symptoms improve after orthognathic surgery because the bite is in a more physiologically balanced position; others see no change or temporary worsening. The relationship between orthognathic surgery and TMJ symptoms remains one of the less predictable aspects of the procedure.