Lefort Maxillary Advancement for Upper Jaw Rehabilitation: A Surgical Insight

Introduction

In long-term edentulous patients, the upper jaw, or maxilla, experiences severe bone resorption, making it difficult for dental practitioners to rehabilitate. Read this article to learn about the Lefort maxillary advancement procedure, which is one of the most preferred surgeries by dental and maxillofacial surgeons for the complex rehabilitation of the upper jaw or maxilla.

Why Does Long-Term Tooth Loss Lead to Complications in Terms of Management or Upper Jaw Rehabilitation?

In many patients with chronic edentulism or tooth loss accompanied by long-term chronic bone resorption in the upper jaw or maxillary region, rehabilitation can be quite challenging even with the gold standard of dental implants, according to current dental research. This is because when a tooth is lost or removed, and the individual allows the extraction site to be resorbed without immediately opting for a dental prosthesis such as a crown, bridge, or dental implant, the subsequent adverse effect is the resorption of the maxillary alveolar process post tooth loss. Even with 3D imaging using advanced radiographic modalities like multidetector CT scanning and CBCT, studies and analyses of multiple documented case reports of edentulous patients of the upper jaw have shown that there can be 3D atrophy of the alveolar bone of the maxilla. Furthermore, due to age-related physiological processes of pneumatization—especially of the most prominent sinus in the face, the maxillary sinus—this can lead to a more detrimental impact when a tooth is lost, either naturally or by extraction, and is not replaced or does not receive timely dental management. Rehabilitation can thus pose a significant challenge to the general dentist, maxillofacial surgeon, and prosthodontist.

What Is the Gold Standard for Complex Rehabilitation?

Though several strategies, ranging from bone augmentation protocols to standard sinus lift procedures and surgery with autogenous bone graft placement, have played a major role in shaping current-day reconstructive and implant surgery, there is a surgical procedure that is just as effective in rehabilitating complex cases or patients with long-term tooth loss or edentulism in the upper jaw. This procedure is called the Lefort 1 maxillary osteotomy or maxillary advancement (upper jaw advancement). In this standard surgical procedure, which can be adopted by general surgeons and maxillofacial surgeons alike, the upper jaw, or maxilla, is positioned in a downward and forward motion, either alone or in conjunction with procedures such as bone grafting of the upper jaw, regenerative procedures of the upper jaw, distraction osteogenesis, inlay grafting of the nasal floor and maxillary/antral areas, onlay grafts, and so on.

What Are the Benefits of the Lefort Maxillary Advancement Procedure?

Your dentist or surgeon will assess the various ways and considerations to implement this surgical procedure, either alone or with the adjunctive or additional interposition therapies listed above. Implant dentists and maxillofacial surgeons are generally advised to follow thorough pre-evaluative protocols before surgical procedures or even routine dental implant surgeries, particularly for the upper jaw region. The benefits of the Lefort maxillary advancement procedure for upper jaw rehabilitation include a significant advantage over other long-duration or complex surgical procedures that may eventually require multiple sessions and have a high rate of surgical morbidity. This procedure helps reduce the duration, risks, and morbidity factors for patients opting for standard dental implants or prosthetic options, such as jaw reconstruction.

In patients suffering from long-term tooth loss or edentulism, the challenges for rehabilitation are significantly increased for the dental operator due to the physiological pneumatization process of the sinuses, progressive bone resorption, and atrophy of the alveolar jaw bone.

What Are the Surgical Steps and Guidelines Followed for the Lefort Maxillary Advancement Procedure?

Let us now look at the surgical steps in this procedure that will be followed by the dental operator, implant, maxillofacial, or plastic surgeon:

• A thorough preoperative evaluation is first carried out by the dentist, which involves creating diagnostic casts or jaw models through digital impressions, ensuring a proper prosthetic workflow. Further, inclusion and exclusion criteria for rehabilitation procedures, such as dental implants, onlay or inlay grafts, and bone augmentation materials, should be assessed before performing the surgery or opting for this mode of treatment.

• The standard inclusion criteria for patients undergoing the Lefort maxillary advancement procedure for upper jaw rehabilitation are that the patients should have a concave profile and present clinically with only three-dimensional maxillary hypoplasia, either severe or moderate. These patients must require full maxillary arch rehabilitation due to complete edentulism in the upper jaw. Patients who do not fit this criterion should be excluded, as the procedure cannot be effectively adopted otherwise.

• Written or informed consent is obtained from patients opting for the surgery, and the Helsinki Declaration guidelines and ethical protocols should be followed by the dental operator in all phases of surgical treatment.

• Through diagnostic examination of intraoral facial records, CBCT (cone-beam computed tomography), and evaluation of vertical dimensions, the maxillomandibular relationship is assessed by the dental surgeon and simulated on an articulator using teeth try-in with the establishment of occlusion through virtual visual software.

• Virtual surgical imaging is used for the Lefort maxillary advancement, with the selection of surgical provisional prostheses like occlusal splints and fixation mini plates.

• Under general anesthesia, bilateral maxillary incisions (crystal approach), mucoperiosteal elevation, and the Lefort osteotomy procedure are performed. A straight osteotome instrument is used to achieve the downward positioning of the maxilla, which is then repositioned as determined by the surgeon. A customized provisional prosthesis is used, and the maxilla is fixed with screws to the jaw to increase stability.

• Interosteotomy sites are then filled with block grafts, dental implants is placed at the preoperatively planned sites, the emergence profile of the implants is checked, and the flap is sutured with resorbable sutures.

• Postoperatively, antibiotic prophylaxis is administered, prosthetic loading can be performed 24 hours after surgery, and regular postoperative evaluations should be conducted to monitor the stability of the maxillary advancement and rehabilitation.

Conclusion

The Lefort maxillary advancement surgical procedure performed by your dental or maxillofacial surgeon has multiple advantages in rehabilitating a complex or severely atrophied upper jaw. It can effectively aid in rehabilitating the upper jawbone on its own in mild to moderate cases of bone resorption (shaping it to accommodate dental implants prosthetically), or it may be used alongside the aforementioned adjuncts in severe bone resorption cases.