Le Fort jaw surgery: what the three levels actually mean

The Le Fort osteotomies are named after René Le Fort, a French surgeon who in 1901 worked out the predictable lines along which the midface fractures. Surgeons later borrowed those lines as deliberate, controlled cuts. There are three levels, and they are not three versions of the same operation — they belong to different worlds of medicine.

Le Fort I: the one that matters for orthodontics

A Le Fort I osteotomy separates the upper jaw — the tooth-bearing part of the maxilla — from the rest of the midface, above the roots of the teeth and below the cheekbones. Once freed, the whole upper jaw can be repositioned and fixed with plates.

It is done through incisions inside the mouth. There is no external scar.

What it can do:

• Advance the upper jaw where the midface is set back, correcting an underbite from the top rather than by pushing the lower jaw back.
• Move it up (impaction) to reduce a gummy smile and close an open bite by allowing the lower jaw to rotate closed.
• Move it down where the upper teeth do not show enough at rest or in smile.
• Widen it by segmenting the jaw into two or three pieces during the same operation, an alternative to SARPE for smaller widths.
• Correct asymmetry by levelling a canted upper jaw.

Le Fort I is frequently combined with BSSO on the lower jaw in the same operation. When both jaws move, the surgery is described as bimaxillary, or double jaw surgery. It is also the maxillary half of maxillomandibular advancement for sleep apnea — see jaw surgery and sleep apnea.

Le Fort II and Le Fort III: a different field

These names come up in online searching, and it is worth being clear about what they are, because almost nobody reading this page needs them.

Le Fort II separates the upper jaw together with the nose, in a pyramid-shaped section. Le Fort III separates the entire midface — upper jaw, cheekbones and nose — from the skull base, advancing the whole middle third of the face.

These are craniofacial operations, not orthodontic ones. They are used for severe congenital midface deficiency, most often in syndromes such as Crouzon, Apert and Pfeiffer, and for major facial trauma reconstruction. They are performed by craniofacial surgical teams in a paediatric hospital setting — in British Columbia that means BC Children's Hospital — with plastic surgery, neurosurgery, ophthalmology, ENT, genetics and orthodontics all involved, often across several operations through childhood.

What Le Fort I recovery is actually like

Most patients spend one to two nights in hospital. Swelling peaks around days two to four and is substantial; it settles over weeks, with the last of it taking months. Numbness of the upper lip, cheeks and upper teeth is expected and usually recovers over weeks to months. The nose is often slightly widened by an upper jaw advancement, and surgeons use techniques to control this. Diet is liquid, then soft, for several weeks. Most people take two to four weeks away from work or school.

Jaws are rarely wired shut in modern practice; elastics guide the bite instead, which most patients find far more tolerable than the reputation suggests.

The orthodontics around it

Braces usually go on 12 to 18 months before surgery and stay on for 6 to 12 months after. Surgical hooks are placed shortly before the operation so the surgeon can use elastics afterwards. The bite is deliberately not made to fit during the pre-surgical phase — it is prepared to fit once the jaw has moved.