Orthognathic Surgery

1341
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C and D, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 32-17, cont’d 
Continued

1342 SECTION 5  Cleft Jaw Deformities
F
E
Prior to surgery with residual cleft defects
After treatment
Prior to and after treatment
E, Occlusal views with orthodontics in progress and after reconstruction. F, Palatal views with orthodontics in progress
and after reconstruction.
• Figure 32-17, cont’d

1343
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
G
H
• Figure 32-17, cont’d  G, Articulated dental casts that indicate analytic model planning. H, Lateral cephalometric radiographs
before and after reconstruction. From Posnick JC: Orthognathic surgery in the cleft patient. In Russell RC, ed: Instructional courses,
Plastic Surgery Educational Foundation, vol 4, St. Louis, Mo, 1991, Mosby–Year Book, p 129.

1344 SECTION 5  Cleft Jaw Deformities
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 32-18  A 24-year-old woman who was born with UCLP. She did not undergo bone grafts in the mixed dentition. She is missing the
lateral incisor on the cleft side. She was referred to this surgeon as an adult and underwent a combined orthodontic and orthognathic surgical
approach. The patient’s procedures included a modified Le Fort I osteotomy in two segments (differential repositioning of the segments) and closure
of oronasal fistula, the alveolar cleft, and the cleft–dental gap; bilateral sagittal split ramus osteotomies; osseous genioplasty; and septoplasty,
inferior turbinate reduction, and nasal floor recontouring. A, Frontal views with smile before and after reconstruction. B, Profile views before and
after reconstruction.

1345
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
D
C
Prior to surgery with residual cleft defects
After treatment
Before and After Treatment
C, Occlusal views with orthodontics in progress and after reconstruction and dental rehabilitation.
D, Palatal views before and after reconstruction.
• Figure 32-18, cont’d 
Continued

1346 SECTION 5  Cleft Jaw Deformities
F
E
E, Articulated dental casts that indicate analytic model planning. F, Lateral cephalometric radiographs
before and after reconstruction. Note that the palatal fistula was successfully closed. Cosmetic modification of the maxillary anterior
teeth was recommended.
• Figure 32-18, cont’d

1347
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
B
Prior to surgery with residual cleft defects
After treatment
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
• Figure 32-19  A 17-year-old girl who was born with UCLP. She did not undergo successful bone grafting in the mixed dentition.
She is missing the lateral incisor on the cleft side. The first bicuspid was extracted on the non-cleft side. She was referred to this
surgeon as a teenager and underwent a combined orthodontic and orthognathic surgical approach. The maxilla had good horizontal
projection and vertical height. Of the options available to manage the residual upper dentoalveolar needs, a right posterior segmental
osteotomy was completed to close the oronasal fistula, the alveolar defect, and the cleft–dental gap. A, Frontal views with smile
before and after reconstruction. B, Occlusal views with orthodontics in progress and after reconstruction.
Continued

1348 SECTION 5  Cleft Jaw Deformities
D
C
C, Palatal views with orthodontics in progress and after reconstruction. D, Articulated dental
casts that indicate analytic model planning.
• Figure 32-19, cont’d

1349
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
Prior to surgery with residual cleft defects
B
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
• Figure 32-20  A 17-year-old girl who was born with UCLP. She underwent lip and palate repair during child­
hood, but she did not undergo effective bone grafting during the mixed dentition. The lateral incisor is not
present at the cleft site. She was referred to this surgeon and underwent a combined orthodontic and orthog­
nathic surgical approach. The maxilla had good horizontal projection and vertical height. Of the options available
to manage the residual upper dentoalveolar needs, a right posterior segmental osteotomy was completed to
close the oronasal fistula, the alveolar defect, and the cleft–dental gap. A, Frontal views with smile before and
after reconstruction. B, Occlusal views with orthodontics in progress and after reconstruction.
Continued

1350 SECTION 5  Cleft Jaw Deformities
E
D
C, Palatal views with orthodontics in progress and after reconstruction. D and
E, Articulated dental casts that indicate analytic model planning.
• Figure 32-20, cont’d 
C

1351
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 32-21  A teenage boy who was born with ectodermal dysplasia and complete UCLP on the left side. He underwent lip and palate closure
during infancy. There are multiple congenital missing teeth in each arch. He was referred to this surgeon for evaluation when he was 14 years old.
He retains only six long-term useful teeth in the maxilla (first and second molars) and displaced left and right canines. The maxilla is vertically and
horizontally deficient. The mandible has satisfactory symmetry and horizontal projection. The patient underwent evaluations by specialists, including
an orthodontist, a prosthodontist, a periodontist, a surgeon, a speech pathologist, an otolaryngologist, and a geneticist. Reconstruction and dental
rehabilitation were felt to require the surgical repositioning of the maxilla followed by an overdenture. In the mandible, crown and bridge rehabilita­
tion would be carried out. The prosthodontist requested 18 mm of horizontal advancement and 14 mm of vertical lengthening of the maxilla. A
two-stage approach to maxillary reconstruction was undertaken.
Stage I surgery included the following: 1) nasotracheal intubation; 2) Le Fort I osteotomy with down fracture and disimpaction; 3) septoplasty
and inferior turbinate reduction; 4) application of a MED I external distraction device; and 5) securing of the MED I device to a prefabricated in-place
chrome cobalt appliance fixed to the maxillary dentition. Successful outpatient distraction of the maxilla to the preferred position was accom­
plished over a 10-day time frame.
Stage II surgery involved the patient’s return to the operating room for the following: 1) awake fiber-optic nasotracheal intubation; 2) removal
of the MED I device; 3) harvesting of the anterior iliac corticocancellous graft; 4) reopening of the circumvestibular incision; 5) securing a prefabri­
cated splint to the maxilla and then applying intermaxillary fixation (18 mm of advancement); 6) rotation of the maxillomandibular complex to achieve
the desired vertical dimension (14 mm of lengthening); 7) application of plate and screw fixation to the maxilla; 8) crafting and inset of corticocan­
cellous grafts to the left and right anterior maxilla; and 9) plate and screw fixation of each graft to the native maxilla. After 6 weeks, the maxilla
achieved initial bone healing. The patient returned to a more regular diet and sports activities at that time. Six months postoperatively, the patient
underwent a pharyngeal flap procedure to achieve velopharyngeal competence and an open rhinoplasty procedure that included a
rib cartilage (caudal strut) graft. Dental rehabilitation included fixed bridgework in the mandibular arch and overdenture construction for the
maxilla. A, Frontal and occlusal views when the patient was 14 years old. B, Computed tomography scan views that indicate the extent of maxillary
hypoplasia.
Continued

1352 SECTION 5  Cleft Jaw Deformities
C
14-mm vertical
20-mm
horizontal advancement
C
D
Orthognathic Surgery; J.C. Posnick
C, Articulated dental casts that indicate analytic model planning. D, Facial and occlusal views before surgery with a
prefabricated chrome–cobalt appliance fixed to the maxillary dentition.
• Figure 32-21, cont’d

1353
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
F
Orthognathic Surgery; J.C. Posnick
E
E, The patient is shown after Le Fort I osteotomy followed by 10 days of MED I distraction to achieve the preferred maxil­
lary position. A computed tomography scan is also shown 10 days after the Le Fort I procedure to demonstrate the advanced maxilla just before
the removal of the MED I device. F, Computed tomography scan views are shown after the stage II procedures with the maxilla in its new location
and now secured with bone graft and plate and screw fixation.
• Figure 32-21, cont’d 
Continued

1354 SECTION 5  Cleft Jaw Deformities
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• Figure 32-21, cont’d

1355
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
displaced or deficient floor of the nose and nasal sill
with rotation of the anterior nasal spine and the
septum toward the cleft. There may also be inade­
quate alveolar bony, gingival, and periodontal support
for the teeth adjacent to the cleft.
4. Cleft–dental gap. Studies confirm that, approximately
93% of the time in patients with UCLP, the lateral
incisor is either congenitally absent or inadequate at
the cleft site.163,164 A hypoplastic lateral incisor or a
supernumerary tooth may be present adjacent to the
cleft, but it will have inadequate root development.
Orthodontic closure of this dental gap by bodily
moving the canine tooth into the bone-grafted lateral
incisor location is generally considered the preferred
approach. For a variety of reasons, this may not have
occurred at the time of referral for orthognathic
surgery. At times, there is mesial angulation of the
canine (i.e., crown tipped) into a marginally grafted
or non-grafted cleft site, while the apex of the root
remains distal. The result may be a full or partial
dental crown gap at the cleft site between the central
incisor and the canine but with an even greater sepa­
ration of the roots.
cleft team’s best efforts, a number of children will not make
themselves available for mixed-dentition grafting (i.e.,
before the eruption of the cleft side canine). In addition, a
percentage of those who do undergo such procedures will
have problems with grafting and require other means of
reconstruction and dental rehabilitation. Williams and col­
leagues documented that, in the United Kingdom, only
84% of children with complete UCLP arrived for mixed-
dentition grafting.177 McIntyre and colleagues documented
that only 75.4% of Scottish children with complete UCLP
were grafted during the mixed dentition.103 Daskalogianna­
kis and colleagues documented that, at The Hospital for
Sick Children in Toronto, children with complete UCLP
underwent mixed-dentition grafting only 56.1% of the
time.27 On a more encouraging note, Felstead and col­
leagues documented a 94% rate of radiographically success­
ful mixed-dentition bone grafting in a consecutive series of
children with UCLP or bilateral cleft lip and palate (BCLP)
who were treated by a single surgeon (n = 53 alveolar cleft
sites).39 Despite a clinician’s preferred approach to cleft
management during infancy, childhood, and early adoles­
cence and despite that clinician’s best efforts, a subgroup of
patients with UCLP patients will present during or after
adolescence with multiple cleft-related problems that may
include the following:
1. Maxillary hypoplasia. The maxilla is often vertically
short and canted (upward on the cleft side), and the
maxillary dental midline is usually shifted off of the
facial midline toward the clefted side. Arch-width
deficiency that results in a dental crossbite is usually
present. The hypoplastic maxilla is retruded in the
horizontal plane, thereby resulting in a concave
midface profile. There will be an Angle Class III mal­
occlusion and negative overjet. In general, the greater
and lesser maxillary segments vary with regard to the
degree of dysplasia, thereby making it difficult to
achieve a satisfactory occlusion and facial appearance
by repositioning the maxilla in one unit. Separation
in two segments (through the cleft) with differential
repositioning is often required for the management
of the arch shape, even if successful mixed-dentition
grafting was accomplished.
2. Residual oronasal fistula. Despite a preference for oro­
nasal fistula closure during the mixed dentition, the
UCLP candidate for orthognathic surgery will often
have residual labial and palatal fistulas. Previous
attempts at closure may have failed. Furthermore,
buccal (non-keratinized) mucosa may have been
placed over the cleft site, thereby resulting in a lack
of attached gingiva (keratinized mucosa) in the tooth-
bearing region and a loss of vestibular depth.
3. Residual bony defects. In the patient with UCLP who
has not been successfully or adequately grafted during
the mixed dentition, a bony defect not just at the
alveolus but throughout the hard palate and the floor
of the nose may exist. This results in an inferiorly
5. Chin dysplasia. The patient with UCLP will frequently
suffer with a lifelong history of obstructed nasal
breathing and an open-mouth posture. This is often
the result of anatomic deformities, including septal
deviations, inferior turbinate hypertrophy, an irregu­
lar nasal floor, and nasal vestibular stenosis. The pres­
ence of a pharyngeal flap since childhood may further
NOTE: There are a variety of reasons why the
teenaged or adult patient may present with a cleft
(lateral incisor) dental gap, including the following: 1)
the patient may have “fallen through the cracks” without
undergoing mixed-dentition grafting; 2) a grafting
procedure may have been carried out but with only
limited “graft take”; or 3) the cleft site may have been
successfully grafted and followed by a “classic occlusion”
approach with the intentional maintenance of the lateral
incisor space for later prosthetic replacement. Clinicians
that advocate this approach believe that “smile
aesthetics” will be more favorable and that maintaining
“cuspid protection” during lateral excursions is necessary
over “group function.”
I have most often found that, for the maxillary
deficient individual with UCLP/BCLP with a congenitally
absent lateral incisor, either orthodontic gap closure or
eventual surgical cleft dental gap closure is preferred
for the achievement of an efficient, long-term, low-
maintenance dentition. In these cases, favorable smile
aesthetics may also benefit from cosmetic enhancements
such as crown lengthening or crown modification via
dental recontouring or augmentation (i.e., composite
resin or veneer buildups).

1356 SECTION 5  Cleft Jaw Deformities
and dental rehabilitation. Cassolato and colleagues have
documented that, in patients with complete UCLP, the
lateral incisor on the cleft side is normal and maintained in
only 7% of cases.17 Unerupted supernumerary teeth are also
extracted either at the time of bone grafting during the
mixed dentition or in conjunction with orthognathic
surgery. The central incisor on the cleft side also has a high
probability of being malformed.
The decision to extract a fully erupted, normally formed
tooth (i.e., the first bicuspid) within the lesser or greater
segment depends on the volume and height of the available
alveolar bone to house the dental roots adjacent to the cleft
and the degree of overall dental crowding within each
segment of the jaw. The completion of the first bicuspid
extraction in the greater segment, the lesser segment, or
both is often required to ensure adequate alveolar bone for
leveling and aligning retained teeth without weakening the
periodontal support of the teeth adjacent to the cleft and
throughout the alveolus (e.g., loss of crestal height, fenestra­
tion or dehiscence of the labial plate).
The orthodontist must be aware that the placement of
preangulated brackets or artistic positioning bends can dis­
place the roots of the teeth adjacent to the cleft from their
alveolar housing with a loss of crestal bone height. A loss of
vertical crest height along the cuspid is likely to occur with
excessive mesial crown tipping. For these reasons, the ortho­
dontic movement of the cleft-adjacent teeth is accomplished
cautiously until the cleft defects are surgically closed, effec­
tively bone grafted, or both.
A potential disadvantage of the modified Le Fort I
approach in a patient with UCLP is that the differential
advancement of the lesser dentoalveolar segment shifts the
preoperative anterior dental gap (i.e., the lateral incisor
region) into the posterior region (i.e., the second molar
region) (see Fig. 32-5 and discussion later in this chapter).
This is no different than the occlusal changes that will occur
when the mixed-dentition bone-grafted cleft–dental gap
(i.e., with absent lateral incisor) is orthodontically closed by
canine substitution. Unfortunately, the mandibular second
molar on the cleft side may no longer have an opposing
maxillary molar. For this reason, the maxillary second molar
should be orthodontically included in the arch form. Occa­
sionally there will be a non-impacted maxillary wisdom
tooth that can oppose the mandibular second molar. Articu­
lated dental models with the maxillary segments in their
proposed postoperative positions are analyzed to confirm
that the posterior maxil­lomandibular occlusion will be
acceptable.
The incorporation of all erupted teeth, including the
second molars, within the orthodontic mechanics (especially
in the lesser maxillary segment) will facilitate the develop­
ment of the desired arch form. A lingual attachment on the
maxillary first-molar bands allows for the use of a transpala­
tal arch. This may be useful to support molar anchorage
during treatment and to stabilize the surgical result
after splint removal. The development of an ideal mandibu­
lar arch is usually straightforward. A decompensated
increase an open-mouth breathing tendency. The
resulting chin deformities that occur during growth
are often characterized by excess vertical length and
horizontal retrusion.
6. Mandibular dysplasia. True mandibular prognathism
or retrognathism is uncommon in the patient with
UCLP. However, the need for mandibular osteoto­
mies is frequent. This should be limited to the cor­
rection of secondary deformities that result in facial
asymmetries and skeletal distortions and the occa­
sional true anteroposterior discrepancy.88,89,171
7. Nasal obstruction and sinus blockage. Obstructed
breathing through the nose and frequent bouts of
sinusitis are typical among patients with UCLP. This
results from a combination of septal deviation;
enlarged inferior turbinates; deformities of the nasal
aperture, the floor of the nose, and the anterior nasal
spine region; and stenosis of the nasal vestibule.
8. VP dysfunction. It has been shown that approximately
20% of patients with a repaired cleft palate will have
VP insufficiency by the time they are 5 years old. The
adolescent with UCLP who arrives for the evaluation
of a cleft jaw deformity may have already undergone
a pharyngoplasty with a pharyngeal flap. The planned
Le Fort I osteotomy with advancement will alter the
upper airway and may also negatively affect VP func­
tion, as described later in this chapter.
Orthodontic Considerations in the
Patient with Unilateral Cleft Lip and
Palate with a Jaw Deformity
The adolescent or adult patient with UCLP who presents
with maxillary hypoplasia and ineffective bone grafting per­
formed earlier during his or her childhood will have two
maxillary segments separated by a cleft (see Figs. 32-11
through 32-21). Each segment will have a degree of skeletal
dysplasia in all three planes of space. From an orthodontic
perspective, each segment should be evaluated and treated
individually in anticipation of Le Fort I segmental
repositioning.
Radiographic assessment is carried out before the ortho­
dontic movement of the teeth adjacent to the bone-deficient
cleft site. The Panorex radiograph is useful for assessing the
overall morphology of the jaws and teeth as well as tooth
angulation. Maxillary occlusal and periapical radiographs
through the cleft site or preferably a cone beam computed
tomography scan will help with the assessment of the
amount of alveolar bone and crestal height surrounding
the teeth.
There is variability with regard to the number of perma­
nent incisors and the amount of alveolar bone in the ante­
rior aspect of the UCLP maxilla. A lateral incisor-like tooth
is frequently found along the edge of the cleft in the lateral
segment. When a poorly formed lateral incisor is present,
it should be extracted in the interest of long-term function

1357
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
comfortable with cleft maxillary advancements of up to
20 mm. He also realized that the adequate mobilization of
the Le Fort I down-fracture was the key step in advancing
the maxilla, whether the patient had clefting or not. With
experience, the value of simultaneously closing the cleft–
dental gap by moving the lesser segment further forward to
position the canine in the lateral incisor location was appre­
ciated. This differential segmental repositioning would
essentially replace an anterior dental gap for an edentulous
space in the posterior maxilla.
Early on, other surgeons without Obwegeser’s level of
expertise reported complications after advancing the maxilla
in patients with UCLP.113-117,119,120 In 1974, Willmar
described the problems that occurred in 17 patients with
UCLP who underwent Le Fort I osteotomy. One patient
had aseptic necrosis and a partial loss of the lesser segment
of the maxilla.178 In 1974, Georgiade suggested that a cam­
ouflage approach with mandibular osteotomies and set-back
was preferred to maxillary advancement to avoid complica­
tions.51 Kiehn and others and Des Prez and Kiehn warned
of blood-supply problems that might occur with maxillary
osteotomies in patients with cleft lip and palate.30,83 In
1975, Henderson and Jackson reported combining lip-scar
revision, anterior fistula closure, and maxillary osteotomy
in a one-stage procedure.69 Their concept was innovative,
but they did not specify details of their technique. In 1978,
Jackson described the technique of Le Fort I osteotomy
in patients with cleft lip and palate and noted that, if a
large fistula was present, extensive flap mobilization for
closure was required, and the blood supply might be
compromised.77
Historically, surgeons were leery of completing a Le Fort
I down-fracture and full mobilization in patients with
UCLP because they feared flap necrosis with a subsequent
loss of bone and teeth.6,7,31-33,52,53,87 In 1980, Tideman and
colleagues proposed the segmental palatal osteotomy for
patients with cleft lips and palates.168 This procedure
required significant subperiosteal degloving with the poten­
tial for compromised flap circulation but without providing
the needed direct exposure for full disimpaction. In 1980,
Sinn also reported on the simultaneous Le Fort I advance­
ment, oronasal fistula repair, and bone grafting of the
alveolar cleft.155 He stressed the importance of preserving
a vertical soft-tissue pedicle, which was similar to that
described by Tideman and colleagues. He completed oste­
otomies through tunnels rather than under direct vision and
used a cheek rotation flap for oral-side closure of the labial
and palatal oronasal fistulas. With this technique, non-
keratinized buccal mucosa (rather than attached gingiva)
was brought into the cleft tooth-bearing region. In 1984,
Ward-Booth and colleagues described the results of Le Fort
II osteotomy in 13 patients with clefts for the management
of midface hypoplasia in an attempt to improve blood
supply to the alveolar segments.175 The residual fistulas were
not simultaneously closed, and fixation occurred with direct
wires, intermaxillary fixation, and external appliances. In
1985, James and Brook described another variation for the
mandibular arch is critical for the effective repositioning of
the maxillary segments into the most favorable position at
the time of orthognathic surgery.
At the time of the operation, the maxillary segments are
secured into a prefabricated acrylic occlusal splint that is
then typically left in place for 5 weeks. The patient is edu­
cated about the application of elastics and encouraged to
remove the elastics intermittently to establish an early range
of mandibular opening after surgery. The orthodontist sees
the patient within 24 hours of splint removal to replace the
maxillary sectional arch wires with a rigid continuous arch
wire. Occlusal maintenance and active orthodontic treat­
ment are reinitiated. Close monitoring is essential to main­
tain the arch form and dental positioning achieved (i.e.,
horizontal, transverse, and vertical). The placement of a
transpalatal appliance (i.e., a wire or a removable palatal
plate) may also be useful to maintain the new arch form
that is created at the time of operation.
Immediate Presurgical Assessment
Approximately 4 to 6 weeks before the operation, the ortho­
dontist will confirm that the preoperative orthodontic
objectives have been met and then place the passive surgical
wires. The surgeon takes the final records, which include
alginate impressions of the maxillary and mandibular arches,
a centric relation bite registration, a face-bow registration,
and direct facial measurements. The patient’s medical and
dental records (e.g., radiographs, consultation reports, facial
and occlusal photographs, dental models, special studies)
are reviewed. Decisions are finalized with regard to the
preferred vector changes (repositioning) of the jaws and the
precise linear (millimeter) distances and angles to be accom­
plished in each jaw for the desired result (see Chapter
12).2,38,44,45,68,76,94,100,101 Analytic model planning is carried
out on the articulated dental casts, and splints are fabri­
cated. The splints assist with the achievement of the precise
occlusion and the preferred facial aesthetics that have been
decided on preoperatively (see Chapter 13).
Orthognathic Approach for Unilateral
Cleft Lip and Palate Deformities
Evolution of Surgical Technique
Historically, the literature warned of possible complications
with maxillary osteotomy among patients with UCLP but
provided only limited and often confusing descriptions of
techniques to guide the orthognathic surgeon in the perfor­
mance of safe, reliable osteotomies to solve these complex
problems.158
As with other aspects of orthognathic surgery, Hugo
Obwegeser’s milestone contributions to cleft skeletal recon­
struction are important (see Chapter 2). By the late 1960s,
Obwegeser succeeded in advancing a cleft maxilla to the
preferred location without the need for a compromised
mandibular
setback
approach.
He
eventually
felt

1358 SECTION 5  Cleft Jaw Deformities
long-term stability.166 Although the issue of skeletal stability
and dental relapse for precise long-term occlusion is impor­
tant, it should not overshadow the value of achieving the
other planned improvements of the airway and enhanced
facial aesthetics.129-142 Unfortunately, the use of DO tech­
niques has not altered the challenges of cleft jaw surgery,
which include the following: 1) a lack of postoperative
growth when maxillary advancement is carried out in chil­
dren; 2) a worsening of VP function in some patients; 3)
injury to the teeth and bones if circulation to the segments
is not maintained; 4) facial and intraoral sensory loss; 5)
suboptimal facial aesthetics when basic principles are not
followed; and 6) concern for postoperative skeletal or dental
relapse (i.e., residual malocclusion). In addition, DO tech­
niques require a prolonged and labor-intensive postopera­
tive convalescence for the patient and family as compared
with the standard approach. Despite these disadvantages,
DO does offer hope to the occasional patient with UCLP
who also has severe maxillary hypoplasia and anodontia (see
Fig. 32-21 and the section about controversies later in this
chapter).
Standard Le Fort I Osteotomy
The adolescent or adult CLP patient with a jaw deformity
but without a residual fistula and with an intact alveolar
ridge of adequate height and volume in the area of the cleft
may have been born without alveolar clefting or had a suc­
cessful graft.34 For those with adequate alveolar ridge height
and volume, a closed palate, and sufficient periodontal
support, a standard Le Fort I osteotomy can be performed
(see Figs. 32-8, 32-9, and 32-10). A segmental maxillary
osteotomy to adjust the arch width, to correct the vertical
dimension, or to close the cleft dental gap to avoid the need
for a prosthetic lateral incisor may also be necessary in some
of these patients (see Chapter 15). Unfortunately, even in
the 21st century, a number of adults and adolescents with
UCLP with maxillary hypoplasia also present with alveolar
defects and oronasal fistulae. For these patients, a modified
(two-segment) Le Fort I osteotomy should be considered,
as discussed in the next section of this chapter (see Figs.
32-11 through 32-21).129-142
Modified Le Fort I Osteotomy
(Two Segments)
In unilateral cleft cases, the dental gap of the [absent]
lateral incisor can be eliminated by advancing the lateral
alveolar process so that the canine is positioned next to the
central incisor. The canine then subsequently is contoured
to match the appearance of the lateral incisor.118,119
HUGO OBWEGESER
A maxillary circumvestibular incision is made from one
zygomatic buttress to the other without the need to main­
tain a labial pedicle. Parallel vertical incisions are then made
labially in the region of the residual oronasal fistula to
correction of maxillary hypoplasia in patients with cleft lips
and palates via the transection of the hard palate.78 They
raised an extensive palatal flap and used three vertical stab
incisions for exposure on the labial aspects of the maxilla.
Access was then achieved through subperiosteal tunneling
and without direct exposure. Fixation was with intermaxil­
lary fixation and a halo head frame, which was maintained
for 10 weeks. A second procedure was required for bone
grafting and palatal fistula closure. The authors expressed
concern that a more direct down-fracture of the maxilla
would result in vascular compromise to the segments. In
1985, Poole and others proposed an additional modifica­
tion of the Le Fort I osteotomy to be used in patients with
cleft palates.128 With their technique, a partial-thickness
palatal flap was elevated, which left the greater palatine
vessels in situ and allowed the maxilla to be repositioned
anteriorly, without displacement of the soft palate. Poole
and colleagues believed that this approach would limit
interference with VP function; they also used small vertical
incisions on the labial aspect that required tunneling and
lacked direct exposure for osteotomies, disimpaction, fistula
closure, bone-graft placement, and plate and screw fixation.
Fixation in this series was with intermaxillary fixation,
direct wires, and a halo craniomaxillofacial head frame.128
During the 1980s and the 1990s, Posnick used and
refined Obwegeser’s original techniques involving Le Fort I
osteotomy for the treatment of UCLP deformities.129-142 A
key aspect was the circumvestibular incision, which allowed
for direct exposure for dissection, osteotomies, disimpac­
tion, fistula closure, septoplasty, inferior turbinate reduc­
tion, pyriform aperture recontouring, bone grafting, and
the application of plate and screw fixation (see Fig. 32-5).
This was found to be a reliable approach that did not involve
the risk of circulation injury to the greater and lesser dento–
osseous–musculo–mucosal segments. The visibility pro­
vided by the circumvestibular incision made possible the
incorporation of routine closure of the cleft–dental gap
through differential maxillary segmental repositioning
without necrosis of the bone or any loss of teeth. This
method also closes the cleft dead space and brings together
the labial and palatal flaps without the need for subperios­
teal undermining, which allows for the closure of recalci­
trant oronasal fistulas without tension and the establishment
of the periodontal health of the cleft adjacent teeth. The
down-fracture provides ideal exposure for septoplasty; for
the reduction of the hypertrophic inferior turbinates; and
for the recontouring of the pyriform rims, the floor of the
nose, and the anterior nasal spine. The success of this
approach, as initially carried out by Obwegeser,114-117,119,120
was confirmed by Bell’s demonstration of the blood supply
to these maxillary segments in animal studies.6-7 The clinical
advantages were then further documented by Posnick and
colleagues in a consecutive series of UCLP patients.129-142
Since the mid 1990s, the literature concerning cleft
orthognathic surgery has mostly focused on use of DO
techniques to avoid the need for complete intraoperative
mobilization of the maxilla in the hopes of improved

1359
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
palatal mucosal soft tissues for oral-side fistula closure. The
differential segmental repositioning approximates the
mucosal edges along the palate, so they do not need to be
sutured. In fact, to limit invaginations of the oral mucosa,
the excision of redundant palatal mucosa is generally
required just before the segments are placed in the splint.
The placement of the splinted maxilla onto the mandibular
dentition should be passive. The extent of maxillary advance­
ment is based on the preferred occlusion and the facial
aesthetics determined preoperatively. The ideal vertical
dimension is achieved intraoperatively on the basis of the
preoperative plan (see Chapter 12). The maxillary osteot­
omy sites are fixed in place with titanium miniplates and
screws at each zygomatic buttress and pyriform rim in
accordance with the principles originally described by
Luhr.92 An additional microplate is frequently applied hori­
zontally across the cleft site to stabilize the closure of the
cleft–dental gap. The intermaxillary fixation is released, and
the occlusion is checked.
The lateral nasal rims, the floor of the nose, and the
anterior nasal spine region are recontoured using a rotary
drill with a watermelon bur to improve the nasal airway and
to enhance nasal aesthetics (see Chapter 15). The dead space
associated with the alveolar cleft has already been closed by
the differential segmental repositioning. Autogenous iliac
cancellous bone graft may be packed along the floor of the
nose to raise the ipsilateral sill and across the cleft palate to
stabilize the segments. Generally, a crafted iliac corticocan­
cellous bloc graft is placed in between the zygomatic and
pyriform fixation plates on each side. Each graft is tightly
wedged into the space created by the horizontal advance­
ment and the vertical lengthening (see Chapters 15 and 18).
An additional microplate is contoured and secured across
the osteotomy, and it also incorporates the graft. With the
cleft–dental gap surgically closed, the redundant labial
mucosa is excised. Attached gingiva and mucosal edges are
approximated without tension and then directly sutured
without the need for rotation flaps.
Mandibular and chin osteotomies to correct secondary
deformities and facial asymmetries are frequently planned.
If so, the osteotomies are completed and secured with plate
and screw fixation in standard sequence (see Chapter 15).
After the completion of all of the osteotomies and the place­
ment of fixation and grafts, the wounds are closed. The
upper and lower teeth are approximated with orthodontic
elastics. When maxillary segmental osteotomies are com­
pleted, the splint remains wired to the upper teeth postop­
eratively (see the orthodontic considerations section earlier
in this chapter).
Avoiding Pitfalls
Mobilization of the Down-Fractured
Cleft Maxilla
Full mobilization of the Le Fort I down-fracture is a critical
step in the achievement of accurate intraoperative maxillary
separate the oral and nasal mucosa on each side of the cleft.
These incisions are perpendicular to the horizontal vestibu­
lar incision and follow the line angles of the teeth adjacent
to the cleft (i.e., the canine and the central incisor). The
nasal and oral mucosa are carefully incised along the palatal
aspect of the residual oronasal fistula. Further separation of
the tissue layers is accomplished when dissecting the nasal
mucosa free of the bony floor during down-fracture. The
complete separation of the oral and nasal layers is necessary
for the initial down-fracture and then later for the fistula
closure. This is accomplished without degloving the palatal
mucosa from the underlying hard palate, because this would
compromise the circulation to the maxillary segments.
Before osteotomy, subperiosteal dissection on the ante­
rior surface of the maxilla is completed up to the infraorbital
foramina. The anterior nasal spine, the pyriform apertures,
and the floor of the nose are also exposed. Dissection con­
tinues posteriorly past the maxillary tuberosities to the
pterygoid–maxillary suture on each side. After retractors
have been put in place, horizontal osteotomies are carried
out above the roots of the teeth and into the maxillary sinus
through the lateral, anterior, and medial maxillary walls
with a reciprocating saw and a long straight blade. The nasal
septum is separated from the base of the maxilla with the
use of a protected chisel. The pterygoid–maxillary sutures
are separated with a curved chisel, and the maxilla is down-
fractured. Direct trauma of the palatal mucosa via compres­
sive forces during mobilization should be minimized,
because such forces could compromise the vascular supply.
Subperichondrial and subperiosteal dissection of the
deviated vomer, the perpendicular plate of the ethmoid, and
the quadrangular cartilage is accomplished after the maxilla
has been down-fractured. Resection of the deviated and
buckled aspects of the septum (i.e., the bone and cartilage)
is done with a rongeurs while preserving the structural
components of the cartilaginous septum (i.e., the dorsal
strut and the caudal strut) that are necessary to prevent a
late saddle-nose deformity (see Chapter 15). If the inferior
turbinates are enlarged, they are also reduced to improve
the airway. The nasal mucosa flaps are sutured for a water­
tight nasal-side closure. If indicated, the impacted maxillary
third molars are removed from above through the maxillary
sinus (see Chapter 15).
The down-fractured maxilla may already be in two seg­
ments if the bony cleft was unrepaired. If the maxilla is
intact but needs correction of the arch form, then it is sepa­
rated using a reciprocating saw with short straight blade.
The approximation of the segments to close the cleft–dental
gap can occur after bony spurs are shaved from the alveolus
along the distal aspect of the central incisor and the mesial
aspect of the canine using a rotary drill with a watermelon
bur. Care is taken to avoid penetrating the lamina dura,
which would expose the dental root and may result in
external root resorption. The maxillary segments are then
ligated into a prefabricated acrylic occlusal splint. The seg­
mental repositioning closes the cleft–dental gap, brings the
alveolar ridges together, and approximates the labial and

1360 SECTION 5  Cleft Jaw Deformities
hypoplastic alveolar ridge at the time of down-fracture is
also not practical, because excessive soft-tissue flap elevation
around the ridge would be required.
Managing the Nasal Cavity and the Nose
In the patient with UCLP, the inferior turbinates will often
be enlarged, asymmetric, and partially blocking the nasal
cavity. The reduction of enlarged inferior turbinates will be
beneficial for breathing and sinus drainage. The procedure
is accomplished through the Le Fort down-fracture (see
Chapter 15 and Fig. 32-10).
In the patient with UCLP, the septal bone and cartilage
generally show significant deviation and thickening, thus
further obstructing the airway. The completion of a submu­
cous resection of the deviated portions of the septum will
be helpful to open the airway. The preservation of caudal
and dorsal cartilaginous struts will prevent a saddle defor­
mity; this is accomplished through the Le Fort down-
fracture (see Chapter 15 and Fig. 32-10).
In the patient with UCLP, the pyriform rims are gener­
ally constricted and asymmetric. The nasal floor is uneven,
and the anterior nasal spine is deviated. After Le Fort down-
fracture, the recontouring of the pyriform rims and the
nasal floor and spine using a rotary drill with a watermelon
bur is helpful to open the airway and improve nasal aesthet­
ics (see Chapter 15 and Fig. 32-10).
Attempts to “control” the nasal soft-tissue envelope with
suturing techniques (e.g., the alar cinch stitch) after Le Fort
I osteotomy are often suggested. In my experience, manipu­
lating the nasal soft tissues with suturing techniques after
Le Fort I may be counterproductive to both the airway and
the facial aesthetics. We anticipate that the nasal soft tissues
will be redraped over the repositioned maxilla and the
recontoured pyriform rims, nasal floor, and nasal spine for
an overall improvement in aesthetics. A definitive rhino­
plasty to fully correct the UCL nasal deformities is often
beneficial; this is best postponed until 6 to 12 months after
jaw reconstruction (see Chapter 38).
Immediately after surgery, the nasal cavity is not packed,
and the septum is not stented. Coagulated blood will par­
tially block nasal breathing. The clots and scab are expected
to dislodge and be self-eliminating after the underlying
mucosa is initially healed (i.e., 5 to 7 days after surgery).
The use of saline nasal sprays and the institution of sinus
precautions are helpful during this time (see Chapter 11).
Management of the Mandibular Deformity
In the individual with UCLP, the mandible is often second­
arily deformed. In a previously published study, 70% of the
patients with UCLP had secondarily deformed mandibles
to the extent that sagittal split ramus osteotomies were
beneficial to improve facial symmetry and proportions.141
The mandibular repositioning is not carried out in an
attempt to avoid maxillary advancement but rather to
improve overall facial morphology (see Chapter 15).
repositioning and then with long-term maintenance. Both
pterygoid and nasomaxillary disimpaction forceps are used
as needed to achieve full mobilization. Taking the necessary
time to slowly complete the disimpaction (i.e., 10 to 15
minutes) is often crucial to achieving the desired results.
Gaining confidence—first through observing and assisting
an experienced cleft jaw surgeon and then by using one’s
own hands—is essential to achieving success with the mobi­
lization process.
Horizontal Advancement and Vertical
Lengthening of the Cleft Maxilla
The surgeon must often carry out significant horizontal
advancement, vertical lengthening, and midline, cant, and
occlusal plane correction to enhance facial aesthetics, achieve
dental health, and open the airway in a patient with UCLP.
The scarring of the palatal soft tissues from previous repairs
may be of concern when planning an extensive advance­
ment. A scarred and hypotonic repaired unilateral cleft lip
may also caution the surgeon against the vertical lengthen­
ing that the midface demands.
In general, to achieve full skeletal correction, all or most
of the negative overjet should be managed in the maxilla.
The sagitally deficient maxilla in a patient with UCLP will
also typically need vertical lengthening. When the maxilla
is fully mobilized and repositioned as described previously,
stabilization with titanium plates and screws (i.e., a plate at
each zygomatic buttress and each pyriform aperture) is per­
formed. The placement of a bloc corticocancellous graft
wedged into the dead space between the zygomatic buttress
and the pyriform aperture plate on each side is generally
necessary (see Chapter 15). Further stabilization across each
graft with a titanium plate and screws is also required (see
Chapter 15).
Closure of Residual Oronasal Fistula and
Alveolar Ridge Management
Ideally, full closure of a residual oronasal fistula and ade­
quate alveolar bone grafting will have been carried out
during the mixed dentition. If not, the modified Le Fort I
osteotomy in two segments (as described previously) pro­
vides the opportunity for complete oronasal fistula closure
of the palatal and labial aspects and for the management of
skeletal deficiencies without the need for direct alveolar
grafting. Many times, grafting and fistula closure will have
been carried out during the mixed dentition but without
complete correction. A residual fistula may remain on the
palatal side; if the dental gap was not closed with the use of
orthodontic mechanics (cuspid advancement) after grafting,
the volume of bone at the cleft site is likely inadequate for
dental implant placement. Unfortunately, when completing
a Le Fort I down-fracture without segmental repositioning,
any residual palatal fistula cannot be reliably closed, because
this would require elevating the palatal flaps and a risk of
aseptic necrosis. Direct augmentation of an intact but

1361
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
palates repaired by many different surgeons who were using
a variety of protocols. The number and extent of previous
revisions of the lip, nose, and palate varied greatly (range,
1 to 9 procedures). Many patients had undergone multiple
attempts at closure of the residual oronasal fistula and at the
reconstruction of the alveolar clefts with bone graft. Seven
of the 66 patients with UCLP had previously undergone
orthognathic surgery by another surgeon; all seven had
residual maxillary hypoplasia, a recalcitrant oronasal fistula,
and a cleft–dental gap.
The basic orthognathic procedure carried out by Posnick
included a modified Le Fort I osteotomy in two segments
(n = 66). Twenty-three of these patients also require simul­
taneous sagittal split ramus osteotomies to correct facial
asymmetry and disproportion. Thirty-five of the 66 patients
(53%) underwent osseous genioplasty (vertical reduction
and horizontal advancement) to improve their profile aes­
thetics and lip position.
The 66 adolescents with UCLP had multiple residual
deformities, and all but one had residual oronasal fistulas of
varying sizes. Sixty-four of the 66 patients (97%) presented
with negative overjet at the central incisors. Sixty of the 66
patients (91%) had a lateral (posterior) crossbite of the
lesser segment and a maxillary dental midline that was not
coincident with the facial midline. An Angle Class III mal­
occlusion was present on the cleft side in 64 of 66 patients.
In 60 of the 66 patients (91%), a congenitally absent or
structurally inadequate lateral incisor was present at the cleft
site. Simultaneous differential repositioning of the maxillary
segments was planned for all 66 patients. In 57 of the 60
patients who presented with a cleft–dental gap, surgical
closure through segmental repositioning also was planned.
Despite the successful preoperative orthodontic cleft–
dental gap closure in six patients, surgical arch width and
coordination problems remained and required segmental
repositioning.
Results
Sixty-one of the 66 patients (92%) underwent successful
simultaneous oronasal fistula closure. In the five patients
with residual fistulas, definitive closure with standard muco­
gingival and palatal flaps as a secondary procedure was
possible and did not require bone grafting. Surgical cleft–
dental gap closure was achieved and maintained in all but
3 of the 57 patients in whom it was attempted. In these
patients, the dental gap closure was achieved initially;
however, over the subsequent 12 months, the teeth in the
lesser segment shifted position. The dental gap opened even
though the fistula remained closed, and skeletal continuity
across the cleft remained intact.
Nine patients required fixed (prosthetic) bridgework,
either to complete the closure of the cleft–dental gap or to
achieve other aspects of dental rehabilitation. A bridge was
required in three patients in whom a dental gap was inten­
tionally left open and in three others when the space
reopened. The techniques of porcelain-veneer finish,
Management of the Chin Deformity
In the patient with UCLP with maxillary hypoplasia, the
chin is often secondarily deformed, with increased vertical
length and a flat pogonion. An intraoral oblique inferior
border osteotomy is carried out with repositioning and
reshaping of the distal chin to accomplish the preferred
morphology (see Chapters 15 and 37).
Clinical Management after Initial
Surgical Healing
Managing the details of the in-hospital and at-home con­
valescence during the initial healing of the orthognathic
patient are essential for a successful outcome (see Chapter
11). Cephalometric and dental radiographs and facial and
occlusal photographs are obtained at standard postoperative
intervals to document patient healing. The orthodontist sees
the patient within 24 hours of splint removal (approxi­
mately 5 weeks after surgery) and replaces the maxillary
sectional arch wires with a rigid continuous arch wire. The
maxillary teeth are ligated together to maintain the surgical
dental-gap closure, the horizontal advancement, and the
transverse expansion. Active orthodontic maintenance and
finishing are started. The use of a transpalatal appliance (i.e.,
a wire or a palatal plate) may also be used to stabilize the
new arch form. Close monitoring by an orthodontist for
skeletal and dental shifts during the first 6 months after
surgery is essential.
Speech can be objectively reassessed 3 to 6 months after
surgery. We prefer to do so with the use of nasoendoscopic
instrumentation. Definitive cleft soft-tissue procedures
(e.g., cleft rhinoplasty, lip scar revision, pharyngeal flap or
flap revision) can be carried out as early as 6 months after
orthognathic surgery. After the orthodontic appliances are
removed, any planned definitive dental restorative work can
be finalized.
Orthognathic Surgery for Unilateral
Cleft Lip and Palate: Review of Study
Patients and Methods
Posnick and Tompson prospectively assessed the cleft defor­
mity and clinical results of 66 consecutive adolescents and
young adults (age range, 15 to 25 years; mean, 18 years)
with UCLP who underwent orthognathic surgery by one
surgeon (Posnick) with the use of a single surgical protocol
during a 6-year time period.141 All patients underwent peri­
operative orthodontic treatment and were judged to be
skeletally mature at the time of jaw surgery. The clinical
follow-up period after maxillary advancement ranged from
1 to 7 years (mean, 40 months). The countries of origin of
the patients varied (e.g., Canada, United States, Eastern
Europe, Southeast Asia), as did their races (e.g., Caucasian,
Asian, African). These patients had their cleft lips and

1362 SECTION 5  Cleft Jaw Deformities
of the Le Fort I osteotomy, perioperative orthodontics, the
age at surgery, the age at final follow up, the amount of
overjet and overbite at the 1 year or more postoperative
visit, and perioperative morbidity.
For all patients, the prospective protocol required a
lateral cephalogram preoperatively, immediately (i.e., 3 to 7
days after surgery), at 6 to 8 weeks, and at 1 year after
surgery. At the time of the clinical review, patients were
excluded from the study if one or more interval cephalo­
grams were not available (n = 7) or if less than 3 mm of
horizontal advancement was required to correct their skel­
etal deficiency (n = 3).
The serial radiographs for each patient were analyzed
with a modified version of the method described by Bach­
mayer and colleagues.5,6 On each preoperative tracing, the
horizontal and vertical coordinates that represented the
patient’s natural head position were constructed so that they
passed through the sella. These reference lines were trans­
ferred and became the x-y grid template onto which all of
the postoperative maxillary positional changes could be
traced and measured. The end result was a Cartesian coor­
dinate system that illustrated the horizontal and vertical
directional changes of the maxilla at intervals after surgery.
The measurements of the differences in the position of the
maxilla at different postoperative points were taken from
the grids and were calculated to within 0.5 mm. In addi­
tion, the incisor overjet and overbite measurements from
the 1-year (or more) postoperative cephalogram were docu­
mented and compared with the measurements taken at the
final (1 year or more postoperative) clinical assessment.
Differences between groups (e.g., pharyngeal flap in place)
were assessed via Student’s t-test. Any association between
the magnitude of surgical change and the degree of relapse
was examined with the Pearson correlation coefficient (r)
and the least-squares linear regression analysis. Correlations
were considered significant when the P value was less
than .05.
Results
During this study period, 45 skeletally mature patients with
UCLP patients underwent Le Fort I maxillary advance­
ment. None were lost to follow up and the final clinical
follow-up examination ranged from 1.5 to 4.5 years (mean,
2.5 years) from the time of the surgical procedure and the
close of the study. Seven patients missed one of their lon­
gitudinal cephalometric records, and three required less
than 3 mm of horizontal advancement to correct their max­
illary deformity. The 10 excluded patients were reviewed
and were not clinically different from the other 35, varying
only for the reasons outlined. All patients in the study were
judged to be skeletally mature at the time of operation on
the basis of the assessment of either a carpal (wrist) radio­
graph or at least two static serial cephalometric radiographs
taken at 6-month intervals. For the 35 patients who were
included in the study, the age at operation ranged from 14
to 25 years (mean, 18 years).
composite resin buildups, and tooth sculpting were used to
resurface incisor teeth in three other patients as a result of
chronic tooth decay and enamel dysplasia.
In all patients, keratinized mucosa was successfully main­
tained along the labial surface of the cleft-adjacent teeth
(n = 132 teeth). Preoperative gingival recession along the
distal aspect of the central incisor as a result of longstanding
limited alveolar support could not be improved at the time
of the orthognathic surgery. Five of the 132 cleft-adjacent
teeth required root canal therapy, and five teeth were noted
to have further gingival recession after the completion of
orthodontic treatment.
The long-term maintenance of overjet was measured
directly from the late (>1 year) postoperative lateral cepha­
lometric radiograph; all but two patients (i.e., 64 out of 66)
maintained a positive overjet. The long-term maintenance
of overbite was also measured directly from the late postop­
erative lateral cephalometric radiograph; 60 of 66 patients
(91%) maintained a positive overbite; 4 patient shifted to
a neutral overbite; and 2 patients relapsed into a negative
overbite.
Complications were few and generally not serious. One
patient who had also undergone septoplasty and inferior
turbinate reduction was returned to the operating room for
nasal packing to manage epistaxis on postoperative day 10.
In another patient, the maxilla was repositioned a second
time to reduce the vertical height (gingival show) for
improved facial aesthetics on postoperative day 3. No loss
of segmental bone or teeth occurred as a result of aseptic
necrosis, infection, or for any other reason.
Skeletal Stability after Modified Le Fort
I for Unilateral Cleft Lip and Palate
Deformity: Review of Study
In general, published studies of long-term skeletal stability
after cleft–orthognathic surgery tend to group populations
that should be considered separately (e.g., BCLP, UCLP,
isolate cleft palate); they have an inadequate follow-up
period (e.g., <1 year) or too small of a sample for statistically
significant results; or they only provide information about
cephalometric measured length and angles rather than eval­
uate clinically relevant parameters (e.g., maintenance of
overjet).
Patients and Methods
Posnick and colleagues reviewed medical records and cepha­
lometric radiographs and completed current surgical and
orthodontic clinical examination of all patients (n = 45)
with UCLP who had undergone Le Fort I osteotomy by a
single surgeon (Posnick) during a 3-year period.139 The fol­
lowing information was noted: all previous maxillofacial
procedures, details of the orthognathic procedures, osteot­
omy stabilization techniques used, the presence of a pha­
ryngoplasty, the extent of bone grafting, the segmentalization

1363
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
We always prefer secondary bone grafting during the mixed
dentition typically with orthodontic closure of the cleft
dental gap. However, the method described does offer an
alternative approach when the opportunity for grafting
during the mixed dentition (i.e., before the eruption of the
permanent canine) is lost and a jaw deformity also exists.
Published studies from major cleft centers in the United
Kingdom, Scotland, and Canada confirm that, despite best
efforts, a number of patients in the mixed dentition will not
arrive for treatment, and a percentage of those who do
will undergo unsuccessful grafting.39,103,108,177 A two-stage
approach to the adolescent or adult with maxillary hypo­
plasia, residual alveolar clefts, oronasal fistulas, a cleft–dental
gap, and nasal obstruction is not cost- or time-effective and,
in my experience, the potential overall morbidity is
increased. It is in these patients with UCLP that the modi­
fied Le Fort I osteotomy offers a reasonable opportunity for
the resolution of residual end-stage problems (e.g., maxil­
lary hypoplasia, alveolar defect, residual fistulas, cleft–dental
gap, nasal obstruction) in a safe and effective way.
In the patient with UCLP, there are several options for
the management of a cleft–dental gap.* From both facial
aesthetic and dental health perspectives, the long-term use
of a removable partial denture is always a second choice.
Fixed bridgework is a viable alternative, but this requires
the partial destruction of adjacent normal teeth, it may look
artificial, it requires replacement at intervals throughout the
patient’s life, and it demands ongoing meticulous oral
hygiene (i.e., high-maintenance dentition). Placement of a
single-tooth osseous integrated implant is an attractive alter­
native, but the implant’s aesthetic success is dependent on
adequate bone height, width, and volume and sufficient
attached gingiva.62,93,122,124,146,165,166,172,174,185 This is not rou­
tinely established at the cleft site, even after bone and gin­
gival grafting. In addition, it requires staged surgical
procedures, and it also produces a high-maintenance denti­
tion. Coordinated comprehensive periodontal and pros­
thetic rehabilitation is required, and even then failure to
provide a natural-looking smile may occur. In a published
study conducted at The Hospital for Sick Children in
Toronto, only 10% of complete UCLP lateral incisor dental
gaps were managed with a dental implant and crown.17
Other dental refinements for a patient’s dysmorphic and
often hypoplastic and decayed anterior maxillary teeth
include porcelain-veneer buildups, composite bonding,
sculpting of the teeth, and bleaching techniques. Each of
these refinements may improve the patient’s function, smile
aesthetics, and self-esteem.
A major advantage of the described modified Le Fort I
(segmental) osteotomies in the patient with UCLP is its
ability to simultaneously close the cleft dead space, the
residual oronasal fistulas, and the alveolar defect and to
stabilize the dentoalveolar segments. The study by Posnick
All 35 study patients underwent modified Le Fort I
osteotomies (two segments) with varying degrees of hori­
zontal advancement, transverse arch widening, and vertical
change. Eleven of the 35 patients also underwent sagittal
split ramus osteotomies of the mandible to correct asym­
metries and secondary deformities; 22 had vertical reduc­
tion genioplasty with or without chin advancement to
improve their profile aesthetics. In 13 of 35 patients, a
pharyngoplasty was in place at the time of the maxillary
osteotomy. None required takedown or modification of the
flap to achieve passive intraoperative maxillary placement.
All 35 patients underwent perioperative orthodontic treat­
ment that was coordinated with their surgical procedure.
No statistically significant differences were seen in the
initial vertical or horizontal surgical changes and the post­
operative maintenance (relapse) between patients who had
maxillary surgery alone or those who had surgery in both
jaws and those who had a pharyngoplasty in place at the
time of their Le Fort I osteotomy (P < .05). Therefore, these
patients were considered a homogeneous group for further
analysis. The mean horizontal advancement at the incisors
achieved for the group was 6.9 mm, with 5.3 mm main­
tained 1 year later. In 11 of the 35 patients, the relapse was
less than 1.0 mm. The amount of horizontal relapse did not
correlate significantly with the amount of maxillary advance­
ment (r = .31).
In the 13 patients with a pharyngoplasty in place at the
time of the Le Fort I osteotomy, the mean effective hori­
zontal advancement was 8.2 mm immediately after the
operation and 6.5 mm 1 year later. Interestingly, the 22
patients without a pharyngoplasty in place required less
horizontal advancement, with a range of 6.4 mm and
4.9 mm maintained at 1 year. The mean vertical change of
the maxilla was 2.1 mm initially after the operation and
1.7 mm 1 year later. In 12 of the 35 patients, no vertical
change was necessary; in the remaining patients, vertical
directional change was necessary and achieved. Analysis
indicated that vertical relapse did not correlate significantly
with the magnitude of change that occurred at the time of
surgery (r = .41). The authors also measured the overjet and
overbite directly from the cephalometric radiographs at the
1-year postoperative interval in each patient. A positive
overjet was maintained in all patients, whereas a positive
overbite was maintained in 86% (30 of 35 patients). This
data confirms that, with the combination of orthodontics
and orthognathic surgery, a functional long-term occlusion
was achieved in most of the patients with UCLP.
Controversies and Unresolved Issues
Staging of Maxillary Reconstruction
The described modified Le Fort I segmental osteotomies as
a method of managing end-stage oronasal fistulas, alveolar
defects, and cleft–dental gaps in patients with UCLP who
have maxillary hypoplasia is not intended to replace stan­
dard techniques and the accepted sequencing of treatment.
*References 1, 10, 17, 58, 62, 64, 74, 93, 112, 122, 124, 145, 146, 159,
161, 163, 165, 166, 172, 174, 176, 185

1364 SECTION 5  Cleft Jaw Deformities
*References 3, 11-13, 18, 21-24, 27, 35-37, 40, 41, 43, 46, 50, 55, 59,
61, 65-67, 71-73, 81, 107, 127, 129-142, 149, 160, 162, 168, 173, 179
Skeletal Relapse after Le Fort I Osteotomy in
Patients with Clefting
There are more than 100 published articles reviewing skel­
etal stability and relapse in patients with clefting who have
undergone Le Fort I advancement with the use of either
standard osteotomy or DO techniques.* Proponents of DO
techniques frequently state that, when more than 10 mm
of horizontal maxillary advancement are required, the use
of standard osteotomies with plate and screw fixation and
bone grafting may lead to a greater degree of relapse.
However, these studies do not report convincing data that
demonstrate significant differences in relapse patterns
between the two techniques. To give this situation some
perspective, it should be noted that only 5% of patients
with clefting who are undergoing Le Fort I advancement
will require more than 10 mm of horizontal advancement
at the incisors. All clinicians agree that this subgroup of
patients is the most challenging to treat, but the reasons for
this go beyond the degree of horizontal maxillary deficiency.
These patients are also likely to present with multiple resid­
ual end-stage deformities (see the section about residual
skeletal deformities earlier in this chapter), multiple missing
teeth, and previously failed surgical procedures.
Aksu and colleagues documented a horizontal maxillary
(skeletal) relapse of 22% in patients with cleft lips and
palates after Le Fort I osteotomy with the use of DO tech­
niques.4 He and colleagues reported their results for adoles­
cent patients with repaired cleft lips and palates and
maxillary hypoplasia who then underwent Le Fort I advance­
ment with the use of an external DO device.65 The patients
(n = 17) were treated at one center between 2000 and 2006,
and they had at least 1 year of follow up and a full set of
records. DO treatment was started on day 5 (1 mm per day)
and continued until a Class II occlusion (i.e., overcorrec­
tion) was achieved. Consolidation time ranged from 4 to
12 weeks, and this was followed by several more months of
face mask therapy. The first four patients (two UCLP and
two BCLP) who were treated developed fibrous non-union,
and all four required reoperation and rigid (i.e., titanium
plate and screw) fixation to achieve union. The authors then
extended the consolidation period to a minimum of 12
weeks for the remaining patients (n = 13); all of these
patients achieved bony union. In the group that achieved
satisfactory bony union (13 out of 17 patients; 76%), the
mean horizontal relapse was 11.9%, with 5 of 13 patients
(38%) developing no better than end-to-end occlusion.
Another orthognathic procedure was necessary in 5 of the
13 patients (38%) who initially achieved bony union to
obtain a satisfactory occlusion. Overall, 9 out of 17 patients
(53%) required two orthognathic procedures. In 2011,
Chen and colleagues reported a 30.7% incidence of hori­
zontal skeletal relapse 1 year after Le Fort I osteotomy in
and colleagues documents the improved long-term peri­
odontal health achieved in the cleft dentoalveolar regions
when this technique is used.141 The long-term benefits to
the patient of the resulting low-maintenance dentition
cannot be over stated. Another advantage of this approach
occurs when the lesser segment is advanced to attain this
goal. By doing so, a relative arch-width expansion is gained
at the mandibular molar and the premolar region without
the actual need for a lateral shift of the whole segment. This
limits any arch-width relapse tendencies.
Velopharyngeal Function after Le Fort I
Advancement
Uncertainties about VP function and the management of
an in-place pharyngeal flap should no longer be limiting
factors when orthognathic surgery is necessary in a patient
with a cleft. A nasoendoscopic guided examination by a
speech pathologist and a surgeon who are familiar with
cleft anatomy can reasonably predict current and expected
VP function in a patient who is scheduled for a Le Fort I
osteotomy (see Chapter 8). When postoperative VP dete­
rioration is anticipated, the patient and family are coun­
seled about the sequencing of treatment. Clinical studies
have now documented that VP function will deteriorate in
a similar fashion when either DO or standard Le Fort I
osteotomy techniques are used.19,20,57,60,79,86 Despite the fre­
quent need for significant maxillary advancement to nor­
malize the skeleton and the facial aesthetics in patients
with UCLP, I have not had to transect an in-place pharyn­
geal flap to achieve maxillary mobilization. Our research
and that of others confirms that a pharyngeal flap in place
at the time of Le Fort I osteotomy does not increase com­
plications nor does it result in a higher incidence of
relapse.141 The definitive reassessment of VP function after
cleft Le Fort I advancement can be carried out 3 months
after surgery. A primary or revision pharyngeal flap can be
safely carried out within 6 months after surgery in con­
junction with cleft rhinoplasty or labial revision, if
indicated.
Mixed Dentition Le Fort I Osteotomy
By the mid 1980s, research clarified that, if jaw surgery is
undertaken in the growing patient with a cleft palate,
another procedure to advance the maxilla will likely be
required when skeletal maturity is reached.181-184 More
recently, several investigators again tested this theory by
proceeding with mixed-dentition Le Fort I procedures using
DO techniques. All research to date indicates that the Le
Fort I advancement carried out during the mixed dentition
in the patient with clefting—whether with standard or DO
techniques—results in no significant further horizontal
growth.21,26,40,41,59,61,75,126 As the mandible continues to grow,
an Angle Class III malocclusion will occur with the need
for either additional Le Fort I advancement or mandibular
set-back.

1365
CHAPTER 32  Cleft–Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
diet and physical activities, and it is generally followed
by several additional months of face mask therapy. The
DO device is also awkward and socially embarrassing, as
it typically blocks the patient’s visual fields (e.g., the
RED, BLUE, or GREEN external DO devices). Further­
more, there is no overall reduction in the potential for
perioperative complications with DO techniques.
• If the cleft maxilla is adequately down-fractured, mobi­
lized, and stabilized with interpositional bone grafts and
rigid plate and screw fixation, it has a high probability
of healing as planned with a predictable and less exten­
sive convalescence than would be necessary with DO.
• An experienced orthognathic surgeon will be more con­
fident with his or her ability to down-fracture and fully
mobilize the cleft maxilla than a less experienced surgeon.
Therefore, the less experienced surgeon will more likely
select DO techniques to avoid the personal stress of the
intraoperative maxillary mobilization process.
• Even for the experienced cleft orthognathic surgeon,
there will be the occasional patient in whom the extent
of maxillary hypoplasia and associated deformities (e.g.,
missing teeth, lack of alveolar bone) will lead him or her
to choose a DO technique. Despite its protracted healing
requirements and its limited ability to correct all of the
cleft deformities, the DO device’s gradual stretching
ability can mobilize even the most recalcitrant maxilla
(see Fig. 32-21).
Recommendations for the Distraction Osteogenesis
Approach
For most cleft patients with maxillary hypoplasia, reserving
DO techniques to serve as a “bail out” when the down-
fractured maxilla cannot be adequately mobilized is the
approach that I recommend. The rare patient and family at
risk can be informed of this contingency plan in advance.
This approach allows the surgeon to have flexibility in the
operating room to make the right decision at the right time
for the patient in need to achieve the most efficient conva­
lescence and the most favorable long-term objectives.
Conclusions
There are now convincing clinical studies that document a
high prevalence of jaw deformities in mature patients with
repaired UCLP. The methods described to manage the ado­
lescent and adult with UCLP who presents with jaw defor­
mities, malocclusion, a residual oronasal fistula, bony
defects, a cleft–dental gap, nasal obstruction, sleep apnea,
and aesthetic needs are generally safe and reliable when
performed by a dedicated orthognathic surgeon and team.
Successful cleft orthognathic and intranasal procedures
provide a stable foundation on which final soft-tissue lip
and nose reconstruction may be carried out.
patients with clefts who were treated with DO techniques
(i.e., the RED device). This was in a consecutive series of
patients who presented with Class III malocclusion as a
result of cleft maxillary hypoplasia and who agreed to a
combined orthodontic and surgical approach.21 Posnick
and colleagues documented the degree of horizontal relapse
and overall occlusal success when using the modified Le
Fort I technique as described in this chapter for patients
with clefts. They measured horizontal change, stability, and
information concerning the maintenance of overjet and
overbite from 1-year or more postoperative cephalometric
radiographs and clinical examinations.141 The results were
reported in accordance with cleft type: patients with UCLP
had 6.9 mm mean advancement with 5.3 mm maintained;
94% of patients with BCLP maintained positive overjet for
the long term; and patients with isolate cleft palate had
6.1 mm mean advancement with 5.1 mm maintained.
Interestingly, the degree of relapse that was documented was
less than that generally reported by clinicians who use DO
approaches (see earlier).
Standard Approach versus Distraction
Osteogenesis Approach to Le Fort I
Advancement
As Obwegeser stated in the 1960s and as was confirmed by
Precious and colleagues, “relapse in cleft patients [after Le
Fort I advancement] may well be more related to failure to
adequately mobilize the maxilla and free it of abnormal soft
tissue attachments than anything inherent in the osteotomy
or the specific [cleft] diagnosis.”113-117,119,120
I agree with Obwegeser when he stated the following:
“Today, many surgeons will resort to the use of distraction
devices to gradually advance the cleft maxilla. Although in
some circumstances this may be appropriate, it should be
remembered that most cleft patients can be treated effi­
ciently, even when requiring significant advancement with
the classic Le Fort I type procedure.”119
Standard thinking is for the surgeon to commit to an
approach (DO versus standard technique) for Le Fort I
advancement before he or she arrives in the operating room.
The surgeon then sticks to the plan, no matter what happens
intraoperatively. On the basis of a review of the literature
and almost three decades of personal experience as a cleft
jaw surgeon, I make the following observations and recom­
mendations in this area.
Observations About the Distraction Osteogenesis
Approach
• DO techniques are always the patient’s second choice
when compared with the standard approach of Le Fort
I osteotomy with rigid (plate and screw) internal fixa­
tion. The length of convalescence after surgery involving
DO is longer; it will include at least 3 months of limited

1366 SECTION 5  Cleft Jaw Deformities
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174. Verdi FJ, Jr, Shanzi GL, Cohen SR, et al:
Use of the Branemark implant in the cleft
palate patient. Cleft Palate Craniofac J
28:301, 1991.
175. Ward-Booth RP, Bhatia SN, Moos KF: A
cephalometric analysis of the Le Fort II
osteotomy in the adult cleft patient.
J Maxillofac Surg 12:208, 1984.
176. Westbrook MT, Jr, West RA, McNeil RW:
Simultaneous maxillary advancement and
closure of bilateral alveolar clefts and

1370 SECTION 5  Cleft Jaw Deformities
oronasal fistulas. J Oral Maxillofac Surg
41:257, 1983.
177. Williams AC, Bearn D, Mildinhall S, et al:
Cleft lip and palate care in the United
Kingdom—the Clinical Standards Advisory
Group (CSAG) study. Part 2: Dentofacial
outcomes and patient satisfaction. Cleft
Palate Craniofac J 38:24–29, 2001.
178. Willmar K: On Le Fort I osteotomy: A
follow-up study of 106 operated patients
with maxillo-facial deformity. Scand J Plast
Reconstr Surg 12(Suppl 1):1–68, 1974.
179. Wiltfang J, Hirschfelder U, Neukam FW,
et al: Long-term results of distraction
osteogenesis of the maxilla and midface. Br J
Oral Maxillofac Surg 40:473, 2002.
180. Witzel MA, Munro IR: Velopharyngeal
insufficiency after maxillary advancement.
Cleft Palate J 14:176, 1977.
181. Wolford LM: Effects of orthognathic surgery
on nasal form and function in the cleft
patient. Cleft Palate Craniofac J 29:546–555,
1992.
182. Wolford LM, Cassano DS, Cottrell DA, et
al: Orthognathic surgery in the young cleft
patient: Preliminary study on subsequent
facial growth. J Oral Maxillofac Surg
66:2524–2536, 2008.
183. Wolford LM, Karras SC, Mehra P:
Considerations for orthognathic surgery
during growth: Part 1. Mandibular
deformities. Am J Orthod Dentofacial Orthop
119:95, 2001.
184. Wolford LM, Karras SC, Mehra P:
Considerations for orthognathic surgery
during growth: Part 2. Maxillary deformities.
Am J Orthod Dentofacial Orthop 119:102,
2001.
185. Zachrisson BU, Stenvik A: Single implants—
optimal therapy for missing lateral incisors?
Am J Orthod Dentofacial Orthop 126:13A–
15A, 2004.

1371

33
Cleft–Orthognathic Surgery:
The Bilateral Cleft Lip and
Palate Deformity
JEFFREY C. POSNICK, DMD, MD
• Facial Growth Implications of Cleft Palate
Repair in the Infant with Bilateral Cleft Lip
and Palate Deformity
• Coordinated Team Approach
• Treatment Protocol
• Timing of Orthognathic Surgery
• Residual Deformities in the Adolescent with
Bilateral Cleft Lip and Palate
• Orthodontic Considerations in the Patient
with Bilateral Cleft Lip and Palate with Jaw
Deformity
• Immediate Presurgical Assessment
• Orthognathic Approach for Bilateral Cleft Lip
and Palate Deformities
• Avoiding Pitfalls
• Clinical Management after Initial Surgical
Healing
• Orthognathic Surgery for Bilateral Cleft Lip
and Palate: Review of Study
• Controversies and Unresolved Issues
• Conclusions
Facial Growth Implications of Cleft
Palate Repair in the Infant with Bilateral
Cleft Lip and Palate Deformity
Ross confirmed that individuals who are born with cleft lip
and palate have intrinsic deficiencies in the midfacial skel­
eton that are made significantly worse by operations.118
Mulliken and colleagues from Boston Children’s Hospital
found that 76.5% of teenagers with repaired bilateral cleft
lip palate (BCLP) required maxillary advancement.43 They
showed that the need for orthognathic surgery is dependent
on the severity of the cleft type as well as the number and
extent of previous operative procedures. Results from The
Hospital for Sick Children in Toronto, Canada, showed
that 65.1% of their patients with BCLP required or under­
went orthognathic surgery, whereas 70% of children with
BCLP who were referred to their team some time after cleft
lip repair were found to require orthognathic surgery.23
David and colleagues from the cleft craniofacial unit in
Adelaide, Australia, followed a consecutive group of patients
with BCLP from birth to maturity and determined the need
for orthognathic surgery.24 Each patient was followed
according to treatment protocol and then at 18 years of age
assessed for dentofacial deformity. A skeletal Class III mal­
occlusion that required orthognathic correction was present
in 17 of the 19 patients (89.5%), whereas the remaining 2
patients were found to have a malocclusion that was man­
ageable with orthodontics alone. Fourteen underwent
orthognathic surgery, and the remaining three declined the
offer for correction.
Saperstein and colleagues discussed facial growth in chil­
dren with complete clefting of the primary palate (i.e., the
lip through the incisal foramen) but with an intact second­
ary palate (i.e., the incisal foramen through the uvula).120
This was a retrospective, cross-sectional analysis of non-
syndromal patients with bilateral complete clefting of the
The reconstruction of bilateral cleft lip and palate is inex­
tricably connected with orthodontic care and skeletal
surgery. The successful management of these individuals is
likely to present a formidable clinical challenge for the
orthognathic surgeon, the orthodontist, and the dental
team.

1372 SECTION 5  Cleft Jaw Deformities
primary palate (n = 7) as compared with those with bilateral
complete clefting of both the primary and secondary palates
(n = 27). Angular and linear measurements of the midfacial
region were made on lateral cephalograms. The research
documented that individuals with a bilateral cleft of the
primary palate who underwent lip repair during infancy
most frequently have a normal or even slightly forward
maxillary position as compared with age-matched controls.
This was in contrast with children with a bilateral cleft of
both the primary and secondary palates who underwent
lip repair followed by palate repair before they were 1 year
old, who demonstrated a high incidence of maxillary defi­
ciency. The study clarified that cleft palate repair carried out
before the patient is 1 year old—and not the cleft lip repair
itself—is responsible for the high incidence of midface
hypoplasia.
It is now clear that orthognathic surgery is a necessary
component of the treatment of a majority of individuals
who are born with BCLP. Unfortunately, the necessary jaw
reconstruction is often considered “too risky” and therefore
postponed, delayed, ignored, or refused. If so, the patient
is likely to be treated with orthodontic and prosthetic cam­
ouflage techniques. Adding further difficulty to successful
rehabilitation is controversy about the indications and con­
fusion regarding the exact techniques, timing, and extent of
surgery needed to achieve reliable and predictable results.
The occlusal, speech, upper airway, and aesthetic objectives
in the adolescent patient with BCLP must first be clarified.
A surgical, orthodontic, and dental treatment plan can then
be coordinated to achieve improved head and neck func­
tion, facial enhancement, and dental rehabilitation.
Coordinated Team Approach
The care of the patient with BCLP is best delivered by
an integrated group of dental and medical specialists
who evaluate and then provide coordinated definitive
treatment.8,77,92 It is no longer acceptable for individual
surgeons, orthodontists, restorative dentists, speech pathol­
ogists, and otolaryngologists to carry out extended treat­
ment without considering all aspects of the patient’s care
and communicating effectively with the patient, the family,
and the collaborating clinicians. The Eurocleft study found
no association between high-intensity treatments and favor­
able results. In other words, the more operations and years
of orthodontic appliances (i.e., heavy burden of care), the
worse the outcome.79
Treatment Protocol
Adolescents and adults with BCLP who also have jaw defor­
mities should be seen at a minimum by an orthodontist, an
orthognathic surgeon, an otolaryngologist, and a speech
pathologist. Additional consultations with other dental (e.g.
a prosthodontist, a pediatric or general dentist, a periodon­
tist) and medical (e.g., sleep specialist, medical geneticist)
specialists are obtained, if necessary. For the initial
evaluation and eventual treatment of the cleft dentofacial
deformity, records and tests should include the following:
medical-quality photographs with views of the face and the
occlusion; cephalometric and dental radiographs; dental
models; direct facial measurements; speech assessment; and
thorough evaluation of the upper airway.
In addition to performing lip, palate, and velopharyngeal
(VP) repairs, the primary cleft surgeon generally plays a role
in advising the patient and the family about the patient’s
further care. If the cleft surgeon is not trained in skeletal
procedures, then a timely and seamless transition to the
maxillofacial surgeon who will continue on with the patients’
reconstruction should go forward. The cleft jaw surgeon
should have a fundamental understanding of the patient’s
dental, speech, upper airway, and aesthetic needs. The
surgeon should request consultation with appropriate spe­
cialists, evaluate the clinical information, and be prepared
to go forward with coordinated and timely up-to-date
orthognathic procedures.
The orthodontist provides interceptive treatment
during the mixed dentition in coordination with bone graft­
ing; and carries out definitive orthodontics in conjunction
with orthognathic surgery, when indicated. From the
mixed-dentition phase, the orthodontist should recognize
the patient with BCLP who will likely be in need of orthog­
nathic surgery.20,21,25,36,52,53,64,80,90,114,117,121,132,145 Instituting
extensive camouflage (dental compensatory) treatment is
likely to jeopardize periodontal health and lead to late
dental relapse of the occlusion. Proceeding with a compro­
mised orthodontic (camouflage) approach should only be
entered into with full disclosure to the family and other
treating clinicians.
Before orthognathic surgery, a speech pathologist per­
forms an evaluation to characterize VP function and to
identify articulation errors that result from the cleft palate,
the jaw deformity, and the dental malocclusion (see Chapter
8). Such evaluation is important, because VP function may
deteriorate after maxillary advancement. A nasoendoscopic
guided speech assessment is preferred to obtain maximum
objective data. VP closure that is adequate before surgery
may become borderline afterward, and VP closure that is
borderline may become inadequate. The successful ortho­
dontic, surgical, and dental correction of crossbites, open
bite, cleft–dental gaps, negative overjet, and residual orona­
sal fistula represents the most effective way to correct the
identified articulation distortions (see Chapter 8).
A thorough evaluation of the upper airway is conducted
to assess for any areas of obstruction (see Chapter 10). A
formal sleep study (polysomnogram) is completed if there
is a suspicion of obstructive sleep apnea (see Chapter 26).
If indicated, simultaneous intranasal procedures to open the
airway should be carried out at the time of orthognathic
surgery (see Chapters 10 and 15).
Discussions with the treating medical and dental consul­
tants as well as the patient and his or her family clarify the
need for and the extent of orthognathic procedures (e.g.,
Le Fort I osteotomy, sagittal ramus osteotomies, osseous

1373
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
1. Maxillary hypoplasia. The anterior maxilla may be
either vertically long, which results in a gummy smile,
or vertically short, which leaves an edentulous appear­
ance. Horizontal deficiency (negative overjet) with a
flat midface and an Angle class III malocclusion is
also part of the usual presentation. The arch width of
the lateral segments is frequently deficient (or at least
pseudodeficient as a result of the negative overjet),
with posterior crossbites. The dental midline may be
shifted off of the facial midline, and the maxillary
lateral segments may be canted. For the individual
who was not effectively grafted during the mixed
dentition, the two lateral segments and the premaxil­
lary segments are separate components of the upper
jaw. In general, each segment will vary with regard to
its degree of vertical and horizontal dysplasia. These
patients are best treated via the differential reposition­
ing of each of the three segments to achieve a satisfac­
tory arch form, occlusion, and facial appearance.
2. Residual oronasal fistula. Although the preference is to
complete fistula closure and bone grafting during
the mixed dentition (i.e., before the eruption of the
canine at each cleft site), some patients with BCLP
will have residual labial and palatal fistulas, with
leakage of fluid through the nose while drinking and
air leakage while speaking. Previous attempts at fistula
closure may have failed as a result of inadequate avail­
able (palatal) soft tissue for wound closure in the
incisal foramen region.
3. Cleft–dental gaps. Approximately 93% of the time,
useful lateral incisors are absent or inadequate at each
cleft site. A rudimentary lateral incisor or supernu­
merary tooth may be impacted or adjacent to each
cleft; if so, they are of no functional value. If hypo­
plastic lateral incisors do erupt in the posterior or
premaxillary segments, they rarely have the root
support needed for long-term function. The result is
often a dental gap at the cleft site between the central
incisor and the canine on each side. If bone grafting
and fistula closure during the mixed dentition were
successfully carried out, then canine eruption fol­
lowed by orthodontic closure of the cleft dental gaps
will have likely been undertaken.
4. Residual bony defects. In the patient with BCLP who
has not had successful or adequate bone grafting
during the mixed dentition, significant residual
defects through the alveolus, the floor of the nose,
and the palate remain. A lack of continuity across the
cleft alveolar ridges results in a mobile premaxilla that
is only attached to the nasal septum and the labial
soft tissues. It is also not uncommon to see only a
limited bridge of bone (on one or both sides) con­
necting the lateral and premaxillary ridge after a pre­
vious bone graft. Unfortunately, this is inadequate
bone volume into which the canine will erupt. In
addition, a limited bone bridge cannot be relied on
genioplasty) and intranasal procedures (e.g., septoplasty,
inferior turbinate reduction, recontouring of the nasal floor
and rims). The overall plan for speech, jaw, upper airway,
and dental rehabilitation and the enhancement of facial
aesthetics is agreed to before the initiation of treatment.
Timing of Orthognathic Surgery
Correction of the cleft jaw deformity is best carried out with
a consideration of skeletal maturity and before the patient
finishes high school.66,69 Maxillofacial growth is generally
complete between the ages of 14 and 16 years in girls and
the ages of 16 and 18 years in boys. However, skeletal
growth is variable, and it may be further clarified by an
analysis of sequential cephalometric radiographs taken at
intervals (see Chapter 17). Patient and family preferences
for the timing of reconstruction on the basis of the patient’s
psychosocial and functional needs (i.e., speech, swallowing,
chewing, and breathing) should also be taken into account.
As early as 1986, investigators showed that, if Le Fort I
advancement is completed during the mixed dentition in
a patient with a cleft palate, then another orthognathic
procedure will be necessary after skeletal maturity is
reached.140-143 All research to date indicates that a Le Fort I
osteotomy carried out at an early age, with the use of either
standard or distraction osteogenesis (DO) techniques,
results in no further horizontal maxillary growth.16,34,35,46,48,59,95
Residual Deformities in
the Adolescent with Bilateral
Cleft Lip and Palate
The adolescent patient with BCLP often has several residual
deformities that can be challenging to manage. The central
deformity is maxillary hypoplasia, which is often combined
with residual oronasal fistula, bone defects, intranasal
obstruction, soft-tissue scarring, and occasionally VP dys­
function (Figs. 33-1 through 33-17). In addition, the
maxillary lateral incisors are usually congenitally absent or
hypoplastic (93% of the time), and the patients often have
cleft–dental gaps.13 Secondary deformities of the nose, the
mandible, and the chin region are also common. The preva­
lence of these residual deformities in mature patients with
BCLP varies widely, depending on the treating clinician’s
philosophy, available expertise, the individual’s intrinsic
biologic growth potential, and patient and family interests.
Published clinical surveys indicate that, despite a cleft
team’s best efforts, a significant number of children with
BCLP will not make themselves available for mixed-
dentition grafting (i.e., before the eruption of the maxillary
canines).33,137 In addition, a percentage of those who do will
undergo unsuccessful grafting procedures and require other
means of reconstruction and dental rehabilitation. For all
of these reasons, a subgroup of individuals with BCLP
continues to present at or after adolescence with multiple
cleft-related challenges that may include the following:
Text continued on p. 1428

1374 SECTION 5  Cleft Jaw Deformities
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• Figure 33-1  A child who was born with bilateral cleft lip and palate underwent lip and palate repair during
early childhood. During the mixed dentition, she presented to this surgeon with a mobile premaxilla, alveolar and
palatal defects, and residual (bilateral) labial and palatal fistulas. She then underwent a short phase of orthodontic
treatment to expand the maxillary arch width. This was followed by iliac grafting of the skeletal defects and fistula
closure. She was fortunate to have adequately developed lateral incisors. A, Facial views during infancy and
early childhood. B, Facial and occlusal views during the mixed dentition with interceptive orthodontic treatment
in progress and before bone grafting.

1375
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
C
D
C, Illustration of incisions for the elevation of flaps, fistula closure, and grafting during
the mixed dentition in a child with BCLP. Maintenance of the labial mucosa to the premaxilla is essential.
D, Illustration of flap and wound closure after grafting for fistula closure. The occlusal splint is secured to the
maxillary segments to immobilize the premaxilla during initial bone healing. Parts C, D are modified from an
original illustration by Bill Winn.
• Figure 33-1, cont’d 
Continued

1376 SECTION 5  Cleft Jaw Deformities
F
Minimal scar from iliac graft
F
Orth
r ognathic Surg
r ery; J.C. Posnick
E
E, Frontal and occlusal views at 14 years of age after successful grafting, fistula closure, and stabilization
of the premaxilla, with definitive orthodontic alignment in progress. F, Views of the healed skin incision used to harvest the iliac
graft.
• Figure 33-1, cont’d

1377
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
G
G, Palatal and radiographic views before and after successful bone grafting and orthodontic alignment.
• Figure 33-1, cont’d

1378 SECTION 5  Cleft Jaw Deformities
©Elsevier Inc.
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• Figure 33-2  A child who was born with bilateral cleft lip and palate and who had
intact nasal sills. She was referred to this surgeon and underwent lip and palate repair
during infancy. During the mixed dentition, she underwent successful bone grafting
with stabilization of the premaxilla. The canines erupted through the grafted cleft sites
and established a normal alveolar ridge. The lateral incisors were essentially normal
and maintained within the arch form. With significant maxillary hypoplasia, the patient
underwent a comprehensive orthodontic and orthognathic approach. Her proce­
dures included Le Fort I osteotomy in three segments (correction of arch width and
curve of Spee, horizontal advancement, vertical lengthening) with interpositional
grafting; bilateral sagittal split ramus osteotomies (clockwise rotation); and septo­
plasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal facial views
before lip repair, after primary lip and palate repair, and at 8 years of age just before
mixed dentition grafting.

1379
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
B
C
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r ognathic Surg
r ery; J.C. Posnick
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r ery; J.C. Posnick
Orth
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r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
B, Frontal views in repose as a teenager before and after reconstruction. C, Frontal views with smile before and after
reconstruction.
• Figure 33-2, cont’d 
Continued

1380 SECTION 5  Cleft Jaw Deformities
D
E
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
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r ery; J.C. Posnick
Orth
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r ery; J.C. Posnick
D, Oblique facial views before and after reconstruction. E, Profile views before and after reconstruction.
• Figure 33-2, cont’d

1381
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
After successful mixed-dentition bone graft
Pre surgery
After treatment
F
F, Occlusal views during the mixed dentition, with orthodontics in progress before orthognathic surgery, and
then after the completion of treatment.
• Figure 33-2, cont’d 
Continued

1382 SECTION 5  Cleft Jaw Deformities
Arch expansion
G
H
G, Articulated dental casts indicate analytic model planning. H, Lateral cephalometric radiographs
before and after reconstruction.
• Figure 33-2, cont’d

1383
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
• Figure 33-3  A child who was born with van der Woude syndrome that included bilateral cleft lip and palate and lower lip pits. He was referred
to this surgeon and underwent lip and palate repair as well as lower lip pit excisions during childhood. He underwent successful mixed-dentition
grafting and fistula closure. As a teenager, he demonstrated maxillary hypoplasia with secondary deformities of the mandible and the nasal cavity.
He then underwent a comprehensive orthodontic and orthognathic/intranasal surgical approach. The patient’s procedures included standard Le
Fort I osteotomy (vertical lengthening, horizontal advancement, and clockwise rotation) with interpositional grafting; bilateral sagittal split ramus
osteotomies (clockwise rotation); osseous genioplasty (horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor
recontouring. A, The patient is shown at the time of birth and then just before mixed-dentition grafting.
Continued

1384 SECTION 5  Cleft Jaw Deformities
B
C
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
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u g
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Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
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u g
r ery; J.C. Posnick
B, Frontal views in repose before and after reconstruction. C, Frontal views with smile before and after
reconstruction.
• Figure 33-3, cont’d

1385
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
D
E
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r ery; J.C. Posnick
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Orth
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r ery; J.C. Posnick
Orth
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D, Oblique facial views before and after reconstruction. E, Profile views before and after reconstruction.
• Figure 33-3, cont’d 
Continued

1386 SECTION 5  Cleft Jaw Deformities
Prior to bone grafting
After successful mixed dentition bone graft and orthodontic cleft dental gap closure
After treatment
F
F, Occlusal views are shown before mixed-dentition bone grafting and fistula closure, with orthodontics in
preparation for orthognathic surgery, and after the completion of reconstruction. A dental implant is planned for the congenitally missing
right maxillary bicuspid when the patient is 18 years old.
• Figure 33-3, cont’d

1387
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
G
H
G, Articulated dental casts indicate analytic model planning. H, Cephalometric radiographs before and after
reconstruction.
• Figure 33-3, cont’d

1388 SECTION 5  Cleft Jaw Deformities
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Prior to maxillary bicuspid extractions
After maxillary bicuspid extractions
A
Or
Orthth
r ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatathicicicicici Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
osnicicici k
Or
Or
Orthth
r ogn
gn
gn
gn
gnatatatata hicicic Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
o nicicicick
• Figure 33-4  A child who was born with bilateral cleft lip and palate underwent lip and palate repair during infancy and early childhood by another
surgeon. During the mixed dentition, she was referred to this surgeon with a mobile premaxilla, alveolar and palatal defects, and residual labial and
palatal fistulas. She had the congenital absence of several permanent teeth. She underwent a short phase of orthodontic expansion and then
successful iliac grafting and fistula closure during the mixed dentition. As a teenager, she underwent a comprehensive orthodontic and orthognathic/
intranasal surgical approach. The patient’s procedures included standard Le Fort I osteotomy (horizontal advancement and vertical shortening);
bilateral sagittal split ramus osteotomies (clockwise rotation); osseous genioplasty (horizontal advancement); and septoplasty, inferior turbinate
reduction, and nasal floor recontouring. A, The patient is shown at the time of birth. B, Facial and lateral cephalometric radiographic views during
the adult dentition before and then after maxillary extractions with orthodontic retraction.

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CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
C
12
D
F
E
G
C, Articulated dental casts that indicate analytic model planning. D, Occlusal view during the adult denti­
tion before extractions. E, Occlusal view after extractions and before orthodontic decompensation. F, Occlusal view after ortho­
dontic retraction and before surgery. G, Occlusal view early after surgical correction.
• Figure 33-4, cont’d 
Continued