Orthognathic Surgery

1391
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
After successful mixed-dentition bone graft and maxillary bicuspid extractions - with orthodontics in progress
After treatment
K
K, Occlusal views before and after reconstruction.
• Figure 33-4, cont’d

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 33-5  A 17-year-old girl who was born with bilateral cleft lip and palate. She underwent lip repair by this surgeon during childhood. This
was followed at another institution by cleft palate repair; a columella lengthening of the nasal soft tissues when she was 5 years old; a pharyngeal
flap for the management of velopharyngeal insufficiency when she was 7 years old; and then bone grafting to the alveolar clefts when she was 8
years old. She was referred back to this surgeon when she was 17 years old and found to have cleft nasal deformities, chronic obstructed nasal
breathing, severe maxillary hypoplasia, secondary deformities of the mandible, and retained wisdom teeth. The maxilla had been successfully grafted
with orthodontic closure of the cleft dental gaps. The patient then underwent reconstruction by this surgeon, including maxillary Le Fort I osteotomy
in two segments with differential repositioning (horizontal advancement +14 mm, vertical lengthening +5 mm, cant correction, and transverse nar­
rowing) with interpositional grafting; bilateral sagittal split ramus osteotomies (asymmetry correction); osseous genioplasty (horizontal advancement);
septoplasty, inferior turbinate reduction, and nasal base recontouring; and the removal of retained wisdom teeth. Before surgery, she underwent a
nasoendoscopic speech assessment that demonstrated the satisfactory closure of the left lateral port with incomplete closure of the right lateral
port (i.e., small air leakage). She maintained adequate velopharyngeal closure after surgery. Orthodontic maintenance and detailing continued and
were followed by a removable maxillary retainer and a fixed lower anterior retaining wire. One year later, the patient underwent cleft rhinoplasty that
included nasal osteotomies, the modification of the lower lateral cartilages, and a rib cartilage (caudal strut) graft. Note that ideal nasal aesthetics
were compromised after a columella lengthening procedure that caused scarring of the soft tissues of the columella and distortions of the alar rims
and tip. A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.

1393
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
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Orth
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Orth
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C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 33-5, cont’d 
Continued

1394 SECTION 5  Cleft Jaw Deformities
Vertical
lengthening
(5 mm)
Mandibular
adjustment
Maxillary advancement (14 mm)
After successful mixed-dentition bone graft
After treatment
Arch Narrowing
E
F
E, Occlusal views with orthodontic appliances in place and then after reconstruction. F and G, Articulated dental
casts that indicate analytic model planning.
• Figure 33-5, cont’d

1395
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
Roll Orientation Correction
G
H
Maxillary advancement (14 mm)
H, Lateral cephalometric radiographs before and after reconstruction.
• Figure 33-5, cont’d

1396 SECTION 5  Cleft Jaw Deformities
B
Residual alveolar cleft
Effective graft
©Elsevier Inc.
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Surg
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r ; J.C.
C.
C.
C. Pos
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©Elsevier Inc.
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Orththththththththththththththththththththththth
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Su
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Surg
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Residual alveolar cleft
Effective graft
A
• Figure 33-6  Three young adults who were born with bilateral cleft lip and palate are shown. Each had undergone
bone grafting during the mixed dentition at another institution. Facial, occlusal, and computed tomography scan views
indicate successful grafting at one cleft site but not at the other. It is important to make this determination when
orthognathic surgery is required. If successful grafting was accomplished at one cleft site, then a circumvestibular
incision can be made with full down-fracture, as one would for an ungrafted unilateral cleft alveolus. If successful
grafting was not accomplished on either side, then a modified Le Fort I osteotomy in three segments would be required
to maintain circulation to each of the three segments (i.e., the premaxilla, the left posterior segment, and the right
posterior segment). This is done to avoid the complication of aseptic necrosis of the premaxilla (see Fig. 33-17).
A, A teenager who was born with van der Woude syndrome and bilateral cleft lip and palate. He underwent successful
grafting of one cleft site but not the other at another institution. He presented to this surgeon for orthognathic surgery.
Facial, occlusal, and computed tomography scan views are shown. B, A teenager who was born with bilateral cleft
lip and palate underwent successful alveolar grafting on the left side but not the right at another institution. He pre­
sented to this surgeon for orthognathic surgery. Facial, occlusal, and computed tomography scan views are shown
and confirm these facts.

1397
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
D
©Elsevier Inc.
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Orthththththth
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icic Su
Surg
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C.
C.
C Po
Po
Po
Po
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Po
Po
Posn
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sn
s icicicicicicicicicick
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thicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
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ry; J.J.J.J.J.J.J.J C.
C.
C.
C.
C.
C.
C.
C.
C.
C Po
Po
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snicicicicicicicicicicick
C
C, A teenage girl who was born with bilateral cleft lip and palate underwent successful alveolar
grafting on the right side but not the left. She then presented to this surgeon for orthognathic surgery. Facial and occlusal
views when the previous patient was 7 years old, before grafting. D, Computed tomography scans of the same girl when
she was 16 years old confirm successful grafting on right side but continued alveolar clefting on left side.
• Figure 33-6, cont’d 
Continued

1398 SECTION 5  Cleft Jaw Deformities
Maintain labial pedicle
Circumvestibular incision
E
F
UCLP
BCLP
E, Illustrations of incisions for a modified Le Fort I osteotomy in two segments either for a patient with unilateral cleft lip
and palate and an open cleft or a patient born with BCLP and a successful graft on just one side. Part E modified from an original illustration by
Bill Winn. F, Illustrations of the incisions required to maintain circulation to each of three segments in an unsuccessfully grafted case of bilateral
cleft lip and palate.
• Figure 33-6, cont’d

1399
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
B
Or
Or
Or
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O ththththththththththththththththththththththththtr ogn
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g atatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
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os
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Or
Or
Or
Or
Or
Or
Or
Or
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Or
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Or
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Or
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Or
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O ththththththththththththththththththththth
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g atatatathicicic Su
Su
Su
Surg
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ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C Posnick
Or
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O ththththththththththththththththththththththththththth
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Su
Su
Su
Su
Su
Su
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Surg
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C.
C.
C.
C.
C.
C.
C.
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C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
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A
• Figure 33-7  An 18-year-old boy was born with bilateral cleft lip and palate (
Video 14). He underwent
lip and palate repair during childhood. Mixed-dentition grafting was not successful. He was then referred to
this surgeon as a teenager and underwent a combined orthodontic and orthognathic surgical approach. The
patient’s procedures included modified Le Fort I osteotomy in three segments with closure of an oronasal
fistula, alveolar defects, and cleft–dental gaps; and stabilization of the premaxilla with interpositional bone
graft; bilateral sagittal split ramus osteotomies (correction of asymmetry); an osseous genioplasty (vertical
reduction and horizontal advancement) and septoplasty, inferior turbinate reduction, and nasal floor recontour­
ing. A, Frontal views at before cleft lip and palate repair. B, Profile and occlusal views during the mixed denti­
tion. Iliac grafting by another surgeon was not successful.
Continued

1400 SECTION 5  Cleft Jaw Deformities
Orth
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Orth
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r ery; J.C. Posnick
Orth
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r ery; J.C. Posnick
Orth
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u g
r ery; J.C. Posnick
C
D
C, Frontal views with smile before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 33-7, cont’d

1401
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
G
15
14
E
Residual cleft defects and mobile pre-maxilla
Residual cleft defects and mobile pre-maxilla
F
E, Occlusal views before and 2 years after reconstruction. A degree of relapse (skeletal versus dental) has occurred.
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after reconstruction (
Video 14).
C, D, E (top center, bottom center), from Posnick JC, Tompson B: Modification of the maxillary Le Fort I osteotomy in cleft-orthognathic surgery:
the bilateral cleft and palate deformity, J Oral Maxillofac Surg 51:2-11, 1993.
• Figure 33-7, cont’d

1402 SECTION 5  Cleft Jaw Deformities
A
B
• Figure 33-8  Illustrations of modified Le Fort I osteotomy in three segments used when
mixed-dentition grafting has not been successfully accomplished (i.e., residual fistula,
alveolar clefts with mobile premaxilla, and cleft dental gaps) and maxillary hypoplasia
requires orthognathic surgery. A, Illustrations of a patient with bilateral cleft lip and palate
before and after three-part maxillary osteotomies with repositioning of the segments.
Septoplasty and inferior turbinate reduction, are also shown. Skeletal views demonstrate
anatomy before and after a modified Le Fort I osteotomy is three segments as described.
B, Palatal views of bone segments before and after repositioning for the closure of cleft–
dental gaps. Both skeletal and soft-tissue views are shown. Early after surgery, a prefab­
ricated splint remains secured to the maxillary dentition. Parts A, C-F, modified from an
original illustration by Bill Winn.

1403
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
C
D
E
F
Palatal
flaps
Labial flap
C, Illustrations of incisions for modified Le Fort I osteotomy in three segments for the treatment of bilateral cleft lip and
palate. D, Illustrations of down-fractured lateral segments demonstrating exposure for nasal-side closure of an oronasal fistula. E, Illustration of
premaxillary osteotomy carried out on the palate side (vomer osteotomy) with the use of a reciprocating saw. F, Illustration demonstrating oral
wounds sutured at the end of the procedure. Note that no sutures are required on the palate side. (From Posnick JC: Cleft orthognathic surgery.
In Russell RC (ed): Instructional Courses. Plastic Surgery Education Foundation, vol. 4, St. Louis, Mosby-Year Book, 1991, pp 129-157.)
• Figure 33-8, cont’d

1404 SECTION 5  Cleft Jaw Deformities
C
D
©Elsevier Inc.
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Orththththththththththththththththththththththththththththththththththththththththththththththth
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Su
Su
Su
Su
Su
Su
Surg
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ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
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©Elsevier Inc.
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O ththththththththththththth
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g atatatatatatatatatata hicicicicicicicic Su
Su
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C.
C.
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©Elsevier Inc.
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A
B
After palate repair
with large fistula
Residual cleft defects and mobile pre-maxilla
• Figure 33-9  A 15-year-old girl was born with bilateral cleft lip and palate. She underwent lip and palate repair during infancy and early
childhood by another surgeon. She retained a large oronasal fistula in the incisal foramen region from the time of the initial palate repair. She
had worn a palatal prosthesis to obliterate the opening, but this interfered with speech articulation and oral hygiene. She was referred to
this surgeon as a teenager and underwent a comprehensive orthodontic and orthognathic approach to close the large oronasal fistula, to
stabilize the maxillary segments, and to restore her occlusion and periodontal health. As part of the preoperative orthodontic treatment, she
underwent extraction of the five teeth for which there was inadequate alveolar bony support. During the operation, she underwent modified
Le Fort I osteotomy in three segments with differential repositioning and interpositional grafting for closure of the large oronasal fistula, the
cleft–dental gaps, and the alveolar defects. She also underwent septoplasty and inferior turbinate reduction to improve nasal airflow. Note
that the maxilla was rehabilitated with the absence of the lateral incisors and a first bicuspid on the right side. A, Facial views before lip and
palate repair. B, Palatal view during early childhood that indicates extensive oronasal fistula just after primary repair. C and D, Facial and
palatal views at 15 years of age, when the patient was referred to this surgeon.

1405
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
X
X
X
X
X
F
E
E, Palatal view and illustrations demonstrating the patient’s skeletal anatomy before and after reconstruc­
tion. The “X”s mark the teeth that are planned for extraction. The black dot and the two arrows indicate the location where the
palatal mucosa will come together. F, Palatal views before and after reconstruction and dental rehabilitation via the technique just
described.
• Figure 33-9, cont’d 
Continued

1406 SECTION 5  Cleft Jaw Deformities
H
I
©Elsevier Inc.
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Orththththththththththththththth
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g atatatatatatatatatatatata hicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Surg
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ry
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C.
C.
C.
C.
C.
C.
C.
C.
C Pos
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©Elsevier Inc.
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Su
Su
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G
X
X
X
X
X
G, Occlusal views before and after reconstruction. H, Occlusal and periapical
radiographs before and after reconstruction and dental rehabilitation. I, Facial views before and after
reconstruction.
• Figure 33-9, cont’d

1407
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
B
C
©Elsevier Inc.
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C.
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©Elsevier Inc.
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Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C Posnick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththth
r ogn
gn
gn
gn
gn
gn
g atatatatathicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
o nick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatathicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O hththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicic Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicici k
A
• Figure 33-10  A 17-year-old boy of His­
panic descent was born with bilateral cleft lip
and palate. He underwent lip and palate repair
during childhood and unsuccessful grafting
during the mixed dentition. He was referred to
this surgeon as a teenager and underwent a
comprehensive orthodontic and orthognathic
approach. The patient’s procedures included
a modified Le Fort I osteotomy in three seg­
ments with differential repositioning and inter­
positional grafting (closure of the oronasal
fistula, the alveolar defects, and the cleft–
dental gaps; stabilization of the premaxilla);
osseous genioplasty (vertical reduction and
horizontal advancement); and septoplasty
and inferior turbinate reduction. Six months
later, he underwent an open rhinoplasty that
included a rib cartilage (caudal strut) graft to
improve nasal tip projection. A, Profile and
occlusal views during the mixed dentition.
B, Profile views during the teenage years
before and after reconstruction. C, Frontal
views during the teenage years before and
after reconstruction and dental rehabilitation.
Continued

1408 SECTION 5  Cleft Jaw Deformities
D
Unfavorable buccal flap
After flap take down and orthognathic correction
D, Occlusal and palatal views before and after reconstruction and dental rehabilitation. B, C ,D from
Posnick JC, Witzel MA, Dagys AP: Management of jaw deformity in the cleft patient. In Bardach K, Morris HL, eds: Multidisciplinary
management of cleft lip and palate, Philadelphia, 1990, W.B. Saunders, p 538.
• Figure 33-10, cont’d

1409
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
C
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatathicicicicicicicicicicic Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththth
r ogn
gn
gn
gn
gn
g atatatatatatatatathicicicicicic Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatathicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Orththththththththththththtr ogn
gn
gn
gn
gn
g atatatathicicicicicicic Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
O thththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatathicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicici k
A
B
• Figure 33-11  A 19-year-old man was born with
bilateral cleft lip and palate. He underwent lip and
palate repair during childhood but did not undergo
grafting during the mixed dentition. He was referred
to this surgeon as a teenager and underwent a com­
prehensive orthodontic and orthognathic approach.
The procedures included a modified Le Fort I oste­
otomy in three segments with differential reposition­
ing and interpositional grafting (closure of the oronasal
fistula, the alveolar defects, and the cleft–dental gaps;
stabilization of the premaxilla) as well as septoplasty
and inferior turbinate reduction. A, Frontal views with
smile before and after reconstruction. B, Oblique
facial views before and after reconstruction. C, Profile
views before and after reconstruction.
Continued

1410 SECTION 5  Cleft Jaw Deformities
E
F
D
D, Occlusal views with orthodontics in progress and after reconstruction. E, Palatal views before and
after reconstruction. F, Articulated dental casts that indicate analytic model planning.
• Figure 33-11, cont’d

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 33-12  A 15-year-old girl was born with bilateral cleft lip and palate. She underwent lip and palate repair during infancy. A superiorly based
pharyngeal flap, lip scar revision, and tip rhinoplasty were carried out when she was 9 years old. She underwent iliac bone grafting to the alveolar
clefts, without success. She was referred to this surgeon as a teenager and underwent a comprehensive orthodontic and surgical approach. The
patient’s procedures included modified Le Fort I osteotomy in three segments with differential repositioning and interpositional grafting (closure of
the oronasal fistula, the alveolar clefts, and the cleft–dental gaps, with stabilization of the premaxilla); bilateral sagittal split osteotomies of the
mandible (clockwise rotation without set-back); oblique osteotomy of the chin (horizontal advancement); removal of retained wisdom teeth; and
septoplasty, inferior turbinate reduction, and recontouring of the pyriform rims. A, Frontal views in repose before and after reconstruction. B, Frontal
views with smile before and after reconstruction.
Continued

1412 SECTION 5  Cleft Jaw Deformities
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 33-12, cont’d

1413
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
S/P failed bone graft with residual cleft defects
Pre surgery
After treatment
E
F
E, Occlusal views before the final phase of orthodontics, with orthodontics in preparation for surgery,
and then after the completion of treatment. F, Palatal views before and after reconstruction.
• Figure 33-12, cont’d 
Continued

1414 SECTION 5  Cleft Jaw Deformities
G
Reconstruction with only 10 maxillary teeth
H
G, Articulated dental casts that indicate analytic model planning. H, Lateral cephalometric views
before and after surgery. Note that the maxillary dentition is reconstructed with only 10 teeth; there was a congenital
absence of the lateral incisors and the removal of the first bicuspids to relieve crowding. The maxillary wisdom teeth were
impacted and not functional and therefore also removed.
• Figure 33-12, cont’d

1415
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
B
Residual cleft defects and mobile pre-maxilla
Residual cleft defects and mobile pre-maxilla
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
• Figure 33-13  An 18-year-old woman who was born with bilateral cleft lip and palate underwent lip and palate repair during child­
hood but did not undergo successful grafting during the mixed dentition. She was referred to this surgeon as a teenager and underwent
a combined orthodontic and surgical approach. The procedures included lateral segmental osteotomies of the maxilla (anterior
advancement of the segments with closure of oronasal fistulas, alveolar defects, and cleft–dental gaps and the stabilization of pre­
maxilla with interpositional grafting) as well as septoplasty and inferior turbinate reduction. A, Frontal views with smile before and after
reconstruction. B, Occlusal views before and after reconstruction.
Continued

1416 SECTION 5  Cleft Jaw Deformities
D
C
Cleft dental gaps
Closure of dental gaps
C, Palatal views before and after reconstruction. D, Articulated dental casts that indicate analytic model planning.
A, B, and C from Posnick JC: Discussion of: Orthognathic surgery in cleft patients treated by early bone grafting, Plast Reconstr Surg 87:840-
842, 1991.
• Figure 33-13, cont’d

1417
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
C
©Elsevier Inc.
Or
Or
Or
Or
Orththththth
r ogn
gn
gn
gn
gn
gnatatatata hicici Su
Surg
r ery
ry; J.C.
C. Pos
osnicick
©Elsevier Inc.
Or
Orththth
r ogn
gn
gn
gn
gn
gn
gn
gnatatatatatatatata hicicicic Su
Su
Su
S rg
r ery
ry; J.C.
C. Pos
os
os
os
osnicicicicick
©Elsevier Inc.
Or
Orth
r ognatathicic Su
Su
Su
Surg
r ery
ry
r ; J.C. Pos
osnicici k
©Elsevier Inc.
Orththththththththth
r ogn
gn
gn
gn
gn
gn
gnatatatatatatatata hicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
o nicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatathicic Su
Su
Su
S rg
r ery
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththtr ogn
gn
gn
gnatatatatatatathicicicicicicic Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicick
A
B
• Figure 33-14  A boy with bilateral cleft lip
and palate underwent lip and palate repair
during infancy. The premaxilla was distorted
soon after birth, and it remained so into his
teenage years. The patient presented to this
surgeon when he was 16 years old for the
management of residual dentoalveolar defor­
mities. The maxillary (lateral) segments were
well positioned, but the premaxilla was three-
dimensionally distorted and mobile, bilateral
labial and palatal fistulas were present, and the
lateral incisors were congenitally absent. It
was possible to surgically reposition (osteoto­
mize) the premaxilla, to bone graft the defects
of the palate and the floor of the nose, and to
close the residual oronasal fistula during one
procedure. A, Facial views in infancy after one
side lip repair. B, Facial views during the mixed
dentition after lip and palate repair. C, Frontal
views with smile before and after premaxillary
osteotomy and reconstruction.
Continued

1418 SECTION 5  Cleft Jaw Deformities
E
F
D
Mobile premaxilla
Cleft Dental Gaps
Closure of Cleft Dental Gaps
Residual fistula
D, Occlusal views before and after premaxillary osteotomy for reconstruction.
E, Palatal views before and after premaxillary osteotomy for reconstruction. F, Articulated dental casts
that indicate analytic model planning.
• Figure 33-14, cont’d

1419
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
B
X
X
X
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
A
• Figure 33-15  A 21-year-old man was born with bilateral cleft lip and palate. He underwent lip and palate repair, unsuccessful
bone grafting, and unfavorable orthognathic surgery (Le Fort I and genioplasty) at another institution. He presented to this surgeon
when he was 21 years old with a jaw deformity, malocclusion, and a limited dentition. He underwent evaluations by a periodontist,
a prosthodontist, a surgeon, a speech pathologist, and an otolaryngologist. He then underwent a comprehensive surgical and
dental rehabilitative approach. After periodontal treatment and further orthodontic (dental) decompensation, the patient’s recon­
struction included maxillary Le Fort I osteotomy in three segments with differential repositioning and interpositional grafting (cant
correction, closing down the cleft gap, closing of the fistula, horizontal advancement, counterclockwise rotation, and vertical
adjustment); bilateral sagittal split ramus osteotomies (asymmetry correction); and septoplasty and inferior turbinate reduction.
This was followed by crown and bridge dental rehabilitation of the maxillary and mandibular dentition and ongoing periodontal
surveillance. A, Frontal and occlusal views before redo orthodontics, surgery, and dental rehabilitation. B, Panorex and lateral
cephalometric radiographs at time of presentation to this surgeon.
Continued

1420 SECTION 5  Cleft Jaw Deformities
D
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
g atathicicic Su
Surg
r ery
ry; J.C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatathicicicicicicicic Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicici k
C
E
Pre surgery with residual cleft defects and mobile pre-maxilla
After treatment
C, Articulated dental models that indicate analytic model planning. D, Facial views with smile before and
after reconstruction and dental rehabilitation. E, Occlusal views before and after reconstruction and dental rehabilitation.
• Figure 33-15, cont’d

A
B
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
• Figure 33-16  A boy who was born with bilateral cleft lip and palate underwent lip and palatal repair and unsuccessful bone grafting at another
institution. He presented to this surgeon when he was 17 years old with a severe jaw deformity and a limited dentition. He underwent evaluations
by an orthodontist, a periodontist, a prosthodontist, a surgeon, an otolaryngologist, and a speech pathologist. He agreed to a comprehensive surgi­
cal and dental rehabilitative approach. After periodontal treatment, orthodontic (dental) decompensation was accomplished. The patient’s recon­
structive surgery included maxillary Le Fort I osteotomy in three segments with differential repositioning and interpositional grafting, (clockwise
rotation, vertical lengthening, and horizontal advancement), bilateral sagittal split ramus osteotomies (clockwise rotation), osseous genioplasty (bur
recontouring to reduce pogonion); and septoplasty and inferior turbinate reduction. After initial healing and orthodontic completion, crown and
bridge prosthetic rehabilitation was carried out. Six months later, the patient underwent an open rhinoplasty that included rib cartilage (caudal strut)
placement. A, Frontal views in repose before and after reconstruction and rehabilitation. B, Frontal views with smile before and after reconstruction
and rehabilitation.
Continued

1422 SECTION 5  Cleft Jaw Deformities
C
D
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C, Oblique facial views before and after reconstruction and rehabilitation. D, Profile views before and after reconstruction
and rehabilitation.
• Figure 33-16, cont’d

1423
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
F
Prior to treatment with residual cleft defects and mobile pre-maxilla
Pre surgery
After treatment with Anterior bridge in place
E
E, Occlusal views before retreatment, with orthodontic appliances in place, and then after reconstruction
and rehabilitation. F, Lateral cephalometric radiographs before and after reconstruction.
• Figure 33-16, cont’d

1424 SECTION 5  Cleft Jaw Deformities
2 weeks after unsuccessful bone graft
B
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatata hicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicick
Or
Or
Or
Or
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Orththththththththththththththththtr ogn
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g atatatatatatatata hicicicicicicic Su
Su
Su
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Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
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o nicicicicicicicicicicicicicicick
Prior to bone graft
A
• Figure 33-17  A child who was born with bilateral cleft lip and palate underwent lip and palate repair
followed by unsuccessful mixed-dentition bone grafting and unfavorable orthognathic surgery with a
loss of the premaxilla to aseptic necrosis at another institution. He also underwent unfavorable sec­
ondary lip and nasal soft-tissue procedures (including columella lengthening) at another institution. He
was referred to this surgeon during his college years for the management of the jaw deformities and
the fistula and for the coordination of his dental rehabilitative needs. He underwent evaluations by a
periodontist, an orthodontist, a prosthodontist, a surgeon, an otolaryngologist, and a speech patholo­
gist. After further orthodontic (dental) decompensation, the patient’s surgery included maxillary Le Fort
I osteotomy in two segments (anterior cleft gap narrowing, fistula closure, horizontal advancement,
vertical lengthening, and interpositional grafting); bilateral sagittal split ramus osteotomies (clockwise
rotation); osseous genioplasty (vertical shortening and horizontal advancement); and septoplasty,
inferior turbinate reduction, and nasal recontouring. The dental gap was surgically narrowed from a
four-tooth gap to a two-tooth gap. With successful healing and the completion of orthodontics, pros­
thetic rehabilitation of the maxillary arch was carried out. A, During the early mixed dentition, before
grafting. B, During the mixed dentition, after unsuccessful grafting.

1425
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
Aseptic necrosis/loss of premaxilla
after circumvestibular incision
D
©Elsevier Inc.
Or
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Or
Or
Or
Orththththththththththth
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gn
gn
gn
g atatatatatatatatathicicicicicicici Su
Su
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Su
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Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry; J.C.
C Pos
os
os
os
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os
os
os
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os
osnick
©Elsevier Inc.
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Or
Orththththththththththtr ogn
gn
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Surg
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ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicicicicicick
C
Residual alveolar clefts and mobile pre-maxilla
despite bone graft
C, As a teenager, before orthognathic surgery. D, After unsuccessful orthognathic surgery at another institu­
tion, including aseptic necrosis of the premaxilla and fistula formation.
• Figure 33-17, cont’d 
Continued

1426 SECTION 5  Cleft Jaw Deformities
F
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Maxillary clockwise
rotation
Closing down cleft gap
E
E, Articulated dental casts that indicate analytic model planning for redo orthognathic surgery. F, Frontal
views with smile before and after redo orthognathic surgery and dental rehabilitation.
• Figure 33-17, cont’d

1427
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
H
I
J
Or
Or
Or
Or
Or
Or
Or
Or
Or
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O ththththththththththththththththththththththththththth
r ogn
gn
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gn
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gn
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gn
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gn
gn
g atatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
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Or
Orthththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
o nicick
G
G, Occlusal views after unsuccessful orthognathic surgery at another institution
with the loss of the premaxilla and after redo orthognathic surgery and dental rehabilitation. H, Palatal views
before and after redo orthognathic surgery and rehabilitation. I, Profile views before and after reconstruction
and rehabilitation. J, Lateral cephalometric radiographs before and after redo orthognathic surgery.
• Figure 33-17, cont’d

1428 SECTION 5  Cleft Jaw Deformities
assessing the overall jaw, the dental anatomy, and the tooth
angulation. Maxillary occlusal and periapical radiographs
through the cleft sites are of some help, but a cone beam
computed tomography scan is ideal to assess alveolar bone
volume, including the height of the alveolar crest, the fen­
estrations and dehiscence of the walls, and, more impor­
tantly, the integrity of the alveolus across each cleft site.
Both the number of permanent incisors and the amount
of dentoalveolar bone in the premaxilla differ widely. Lateral
incisor-like teeth are frequently found along the edges of
the premaxilla or the lateral segments. These are generally
rudimentary, with poor root form, and they are best
removed. Unerupted supernumerary teeth should be
extracted either at the time of bone grafting during the
mixed dentition or in conjunction with orthognathic
surgery. A useful lateral incisor at the cleft site is only found
in 7% of patients. The lateral incisor’s usefulness should be
assessed in accordance with root (rather than crown) mor­
phology (see the discussion of orthodontic space closure
versus prosthetic replacement later in this chapter).13
The decision to extract additional teeth in the lateral
segments depends on the width and height of available
alveolar bone and the degree of dental root crowding in each
segment. Extractions of the first bicuspids may be necessary
to ensure that there is adequate bone for leveling and align­
ing teeth in each lateral segment without irreversibly weak­
ening the periodontal support of the dental roots next to
the clefts.
The placement of preangulated brackets or artistic posi­
tioning bends can displace the root apices from their alveo­
lar housing, with a rapid loss of crestal bone height along
the mesial of the cuspid and distal of the incisor. Excessive
mesial tipping of the canine should also be avoided. Some
patients lack sufficient bone in the premaxilla to fully align
the incisors preoperatively. In these cases, more complete
orthodontic straightening is best accomplished after the
cleft defects are surgically closed and healed.
The incorporation of all erupted and maintained maxil­
lary teeth (including the second molars) into the orthodon­
tic mechanics will facilitate the development of the desired
postoperative arch form. A lingual attachment on the first
molar band allows for the use of a transpalatal appliance for
indirect anchorage to assist with bringing the second molars
into alignment.
The development of an ideal mandibular arch is critical
to the effective repositioning of the upper maxillary seg­
ments in the most favorable position at the time of orthog­
nathic surgery. Extractions in the mandibular arch are
generally not required, but this depends on the space
requirements needed to position the incisors ideally over the
basal bone.
Immediate Presurgical Assessment
Two to six weeks before the operation, the orthodontist will
confirm that the preoperative orthodontic objectives have
been met and place the passive surgical wires. The surgeon
to provide circulation to the premaxilla at the time of
a Le Fort I down-fracture through a circumvestibular
incision.
5. Chin dysplasia. The patient with BCLP is often a
forced mouth breather with an open-mouth posture.
In addition, if a pharyngoplasty was placed for man­
agement of VP insufficiency, then a chronic open
mouth posture may also be present. Secondary
deformity of the chin often occurs as a result of the
longstanding open-mouth posture during growth
(see Chapter 4). The deformity is characterized by
excess vertical height and horizontal deficiency (see
Chapter 37).
6. Mandibular dysplasia. True mandibular prognathism
is uncommon in the patient with BCLP. Mandibular
ramus osteotomies should be used to correct second­
ary deformities such as facial asymmetry, skeletal dis­
proportions, and the occasional true anteroposterior
malformation.
7. Nasal obstruction and sinus blockage. Obstructed
breathing through the nose and frequent sinusitis
are typical in the individual who is born with BCLP.
This results from a combination of septal deviation,
enlarged inferior turbinates, tight nasal apertures, and
scarred (collapsed) internal and external nasal valves
(see Chapter 10). A pharyngeal flap may also contrib­
ute to nasal obstruction, mucous trapping, and sinus­
itis. The presence of obstructive sleep apnea should
be considered and ruled out (see Chapter 26).
8. VP dysfunction. It is estimated that approximately
20% of patients with a repaired cleft palate demon­
strate VP dysfunction by the time they are 5 years
old. The adolescent patient with BCLP who arrives
for the evaluation of a jaw deformity may have a
pharyngeal flap in place. Despite the presence of a
pharyngeal flap, the patient still may have VP dys­
function (see Chapter 8). Although a Le Fort I oste­
otomy with advancement is likely to improve the
upper airway and speech articulation, it can have a
negative impact on VP function. These disparate
effects of the surgical plan should be taken into
account and shared with the patient and the family
(see chapter 8).
Orthodontic Considerations in the
Bilateral Cleft Lip and Palate Patient
with a Jaw Deformity
The patient with BCLP who has not undergone effective
bone grafting during the mixed dentition will have three
separate maxillary segments, each with a degree of dysplasia
in all three planes. Each segment should be assessed and
treated individually by the orthodontist in anticipation of
segmental surgical repositioning. Radiographic analysis is
essential before any orthodontic movement is initiated in
the patient with BCLP. The Panorex film is useful for

1429
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
mention surgical dental gap closure in the single patient
with BCLP. James and Brook,62 Poole and colleagues,97 and
others also described cleft–orthognathic techniques that
involved the use of limited incisions and indirect exposure
with subperiosteal tunneling. They believed that the staging
of the fistula closure and the Le Fort I osteotomy was neces­
sary to avoid premaxillary segment necrosis.
Posnick clarified the safety of segmental Le Fort I oste­
otomy techniques for patients with a BCLP jaw deformity.
The documented favorable results confirm its value for the
routine, one-stage management of those with a residual
fistula, alveolar clefts, and dental gaps.98-113 The technique
is based on an understanding of the circulatory require­
ments of each of the three maxillary units in a patient who
has not undergone a successful bone graft to unite the
clefted segments. The authors confirmed that each of the
three segments can be safely osteotomized, fully mobilized,
and relocated in accordance with the patient’s functional
needs and aesthetic objectives. The premaxilla can be oste­
otomized (i.e., Vomer osteotomy) and raised as a dento–
osseous–musculo–mucosa flap that is based on the labial
mucosal pedicle. This technique was first described by Wun­
derer in 1962 and used extensively in patients without
clefts.144 Attention to detail is necessary to preserve the
attachments of the labial soft-tissue–mucosal pedicle to the
premaxilla. The validity of this flap’s circulation was proven
by Bell and colleagues in rhesus monkeys (see Chapter 2).5
The labial soft-tissue pedicle ensures flap survival and safe
repositioning of the premaxillary (dento–osseous–musculo–
mucosa) segment.7 The technique of maintaining a blood
supply to the down-fractured posterior (lateral) segments
after a direct circumvestibular incision was originally
described by Schuchardt and later confirmed experimen­
tally by Bell.6
Standard Le Fort I Osteotomy
The subgroup of patients with BCLP with intact alveolar
ridges on one or both sides may have been born with bilat­
eral clefts of their lips but with intact alveolar ridges on both
sides, an intact alveolar ridge on just one side, or alveolar
clefts that have been successfully grafted during the mixed
dentition on one or both sides. For the adolescent or adult
with BCLP who presents with a jaw deformity and intact
alveolar ridges on both sides, a standard Le Fort I down-
fracture can be carried out to correct the maxillary defor­
mity (see Chapter 15) (Figs. 33-2 through 33-5). The
adolescent with BCLP with an intact alveolar ridge on one
side (the other side having residual alveolar clefting and
an oronasal fistula) is essentially presenting with the same
anatomy as a patient with unilateral cleft lip and palate who
has not undergone any grafting. The surgical approach
(technique) for this patient is the same as that described for
the individual with an un-grafted unilateral cleft lip and
palate (see Chapter 32) (Fig. 33-6). For all others born with
BCLP and who present with un-grafted (open) alveolar
clefts, the modified Le Fort I osteotomy in three segments
then takes final records, including alginate impressions of
the maxillary and mandibular arches, a centric bite registra­
tion, a face-bow registration, and direct facial measure­
ments. Past medical and dental records (e.g., radiographs,
consultation reports, facial and occlusal photographs, dental
models, special studies) are reviewed. Computed tomogra­
phy scan views of the cleft alveolus can be helpful to assess
bone volume. Decisions are finalized regarding preferred
vector changes of the jaws and the precise linear distances
and angles to be accomplished in each jaw for the desired
results (see Chapter 12).2,37,38,74,75 Analytic model planning
is carried out on the articulated dental casts, and splints are
fabricated. The splints assist with the achievement of the
precise occlusion and the preferred facial aesthetics that
were determined preoperatively (see Chapter 13).
Orthognathic Approach for Bilateral
Cleft Lip and Palate Deformities
Evolution of Surgical Technique
Surgical attempts to correct jaw disharmonies in patients
with BCLP date back to Steinkamm’s 1938 description of
a Le Fort I osteotomy in a patient with BCLP.123 The early
literature warned of complications with maxillary osteot­
omy in patients with BCLP and offered incomplete descrip­
tions of surgical techniques to guide the surgeon in the
performance of safe and reliable osteotomies.9,26-30,41,42,68
However, Hugo Obwegeser’s milestone contributions to
cleft skeletal reconstruction are important (see Chapter
2).82-88 Although he succeeded in advancing a cleft maxilla
to the preferred occlusion without the need for a mandibu­
lar set-back, other clinicians did not share his enthusiasm.
Jackson and colleagues stated that patients with BCLP who
required jaw surgery must first undergo successful fistula
closure and bone grafting, and they postulated that “only
then should a Le Fort I or Le Fort II procedure be consid­
ered.”61 Ward-Booth and others described a Le Fort II oste­
otomy that was designed to protect the circulation to the
premaxillary segment.135 In 1974, Willmar described the
complications associated with the Le Fort I osteotomy.138
Eight of the 106 patients in this study had BCLP, and one
died after surgery. However, details of the operative tech­
nique were not mentioned. In 1980, Sinn described modi­
fications for bilateral maxillary alveolar cleft repair in
combination with Le Fort I osteotomy.122 He suggested
mobilization of the lateral segments and closure of the
bilateral fistula with cheek flaps. Tideman and colleagues
described at least one patient with BCLP who underwent a
Le Fort I advancement through limited vertical incisions
and subperiosteal tunneling for osteotomy exposure.130
Westbrook and associates described simultaneous maxillary
advancement and the closure of bilateral clefts and oronasal
fistulas.136 They used limited incisions with the objective of
maintaining maximum blood supply to the lateral maxillary
segments, but this prevented direct exposure of the maxil­
lary walls and full mobilization. The authors did not

1430 SECTION 5  Cleft Jaw Deformities
connected to its underlying bone, because blood flows
through this mucosa pedicle into the premaxillary bone and
teeth. The nasotracheal tube is visualized and protected
during the osteotomy that separates the vomer from the
premaxillary flap. With the lateral segments down-fractured
and the premaxillary segment out-fractured, the internal
structures of the nose are directly visualized.
If the nasal septum is deviated, submucosal exposure
allows resection of the obstructing portions of the vomer,
the perpendicular plate of the ethmoid, and the quadran­
gular cartilage using a rongeur. The structural components
of the quadrangular cartilage (i.e., the dorsal and caudal
strut) are preserved to prevent a late saddle deformity. The
inferior turbinates, if enlarged, are reduced along the whole
inferior aspect of the turbinate. The raw surfaces are then
cauterized for hemostasis. The reduction of hypertrophic
inferior turbinates will both facilitate nasal-side mucosal
flap closure and improve nasal airflow after healing. The
nasal mucosal flaps are sutured to obtain as watertight of a
nasal-side closure as possible.
The lateral maxillary segments are ligated into the pre­
fabricated acrylic occlusal splint. This is followed by the
ligation of the premaxillary segment. Through this proce­
dure, the cleft–dental gap on each side and the dead space
associated with the bony clefts are closed. To accomplish
dental gap closure, it is generally necessary to remove spurs
of alveolar bone at the interface of the lateral and premaxil­
lary segments using a rotary drill with a small watermelon
bur. This is done without perforation through the lamina
dura, which could injure the dental roots. The differential
advancement of the lateral segments also approximates the
labial and palatal mucosal flaps for effective oral-side fistula
closure. The suturing of the palatal mucosa is not necessary,
because the segmental repositioning approximates the fresh­
ened mucosal edges along the palate. The palatal mucosa
must remain adherent to the underlying bone to ensure
adequate circulation to each of the lateral segments. All
three segments are now secure in the prefabricated acrylic
splint.
The maxilla, which has been secured to the splint, is
advanced and repositioned to the mandible. The jaws are
then secured together with intermaxillary fixation. The pre­
ferred vertical dimension, which was determined preopera­
tively, is achieved to improve the facial height and the
lip-to-tooth relationships. Titanium plates are conformed
across the osteotomy sites at each zygomatic buttress and
each pyriform aperture and then secured with screws. The
intermaxillary fixation is released, and the occlusion is
checked.
The intermediate splint is removed and the lateral seg­
ments are secured with wires into the final splint. A small
amount of autogenous (iliac) cancellous bone graft is packed
along the floor of the nose and the cleft (hard) palate
on each side before securing the premaxilla into the final
splint. The dead space associated with the alveolar cleft
will be effectively closed once the premaxilla is secured into
the splint.
described in the next section should be considered (see Figs.
33-7 through 33-17).
Modified Le Fort I Osteotomy in
Three Segments
Unfortunately, in current clinical practice, a percentage of
patients with BCLP jaw deformities continue to present
with alveolar clefts, residual oronasal fistulae, and mobile
premaxillae. When completing a Le Fort I osteotomy in the
BCLP patient with open alveolar clefts, specific incision
placement is critical to maintain circulation to each of the
three segments (see Figs. 33-7 through 33-17).
A buccal (labiolateral) incision is made on each side in
the depth of the vestibule, which extends from the zygo­
matic buttress (just anterior and gingival to the parotid
duct) forward to the location of the residual oronasal fistula.
A vertical incision then continues down the mesial line
angle of the canine (or, if the canine is missing, the most
mesial tooth in each lateral segment). This mesial line angle
vertical incision begins to separate the oral and nasal mucosa
through the fistula. On the labial aspect of the premaxilla,
a vertical incision then joins the more posterior vestibular
incision and continues down along the distal line angle of
the central incisor on each side to further separate the oral
and nasal mucosa of the fistula. Care is required to prevent
any disruption of or incision into the mucosa within the
labial vestibule of the premaxilla.
The nasal and oral mucosa are also sharply incised and
separated on the palatal aspect of the premaxilla and on the
palatal aspect of each lateral segment. When this occurs,
there is complete separation of all oral and nasal mucosa of
the fistula. Care is taken to prevent any disruption or sepa­
ration of the palatal mucosa from its underlying hard palate.
Each lateral maxillary segment depends on this palatal soft
tissue for circulation into the palatal bone.
Next, on the labial side, subperiosteal soft-tissue dissec­
tion exposes the anterolateral aspect of the maxilla of each
lateral segment. A maxillary (Le Fort I type) osteotomy is
then performed through the lateral, anterior, and medial
maxillary walls using a reciprocating saw with a long,
straight blade. The pterygomaxillary sutures are separated
with a curved osteotome. The vomer is often not attached
to either lateral segment. However, if it is, a guarded osteo­
tome is used to separate it from the maxilla before the lateral
segments can be successfully down-fractured. The lateral
segments are then down-fractured and disimpacted for
three-dimensional repositioning.
Next, attention is turned to completing an “out-fracture”
of the premaxillary segment. The nasal mucosa is further
dissected from the palatal mucosa on the posterior side of
the premaxilla. The nasal mucosa and the soft tissues are
pushed superiorly into the nose. An osteotomy is performed
to free the premaxilla from the vomer. The osteotomy is
generally performed using a reciprocating saw with a short,
straight blade from the palatal side. It is imperative that the
labial vestibule mucosa (pedicle) to the premaxilla remain

1431
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
Most deficient BCLP maxilla will also require vertical
lengthening. A repaired bilateral cleft lip that has minimal
elevation with smile or that appears short and hypotonic
may caution the surgeon against the vertical lengthening
that the midface requires. The surgeon should fight the
tendency to “underlengthen” the midface.
After the maxilla is fully mobilized and positioned, as
described previously, stabilization is with titanium plates
and screws (a plate with screws at each zygomatic buttress
and pyriform rim).71 The placement of a bloc corticocancel­
lous graft wedged into the dead space between the zygo­
matic buttress and the pyriform rim plate on each side is
generally necessary (see Chapter 18). Further stabilization
across each graft with a titanium microplate and screws is
also required (see Chapter 15). When a modified (three-
segment) Le Fort I osteotomy is carried out, the soft-tissue
pedicle that provides circulation to each bone flap must be
protected during mobilization, graft placement, and stabi­
lization, as described previously.
Closure of Residual Oronasal Fistula and
Alveolar Cleft Management
Ideally, full closure of residual oronasal fistula and adequate
alveolar bone grafting will have been carried out during the
mixed dentition. If not, the modified Le Fort I in three
segments (as described previously) for the patient with
BCLP provides the opportunity for complete oronasal
fistula closure on both the palatal and labial sides, the
management of the cleft skeletal deficiencies, and the sta­
bilization of the premaxilla without the need for direct
alveolar grafting. Not uncommonly, grafting and fistula
closure were carried out during the mixed dentition, but
with only partial success. A residual fistula may remain,
and the premaxilla may not have union with one or both
lateral segments. Unfortunately, when completing a Le
Fort I procedure in the patients with BCLP with residual
fistula and non-bridging alveolar ridges, fistula closure and
union across the ridge can only be accomplished with the
use of the modified segmental approach, as described pre­
viously. Augmentation of an intact but hypoplastic alveolar
ridge at the time of down-fracture is not advisable, because
additional soft-tissue dissection around the alveolar ridge
would be required with a risk of compromised circulation
and aseptic necrosis. The option of placing a corticocancel­
lous bloc graft into the alveolar defect at the time of Le
Fort I down-fracture is also not feasible for the same
reasons.
Managing the Nasal Cavity and the Nose
In the patient with BCLP, the inferior turbinates are gener­
ally enlarged and partially blocking the nasal cavity. If so,
the reduction of the inferior turbinates will be beneficial for
breathing and sinus drainage; this is simultaneously accom­
plished through the down-fracture (see Chapter 15 and
illustrations in this chapter).
A bloc of corticocancellous iliac bone is crafted and
interposed along the bony gap created on each side when
the lateral segments were advanced. The graft is placed
between the zygomatic and pyriform plates. An additional
microplate is placed from the superior maxilla, across the
graft to the inferior maxilla, and then secured with screws.
With the cleft–dental gaps surgically closed, the labial gin­
gival mucosa on each side is directly approximated without
the need for mucosal advancement flaps. If indicated, man­
dibular and chin osteotomies and removal of wisdom teeth
are completed in the usual sequence and then fixed in place
(see Chapter 15).
After wound closure, the occlusion is maintained with
elastics. The elastics may be removed for immediate post­
operative airway management and then reapplied as indi­
cated. Maintenance of the occlusion and retraining of the
muscles are accomplished with intermittent elastics during
the next 5 weeks. For the modified Le Fort I osteotomy in
three segments, the splint frequently remains ligated to the
maxillary orthodontic brackets for a total of 7 weeks. At the
time of splint removal, the orthodontist replaces the seg­
mented maxillary surgical wires for a continuous rigid one.
The treating orthodontist actively maintains the surgically
achieved arch form and cleft–dental gap closures. The place­
ment of a transpalatal appliance secured into the lingual
tubes on the maxillary first molar bands may be a useful
adjunct to maintain the arch form after the splint is removed.
Avoiding Pitfalls
Mobilization of the Down-Fractured
Cleft Maxilla
Full mobilization of the Le Fort I osteotomy in the patient
with BCLP is the critical step needed for the achievement
of accurate intraoperative positioning and then long-term
maintenance of the maxilla. The intraoperative use of both
pterygoid and nasomaxillary disimpaction forceps is impor­
tant for full mobilization. Taking the necessary time to
slowly complete the disimpaction (10 to 15 minutes) is
often crucial to the achievement of the desired results.
Gaining experience—first through observing and assisting
an experienced cleft orthognathic surgeon and then by
using one’s own hands—is essential to achieving confidence
in the mobilization process.
Horizontal Advancement and Vertical
Lengthening of the Cleft Maxilla
The surgeon must often carry out significant advancement
and vertical lengthening of the BCLP maxilla to fully
enhance facial aesthetics, to correct the occlusion, and to
open the airway. Scarring of the palatal soft tissues from
previous repairs may be of concern when considering sig­
nificant advancement.
In general, to achieve full skeletal correction, all or most
of the negative overjet should be managed in the maxilla.

1432 SECTION 5  Cleft Jaw Deformities
out with repositioning 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 initial healing is essential for a successful
outcome after BCLP orthognathic surgery (see Chapter 11).
Cephalometric and dental radiographs and facial and occlu­
sal photographs are obtained at standard postoperative
intervals to document clinical progress. The orthodontist
sees the patient within 24 hours of splint removal (approxi­
mately 5 to 7 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 and the overall arch form. Active ortho­
dontic maintenance and finishing are started. The use of a
transpalatal appliance (i.e., a wire or a palatal plate) may
also be used to further 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 evaluate VP function with the use of
nasoendoscopic instrumentation when feasible. 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
Bilateral Cleft Lip and Palate:
Review of Study
Patients and Methods
Posnick and Tompson assessed the clinical results of 33
consecutive adolescents (age range, 16 to 24 years; mean,
18 years) with BCLP who underwent orthognathic surgery
by a single surgeon (Posnick) over a 6-year period using the
modified Le Fort I osteotomy as described previously.113 All
patients underwent perioperative orthodontic treatment,
and all were judged to be skeletally mature at the time of
jaw surgery. The clinical follow-up period ranged from 1 to
7 years (mean, 40 months) at the close of the study. The
country of origin of the patients varied (e.g., Canada,
United States, Eastern Europe, Southeast Asia), as did their
race (e.g., Caucasian, Asian, African). The patients’ initial
surgeons varied, as did their treatment protocols. All patients
had undergone primary lip and palate repair during infancy.
The number and extent of other operations (i.e., soft-tissue,
lip, nasal, and palatal procedures) varied greatly (range: 1 to
10 procedures). Many patients had undergone additional
In the patient with BCLP, the septum (bone and carti­
lage) may be significantly deviated, thus further obstructing
the airway. The completion of a submucosal resection to
open the airway with preservation of the caudal and dorsal
cartilaginous struts to prevent a saddle deformity is benefi­
cial. This is accomplished through the Le Fort down-fracture
(see Chapter 15 and illustrations in this chapter).
In the patient with BCLP, the pyriform rims and the
nasal floor may be irregular, which results in negative effects
on the airway and the nasal aesthetics. If successful grafting
had previously been accomplished, recontouring of the
pyriform rims, the nasal floor, and the nasal spine using a
rotary drill with a watermelon bur through the circumves­
tibular incision is helpful to open the airway and to improve
nasal aesthetics. This cannot be simultaneously accom­
plished with the three-segment modified Le Fort I proce­
dure in these patients (see Chapter 15 and illustrations in
this chapter).
Surgical attempts to control the nasal soft-tissue enve­
lope with suturing techniques (e.g., the alar cinch stitch)
after Le Fort I osteotomy are often suggested. In my experi­
ence, manipulating the nasal soft tissues with suturing tech­
niques at the time of Le Fort I osteotomy in the patient
with BCLP is often counterproductive to both the airway
and the aesthetics, because it does not address the primary
problem, as described previously. We anticipate that the
nasal soft tissues will redrape over the repositioned and
recontoured maxilla and the nasal base to result in an overall
improvement in aesthetics. A definitive rhinoplasty is
usually planned for 6 to 12 months after jaw surgery (see
Chapter 38).
Immediately after surgery, the nasal cavity is not packed,
and the septum is not stented. It is expected that coagulated
blood will partially block the airway. The clots will dislodge
and be self-eliminating by approximately 5 to 7 days after
surgery. The use of saline nasal sprays and the institution of
sinus precautions are both helpful during this time (see
Chapter 11).
Management of the Mandibular Deformity
In the patient with BCLP, the mandible is often secondarily
deformed. In a previously published study, we documented
that, in a significant percentage of individuals with BCLP,
the lower jaw will also benefit from sagittal split ramus
osteotomies to improve facial symmetry and propor­
tions.108,112,113 The mandibular repositioning is not carried
out in an attempt to avoid maxillary advancement but
rather to improve overall morphology (see Chapter 15).
Management of the Chin Deformity
In the BCLP patient with maxillary hypoplasia, the chin is
often secondarily deformed. Increased vertical length and a
flat pogonion are typical. If these are present, an intraoral
oblique inferior border osteotomy is simultaneously carried

1433
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
missing, and a “closed down” but residual gap was planned.
Dental restorative work was then carried out. Two other
patients had undergone the orthodontic completion of gap
closure.
The long-term maintenance of overjet and overbite was
measured directly for each patient from the late (>1 year)
postoperative lateral cephalometric radiograph. Most
patients (31 of 33; 94%) maintained a positive overjet. Two
of the 33 patients (6%) shifted into neutral overbite, and 4
of the 33 patients (12%) relapsed into a negative overbite.
There were no cases of infection that required the extended
use of antibiotics or drainage, and there was no postopera­
tive hemorrhage that required a return to the operating
room. No teeth or dentoalveolar segments were lost to
aseptic necrosis, direct surgical trauma, infection, or any
other cause. No patients underwent reoperation (orthogna­
thic procedures) for suboptimal facial aesthetics or signifi­
cant residual malocclusion.
Controversies and Unresolved Issues
Staging of Maxillary Reconstruction
The described modified Le Fort I osteotomy method for
the management of the maxillary deformity in an adoles­
cent or adult patient with BCLP who also presents with
missing teeth, oronasal fistulae, alveolar defects, cleft–
dental gaps, and nasal obstruction is not intended to
replace standard techniques and the accepted sequencing
of treatment earlier during childhood.99 However, it does
offer an effective reconstructive option after the opportu­
nity for grafting the alveolus during the mixed dentition
before the eruption of the permanent canines is lost and
if a jaw deformity coexists. A two-stage approach for the
adolescent with BCLP with maxillary hypoplasia, residual
alveolar clefts, oronasal fistulae, cleft–dental gaps, a mobile
premaxilla, and nasal obstruction is neither cost-effective
nor time-efficient, and there may be increased morbidity. It
is in these patients with BCLP that the modified Le Fort I
osteotomy in three segments with the differential reposi­
tioning of each segment offers a reasonable opportunity for
correction.98-113
Closure of Large Residual Palatal Fistula
Other indications for maxillary segmental osteotomies
include the small group of adults (i.e., those in the perma­
nent dentition) with BCLP who may have a satisfactory
overjet or overbite but who have large residual palatal and
bilabial fistulae, cleft–dental gaps, and mobile premaxillae.
The difficulty in achieving successful fistula closure is the
lack of oral-side soft tissue to secure a watertight palate
closure in the incisal foramen region. In general, there are
only two surgical options for management. One consider­
ation is an anteriorly based dorsal tongue flap that is com­
bined with an autogenous bone graft. If the size of the
attempts to close the residual oronasal fistula as well as bone
grafting to fill the alveolar clefts. The basic orthognathic
procedures that were carried out included a modified Le
Fort I osteotomy (n = 33). Ten of these patients also under­
went simultaneous sagittal split ramus osteotomies of the
mandible to correct secondary deformities. Fourteen under­
went osseous genioplasty (vertical reduction and horizontal
advancement) of varying degrees to improve profile aesthet­
ics and lip posture.
In the study group, all of the patients with BCLP required
closure of residual bilateral labial and palatal fistulas.
Twenty-six of the 33 patients had a negative overjet of the
incisors, which indicated horizontally maxillary hypoplasia.
Twenty-eight of the 33 patients also had posterior crossbites
in the lateral (lesser) segments, which indicated constriction
of the maxillary arch despite orthodontic treatment. Thirty
patients had a cleft–dental gap on each side, and one to
three teeth were missing at each cleft site; one patient had
a cleft–dental gap on just one side; and the remaining two
patients had undergone successful gap closure via orthodon­
tic treatment but had residual fistula and alveolar defects.
For the 30 patients with bilateral cleft–dental gaps, simul­
taneous surgical closure via the differential advancement of
the maxillary segments was planned. All 33 patients had
mobile premaxillae, thereby indicating inadequate bone
bridging across the cleft alveolar regions on each side. Of
the 66 cleft sites, 59 had either congenitally absent or inad­
equate lateral incisors. Ninety-three percent of patients had
an Angle Class III malocclusion on each side.
Results
All 33 adolescent patients with BCLP patients presented
with residual oronasal fistulae, mobile premaxillae, and
maxillary hypoplasia.113 Twenty-six patients underwent suc­
cessful one-stage complete fistula closure and full stabiliza­
tion of the premaxillary segment through modified Le Fort
I osteotomy, with differential maxillary segmental reposi­
tioning. The seven patients who retained small fistulas (all
in the incisive foramen region) also retained a degree of
mobility of the premaxillary segment. Final fistula closure
involved the use of local flaps with additional bone grafting
to achieve bony union of the premaxilla to the lateral
segments.
All 33 patients successfully achieved and maintained
keratinized gingiva over the cleft site and the cleft-adjacent
teeth on each side. A degree of gingival recession occurred
along the medial aspect of the canine (or the first premolar
when the canine was absent) or the distal aspect of the
incisor in 7 of the 132 cleft-adjacent teeth. None of the
cleft-adjacent teeth required root canal therapy. Five patients
required fixed prostheses to either replace missing teeth or
to improve the aesthetics of the incisors as a result of poor
enamel quality or congenital dysplasia. Thirty-one patients
who had cleft–dental gaps underwent successful closure. In
three patients, both the lateral incisor and the canine were

1434 SECTION 5  Cleft Jaw Deformities
non-extraction therapy and the maintenance of each cleft–
dental gap (i.e., lateral incisor region), followed by a single-
tooth dental implant placement or the use of another
prosthetic option. Unfortunately, in the maxillary-deficient
patient with BCLP, dental crowding generally exists, and
extractions or closure of the dental gaps will be required to
avoid long-term periodontal sequelae.
In a non-cleft population, only a few studies compare
the results of orthodontic space closure (OSC) with pros­
thetic replacement for the management of congenitally
absent maxillary lateral incisors. The absence of high-
quality clinical research to evaluate an implant replace­
ment option (as apposed to a bridge) continues to fuel the
discussion of what constitutes the optimal treatment of a
missing lateral incisor in the patient with a cleft. It has
been documented in several studies that, for an individual
with an alveolar cleft, OSC results in a healthier periodon­
tium and greater patient satisfaction than classic prosthetic
replacement.81 OSC in patients with clefts after successful
alveolar bone grafting has the added advantage of allowing
the canine to be positioned into the lateral incisor loca­
tion, thereby resulting in an improved alveolar ridge mor­
phology.1,22 A single-tooth dental implant option for the
management of the cleft–dental gap in the patient with
BCLP is an attractive theoretical alternative, but it requires
the presence of an intact maxilla (i.e., the stability of
the premaxilla to each lateral segment) with adequate alve­
olar bone volume, interproximal crestal height, and suffi­
cient attached gingiva at each cleft site for favorable
implant placement, dental aesthetics, and long-term
maintenance.49,72,91,93,115,116,128,129,133,134,146
Unfortunately, these anatomic parameters are not often
met in patients with BCLP. Furthermore, these dental
procedures are rarely covered by medical insurance, which
adds to the family’s financial burden. This approach also
requires the meticulous coordination of a spectrum of
dental specialists (e.g., orthodontist, periodontist, prostho­
dontist, surgeon) who have expertise and dedication in the
area of cleft deformity treatment. Even if implant placement
and crown restoration are successful, this will create a long-
term high-maintenance dentition for the patient. This com­
bination of factors usually favors OSC when feasible or
surgical space (dental gap) closure (via modified Le Fort I
osteotomy) when appropriate. OSC is preferably accom­
plished by successful mixed-dentition grafting and ortho­
dontic dental gap closure. Oosterkamp and colleagues
completed a retrospective study of adults with BCLP who
were missing a permanent lateral incisor at each cleft site.89
The patients were treated either with orthodontic space
closure (n = 17) or via prosthetic replacement (n = 10). The
purpose of the study was to compare the dental aesthetics
and function of OSC versus those of the prosthetic replace­
ment of the lateral incisors in patients with BCLP. The
predominant mode of prosthetic replacement was resin-
bonded bridges. Dental aesthetics were evaluated by the
patients themselves and by a professional panel. Mandibular
function was evaluated by means of the standardized
fistula, the amount of dead space, and the tissue deficit is
extensive, even a tongue flap and a bone graft will likely fail.
The best option in these difficult cases is to obturate the
fistula and to maintain the cleft–dental gaps with a tempo­
rary partial denture until early skeletal maturity (i.e., adult
dentition). A modified Le Fort I osteotomy (either two or
three segments) with differential repositioning is then per­
formed. By advancing the lateral segments, closure of the
fistula, dental gaps, and dead space can generally be achieved
(Fig. 33-9). If there is horizontal, transverse, or vertical
deficiency or deformity of the maxilla, it is simultaneously
managed.
Management of Complex Dental
Rehabilitation
Another indication for the modified Le Fort I osteotomy
(two or three segments) in the adult with BCLP is to assist
with complex dental rehabilitation when excessive cleft and
congenital anodontia gaps exist, with or without residual
fistula. There are times when horizontal maxillary projec­
tion may be satisfactory; however, a functional arch form
can best be achieved through segmental Le Fort I osteoto­
mies that are planned in conjunction with dental rehabilita­
tion (Fig. 33-15).
Malocclusion after Modified
Le Fort I Osteotomy
Despite the advantages of the described modified Le Fort I
osteotomy for complex BCLP deformities, there are two
occasional unresolved long-term shortcomings of this pro­
cedure. The first is the tendency for medial, superior, and
posterior drift (relapse) of the lateral segments after surgical
correction. To combat this relapse pattern, planned surgical
overcorrection as well as rigid transverse maintenance early
after surgery with an acrylic splint and then medium term
(6 months) orthodontic retention techniques are essential.
The second unresolved problem is the less than ideal
success rate of 80% to 85% for complete fistula closure
and premaxillary segment stabilization to the lateral seg­
ments. This is a result of the limited bone volume of the
premaxilla in many patients and the inability to apply plate
and screw stabilization (i.e., of the premaxilla to each
lateral segment) without compromise of the anterior max­
illary circulation, which is dependent on the labial mucosa
pedicle.
Philosophy Concerning the Importance of
a “28-Tooth Angle Class I Occlusion”
Another controversy for the reconstruction of the patient
with BCLP centers on a philosophy of the importance of
achieving a “28-tooth Angle Class I occlusion” with tradi­
tional “cuspid protection” rather than accepting “group
function” during lateral excursions.10,45,49,119,124,126,127 The
achievement of a 28-tooth occlusion would require

1435
CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
Skeletal Relapse after Le Fort I Osteotomy in
Patients with Clefting
There are more than 100 published articles reviewing
skeletal stability and relapse in patients with clefting
who have had Le Fort I advancement with the use
of
either
standard
osteotomies
or
DO
tech­
niques.3,11,12,17-19,31,32,39,40,51,54-58,60,65,70,78,96,125,139 These studies
do not demonstrate convincing differences in relapse pat­
terns between the two techniques. Proponents of DO tech­
niques frequently state that, when more than 10 mm of
maxillary advancement is required, the use of standard Le
Fort I osteotomy techniques with plate and screw fixation
and bone grafts may lead to a greater degree of relapse. To
put this in perspective, it should be noted that only 5% of
patients with clefting who are undergoing Le Fort I advance­
ment will require 10 mm or more of horizontal advance­
ment at the incisors. All clinicians will agree that this
subgroup of cleft patients (5%) is the most challenging. The
reasons for this go beyond the degree of horizontal maxillary
deficiency. These patients are also likely to present with
multiple residual end-stage deformities (see the section
about residual skeletal deformities earlier in this chapter)
and previously failed surgical procedures. Aksu and col­
leagues documented a horizontal maxillary relapse rate of
22% after Le Fort I osteotomy in patients with clefting who
were treated with DO techniques.4 This was found at the
3-year follow-up evaluation in a series of adult patients with
repaired cleft lips and palates who presented with maxillary
hypoplasia.
He and colleagues reported their results of treating ado­
lescents with repaired cleft lip and palate and maxillary
hypoplasia with Le Fort I advancement via an external DO
device.50 The patients (n = 17) were treated at one center
between 2000 and 2006 and had at least 1 year of follow
up and a full set of records. DO treatment started on day
5 (1 mm/day) and continued until a Class II occlusion
(overcorrection) 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 treated
patients—two with unilateral cleft lip and palate and two
with BCLP—developed fibrous non-union; all four required
reoperation and rigid fixation to achieve bony union. The
authors then extended the consolidation period to a
minimum of 12 weeks for the remaining patients (n = 13),
at which point all patients had 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 out of 13 patients (38%) developing no better than
“end-to-end” occlusion. Another orthognathic procedure
was necessary to obtain a satisfactory occlusion in 5 of the
13 patients (38%) who had initially achieved bony union.
Overall, 9 out of 17 patients (53%) required two orthog­
nathic procedures.
In 2011, Chen and colleagues reported a 30.7% inci­
dence of horizontal relapse after Le Fort I osteotomy with
the use of DO techniques in patients with clefting who
Mandibular Function Impairment Questionnaire. The level
of mandibular impairment was calculated with the use of
the standardized Functional Impairment Rating Scale. With
respect to dental aesthetics, no significant differences
between patients treated with OSC and prosthetic replace­
ment were found. With respect to function, the level of
mandibular impairment was significantly higher among
patients who were treated with prosthetic replacement as
compared with those treated with OSC.
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 BCLP. A nasoendoscopic guided examination by a
speech pathologist and a surgeon who is familiar with
cleft anatomy can closely predict current and expected VP
function in a patient who is scheduled for a Le Fort I oste­
otomy (see Chapter 8). When postoperative VP deteriora­
tion is anticipated, the patient and the family are counseled
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 oste­
otomy techniques are used in the patient with a cleft
patient.14,15,44,47,63,67,73,76,94,131 Despite the frequent need for
significant maxillary advancement to normalize the skeleton
and the facial aesthetics of patients with BCLP, we have not
had to or seen an advantage to transecting an in-place pha­
ryngeal flap to achieve maxillary mobilization and the
desired advancement. Our research and that of others con­
firms that a pharyngeal flap in place at the time of Le Fort
I osteotomy does not increase complications nor does it
result in a higher incidence of relapse.113 The definitive reas­
sessment of VP function after cleft Le Fort I advancement
can be carried out 3 to 6 months after surgery. A primary
or revision pharyngeal flap can be carried out 6 months after
orthognathic correction in conjunction with cleft rhino­
plasty or labial revision, if indicated.
Mixed-Dentition Le Fort I Osteotomy
By the mid 1980s, research clarified that, if jaw surgery is
undertaken during the mixed dentition in the patient with
a cleft palate, then another procedure to advance the maxilla
will likely be required after skeletal maturity is reached.140-144
More recently, several investigators again tested this theory
by proceeding with mixed-dentition Le Fort I osteotomies
in these patients using DO techniques.16,34,35,46,48,59,95 All
research to date indicates that the Le Fort I advancement
carried out during the mixed dentition in the patient with
clefting—whether by standard or DO techniques—results
in no further significant horizontal growth. If the mandible
continues to grow in length, an Angle Class III malocclu­
sion will occur with the need for additional Le Fort I
advancement or mandibular set-back.

1436 SECTION 5  Cleft Jaw Deformities
• If the cleft maxilla is down-fractured, adequately mobi­
lized, and stabilized with interpositional bone grafts and
plate and screw fixation, it has a high probability of
healing as planned with a predictable and less extensive
convalescence than DO.
• An experienced cleft orthognathic surgeon will be more
confident in his or her ability to down-fracture and fully
mobilize the BCLP maxilla than a less experienced
surgeon. Therefore, the less experienced surgeon will be
more likely to choose DO techniques to avoid the per­
sonal 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, residual fistula) will
lead him or her to choose DO techniques. 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 patients with BCLP and 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 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
Clinical studies document a high prevalence of jaw deformi­
ties in mature patients with BCLP. Safe and reliable surgical
methods are now available to manage the presenting cleft
jaw deformity, malocclusion, and other simultaneous resid­
ual defects (e.g., oronasal fistulae, bony defects, cleft–dental
gaps, nasal obstruction). These techniques offer the surgeon
an opportunity to improve the patient’s head and neck
function, to enhance the patient’s facial aesthetics, and to
positively affect the patient’s long-term quality of life and
well-being.
presented with Class III malocclusion.16 Interestingly,
Posnick and colleagues documented a more limited degree
of horizontal relapse and overall success when using the
modified Le Fort I techniques described for cleft patients.113
Stability and relapse were measured by a review of postop­
erative (≥1 years) cephalometric analysis and clinical exami­
nation.113 This was reported by cleft type: 94% of patients
with BCLP maintained a positive overjet long term; those
with unilateral cleft lip and palate achieved 6.9 mm of
advancement, with 5.3 mm maintained for the long term;
and those with isolated cleft palate (ICP) had 6.1 mm of
advancement, with 5.1 mm maintained over the long
term. All of the ICP patients maintained positive overjet
long-term.
Standard Approach versus Distraction
Osteogenesis Approach to Le Fort I
Advancement
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 as described.”87
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 and rigid internal fixation. The length of
downtime after surgery involving DO is longer (≥3
months of limited diet and physical activity), and it is
followed by several additional months of face mask
therapy. There is no reduction in the perioperative com­
plications when using DO techniques rather than stan­
dard techniques. The device is also awkward and socially
embarrassing, and it typically blocks the patient’s visual
fields (e.g., the RED, BLUE, or GREEN external DO
devices).
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CHAPTER 33  Cleft–Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
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