Orthognathic Surgery

1441

34
Cleft–Orthognathic Surgery: The
Isolated Cleft Palate Deformity
JEFFREY C. POSNICK, DMD, MD
• Facial Growth Implications of Cleft Palate
Repair in the Infant with Isolated Cleft Palate
• Coordinated Team Approach
• Treatment Protocol
• Timing of Orthognathic Surgery
• Residual Deformities in the Adolescent with
Isolated Cleft Palate
• Orthodontic Considerations in the Patient
with Isolated Cleft Palate with a Jaw
Deformity
• Immediate Presurgical Assessment
• Orthognathic Surgical Approach for Isolated
Cleft Palate
• Clinical Management after Initial Surgical
Healing
• Orthognathic Surgery for Isolated Cleft
Palate: Review of Study
• Controversies and Unresolved Issues
• Conclusions
Facial Growth Implications of Cleft
Palate Repair in the Infant with Isolated
Cleft Palate
Ross documented that at least 20% of Caucasian individu­
als with ICP who undergo repair during infancy will experi­
ence maxillary hypoplasia that results in malocclusion that
is not responsive to either traditional or compensatory
ortho­dontic maneuvers alone.86 Chen and colleagues
reported on horizontal maxillary growth in both children
and adults with Eastern Chinese ethnic backgrounds and
with unoperated and operated ICP.14 There were two study
groups: individuals in Group 1 had non-syndromal and
unoperated ICP that was evaluated during the mixed denti­
tion (n = 16); individuals in Group 2 had non-syndromal
and unoperated ICP that was evaluated during the perma­
nent dentition (n = 25). The control groups included
patients with ICP who underwent repair during childhood
as well as non-cleft individuals with Class I occlusion that
was evaluated during both the mixed and permanent denti­
tions. Lateral cephalograms of all subjects were analyzed.
The results of the mixed dentition groups showed almost
normal sagittal growth in unoperated patients except for the
reduced anterior-posterior maxilla length. In contrast, the
operated patients showed reduced length of both the maxilla
and mandible, as well as a clockwise rotation of the man­
dible. The analysis of the permanent dentition groups
showed that in both the unoperated and operated ICP
patients, there were reductions in maxilla length, mandibu­
lar protrusion, and maxillary retrusion. Interestingly, there
appeared to be no correlation between maxillary growth
restriction and the extent of the congenital clefting of the
secondary palate (i.e., soft palate only versus hard and soft
palate). The authors concluded that, for individuals born
with ICP, the etiology of the maxillomandibular deficiency
likely results from a combination of factors, including the
intrinsic primary (cleft) defect; secondary hypoplasia as a
result of the surgical repair during infancy (iatrogenic); and
functional (environmental) factors (e.g., the effects of
muscles of mastication, respiratory patterns, mandibular
Isolated cleft palate (ICP) is a separate entity from cleft lip
and palate. ICP has a different genetic pattern and associ­
ated anomalies, and it involves unique intraoral and facial
anatomy and its own potential for head and neck dysfunc­
tion. It is estimated that approximately 30% of individuals
born with cleft palate only (i.e., no cleft lip or alveolus) will
have other associated malformations or be part of a known
syndrome. Patients with ICP have a variety of jaw, dental,
upper airway, and speech-related needs during childhood
and into adolescence. The surgical repair of cleft palate
during infancy with revision later in childhood, when it is
needed to ensure adequate velopharyngeal competence,
may result in disturbed growth of the upper jaw.

1442 SECTION 5  Cleft Jaw Deformities
rest posture; see Chapter 4). These results were similar to
those of Yoshida and colleagues, who found that individuals
with ICP frequently end up with maxillary horizontal defi­
ciency and clockwise rotation of the maxillomandibular
complex that tend to become worse as the child reaches
adulthood.99
A significant percentage of adolescent patients who were
born with ICP will present with a jaw deformity that
requires, at minimum, a maxillary Le Fort I (down-fracture)
osteotomy to align the jaws.5,85 When indicated, this is
combined with mandibular and chin osteotomies to achieve
improved facial proportions and with intranasal procedures
(i.e., septoplasty and inferior turbinate reduction) to
improve nasal breathing.
Coordinated Team Approach
The facial reconstructive and dental rehabilitation of an
individual with ICP is best delivered via collaborative care
provided by appropriate medical and dental specialists.6,62,71
It is no longer justified for individual practitioners—whether
they are surgeons, orthodontists, restorative dentists, speech
pathologists, or otolaryngologists—to carry out extensive
treatment without informing the patient and his or her
family of available options and considering clinical input
from the other specialists who are caring for the patient.
Treatment Protocol
Patients who are referred for possible orthognathic surgery
are seen by an orthodontist, an orthognathic surgeon, a
speech pathologist, and an otolaryngologist. Consultation
with other medical (e.g., sleep specialist, geneticist) and
dental (e.g., periodontist, restorative dentist) specialists
may also be indicated. Initial records and tests include,
at minimum, medical-quality photographs, including
views of the face and the occlusion; cephalometric and
Panorex radiographs; dental models with centric bite regis­
tration; speech assessment with instrumentation (ex. naso-
endoscopy); and a thorough evaluation of the upper airway.
Discussions with the medical and dental consultants, the
family, and the patient are needed to set the clinical objec­
tives. Decisions about the timing and extent of the ortho­
dontic, surgical, and dental treatments are made in an effort
to reach the chosen objectives.
The primary cleft surgeon completes the patient’s palate
repair during infancy, and this is followed by pharyngeal
procedures later during the patient’s childhood if they are
required to improve velopharyngeal function. The surgeon
is also likely to play an important role in directing the
patient’s care throughout adolescence and into adulthood.
If the cleft surgeon is not trained in skeletal procedures,
then a timely and seamless transition to the maxillofacial
surgeon who will continue on with the patient’s reconstruc­
tion is necessary. The orthodontist identifies early abnormal
facial growth patterns and may carry out interceptive treat­
ment.6,10,11,18,19,27,34,51,55,64,65,87,90,91 Definitive orthodontic
treatment is coordinated with orthognathic surgery, when
indicated.33 Extensive compensatory orthodontic treatment
is likely to jeopardize periodontal health and to lead to
dental relapse with recurrent malocclusion. Camouflage
orthodontics should be avoided for these reasons and only
be entered into with full disclosure to the family and other
treating clinicians.
Before orthognathic surgery is performed, the speech
pathologist performs an evaluation to assess the patient’s
velopharyngeal function; this will ideally include nasoendo­
scopic instrumentation. Such evaluation is important,
because velopharyngeal function may deteriorate after
maxillary Le Fort I osteotomy with advancement (see
Chapter 8). Velopharyngeal closure that was adequate
before surgery may become borderline afterward, and
closure that was borderline may become inadequate. In the
past, investigators have speculated that, if the distraction
(DO) technique is used to advance the Le Fort I osteotomy,
then velopharyngeal function will not deteriorate. However,
clinical studies have now documented that velopharyngeal
function will deteriorate in a similar fashion after Le Fort I
advancement when either DO or standard techniques are
used.12,13,35,37,50,54,58,61,72,89,94 Articulatory distortions that
result from the jaw discrepancy and malocclusion also are
identified by the speech pathologist, and cause-and-effect
relationships are determined. It is known that the successful
orthodontic and surgical correction of crossbites, open bite,
residual palatal fistulas, and negative overjet will generally
correct the presenting articulation errors (see Chapter 8).
The otolaryngologist plays a role in the assessment of
upper airway and middle ear function. Chronic nasal
obstruction and sinusitis are frequent in the patient with a
cleft palate. Mucous trapping may also be a problem after
a pharyngeal flap procedure. If sleep apnea is suspected, an
attended polysomnogram should be carried out (see Chapter
26). If intranasal procedures (i.e., septoplasty and inferior
turbinate reduction) are needed to improve breathing, they
should be simultaneously carried out in conjunction with
orthognathic surgery (see Chapter 10).
Timing of Orthognathic Surgery
The correction of the jaw deformity associated with ICP is
best carried out when the skeleton is mature and before
the patient completes high school, if feasible. Maxillofacial
growth is generally complete between the ages of 14 and
16 years in girls and between the ages of 16 and 18 years
in boys. However, skeletal growth is variable, and it may
be further clarified via the analysis of sequential cephalo­
metric radiographs (see Chapter 17). Input from the patient
and the family regarding the timing of surgery and the
patient’s functional needs (e.g., breathing, speech, chewing,
swallowing, body image, self-esteem) are also important
considerations.
As early as 1986, clinicians clarified through preliminary
studies that, if jaw surgery is undertaken in the growing
patient with a cleft palate patient, revision orthognathic

1443
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
combination with a degree of maxillary deficiency
and clockwise rotation of the maxillomandibular
complex. The occlusion may be satisfactory with
orthodontic compensation; however, the maxillo­
mandibular horizontal deficiency with clockwise
rotation is aesthetically obvious, and it may also nega­
tively affect the upper airway (see Ch. 26).
6. Nasal obstruction and sinus blockage. Obstructed
breathing through the nose and intermittent sinusitis
are frequent in the individual who is born with ICP.
This may result from a combination of septal devia­
tion and enlarged inferior turbinates. An in-place
pharyngoplasty (e.g., a superiorly based flap, a
sphincteroplasty) may also be a cause of partial naso­
pharyngeal obstruction. These findings will also pre­
dispose these patients to obstructive sleep apnea (see
Chapter 26).
7. Velopharyngeal dysfunction. It has been documented
that approximately 20% of individuals with a
repaired cleft palate will demonstrate velopharyngeal
insufficiency by the time that they are 5 years old.
The adolescent with ICP who is arriving for the evalu­
ation of a cleft jaw deformity may have a pharyngo­
plasty in place. The Le Fort I osteotomy with
advancement is likely to improve the upper airway,
but it may negatively affect velopharyngeal function
(see Chapter 8).
Orthodontic Considerations in the
Patient with Isolated Cleft Palate with
a Jaw Deformity
A primary goal of presurgical orthodontic treatment in the
teenager with an ICP jaw deformity is to eliminate all exist­
ing dental compensations. Instituting camouflage treatment
is likely to jeopardize periodontal health, lead to dental
relapse, and it may also cause root resorption (see Chapter 5).
Correcting incisors inclination eliminating crowding,
spacing, and rotations are all important orthodontic con­
siderations. The arch form objectives are to achieve a satis­
factory occlusion at operation that can be detailed afterward.
To eliminate dental compensations, extractions may be
required. When maxillary hypoplasia with negative overjet
results in posterior crossbites as a result of “pseudo” con­
striction, it is important to not orthodontically overexpand
the arch width. In the patient with ICP patient as compared
with the patient with unilateral or bilateral cleft lip and
palate, treatment is simplified because the alveolus is intact
(i.e., there are no alveolar clefts) and there is generally a full
complement of teeth.
Immediate Presurgical Assessment
When approaching the time of surgery, updated records are
obtained, including alginate impressions of the maxillary
surgery will likely be required after skeletal maturity is
reached.95-98 More recently, other investigators have tested
this theory by proceeding with Le Fort I osteotomy involv­
ing DO methods during the mixed dentition. Studies to
date indicate that a Le Fort I osteotomy carried out during
the mixed dentition, whether with a standard or a DO
technique, results in limited or no further horizontal maxil­
lary growth.17,36,46,73,74 As the mandible continues to grow,
an Angle Class III malocclusion recurs with the need for
either additional Le Fort I advancement or mandibular
set-back.
Residual Deformities in the Adolescent
with Isolated Cleft Palate
The adolescent or adult patient with ICP who is referred
for orthognathic evaluation will have an intact alveolar
ridge and generally will have a full complement of teeth.
However, these individuals may present with one or more
of the following residual cleft-related problems (Figs. 34-1
through 34-9):
1. Maxillary dysplasia. When maxillary dysplasia occurs
in the patient with ICP, it generally follows one of
two patterns. The first and most frequently seen is
horizontal maxillary retrusion, generally with a degree
of vertical deficiency and often with clockwise rota­
tion of the maxillary plane. The second pattern is
vertical maxillary excess with a more limited degree
of horizontal retrusion. The latter tends to occur in
the presence of nasal obstruction with forced mouth
breathing and an open-mouth posture, especially if a
pharyngeal flap was placed during childhood (see
Chapter 4).
2. Residual oronasal (palatal) fistula. There may be a
residual midline palatal fistula located in the region
between the incisive foramen and the soft palate. This
is a residual defect that occurs after initial palate
repair earlier in life.
3. Residual bony defects. The alveolus is not clefted, but
residual bony defects of the hard palate are to be
expected. The hard palate bony defects do not gener­
ally require grafting or reconstruction.
4. Chin dysplasia. The patient with ICP will frequently
be a mouth breather with resulting open-mouth
posture. The end result is often a vertically long and
flat chin (i.e., a limited projection of the pogonion).
If the Robin sequence was present at birth, a degree
of microgenia will likely be a component of the defi­
ciency (see Chapter 4).
5. Mandibular dysplasia. True mandibular prognathism
in the patient with ICP is not common, but it may
be seen more frequently among patients with certain
ethnic backgrounds (e.g., Asian). A degree of man­
dibular retrognathism as a residual aspect of the
Robin sequence is likely. This often occurs in
Text continued on p. 1465

1444 SECTION 5  Cleft Jaw Deformities
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A
B
• Figure 34-1  A 19-year-old woman who was born with
isolated cleft palate. The maxillary deformity is characterized
primarily by horizontal deficiency. The patient underwent
mandibular first bicuspid extractions. She was referred to
this surgeon and agreed to a comprehensive orthodontic
and orthognathic surgical approach. The patient’s proce­
dures included Le Fort I osteotomy (horizontal advancement,
vertical lengthening, and clockwise rotation) with interposi­
tional grafting; osseous genioplasty (vertical reduction
and horizontal advancement); and septoplasty and inferior
turbinate reduction. A, Frontal views in repose before and
after reconstruction. B, Frontal views with smile before
and after reconstruction. C, Profile views before and after
reconstruction.

1445
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
E
F
Ortho in progress after mandibular bicuspid extraction
After treatment
D
D, Occlusal views during orthodontics and after reconstruction. E, Articulated dental
casts indicate analytic model planning. F, Lateral cephalometric radiographs before and after reconstruction.
A, C, D (top center and bottom center), E (right), from Posnick JC: Skeletal stability and relapse patterns
after Le Fort I osteotomy using miniplate fixation in patients with isolated cleft palate. Plast Reconstr Surg
94:51, 1994.
• Figure 34-1, cont’d

1446 SECTION 5  Cleft Jaw Deformities
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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A
B
• Figure 34-2  A 19-year-old woman who was born
with isolated cleft palate. The deformity is character­
ized by vertical maxillary excess and jaw asymmetry.
The patient underwent four-bicuspid extractions.
She was referred to this surgeon and agreed to
a comprehensive orthodontic and orthognathic
approach. The patient’s procedures included Le
Fort I osteotomy (minimal horizontal advancement,
clockwise rotation, vertical intrusion, and asymmetry
correction); bilateral sagittal split ramus osteotomies
(correction of asymmetry); osseous genioplasty (ver­
tical reduction); and septoplasty, inferior turbinate
reduction, and nasal recontouring. A, Frontal views
in repose before and after reconstruction. B, Frontal
views with smile before and after reconstruction.
C, Profile views before and after reconstruction.

1447
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
E
F
Prior to treatment after four-bicuspid extractions
After treatment
D
D, Occlusal views with orthodontics in progress and after reconstruction. E, Articulated dental casts
indicate analytic model planning. F, Lateral cephalometric radiographs before and after reconstruction.
• Figure 34-2, cont’d

1448 SECTION 5  Cleft Jaw Deformities
A
B
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A
©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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C. Pos
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o nicicicick
• Figure 34-3  A 17-year-old girl who was born
with isolated cleft palate. The deformity is charac­
terized primarily by horizontal maxillary deficiency
and a palate fistula. The patient was referred to this
surgeon and agreed to a comprehensive orthodon­
tic and orthognathic approach. The maxillary lateral
incisors were congenitally absent. The patient’s
procedures included a Le Fort I osteotomy (horizon­
tal advancement and vertical lengthening) with
interpositional grafting. One year after the initial pro­
cedure, she underwent an anterior-based dorsal
tongue flap procedure for palatal fistula closure.
A, Frontal views in repose before and after recon­
struction. B, Frontal views with smile before and
after reconstruction. C, Profile views before and
after reconstruction.

1449
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
E
F
Prior to surgery with absent maxillary lateral incisors
After treatment
D
D, Occlusal views with orthodontics in progress and after reconstruction. E, Articulated dental casts
indicate analytic model planning. F, Lateral cephalometric radiographs before and after reconstruction. A, C, D, F, from
Posnick JC, Tompson B: Cleft–orthognathic surgery: complications and long-term results. Plast Reconstr Surg 96:255, 1995.
• Figure 34-3, cont’d

1450 SECTION 5  Cleft Jaw Deformities
• Figure 34-4  The patient from Figure 34-3 is shown after the successful placement of an anterior-based dorsal
tongue flap for palatal fistula closure. A, Palatal views before and after the tongue-flap closure of a recalcitrant fistula.
B, Facial views of the patient demonstrating a full range of tongue motion after the harvesting of tissue for palatal
reconstruction.
B
©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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Su
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Surgery
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C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
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C.
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©Elsevier Inc.
Or
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Orthththththththththththththththththththththththththththththththththththththththththththththogn
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Su
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Surgery
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C.
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C.
C.
C.
C.
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C.
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C.
C.
C.
C.
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C.
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A

1451
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
B
C
D
E
Or
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g atatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicic Su
Su
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S rgery
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C.
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C.
C.
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C.
C.
C.
C.
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A
• Figure 34-5  A 17-year-old girl with a recalcitrant fistula at the incisal foramen region. The fistula had
been present since the time of her initial cleft palate repair, despite several attempts at closure at another
institution during the patient’s childhood. She was referred to this surgeon for management. The fistula
at the incisive foramen was successfully closed with an anteriorly based dorsal tongue flap. A, Facial
views before fistula closure. B, Intraoperative view of the palatal fistula, with ink used to mark the extent
of the bony defect. C, Local palatal flaps were developed and turned over for nasal-side closure. D, The
elevated anteriorly based dorsal tongue flap is shown. It measured two thirds of the width of the tongue
and was approximately 5 cm in length. E, The flap is inset to cover the oral side of the palatal defect.
The tongue flap is then sutured to the adjacent palatal tissue three quarters of the way around. The
posterior aspect of the flap is not sutured, because this would compromise flap circulation. The oro-
tracheal tube can be seen on the side of the tongue.
Continued

1452 SECTION 5  Cleft Jaw Deformities
H
I
G
©Elsevier Inc.
Or
Or
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Or
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Or
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O hththththththththththththththththththththththththt ogn
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g atatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surgery
ry
ry
ry
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ry
ry
ry
ry
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ry
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ry
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ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
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©Elsevier Inc.
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g atatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surgery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C. Pos
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osnicicicicicicicicicicicicicicicici k
F
F, Range of motion of the tongue is demonstrated at 10 days after flap inset
and before flap release. G, Illustration of a cross-sectional sagittal view of face. The tongue flap is shown
inset into the palate. Intra-operative view just 10 days after the procedure is also shown. She is returned
to the operating room for flap release and inset. H, Intraoperative view of the dorsum of the tongue
just after sectioning of the flap and before recontouring. I, Palatal view of bulky tongue tissue on the
roof of the mouth before recontouring.
• Figure 34-5, cont’d

1453
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
L
J
K
©Elsevier Inc.
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Or
Or
Or
Or
Or
Or
Or
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O ththththththththththth
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Su
S rgery
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C.
C.
C.
C.
C. Po
Po
Po
Po
Po
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Po
Po
Po
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snicicicicicicicicicick
©Elsevier Inc.
Or
Or
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O ththththththththogna
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C.
C.
C.
C.
C.
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Po
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Posn
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©Elsevier Inc.
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r ; J.J.J.J.J.J C.
C.
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©Elsevier Inc.
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thicicicicicicicicicicicicic Su
Su
S rgery
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C.
C.
C.
C.
C.
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C.
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Po
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sn
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snicicicicicicicicicicicick
M
J, Palatal view 3 months after flap inset and before debulking. K, Dorsum
of the tongue 3 months after flap inset. L, Palatal views before and 8 months after the tongue flap
was placed and debulking procedure completed. M, Demonstration of the range of tongue motion
3 months after flap release.
• Figure 34-5, cont’d

1454 SECTION 5  Cleft Jaw Deformities
A
B
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
• Figure 34-6  A 16-year-old girl who was born with isolated cleft palate. The deformity is characterized by horizontal and vertical deficiency of
the maxilla and obstructed nasal breathing. The patient agreed to a comprehensive orthodontic and orthognathic surgical approach. Her maxillary
first bicuspids were removed. The patient’s procedures included Le Fort I osteotomy (horizontal advancement and vertical lengthening) with
interpositional grafting; osseous genioplasty (vertical reduction and horizontal advancement); and septoplasty and inferior turbinate reduction.
A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.

1455
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
C
D
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 34-6, cont’d 
Continued

1456 SECTION 5  Cleft Jaw Deformities
F
G
Prior to surgery after maxillary bicuspid extractions
After treatment
E
E, Occlusal views with orthodontics in progress and after reconstruction. F, Articulated dental casts
that indicate analytic model planning. G, Lateral cephalometric radiographs before and after reconstruction.
• Figure 34-6, cont’d

1457
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 34-7  A woman in her early 20s who was born with isolated cleft palate. The deformity is characterized primarily by the horizontal and
vertical deficiency of the maxilla. She was referred to this surgeon and agreed to a comprehensive orthodontic and orthognathic surgical approach.
She had a congenital absence of some of her teeth, and also required extractions. All total four bicuspids in the maxilla and two bicuspids in the
mandible are missing. The patient’s procedures included Le Fort I osteotomy (horizontal advancement and vertical lengthening) with interpositional
grafting; osseous genioplasty (vertical reduction and horizontal advancement); and septoplasty and inferior turbinate reduction. A, Frontal views in
repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.
Continued

1458 SECTION 5  Cleft Jaw Deformities
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Profile views before and after reconstruction. D, Worm’s-eye views before and after reconstruction.
• Figure 34-7, cont’d

1459
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
F
G
Presurgery after maxillary four-bicuspid and mandibular two-bicuspid extraction / congenital absence
After treatment
E
E, Occlusal views with orthodontics in progress and after reconstruction. F, Articulated dental casts
that indicate analytic model planning. G, Lateral cephalometric radiographs before and after reconstruction. A, B, C (left),
E (top middle, bottom middle), F, G, from Posnick JC, Ewing MP: The role of plate and screw fixation in the treatment of cleft
lip and palate jaw deformities. In Yaremchuk MJ, Gruss JS, Manson PM, eds: Rigid fixation of the craniomaxillofacial skeleton.
Stoneham, Mass, 1992, Butterworth, pp 466–485.
• Figure 34-7, cont’d

1460 SECTION 5  Cleft Jaw Deformities
C
©Elsevier Inc.
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Su
Su
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©Elsevier Inc.
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Su
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A
B
• Figure 34-8  A 16-year-old girl who was born with
isolated cleft palate. The deformity is characterized
primarily by the horizontal and vertical deficiency of
the maxilla and chronic obstructed nasal breathing.
The patient was referred to this surgeon and under­
went a combined orthodontic and orthognathic sur­
gical approach. Four bicuspids were removed. The
patient’s procedures included Le Fort I osteotomy
(vertical lengthening and horizontal advancement)
with interpositional grafting; sagittal split ramus
osteotomy of the mandible (clockwise rotation);
osseous genioplasty (vertical reduction and horizon­
tal advancement); and septoplasty and inferior tur­
binate reduction. A, Frontal views with smile before
and after reconstruction. B, Oblique views before
and after reconstruction. C, Profile views before and
after reconstruction.

1461
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
E
Presurgery after four-bicuspid extractions
After treatment
D
D, Occlusal views with orthodontics in progress and after reconstruction. E, Lateral cephalometric radiographs
before and after reconstruction.
• Figure 34-8, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 34-9  A woman in her late 20s who was born with isolated cleft palate. She developed a jaw deformity with malocclusion. Attempts to
neutralize the occlusion included four bicuspid extractions with 6 years of orthodontic growth modification and orthodontic mechanics when the
patient was between 11 and 17 years old. She was left with generalized labial bone loss and gingival recession, especially of the lower anterior
teeth. She presented to this surgeon as an adult with a lifelong history of obstructed nasal breathing and a long face growth pattern that involved
the maxilla, the mandible, and the chin; this included excess anterior facial height and horizontal retrusion. She was evaluated by clinicians in many
specialties, including periodontics, prosthodontics, orthodontics, surgery, speech pathology, and otolaryngology. She underwent periodontal treat­
ment and then ortho­dontic decompensation. The patient’s procedures included Le Fort I osteotomy (horizontal advancement, vertical intrusion and
clockwise rotation); bilateral sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical
reduction and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before
and after reconstruction. B, Frontal views with smile before and after reconstruction.

1463
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 34-9, cont’d 
Continued

1464 SECTION 5  Cleft Jaw Deformities
Prior to retreatment after four-bicuspid extractions
Pre surgery
After treatment
E
E, Occlusal views before retreatment, after orthodontic decompensation, and after reconstruction.
• Figure 34-9, cont’d

1465
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
F
G
Arch expansion
8
Mandibular counter-
clockwise rotation
Maxillary clockwise
rotation
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric
views before and after reconstruction.
• Figure 34-9, cont’d 
and mandibular arches, a centric relation bite registration,
a face-bow registration, and facial measurements. The
patient’s medical and dental records are reviewed, including
radiographs; dental models; photographs of the face and the
occlusion; and special studies. Decisions are made with
regard to the preferred changes (i.e., repositioning) of the
jaws and the precise millimeter distances and angles required
in each jaw to achieve the desired result (see Chapter 12).59,60
Analytic model planning is carried out on the articulated
dental casts, and splints are constructed. The splints assist
with the achievement of the precise occlusion and the pre­
ferred facial aesthetics that were determined preoperatively
(see Chapter 13).
Orthognathic Surgical Approach for
Isolated Cleft Palate
Evolution of Surgical Techniques
In general, the primary jaw deformity observed in the
adolescent with ICP is maxillary hypoplasia or dysplasia
as a result of the original cleft deformity and the subse­
quent surgical interventions.31,32 The usual reconstructive
procedure to consider is a Le Fort I maxillary osteot­
omy.20,28,30,47,53,56,92 Obwegeser showed that a circumvestib­
ular incision with the separation of the pterygoid maxillary
sutures followed by down-fracture and the disimpaction of

1466 SECTION 5  Cleft Jaw Deformities
orthodontic maintenance of the surgical result and the
detailing of the occlusion are generally resumed after initial
healing (i.e., 5 weeks after surgery). A seamless transition
from the surgeon to the orthodontist for ongoing care is
essential. Speech and velopharyngeal function maybe reas­
sessed 3 months after surgery. If a pharyngeal flap, a revision
pharyngoplasty, or final palatal fistula closure is required,
this can be carried out 6 months after the orthognathic
procedure.
Orthognathic Surgery for Isolated Cleft
Palate: Review of Study
In a previously published study, we assessed initial and long-
term skeletal stability after Le Fort I osteotomy in 14 skel­
etally mature patients with ICP who underwent palate
repair during infancy and who then presented as adolescents
with maxillary dysplasia and malocclusion.83
Patient and Methods
In a study by Posnick and colleagues, the medical records,
longitudinal cephalometric radiographs, and current clini­
cal examinations of all patients with ICP who underwent
Le Fort I osteotomy over a 3-year period by a single surgeon
(Posnick) were reviewed.83 The following information was
noted: all previous cleft and maxillofacial surgical proce­
dures; stabilization techniques; the presence of a pharyngo­
plasty; the use of a bone graft; perioperative orthodontics;
age at surgery; perioperative morbidity; and, at final follow
up, the amount of overjet and overbite of the incisors.
All patients were skeletally mature at the time of the opera­
tion. In all patients, lateral cephalograms were taken before
surgery and at 3 to 7 days, 6 to 8 weeks, and 1 year
postoperatively.
On each preoperative radiograph, the facial plane was
constructed for each patient. At the level of the palatal
plane, a perpendicular plane was constructed to form a
Cartesian coordinate system that was referenced for skeletal
measurements. The serial radiographs taken after surgery
were superimposed on the anterior cranial base structures
with the Cartesian coordinate axes as planes of reference.
Vertical and horizontal directional changes were then mea­
sured at each postoperative interval. With the radiographs
superimposed, the amount of horizontal advancement was
measured by the method of anatomic best fit. Vertical
change over time was analyzed anteriorly at the incisor area
and posteriorly at the first molar area. Actual measurements
could be determined reliably within 0.5 mm. The 1-year
postoperative lateral cephalograms also were assessed for the
measurement of incisor overjet and overbite.
Differences between groups were assessed by Student’s
t-test. Associations between the magnitude of surgical
advancement and the degree of relapse were examined by
the Pearson correlation coefficient (r) and by least-squares
linear regression analysis. Correlations were considered sig­
nificant when the P value was less than .05.
the maxilla was not only possible but clinically relevant.66-70
This allowed the maxilla to be moved in any direction,
either as one unit or in segments. Obwegeser clarified that
full mobilization of the down-fractured maxilla was essen­
tial to the achievement of an orthognathic correction on
the operating room table and to the limiting of skeletal
relapse over time. Bell and others validated the use of the
Obwegeser Le Fort I technique to allow for adequate
blood supply for routine satisfactory bone healing without
aseptic necrosis or dental injury (see Chapter 2).3,4,7,21-24
Current Operative Technique
The surgical technique for management of the maxillary
deformity involves a standard circumvestibular incision and
Le Fort I osteotomy (see Chapter 15).75-81,83,84 In the patient
with ICP, the soft-tissue dissection may be difficult just
before down-fracture as a result of the scarring of the nasal
mucosa to the palatal tissue. There will be a need to sharply
separate the oral and nasal layers completely during the
down-fracture procedure. Note that this is not a contrain­
dication to maxillary surgery but rather just a technical
point. Care is taken to prevent the subperiosteal dissection
(i.e., separation) of the palatal mucosa from the underlying
hard palate, because this would compromise circulation to
the down-fractured maxilla. Although it is of interest, the
presence of a pharyngeal flap generally does not alter the
surgical approach. This author has not found it necessary
to section an in-place flap to accomplish the planned surgi­
cal objectives.
Residual palatal oronasal fistulas in the patient with ICP
will be difficult to close simultaneously with the Le Fort I
procedure; the elevation and transposition of palatal flaps
are generally required to do so, and this would compromise
the blood supply to the down-fractured maxilla. Interest­
ingly, if a water-tight nasal side closure can be achieved
through the down-fractures before the maxilla is fixed in its
new location, then the residual palatal side mucosa separa­
tion will frequently heal by secondary intention. However,
if a palatal fistula remains, it can be closed 6 months to 1
year after the orthognathic procedure, either with local
palatal flaps or, if necessary, by using an anteriorly based
dorsal tongue flap.82
The simultaneous management of secondary deformities
frequently requires bilateral sagittal split osteotomies of the
mandible and an oblique osteotomy of the chin. If removal
of impacted wisdom teeth is recommended for long-term
dental health this is accomplished at the same time. If sep­
toplasty or inferior turbinate reduction or both are required
to improve nasal airflow, then the procedures are also carried
out simultaneously (see Chapter 10).
Clinical Management after Initial
Surgical Healing
After surgery, cephalometric and Panorex radiographs and
facial photographs are obtained at standard intervals. The

1467
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
2.0 mm immediately after the operation and 1.4 mm after
1 year. The mean posterior vertical change of the maxilla
was 2.7 mm immediately after the operation and 1.9 mm
after 1 year (mean relapse, 0.8 mm).
Controversies and Unresolved Issues
Skeletal Stability after Le Fort I Osteotomy
The study by Posnick and Taylor assessed the skeletal stabil­
ity and relapse patterns in mature adolescents and young
adults with ICP who underwent palate repair during infancy
and who later developed maxillary dysplasia that required
orthognathic surgery for the improvement of facial balance,
the airway and the occlusion.83 Interestingly, the skeletal
stability in the patients with ICP after Le Fort I osteotomy
was somewhat better than that documented in patients with
unilateral cleft lip and palate. Posnick and Taylor’s study
confirm that an in-place pharyngoplasty does not contrib­
ute to relapse or increase perioperative morbidity. Roughly
half the measured horizontal and vertical relapse occurred
during the first 6 weeks after the operation, and the remain­
der occurred during the rest of the first year. A long-term
positive overjet and overbite was maintained in all patients.
The Standard Approach versus the Distraction
Approach to Le Fort I Advancement
The use of a DO technique to reposition the maxilla gradu­
ally over several weeks into the preferred horizontal position
and to then hold the maxilla in place with the DO appliance
for several months during the consolidation phase is rela­
tively inconvenient and costly to the patient, the family, and
the health care system. It remains a distant second choice
as compared with the standard approach when the surgeon
is able to down-fracture the maxilla, adequately mobilize it,
and then place it into the preferred position in the operating
room. The standard approach originally described by Obwe­
geser during the 1960s and then continually refined offers
a safe and effective way to manage most jaw deformities that
occur in the patient with ICP.66-70 Despite two decades of
use, the DO technique for maxillary advancement has not
been shown to offer less morbidity or improved stability for
the patient with a cleft jaw deformity.* It does not allow for
the correction of the deformity during childhood, as many
clinicians had initially hoped it would. No horizontal
growth can be expected after a Le Fort I osteotomy is carried
out, whether with a DO approach or a standard appro
ach.17,36,46,73,74,95-98 The DO approach has not diminished the
occasional occurrence of velopharyngeal insufficiency after
Le Fort I osteotomy, and it has not eliminated the problem
of skeletal relapse.12,13,35,37,50,54,58,61,72,89,94 Alternatively, the
DO approach is useful in unusual circumstances, when the
surgeon is not able to adequately mobilize and fully advance
the maxilla as planned in the operating room. For patients
All patients underwent a standard one-piece Le Fort I
osteotomy extended through the zygomatic buttress (i.e.,
below the malar eminence) and anteriorly into the pyriform
apertures. After titanium mini-plates were used to rigidly
fix the osteotomy in place, crafted corticocancellous iliac
bone grafts were wedged between the zygomatic buttress
and the pyriform aperture on each side and secured with an
additional micro-plate and screws. Simultaneous bilateral
sagittal split ramus osteotomies were used in 4 of 14 patients
to manage secondary deformities. All subjects underwent a
simultaneous osseous genioplasty. In all patients, the pre­
fabricated splint secured to the maxillary orthodontic brack­
ets confirmation that the occlusion remained unchanged for
5 weeks.
The age at operation ranged from 17 to 25 years
(mean, 19 years). During the study period, the ICP patients
(N = 14) represented just 12% of the surgeon’s patients with
cleft lips and palates who underwent orthognathic surgery.
All study patients had a complete set of longitudinal records
(clinical and cephalometric) and were available for late post­
operative clinical reassessment. Clinical follow up ranged
from 1.5 to 5.5 years (mean, 2.5 years) after surgery at the
close of the study.
Results
Perioperative morbidity was unremarkable when patients
were reviewed for cardiopulmonary compromise, maxillo­
facial infections, hemorrhage, aseptic necrosis, loss of teeth,
or the need for root canal therapy. All patients maintained
a positive overjet and overbite at the incisor level, which was
documented on both the 1-year clinical and cephalometric
examinations. No significant difference was seen in vertical
or horizontal surgical change or in postoperative relapse
between those who had Le Fort I osteotomy only (n = 10)
and those who underwent simultaneous Le Fort I and
bilateral sagittal split ramus osteotomies of the mandible
(n = 4) or between those who underwent iliac bone grafts
(n = 10) and those who did not (n = 4). With reference to
these variables, the patients were therefore considered a
homogeneous group for the purposes of further analysis.
As measured directly from the serial cephalometric radio­
graphs for each patient, the mean horizontal advancement
achieved was 6.4 mm, and 5.4 mm of advancement was
maintained at 1 year. Three of the 14 patients showed no
more than 0.5 mm of relapse, and none had more than 1.5
mm of relapse. In the eight patients without a pharyngo­
plasty in place at the time of Le Fort I osteotomy, the hori­
zontal advancement was 6.1 mm immediately after the
operation and 5.1 mm 1 year later. The remaining six
patients achieved a similar horizontal advancement both
immediately after the operation (6.9 mm) and 1 year later
(5.9 mm).
The vertical change that was achieved initially and then
maintained over the long term was analyzed in both the
anterior and posterior regions of the upper jaw to assess
regional differences in skeletal ability patterns more accu­
rately. The mean anterior vertical change of the maxilla was
*References 1, 2, 8, 9, 15, 16, 25, 26, 29, 38, 39, 40-45, 48, 49, 52, 57,
63, 78, 83, 84, 88, 93

1468 SECTION 5  Cleft Jaw Deformities
downtime for the patient during the initial convalescence
period (see Figure 34-4 and 34-5).
Conclusions
Patients with ICP present varied dental, occlusal, upper
airway, middle ear, speech-related, and aesthetic needs
throughout their childhood, adolescent, and adult years. At
least 20% of these patients who undergo palate repair
during infancy will develop maxillary dysplasia that is not
responsive to orthodontic treatment alone. An integrated
comprehensive surgical–orthodontic approach is required
to resolve these problems at the time of skeletal maturity.
When indicated, a Le Fort I osteotomy in combination
with mandibular, chin, and intranasal procedures represents
the standard of care for the establishment of improved
facial balance, occlusion and dental rehabilitation, and
breathing.
of special concern, the surgeon may wish to discuss the DO
option before the Le Fort I advancement occurs. If the
surgeon is unable to sufficiently mobilize and reposition the
maxilla with the use of standard techniques, then a DO
appliance can be placed (see Chapter 32).
Closure of Large Residual Palatal Fistula
When a recalcitrant large oronasal fistula at the incisal
foramen region remains in a patient with ICP, palatal flaps
alone may not be adequate for closure. In these cases,
options are limited. This author often suggests achieving
nasal side closure with the use of local full-thickness palatal
(turnover) flaps and then obtaining oral side closure by
elevating and placing an anteriorly based dorsal tongue
flap. The tongue flap will provide needed vascularized soft
tissue for effective fistula closure on the oral side.82 This
approach does require the sacrifice of a small portion of
the tongue donor site, a second general anesthetic, and
References
1. Aksu M, Saglam-Aydinatay B, Akcan CA,
et al: Skeletal and dental stability after
maxillary distraction with a rigid external
device in adult cleft lip and palate patients. J
Oral Maxillofac Surg 68:254–259, 2010.
2. Araujo A, Schendel SA, Wolford IM, et al:
Total maxillary advancement with and
without bone grafting. J Oral Surg 36:849,
1978.
3. Bell WH, Fonseca RJ, Kennedy JW III, et al:
Bone healing and revascularization after total
maxillary osteotomy. J Oral Surg 33:253,
1975.
4. Bell WH: Le Fort I osteotomy for correction
of maxillary deformities. J Oral Surg 33:412,
1975.
5. Berkowitz S: State of the art in cleft palate or
facial growth and dentistry: A historical
perspective. Am J Orthod 74:564–576, 1978.
6. Bishara SE: Cephalometric evaluation of facial
growth in operated and nonoperated
individuals with isolated clefts of the palate.
Cleft Palate J 3:239–245, 1973.
7. Bloomquist DS: Intraoperative assessment of
maxillary perfusion during Le Fort I
osteotomy [discussion]. J Oral Maxillofac Surg
52:831, 1994.
8. Braun TW, Sotereanos GC: Orthognathic and
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adolescent cleft patient. Aust Dent J 22:338,
1977.

1469
CHAPTER 34  Cleft–Orthognathic Surgery: The Isolated Cleft Palate Deformity
29. Freihofer HPM Jr: Results of osteotomies of
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44. Horster W: Experience with functionally
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45. Houston WJB, James DR, Jones E, Kavvadia
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46. Huang CS, Harikrishnan P, Liao YF, et al:
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47. Hui E, Hägg EU, Tideman H: Soft tissue
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48. Jackson IT: Cleft and jaw deformities.
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49. James D, Brook K: Maxillary hypoplasia in
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50. Janulewicz J, Costello BJ, Buckley MJ, et al:
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51. Jorgenson RJ, Shapiro SD, Odiner KL:
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52. Kanno T, Mitsugi M, Hosoe M, et al:
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53. Kiehn CL, DesPrez JD, Brown F: Maxillary
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54. Ko EW, Figueroa AA, Guyette TW, et al:
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J Craniofac Surg 10:312–320,
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55. Lu D-W, Shi B, Wang H-J, Zheng Q: The
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387, 2007.
56. Luhr HG: Zur stabilen osteosynthese bei
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57. Luyk NH, Ward-Booth RP: The stability of
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58. Marrinan EM, LaBrie RA, Mulliken JB:
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Craniofac J 35:95–100, 1998.
59. McCance AM, Moss JP, Fright WR, et al:
Three-dimensional analysis techniques.
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60. McCance AM, Orth M, Moss JP, et al:
Three-dimensional analysis techniques. Part 4:
Three-dimensional analysis of bone, and soft
tissue to bone ratio of movements in 24 cleft
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preliminary report. Cleft Palate Craniofac J
43:58–62, 1997.
61. McComb R, Marrinan E, Nuss RC, et al:
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62. McKinstry RE: Cleft palate dental care: A
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63. Molina F, Ortiz Monasterio F, de la Paz
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1998.
64. Motohashi N, Kuroda T, Filho LC, et al: P-A
cephalometric analysis of nonoperated adult
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65. Nanda SK: Patterns of vertical growth in the
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66. Obwegeser HL: Surgery as an adjunct to
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353, 1966.
67. Obwegeser HL: Surgical correction of
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Paper read at the First International
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68. Obwegeser HL: Surgical correction of small
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deformity. Plast Reconstr Surg 43:351,
1969.
69. Obwegeser HL: Surgical correction of
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70. Obwegeser HL, Lello GE, Farmand M:
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71. Perko M: The history of treatment of cleft lip
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72. Phillips JH, Klaiman P, Delorey R,
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73. Polley JW, Figueroa AA: Management of
severe maxillary deficiency in childhood
and adolescence through distraction
osteogenesis with an external, adjustable,
rigid distraction device. J Craniofac Surg
8:181, 1997.

1470 SECTION 5  Cleft Jaw Deformities
74. Polley JW, Figueroa AA: Rigid external
distraction: Its application in cleft maxillary
deformities. Plast Reconstr Surg 102:1360,
1998.
75. Posnick JC: Orthognathic surgery in the cleft
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77. Posnick JC: The treatment of secondary and
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patient: Surgical and orthodontic therapy.
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1992.

1471

SECTION 6  Post-Traumatic Dentofacial Deformities
35
Management of Secondary Jaw
Deformities after Maxillofacial Trauma
JEFFREY C. POSNICK, DMD, MD
• Posttraumatic Temporomandibular Joint
Ankylosis in the Pediatric Population
• Posttraumatic Saddle-Nose Deformity
• Posttraumatic Orthognathic Deformities
• Posttraumatic Segmental Dentoalveolar
Defects
• Conclusions
Posttraumatic Temporomandibular
Joint Ankylosis in the Pediatric
Population
Background
The treatment of TMJ ankylosis poses challenges to the
maxillofacial surgeon as a result of technical difficulties asso­
ciated with access to the joint, the currently available autog­
enous and prosthetic TMJ replacement options, and the
high incidence of ankylosis recurrence. Failure to restore
adequate mandibular opening is likely to result in speech
and swallowing impairment; difficulty with mastication;
poor oral hygiene and dental neglect; continued facial
growth disturbances; and the potential for airway compro­
mise. The surgical management of bony ankylosis of the
TMJ requires the complete excision of the involved osseous
mass with intraoperative achievement of satisfactory passive
mouth opening. The immediate reconstruction with a cos­
tochondral rib graft is often carried out, and this is followed
by a postoperative physiotherapy regimen to maintain
mouth opening. A number of authors have critically evalu­
ated the treatment of TMJ ankylosis in adults, with less
emphasis placed on addressing this problem exclusively in
the pediatric population.*
In a study by Posnick and colleagues, a consecutive series
of nine pediatric patients (mean age, 7.7 years) who under­
went a standardized treatment protocol for 13 affected
ankylosed temporomandibular joints was reviewed.88 Four
patients had unilateral TMJ ankylosis, and five had bilateral
ankylosis. One child required bilateral release but only uni­
lateral reconstruction. Radiographic evidence demonstrated
bony ankylosis in all 13 operated joints. Two patients had
Despite the best of intentions by the primary trauma team,
a subgroup of individuals who sustain facial injuries later
present with deformities that require secondary reconstruc­
tion. The initial evaluation and resuscitation of the indi­
vidual who has sustained craniomaxillofacial trauma is
similar to that of patients with other organ system injuries.
At times, the patient’s general health and other body region
injuries are likely to take precedence over the management
of any facial fracture. In addition, there are treatment
options to consider for each craniomaxillofacial fracture,
and judgment is required to select the approach that is most
likely to result in a favorable outcome: open versus closed
reduction; method of fixation; grafting requirements;
immediate or delayed dental treatment; and the manage­
ment of associated soft-tissue injuries. Treatment is indi­
vidualized to accommodate the healing of each fracture and
to simultaneously consider cerebral function, vision, breath­
ing, chewing, swallowing, speech, the cervical spine, and
temporomandibular joint (TMJ) injuries and to maintain
cardiovascular health. Another factor is the residual facial
growth requirements in a child who sustains an injury and
who has not yet reached skeletal maturity. If the injured and
repaired craniomaxillofacial bones do not grow normally,
secondary deformities result over time. For all of these
reasons, secondary deformities after facial skeletal injury
(with or without effective primary repair) may occur and
require later reconstruction. Specific patterns of secondary
maxillofacial deformities are seen with enough frequency
that each is reviewed separately.
*References 1, 3-6, 8, 12, 13, 16-19, 34, 36, 41, 42, 44-47, 56, 57, 59,
61, 62, 67, 68, 71, 73, 76, 78-81, 87, 88, 96, 98-100, 102-104, 116,
119, 120, 122, 123

1472 SECTION 6  Post-Traumatic Dentofacial Deformities
previously undergone surgical intervention of the TMJ. The
cause of ankylosis within the study group was primarily
traumatic or congenital. The protocol that was followed
included complete excision of the involved ankylotic struc­
tures with mobilization through coronal scalp and Risdon
neck incisions as well as the achievement of wide mouth
opening. This was followed by immediate costochondral
grafting. Fixation with mini-plates and screws allowed for
early mobilization with the rapid institution of a physio­
therapy program (Fig. 35-1).
For the study patients, despite the achievement of full
passive mouth opening in the operating room, less long-
term success was realized. Those with unilateral TMJ anky­
losis maintained the best long-term vertical opening. On
average, they went from 5 mm of maximum vertical opening
(separation of the incisors) before surgery to 25 mm of
active range of motion maintained for the long term. For
patients with bilateral TMJ ankylosis, the maximum long-
term incisal opening was only 18 mm. Mean follow-up
duration at the close of the study was 2 years. Perioperative
complications were minimal, with no evidence of infection,
facial nerve injuries, or need for transfusion. In general,
patients with unilateral or bilateral ankylosis of traumatic
cause achieved satisfactory functional results after surgery,
whereas those in the bilateral congenital TMJ ankylosis
group attained results that were far more limited. This likely
represents limitations in the intrinsic neuromotor function
of the congenital cases.
Controversies and Unresolved Issues
Knowing the cause of TMJ ankylosis helps with the under­
standing of its pathophysiology. In developed countries, the
most common etiology is trauma, followed by infec­
tion.33,48,121,125,126 Topazian found an association with trauma
in 39% and with infection in 43% of patients with TMJ
ankylosis (N = 229).119 Since the late 1970s, authors have
found trauma to be a more frequent cause than infection,
probably because of the use of antibiotics to combat the
latter. In a report of a series of patients with TMJ ankylosis,
Rajgopal and colleagues concluded that 80% of cases were
traumatic in origin.96 Unfortunately, these reviews lumped
both pediatric and adult patients together.
Surgical attempts to release TMJ ankylosis have been
described dating back to 1850.5 Since then, ankylosis
release followed by reconstruction using a variety of
alloplastic
and
autogenous
materials
has
been
repoted.9,15,34,46,50,53,62,68,72,79,81,101,114,124,129 Although Gillies
first described costochondral grafting for TMJ reconstruc­
tion in 1920,30 it was Poswillo93,94 and MacIntosh and
Henny53 who popularized its use during the 1970s. Poswillo
attempted to demonstrate the histologic and physiologic
similarities between the mandibular condyle and rib carti­
lage in humans.93 MacIntosh and Henny described 26 cases
of costochondral grafting for mandibular condyle replace­
ment, with 6 of them being for ankylosis.53 Their approach
included graft stabilization with interosseous wires and
intermaxillary fixation (IMF) for 6 to 8 weeks. They claimed
subsequent growth of the grafts in their pediatric patients,
but they failed to provide any objective data.
In 1973, Kennett reported on two cases of unilateral
TMJ ankylosis in young patients who underwent the com­
bination of condylectomy, coronoidectomy, and reconstruc­
tion with a wired rib graft.45 He concluded that ankylosis
in children should be treated as soon as possible and that
recurrence is the most frequent complication. In 1986,
Munro and colleagues reviewed their series of 18 adult and
pediatric patients with TMJ ankylosis and facial defor­
mity.67 Their reconstruction included interosseous wiring of
the rib graft and 8 weeks of IMF followed by physiotherapy.
They demonstrated better results in unilateral ankylosis
cases than in bilateral cases. The next year, Lindqvist and
associates described 27 patients of varying ages with TMJ
ankylosis; 25 of them underwent costochondral graft recon­
struction. Fixation was also by direct interosseous wires, but
IMF was reduced to 3.5 weeks to encourage early mobiliza­
tion and to limit recurrence. The maximum incisor opening
improved from 16 mm to 31 mm. In 1987, Politis and
others reported satisfactory results in six patients (five
adults) with ankylosis.81 They employed a preauricular
approach that involved the use of costochondral grafts and
either wire or plate and screw fixation followed by 2 or 6
weeks of IMF, respectively. However, 50% of their patients
developed seventh cranial nerve palsies. In 1990, Kaban and
colleagues described their experience in 14 adult and pedi­
atric patients with TMJ ankylosis and indicated satisfactory
results.41,42 The protocol reported by Posnick and colleagues
was similar to that of Kaban and colleagues except that the
former found that the use of a mini-plate with screw fixa­
tion improved stability (as compared with interosseous wire
fixation), thereby allowing for the minimal use of IMF and
the early initiation of mandibular range of motion with
active physiotherapy.88
In 2009, Kaban and colleagues described an updated
protocol for the management of TMJ ankylosis exclusively
in children.78,79,122,123 They restated their observation that
the most common cause of treatment failure was inadequate
resection of the ankylotic mass followed by the failure to
achieve adequate passive maximum opening in the operat­
ing room. Clearly, unless adequate passive mandibular verti­
cal opening is achieved in the operating room, failure will
inevitably occur. Unfortunately, this is no guarantee that
mouth opening will be maintained. Their seven-step proto­
col consisted of the following:
1. Complete excision of the fibrous and/or bony anky­
lotic mass
2. Coronoidectomy of the affected side
3. Coronoidectomy of the contralateral side if steps 1
and 2 do not result in a maximum incisal opening
(>35 mm) or opening to the point of dislocation of
the unaffected TMJ
4. Lining of the TMJ with either a temporalis myofascial
flap or the native disc, if it can be salvaged

1473
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
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• Figure 35-1  A 5-year-old girl
was referred to this surgeon after
intracapsular condyle fractures of
the mandible resulted in bilateral
temporomandibular joint ankylosis.
These fractures were unrecognized
and went untreated at the time of
injury 1 year earlier. A, Preoperative
frontal
views
showing
maximal
opening limited to 4 mm. B, Preop­
erative computed tomography scan
that demonstrates the bony ankylo­
sis of each condyle to its zygomatic
arch. Intraoperative view demon­
strates ankylosis to the zygomatic
arch to the condyle as viewed
through the coronal scalp incision.
C, Intraoperative view of costochon­
dral graft placement through the
coronal scalp incision. Stabilization
of the rib graft through Risdon neck
incision with the use of a mini-plate
and screws.
Continued

E
F
Or
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Or
Or
Or
Orthththththththththththththththththththththth
r ogn
gn
gn
gn
g atatatatatathicicicic Su
Surg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
o nicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththtr ogn
gn
gn
g atatatata hicic Su
Surg
r ery
ry
r ; J.C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththth
r ogn
gn
gn
gn
g atatatatatathicicicici Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C Posnicicicicicicicicicicicicicicicicicick
D
D, Facial views 1 year after reconstruction showing good cranial nerve VII function and sat­
isfactory vertical mouth opening being maintained. E, Postoperative Panorex and anteroposterior facial radiographs.
F, Facial view with maximum mouth opening maintained 3 years after reconstruction but with asymmetrical overgrowth
of the costochondral grafts. Occlusal view 3 years after reconstruction that shows an asymmetrical Angle class III
malocclusion as a result of the overgrowth.
• Figure 35-1, cont’d

1475
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
5. Reconstruction of the ramus condyle unit with either
proximal segment osteotomy and distraction osteo­
genesis or costochondral graft and plate and screw
fixation
6. Early mobilization of the jaws: If distraction osteo­
genesis is used to reconstruct the ramus condyle unit,
mobilization begins the day of operation. In patients
who are undergoing costochondral graft reconstruc­
tion, mobilization begins after 10 days of IMF.
7. All patients receive rigorous physiotherapy after
surgery to maintain mouth opening, generally for at
least 3 to 6 months
Observations and Recommendations
Several generalizations can be made about pediatric patients
with TMJ ankylosis. First, in first-world countries as in the
adult population, trauma remains a prevalent cause, and
this is followed closely by congenital issues. In underdevel­
oped countries, infection continues to be an important
causative factor.92 Second, although patients with unilateral
ankylosis present with a severely limited preoperative
opening, they are more likely to achieve satisfactory long-
term functional results. Third, children with bilateral con­
genital TMJ ankylosis generally attain poor long-term
results, despite adequate intraoperative release. This is likely
the result of associated masticatory muscle anomalies,
neuromuscular discoordination, or longstanding muscular
disuse atrophy. Fourth, the use of mini-plate and screw fixa­
tion of the graft diminishes the need for immobilization,
thereby allowing for the early institution of physiotherapy.
Unfortunately, this does not guarantee the maintenance of
a satisfactory long-term opening. Fifth, when a costochon­
dral graft is used in children, only several millimeters of
cartilage should remain. This is to limit the frequent com­
plication of overgrowth and its complex secondary deformi­
ties. In clinical practice, overgrowth after costochondral
grafting remains a frequent occurrence (see Chapter 28
and Fig. 35-1). Sixth, for most patients, reconstruction to
achieve long-term maxillomandibular harmony must wait
until they have achieved skeletal maturity (i.e., 14 to 18
years of age).
Posttraumatic Saddle-Nose Deformity
Background
Nasal injuries are often recognized but then ignored as
being unimportant.11,82,86 When a depressed nasal fracture
occurs in a child, injury to the growth center leaves the nose
prone to a so-called “saddle deformity” with flattening of
the osseocartilaginous vault.63 In general, the overlying soft
tissues, the upper and lower lateral cartilages, and the nasal
lining are distorted but remain intact. Reconstruction of a
saddle deformity that involves the bony and cartilaginous
dorsum is generally carried out with an autogenous graft
(e.g., chondral, costochondral, iliac, split- or full-thickness
cranial) (Fig. 35-2).27,28,32,38,60,74,91,117,118,131 The use of an allo­
genic graft (e.g., porous polypropylene) is always a second
choice as a result of a higher incidence of associated infec­
tion and extrusion.43 The type of graft material selected
(e.g., bone, cartilage, allograft), the method of fixation, the
incisions required for access, the extent of dorsum that
requires reconstruction, and the timing of treatment are all
important details and will vary according to the age of the
patient, the extent of the deformity, and the surgeon’s per­
sonal preferences (see Chapter 38).
Involvement of Both the Bone and the
Cartilage Vault
The autogenous graft used (e.g., chondral, costochondral,
rib, iliac, split- or full-thickness cranial) is contoured to
provide reasonable nasal dorsum morphology. When the
whole dorsum requires reconstruction (i.e., the radix to
the nasal tip), the lower lateral cartilages are sutured over
the top of the graft to provide a more natural tip contour
and feel (see Fig. 35-2). When a bone graft extends from
the radix to the tip, minor degrees of graft resorption at the
tip should be anticipated. When correcting the saddle
deformity with bone graft, freshening the base of the nasal
bones with a rotary drill before graft placement is carried
out; the onlay graft will then rest on a bleeding base. The
accurately shaped graft is either dovetailed into a bony
groove at the nasofrontal process or abutted to the frontal
bones while resting evenly on the contoured and freshened)
dorsal base to establish the correct nasofrontal angle. Stabi­
lization of the bone graft is either with microplates and
screws or transcutaneous Kirschner wires, depending on the
access provided by the incisions that are used for the recon­
struction. If a coronal scalp incision or a direct vertical nasal
incision is used, plate and screw fixation is easily accom­
modated. An open approach (i.e., a columella splitting inci­
sion) should be combined when a coronal scalp incision is
used to best manage the lower lateral cartilages and the nasal
tip (see Chapter 38 and Fig. 35-2).
Involvement of the Cartilage Vault Only
When the saddle deformity causes collapse of the septal
cartilage without injury to the nasal bones, then a cartilage
graft reconstruction is preferred. A rib cartilage dorsal
strut graft is crafted and placed flush with the nasal bones.
The graft then extends caudal to the tip. The tip of the
dorsal strut graft is joined to a second rib cartilage graft
(caudal strut) that extends from the base of the maxilla to
the nasal tip. The caudal strut is stabilized with a short
buried Kirschner wire (no. 35 threaded) that is secured to
the base of the maxilla/anterior nasal spine region and then
pierced into the graft (Fig. 35-3). There is no advantage to
harvesting the L-shaped rib cartilage graft as one unit. The
separately crafted dorsal strut and caudal strut grafts are
then joined together at the tip with non-resorbable suture.
The lower lateral cartilages are sutured together and over the

1476 SECTION 6  Post-Traumatic Dentofacial Deformities
B
Donor site
Or
Or
Or
Or
Or
Orthth
r ogn
gn
gn
gn
g atathicic Su
Surg
r ery
ry; J.C.
C.
C Pos
o nicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatathicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
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os
os
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o nicicicicicicicicicicicici k
A
• Figure 35-2  A 4-year-old boy fell and hit the bridge of his nose on a hard tabletop, which resulted in a saddle-nose deformity (i.e. osseous and
cartilagenous vault). He arrived for evaluation when he was 8 years old and then underwent reconstruction through a coronal scalp incision with
nasal osteotomies (in-fracture) and the placement of fixed crafted full-thickness cranial grafts. A, Frontal view at 3 years of age just before injury
and at 8 years of age just before surgery. B, Intraoperative views through the coronal scalp incision that show the frontonasal region and the
proposed right calvarial donor site. Crafted full-thickness cranial bone grafts are shown before placement for nasal reconstruction. Stabilization is
achieved with microplates and screws. A close-up view of the frontonasal region shows the full-thickness cranial bone grafts in place and stabilized
with microplates and screws.

1477
CHAPTER 35  Management of Secondary Jaw Deformities after Maxillofacial Trauma
E
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g atatatatatatatathicicicicicic Su
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C Pos
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g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
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r ery
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C.
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C.
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C.
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C.
C.
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C.
C Pos
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osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
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gn
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g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
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Su
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C.
C.
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C.
C.
C.
C.
C.
C.
C Pos
os
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C
D
C, Frontal views before and 6
months after reconstruction. D, Oblique views before and
6 months after reconstruction. E, Lateral radiographs of the
nose before and 6 months after reconstruction.
• Figure 35-2, cont’d 
Continued