Khe Hở Môi Và Vòm Miệng: Chẩn Đoán Và Quản Lý Điều Trị (Cleft Lip and Palate)

545
24 LeFort I Osteotomy
24.4
Technique (Fig. 24.6 )
Unless work is to be done on the nose, a nasal
intubation is used. If the premaxilla is absent,
an oral tube can be used and simply brought
through the central empty space. Schendel et al.
( 1979 ) described a technique whereby they
brought an oral tube behind the maxillary tuber-
osity; however, it seems that this method is
dif fi cult unless a major advancement is to be
performed. It also precludes putting a bone graft
in the pterygomaxillary gap. It is better to
perform the lip and nasal work surgery at a
separate sitting.
Fig. 24.6 LeFort I osteotomy ( a ) Osteotomy through lat-
eral maxilla. ( b ) Osteotomy through the medial portion of
the maxilla. ( c ) Separation of the volar from the septum
with a double guarded osteotome. ( d ) Pterygomaxillary
maxillary disjunction with a curved Tessier osteotome.
( e ) Digital down fracture of the osteotomized segment. ( f )
Further mobilization with a row of forceps* if necessary.
( g ) Retrotuberocity anterior levering with a blunt elevator

546
S.A. Wolfe and S. Berkowitz
If the alveolus is intact, and expansion of the
maxilla is not required, the LeFort I osteotomy is
an easy procedure. The nonintubated nostril is
packed with cocaine/epinephrine-impregnated
gauze, as for a rhinoplasty, and the upper labial
sulcus is in fi ltrated with a 1: 200,000 epinephrine/
hyaluronidase solution. The incision is made above
the re fl ection of the sulcus, sparing the frenulum.
The mucosal incision does not extend beyond the
fi rst molar. Subperiosteal dissection of the anterior
maxilla is carried out to the infraorbital rims, visu-
alizing the infraorbital nerves, and then taken pos-
teriorly beneath the mucoperiosteal tunnel to the
pterygomaxillary space using a Cushing elevator.
If the dissection is strictly subperiosteal, there is
no bothersome exposure of the buccal fat. The
piriform aperture is dissected, sometimes remov-
ing a portion of the nasal spine, and the nasal
mucoperiosteum is dissected back to the hard pal-
ate–soft palate junction. The septum either can be
separated bluntly from the vomer or a guarded
osteotome can be used. The osteotomy is per-
formed largely with the reciprocating saw, starting
laterally in the thick bone beneath the buttress of
the zygoma and proceeding medially through thin-
ner bone (Fig. 24.6a, b ). The osteotomy through
the piriform aperture and medial wall of the antrum
is done with the saw blade pointed laterally
(Fig. 24.6b, c ). Section of the palatine bone, the
sole attachment of the maxillary tuberosity to the
pterygoid plate of the sphenoid, is done with either
a curved Dautrey osteotome or the somewhat
larger Kawamoto osteotome (Fig. 24.6d ). The lat-
eral osteotomy can be taken a bit further back by a
few taps on a straight osteotome, and the medial
antral wall can be further sectioned with a guarded
nasal osteotome. At this point, the only remaining
attachment of the lower maxillary segment is the
posterior wall of the antrum, and fi rm, downward
fi nger pressure on the maxilla is usually enough to
produce a down-fracture (Fig. 24.6e ). If not, the
Rowe forceps can be inserted underneath the nasal
mucosa and the maxilla completely mobilized
with a downward and side-to-side motion. It can
be further mobilized with a blunt elevator used as
a lever (Fig. 24.6f, g ).
The maxilla is then placed in the desired
occlusal relation with the mandible, and both
jaws are placed in the desired relation with the
rest of the face. An autogenous iliac or cranial
bone graft is used when the face is to be length-
ened, when the degree of advancement is more
than 5–6 mm, or when the patient has a cleft. If
the maxilla is shortened, the resected bone is
placed over the osteotomy lines.
Sometimes the alveolus is intact, but the max-
illa may need to be expanded as in a cleft patient
who has had a bone graft of the alveolar cleft.
This procedure is easily performed from above,
and the palatal mucosa is kept intact if possible.
The section is performed with the reciprocating
saw, and an elevator is inserted to gently pry the
two segments apart. The expansion forceps can
be used if required. If the palatal mucosa abso-
lutely prevents expansion, it is divided, creating
an alveolar and anterior palatal cleft (Fig. 24.6 ).
If there is an alveolar cleft to begin with, the
two maxillary segments are handled indepen-
dently and brought into proper occlusion with the
mandible. The palatal cleft–nasal fl oor defect is
bone-grafted, and if necessary a transportation
fl ap is developed from the buccal sulcus (Burian)
to close the palatal defect. In rare instances a
tongue fl ap is required. The nasal lining, which
was carefully dissected at the beginning, is
closed before the palatal bone graft is inserted
(Fig. 24.7 ).
The procedure has now reached a stage that is
the same regardless of whether the alveolus was
initially intact.
Osteosynthesis wires are passed between the
upper and lower portions of the maxilla, and sus-
pensory wires are taken through the thick bone
beneath the zygomatic buttress laterally.
If bone grafts are required, they are placed
either between or over the osteosynthesis ante-
riorly. If the advancement is more than 5–6 mm,
bone grafts can be wedged into the pterygomaxil-
lary gap. This step is facilitated by using a trac-
tion wire placed through the thick bone beneath
the nasal spine. The wire is used to pull the max-
illa to the opposite side, which opensthe gap and
allows impaction of the bone graft. The suspen-
sory wires from the buttress are brought through
the inferior mucosal fl ap and wired to the upper
arch bar. If further suspensory wires are needed,

547
24 LeFort I Osteotomy
they can be brought down from the infraorbital
rim. Circumzygomatic wires are almost never
used: They pull the maxilla back, they are too long
(long wires can “stretch” more than short wires),
and they do not prevent the anterior maxilla from
rocking downward (Figs. 24.8 and 24.9 ).
Like the sagittal splitting procedure for the
mandible, the LeFort I osteotomy, once mastered,
Fig. 24.7 LeFort I osteotomy in a patient with a unilat-
eral cleft. Autogenous bone grafts are always used, not
only to help consolidation and prevent relapse but to
improve appearance. I use an iliac or cranial bone graft on
all cleft patients, as these patients are likely to have a
relapse. Generally, the bone can also be used as an onlay
to fi ll out a de fi cient maxilla. If the advancement is less
than 5–6 mm, bone is placed only over the anterior osteot-
omies and in the alveolar and palatal cleft, if present. The
use of anything other than a fresh autogenous bone graft is
unwise. It takes about 15 min to harvest the needed amount
of iliac or cranial bone, and the patient will be comfort-
able as far as the hip is concerned within 1–2 weeks. By
this time, autogenous grafts will have consolidated.
Consolidation with cadaver or demineralized bone or with
hydroxylapatite may require 6 months, if indeed it occurs
at all. Are we doing the patient a favor here by “sparing”
him or her an iliac bone graft? Probably not

548
S.A. Wolfe and S. Berkowitz
Fig. 24.8 Case JR-AT-94. Midfacial advancement to cor-
rect an anterior crossbite and improve facial aesthetics and
occlusion. Surgical history: this patient was originally
treated in Honduras. Lip closure at 2 months, and palatal
closure at 8 months of age. No attempt was made to close
the palatal fi stulae. Oral facial evaluation: Midfacial hyp-
oplasia with an anterior and right buccal crossbite.
Treatment plan: Advance and expand both dental arches
and close the palatal fi stulae when surgically advancing
the maxilla. Results: Although the patient had a cleft of
the lip and palate with twinned deciduous lateral incisors
in the line of the cleft, one of the permanent lateral inci-
sors was well developed, the other malformed. The mal-
formed impacted tooth was extracted, a secondary alveolar
cranial bone graft, and fi stula closing procedure were all
performed at the same time (13–11). A LeFort I maxillary
advancement brought the teeth into Class I relationship

549
24 LeFort I Osteotomy
Fig. 24.9 Case JR (AT-94). Surgical maxillary advancement (LeFort I). Pre-and postmaxillary advancement
can provide a solution to a number of maxillary
problems. After the horizontal osteotomy, down-
fracture, and mobilization, the maxilla can be:
1. Advanced directly with or without a bone
graft (noncleft class III patient).
2. Advanced, or advanced and expanded trans-
versely, with a bone graft (cleft patient).
3. Moved superiorly after resection of a mea-
sured amount of maxilla above the horizontal
osteotomy (long face: vertical maxillary
excess). Differential upward movement can
also be used to close an anterior open bite.
4. Moved inferiorly, with a bone graft (short
face: vertical maxillary de fi ciency).
5. Sectioned into multiple segments with dental
extractions: Wassmund or Schuchardt proce-
dure from above.
6. Moved directly backward. It is dif fi cult to do
(the resection should be of the maxillary
tuberosity after extraction of the third molars
rather than of the pterygoid plate). The same
result can generally be achieved by an associ-
ated segmental osteotomy performed more
anteriorly.

550
S.A. Wolfe and S. Berkowitz
CASE. # JR. AT-94
Pre-op
SNA
NAPO
SNPO
ANB
72
172
75
1
76
176
75
5
Post-op - - -
Fig. 24.10 Case JR. Lateral
cephalometric tracings
before and after LeFort I
maxillary advancement and
inferior positioning. The
mandible autorotated
posteriorly reducing the
mandibular prominence.
Maxillary advancement
moved the upper lip forward
while the lower lip remained
practically in the same
position
24.5
Multiple Maxillary Osteotomies
With the maxilla in the down-fractured position,
multiple osteotomies can be performed from
above, which, coupled with dental extractions,
permit correction of complex malarrangements
of the maxilla in one stage. The circulation to the
anterior segment comes entirely through the pal-
atal mucoperiosteum, and one must be certain
that there are no protrusive edges from the
occlusal splint to impinge on the anterior palate.
Any number of transverse or sagittal osteotomies
can be performed depending on the requirements
of the individual case.
Class III malocclusion following isolated cleft
palate repair. The patient had a large palatal cleft
that was closed at 18 months of age with a von
Langenbeck repair. Because of severe velopharyn-
geal insuf fi ciency, a bipedicle island fl ap incorpo-
rating both greater palatine arteries was positioned
at age 7, along with a palatal pushback. Following
this procedure speech has been normal, but the
patient showed subsequent restriction of maxillary
growth, both transversely and in the posteroante-
rior direction. After preliminary orthodontic expan-
sion of the maxilla, a LeFort I osteotomy was done
at age 16. The maxilla was advanced without
dif fi culty and stabilized in the usual fashion with
iliac bone grafts. The mucosa beneath the horizon-
tal incision at the end of the procedure was pale
blue, which is not unusual in a cleft patient.
However, over the next few days the upper portion
of the mucosal fl ap proceeded to slough in a way
that suggested lack of blood supply more than
infection. Healing eventually occurred, with partial
obliteration of the upper labial sulcus and partial
exposure of the roots of the central incisors, which
required periodontal treatment. Despite vigorous
and sustained postoperative orthodontic treatment,
the occlusion relapsed to a Class III relation.
Figure 24.10 shows a patient who has had a
unilateral palatal island fl ap can safely undergo a
LeFort I osteotomy, but as this patient demon-
strates, it is not a safe procedure in one who has
had diversion of both greater palatine arteries.
Either the mandible should be moved back or a

551
24 LeFort I Osteotomy
Fig. 24.11 ( a – j ) Class III malocclusion following iso-
lated cleft palate repair. The patient had a large palatal cleft
that was closed at 18 months of age with a von Langenbeck
repair. Because of severe velopharyngeal insuf fi ciency, a
bipedicle island fl ap incorporating both greater palatine
arteries was positioned at age 7, along with a palatal push-
back. Following this procedure speech has been normal,
but the patient showed subsequent restriction of maxillary
growth, both transversely and in the posteroanterior direc-
tion. After preliminary orthodontic expansion of the max-
illa, a LeFort I osteotomy was done at age 16. The maxilla
was advanced without dif fi culty and stabilized in the usual
fashion with iliac bone grafts. The mucosa beneath the
horizontal incision at the end of the procedure was pale
blue, which is not unusual in a cleft patient. However, over
the next few days the upper portion of the mucosal fl ap
proceeded to slough in a way that suggested lack of blood
supply more than infection. Healing eventually occurred,
with partial obliteration of the upper labial sulcus and par-
tial exposure of the roots of the central incisors, which
required periodontal treatment. Despite vigorous and sus-
tained postoperative orthodontic treatment, the occlusion
relapsed to a Class III relationship. Figure 24.10 shows a
patient who has had a unilateral palatal island fl ap can
safely undergo a LeFort I osteotomy, but as this patient
demonstrates, it is not a safe procedure in one who has had
diversion of both greater palatine arteries. Either the man-
dible should be moved back or a LeFort II osteotomy per-
formed in which most of the anterior vestibular
mucoperiosteum is preserved. ( a , b ) A raw area of the
anterior palate following placement of a bipedicle island
fl ap showing rapid healing by secondary epithelialization.
( c , d ) Subsequent maxillary deformity 5 years later. Note
the transpalatal scar band
a
b
c
d

552
S.A. Wolfe and S. Berkowitz
Fig. 24.11 (continued)
e
i
l
m
j
k
f
g
h
( e – j ) Before and after LeFort I
osteotomy. Note the appearance of the gingiva above the
maxillary incisors. ( k ) There is partial exposure of the
roots of the central incisors. ( l , m ) Degree of relapse after
6 months, with partial obliteration of the upper labial
sulcus

553
24 LeFort I Osteotomy
LeFort II osteotomy performed in which most of
the anterior vestibular mucoperiosteum is pre-
served. Figure 24.10 shows a raw area of the
anterior palate following placement of a bipedicle
island fl ap showing rapid healing by secondary
epithelialization. Figure 24.10 shows subsequent
maxillary deformity 5 years later. Note the trans-
palatal scar band.
Fig. 24.12 Bilateral cleft with absent premaxilla.
Original treatment had been administered in Cuba, and
the premaxilla had been excised at the time of the lip clo-
sure. Severe maxillary collapse ensued. A LeFort I osteot-
omy and maxillary expansion was performed, with bone
grafting of the palatal cleft. A prosthesis replaced the
missing teeth. Following this, Ralph Millard proceeded
with a cleft lip rhinoplasty and Abbe fl ap

554
S.A. Wolfe and S. Berkowitz
References
Bralley RC, Schoeny ZG (1977) Effects of maxillary
advancement on the speech of a sub-mucosal cleft
palate patient. Cleft Palate J 14:98–101
Carpenter CWS, Nanda RS, Currier GF (1989) The
skeletal stability of LeFort I downfracture osteot-
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922–925
Champy M (1980) Surgical treatment of midface deformi-
ties. Head Neck Surg 2:451–465
Dez Prez JD, Kiehn CL (1974) Surgical positioning of the
maxilla. In: Georgiade NG (ed) Symposium on man-
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Epker BN (1981) Superior surgical repositioning of the
maxilla: long term results. J Oral Maxillofac Surg
9:237–246
Epker BN, Wolford LM (1976) Middle-third facial osteot-
omies – their use in the correction of acquired and
developmental dentofacial and craniofacial deformi-
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Friehofer HPM Jr (1977) Results of osteotomies of the
facial skeleton in adolescence. J Maxillofac Surg
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Hochban W, Ganz C, Austermann KH (1993) Long-term
results after maxillary advancement in patients with
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Horster W (1981) Rezidive und Komplikationen nach
Anwendung von Osteosyntheseplatten in der korrek-
tiven Chirurgie von Mittelgesichtsanomalien. Fortschr
Kiefer Gesichtschir 26:142–144
Houston WJB, James DR, Jones E, Kavvadia S (1989)
LeFort I maxillary osteotomies in cleft palate cases.
J Crainiomaxillofac Surg 17:9–15
Iannette G, Chimenti C, Di Paolo C (1989) Five year
follow-up LeFort I maxillary osteotomies in cleft pal-
ate cases. J Craniomaxillofac Surg 17:9–15
Jabaley ME, Edgerton MT (1969) Surgical correction of
congenital midface retrusion in the presence of man-
dibular prognathism. Plast Reconstr Surg 44:1–8
Luyk NH, Ward-Booth RP (1985) The stability of LeFort
I-advancement osteotomies using bone plates without
bone grafts. J Maxillofac Surg 13:250–253
Persson G, Hellem S, Nord PG (1986) Bone plates for
stabilization LeFort I-osteotomies. J Maxillofac Surg
14:69–73
Posnick JC, Ewing MP (1990) Skeletal stability after LeFort
I maxillary advancement in patients with uni-lateral
cleft lip and palate. Plast Reconstr Surg 5:706–710
Prof fi t WR, Phillips C (1987) Stability following superior
repositioning of the maxilla by LeFort I-osteotomy.
Am J Orthod Dentofacial Orthop 92:151–161
Rosen HM (1986) Miniplate fi xation of the LeFort
I-osteotomy. Plast Reconstr Surg 78:748–754
Schendel SA, Oeschlaeger M, Wolford LM, Epker BN
(1979) Velopharyngeal anatomy and maxillary
advancement. J Maxillofac Surg 7:116–124
Schwarz C, Gruner E (1976) Logopaedic fi ndings following
advancement of the maxilla. J Maxillofac Surg 4:40–55
Teuscher K, Sailer HF (1982) Stability of LeFort
I-osteotomy in Class III cases with retropositioned
maxillae. J Maxillofac Surg 10:80–83
Ward-Booth RP, Bhatia SN, Moos KF (1984) A cephalo-
metric analysis of the LeFort I-osteotomy in the adult
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Witzel MA, Munro IR (1977) Velopharyngeal insuf fi ciency
after maxillary advancement. Cleft Palate J 14:176–180
Wolfe SA, Berkowitz S (1989) Plastic surgery of the facial
skeleton. Little, Brown, Boston

Part XI
Orthognathic Surgery

557
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_25, © Springer-Verlag Berlin Heidelberg 2013
25
25.1
Facial Growth Implications of
Cleft Palate Repair in Infancy
25.1.1 Unilateral Cleft Lip and Palate
Ross completed a multicentered long-term facial
growth study to assess the need for orthognathic
surgery in individuals born with complete UCLP,
having undergone primary lip and palate repair in
childhood (Ross 1987 ; Abyholm et al. 1981 ) . He
concluded that even by the most conservative stan-
dards and in conjunction with maximum compen-
sating orthodontic camou fl age maneuvers, at least
25 % of adolescents with UCLP require orthog-
nathic surgery to achieve even the limited objec-
tive of an acceptable occlusion. Their research
indicated that only 25 % of UCLP adolescents had
near-normal maxillary growth. The other 50 %
were in a borderline category with some degree of
maxillary hypoplasia. Ross stated that individuals
born with cleft lip and palate have intrinsic
de fi ciency in the midfacial skeleton that is made
worse by operations. More recently, Mulliken and
colleagues reviewed the prevalence of LeFort I
osteotomy in patients with cleft lip/palate treated
at Boston Children’s Hospital (Good et al. 2007 ) .
They found that 48 % of their repaired UCLP
patients required orthognathic surgery. Similarly,
the Hospital for Sick Children (Toronto, Canada)
found that 48.3 % of their complete UCLP patients
required orthognathic surgery. When they looked
at all patients with UCLP referred to their center,
they found that 59.4 % needed jaw reconstruction
(Fig. 25.1 ) (Daskalogiannakis and Mehta 2009 ) .
Other earlier research con fi rms and compliments
these fi ndings (Capelozza Filho et al. 1996 ; Correa
Normando et al. 1992 ; DeLuke et al. 1997 ; Filho
1996 ; Friede and Lilja 1994 ; Fudalej et al. 2009a, b ;
Gnoinski 1987 ; Jorgenson et al. 1984 ; Linton
1998 ; Mars et al. 1987, 1992 ; Mars and Houston
1990 ; Mølsted et al. 2005 ; Motohashi et al. 1994 ;
Nanda 1988 ; Nollet et al. 2005 ; Palmer et al. 1969 ;
Roberts et al. 1996 ; Schnitt et al. 2004 ; Smabel
1994 ; Susami et al. 2006 ) .
Reconstruction of the alveolar process in
UCLP patients is an essential part of cleft care.
Accomplishing this goal provides support for
the alar base of the nose, the teeth in the cleft
region, and the periodontium of those teeth.
There are three basic methods described for the
closure of the cleft alveolus. The surgical options
include: primary bone grafting, secondary bone
grafting, and gingival periosteoplasty (GPP).
The method of primary bone grafting is now
Cleft Jaw Deformities
and Their Management
Jeffrey C. Posnick
J. C. Posnick , DMD, M.D., FRCS (C), FACS
Director, Posnick Center for Facial Plastic Surgery ,
5530 Wisconsin Ave, Suite 1250 , Chevy Chase ,
MD 20815 , USA
Clinical Professor of Surgery and Pediatrics ,
Georgetown University , Washington , DC , USA
Adjunct Professor of Orthodontics ,
University of Maryland, Baltimore College
of Dental Surgery , Baltimore , MD , USA
Adjunct Professor of Oral and Maxillofacial Surgery ,
Howard University College of Dentistry ,
Washington , DC , USA
e-mail: jposnick@drposnick.com,

558
J.C. Posnick
Fig. 25.1 This is a senior high school student who was
born with a complete UCLP ( left side ). He underwent lip
and palate repair at another institution. He was then referred
to this surgeon and underwent effective bone grafting and
fi stula closure in the mixed dentition. He developed a jaw
deformity characterized by maxillary de fi ciency and sec-
ondary deformities of the mandible and intranasal cavity.
He underwent a combined orthodontic and surgical
approach. Orthodontic (dental) decompensation included
cleft-dental gap (absent lateral incisor) closure. He then
underwent reconstruction including maxillary LeFort I
osteotomy (horizontal advancement, vertical shortening,
midline correction, cant correction, clockwise rotation);
sagittal split ramus osteotomies (clockwise rotation,
asymmetry correction); osseous genioplasty (vertical short-
ening); and septoplasty/inferior turbinate reduction/recon-
touring of fl oor of nose. Six months after successful
orthognathic surgery, he underwent cleft rhinoplasty includ-
ing rib cartilage (caudal strut) grafting. ( a ) He is shown in
the mixed dentition prior to bone grafting. ( b ) Frontal views
in repose before and after reconstruction
a
b

559
25 Cleft Jaw Deformities and Their Management
( c ) Frontal views with smile before and after reconstruction. ( d ) Oblique facial views before and
after reconstruction
Fig. 25.1 (continued)
c
d

560
J.C. Posnick
( e ) Pro fi le views before and after reconstruction. ( f ) Occlusal views prior to orthodontics, with
orthodontic dental decompensation in progress, and after reconstruction
Fig. 25.1 (continued)
Prior to Tx
Pre Surg
After Tx
f
e

561
25 Cleft Jaw Deformities and Their Management
( g , h ) Articulated dental casts before and after reconstruction
Fig. 25.1 (continued)
Maxillary
clockwise
rotation
g
Mandibular
adjustment
Maxillary
cant
correction
Mandibular
adjustment
h

562
J.C. Posnick
generally recognized to result in severe midface
growth disturbance and has therefore been uni-
versally abandoned throughout the world
(Hathaway et al. 1999 ; Posnick 1991a, b ;
Rosenstein 1997 ) . The use of secondary (mixed
dentition) bone grafting (Abyholm et al. 1981 ;
Boyne and Sands 1972 ; Daskalogiannakis and
Ross 1997 ; Hall and Posnick 1984 ) is generally
recognized as an effective method to avoid the
problem of midface growth disturbance and is
successfully achieved to support the alar base, to
provide bone for eruption of the canine through
the cleft side, and to establish effective peri-
odontal support. The technique of gingival
periosteoplasty (GPP) was fi rst described by
Skoog in 1965 as a method to achieve fusion
across the cleft alveolus at the time of lip repair
(Skoog 1965 ) . The goal was to “remove” the
cleft in infancy with the hope that no harm
would result. Millard combined the “Latham
device” to position the alveolar ridges close to
one another before going forward with the GPP
procedure at the time of cleft lip repair (Millard
et al. 1990, 1999 ) . Grayson and Cutting later
proposed the use of a nasoalveolar molding
(NAM) device prior to GPP and primary lip
repair to accomplish the same alveolar ridge
fusion (Grayson and Cutting 2011 ) . Since the
late 1970s, clinical studies have been carried out
to assess the long-term effects of GPP on midfa-
cial growth in cleft patients. The studies con-
ducted by Millard et al. ( 1999 ) , Mølsted et al.
( 2005 ) , Berkowitz and colleagues ( 2004 ) , Matic
and Powers ( 2008 ) , Renkielska et al. ( 2005 ) ,
Henkel and Gundlach ( 1997 ) , and Tomanova
and Mullerova ( 1994 ) have all found that patients
treated with GPP had poor occlusal relationships
with a high need for orthognathic surgery in the
teenage years. More recently, Hsin-Yi Hsieh and
colleagues completed a retrospective clinical
study to evaluate the effects of GPP on facial
growth of patients with UCLP (Hsieh et al.
2010 ) . This was a well-done clinical study of a
consecutive series of patients that were placed
in two study groups, those receiving NAM treat-
ment with GPP and those receiving NAM treat-
ment without GPP. The use of gingival
periosteoplasty at the time of lip repair was
found to have signi fi cant negative effects on the
maxillary position (SNA), intermaxillary posi-
tion (ANB), maxillary length (PMP-ANS), and
maxillary alveolar length (PMP-AN) at the age
( i ) Lateral Cephalometric radiographs before and after reconstruction
Fig. 25.1 (continued)
i

563
25 Cleft Jaw Deformities and Their Management
of 5 years. The authors concluded that in patients
with an alveolar cleft , the sagittal growth of the
maxilla was signi fi cantly adversely affected by
the gingival periosteoplasty (GPP) procedure.
25.1.2 Bilateral Cleft Lip and Palate
Mulliken and colleagues from Boston Children’s
Hospital found that 76.5 % of teenagers with
repaired BCLP required maxillary advancement
(Good et al. 2007 ) . They showed that the need for
orthognathic surgery is dependent on the severity
of the cleft type as well as the number and extent
of previous operations performed. Results from
the Hospital for Sick Children (Toronto, Canada)
showed that 65.1 % of their BCLP patients required
or underwent orthognathic surgery, while 70 % of
BCLP patients referred to their team sometime
after cleft lip repair were found to require orthog-
nathic surgery (Daskalogiannakis and Mehta
2009 ) . David et al. from the Cleft Craniofacial
Unit in Adelaide, Australia, followed a consecu-
tive group of BCLP patients from birth to maturity
and determined the need for orthognathic surgery
(David et al. 2006 ) . A skeletal class III malocclu-
sion requiring orthognathic correction was present
in 17 of the 19 consecutive patients followed to the
age of 18 years (89.5 %) (Figs. 25.2 , 25.3 , and
25.4 ). Other earlier research con fi rms and compli-
ments these fi ndings (Harada et al. 2002 ; Lisson
and Trankmann 1997 ; Pruzansky 1985 ) .
a
b
Fig. 25.2 A 40-year-old
woman born with BCL and
pitting of the lower (central)
lip. At the time of preg-
nancy, ultrasound con fi rmed
twins; one of which was
suspected of having BCLP
and the other to have UCLP.
This was documented at the
time of delivery. ( a ) Family
with van der Woude
syndrome including mother
with repaired BCLP and
newborn twins. ( b ) Twin A
with BCLP and twin B with
UCLP

564
J.C. Posnick
a
b
c

565
25 Cleft Jaw Deformities and Their Management
Fig. 25.3 A 16-year-old girl born with van der Woude
syndrome including UCLP and lower lip pits (see
Fig. 25.3 ). She underwent lip and palate repair in early
childhood followed by successful bone grafting and fi stula
closure in the mixed dentition. She was with normal
maxillary growth and underwent standard orthodontic
treatment with maintenance of the cleft-dental gap. She
underwent an open rhinoplasty including use of a rib
cartilage (caudal strut) graft at 15 years of age. There is
suf fi cient bone volume for a dental implant. Implant place-
ment is planned for 18 years of age. ( a ) Facial views at the
time of birth and in the mixed dentition just prior to alveo-
lar bone grafting. ( b ) Facial and occlusal views as a teen-
ager after rhinoplasty prior to dental implant placement.
( c ) Panorex as a teenager during orthodontic treatment
indicates successful bone grafting of the alveolar cleft
a
b
Fig. 25.4 A child born with van der Woude syndrome
including BCLP and lower lip pits (see Fig. 25.3 ). He
underwent lip and palate repair including lower lip pit exci-
sions in childhood. He underwent successful mixed denti-
tion grafting and fi stula closure. As a teenager, he
demonstrates maxillary hypoplasia with secondary defor-
mities of the mandible and chin region. He then underwent
a combined orthodontic and orthognathic/intranasal surgi-
cal approach. The procedures include standard LeFort I
osteotomy (vertical lengthening, horizontal advancement,
clockwise rotation with interpositional grafting); bilateral
sagittal split ramus osteotomies (clockwise rotation);
osseous genioplasty (horizontal advancement); and septo-
plasty/inferior turbinate reduction/nasal fl oor recontouring.
( a ) He is shown at the time of birth and then just prior to
mixed dentition grafting. ( b ) Frontal views in repose before
and after reconstruction

566
J.C. Posnick
( c ) Frontal views with smile before and after reconstruction. ( d ) Oblique facial views before and
after reconstruction. ( e ) Pro fi le views before and after reconstruction
Fig. 25.4 (continued)
d
e
c

567
25 Cleft Jaw Deformities and Their Management
( f ) Occlusal views are shown prior
to bone grafting/ fi stula closure, after orthodontics in prepa-
ration for orthognathic surgery and after reconstruction.
The congenitally missing right maxillary bicuspid is
planned for placement of a dental implant at 18 years of
age. ( g ) Articulated dental casts before and after model
planning
Fig. 25.4 (continued)
Mixed dention
prior to
bone grafting
Pre surgery
After Tx
f
g

568
J.C. Posnick
25.1.3 Isolated Cleft Palate
Ross documented that at least 20 % of Caucasians
with ICP who underwent repair in infancy will
experience maxillary hypoplasia resulting in
malocclusion that is not responsive to either tra-
ditional or compensatory orthodontic maneuvers
alone (Abyholm et al. 1981 ) . Chen et al. reported
on horizontal maxillary growth in both children
and adults of eastern Chinese ethnic background
with unoperated and operated isolated cleft pal-
ate (Chen et al. 2009 ) . Interestingly, the results of
the unoperated mixed dentition individuals with
ICP showed almost normal horizontal growth.
The operated (repaired cleft palate) mixed denti-
tion patients showed reduced length of both the
maxilla and mandible and clockwise rotation of
the maxillomandibular complex. Analysis of the
permanent dentition groups showed reductions in
maxillary length and reduced maxillary and man-
dibular horizontal projection. The authors con-
cluded that for an individual born with ICP, the
high incidence of maxillomandibular de fi ciency
likely results from a combination of factors
including the intrinsic primary cleft defect, sec-
ondary hypoplasia due to the surgical repair in
infancy, and functional factors (e.g., effects of
muscles of mastication, respiratory pattern, and
mandibular rest posture (Canady et al. 1997 ) )
(Fig. 25.5 ).
h
( h ) Cephalometric radiographs before and after reconstruction
Fig. 25.4 (continued)

569
25 Cleft Jaw Deformities and Their Management
a
b
c
Fig. 25.5 A woman in her late
20s born with isolated cleft
palate. She underwent palate
repair in infancy. She developed
a jaw deformity with malocclu-
sion. Attempts to neutralize the
occlusion included four bicuspid
extractions and 6 years of growth
modi fi cation and orthodontic
mechanics (from age 11 to
17 years). 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
involving the maxilla, mandible,
and chin region. There was
excess lower anterior vertical
height and horizontal retrusion
(maxilla and mandible). She
underwent evaluations including
periodontics, prosthodontics,
orthodontics, surgery, speech
pathology, and ENT. Periodontal
treatment and then orthodontic
decompensation followed.
Surgery includes LeFort I
osteotomy (vertical shortening,
clockwise rotation, horizontal
advancement); bilateral sagittal
split ramus osteotomies
(horizontal advancement and
counter clockwise rotation);
osseous genioplasty (vertical
shortening, horizontal advance-
ment); and septoplasty/inferior
turbinate reduction/recontouring
of the nasal fl oor. ( a ) Frontal
views in repose prior to and after
reconstruction. ( b ) Frontal views
with smile before and after
reconstruction. ( c ) Oblique facial
views before and after
reconstruction

570
J.C. Posnick
( d ) Pro fi le views before and after reconstruction. ( e ) Occlusal views prior to re-treatment, after
orthodontic decompensation and 1 year after reconstruction
Fig. 25.5 (continued)
Prior to re-Tx
4 bic ext
Pre Surg
After Tx
e
d

571
25 Cleft Jaw Deformities and Their Management
( f ) Articulated dental casts after model planning. ( g ) Lateral cephalometric views before and
after reconstruction
Fig. 25.5 (continued)
Maxillary Clockwise
rotation
Arch expansion
Mandibular Counter
Clockwise rotation
f
g

572
J.C. Posnick
25.2
Coordinated Team Approach
Care of the cleft patient (i.e., UCLP, BCLP, and
ICP) is best delivered by an integrated group of
specialists who evaluate and provide de fi nitive
care (Berkowitz 1978 ; Kapp-Simon 1995 ;
Leonard et al. 1991 ) . It is no longer acceptable
for individual practitioners (e.g., surgeons,
orthodontists, restorative dentists, speech
pathologists, or otolaryngologists) to carry out
extended treatment without considering all
aspects of the patient’s care and without dis-
cussing options with all members of the team
(Cohen et al. 1995 ) .
The need for coordinated and ef fi cient cleft
care was con fi rmed by the Eurocleft study which
found a lack of association between “high-
intensity disjointed treatment” and favorable
results. The greater the number of operations
and years of orthodontic appliances worn (heavy
burden of care), the worst the clinical outcome
for the patient (Hathaway et al. 2011 ; Shaw
et al. 1992 ; Sinko et al. 2008 ; Tulloch 1993 ;
Williams et al. 2001 ) .
A frequent road block to successful recon-
struction and dental rehabilitation of the midface-
de fi cient adolescent born with a cleft is
disagreement between clinicians about the indi-
cations, most effective surgical techniques, and
timing for intervention. The surgeon, orthodon-
tist, dental and medical team, patient, and family
must fi rst agree on the dental, occlusal, speech,
upper airway, and aesthetic objectives. Only then
can effective treatment go forward.
25.3
Treatment Protocol
Patients presenting with a cleft jaw deformity
referred for possible orthognathic surgery are at a
minimum seen by an orthodontist, orthognathic
surgeon, otolaryngologist, and speech patholo-
gist. Additional consultations are held with a
prosthodontist, pediatrician/general dentist, peri-
odontist, and other medical specialist (i.e., sleep
specialist, geneticist), as indicated. For evalua-
tion of the cleft dentofacial deformity, records
and tests should include at a minimum medical-
quality photographs with views of the face and
occlusion, cephalometric and dental radiographs,
dental models and a centric relation (CR) bite,
direct facial measurements, nasoendoscopic
speech and velopharyngeal assessment, and thorough
evaluation of the upper airway.
The primary cleft surgeon not only performs
repair of the cleft lip and palate and corrects
velopharyngeal insuf fi ciency when present but
generally plays a role in directing the patient’s
overall care. If a cleft surgeon is not trained in
skeletal procedures, then a timely and seamless
transition to the maxillofacial surgeon should
occur. The maxillofacial surgeon caring for the
cleft patient with a skeletal deformity should have
a fundamental understanding of the patient’s den-
tal, speech, upper airway, and aesthetic needs. He
should request consultations with appropriate
specialists, evaluate the clinical information, and
be prepared to perform orthognathic and intrana-
sal procedures.
The orthodontist provides appropriate inter-
ceptive treatment in the mixed dentition, identi fi es
early abnormal skeletal growth patterns, and car-
ries out de fi nitive orthodontic treatment in con-
junction
with
orthognathic
surgery
when
indicated. From the mixed dentition phase, the
cleft orthodontist should recognize the patient
who may need orthognathic surgery. Instituting
extensive camou fl age (dental compensatory)
treatment is likely to jeopardize periodontal
health, lead to dental relapse, and may cause root
resorption. Proceeding with a compromised
(camou fl age) orthodontic approach should only
be entered into with full disclosure to the family
and other treating clinicians.
Before orthognathic surgery, a speech pathol-
ogist experienced in cleft care performs an evalu-
ation to characterize both velopharyngeal function
and to identify articulation errors resulting from
the cleft jaw deformity and dental malocclusion.
A baseline evaluation is important because
velopharyngeal function may deteriorate after
maxillary advancement. A nasoendoscopic-
guided speech assessment is preferred to provide
maximum objective data without radiation expo-

573
25 Cleft Jaw Deformities and Their Management
sure. Velopharyngeal (VP) closure that was ade-
quate before surgery may become borderline
afterward, and VP closure that was borderline
may become inadequate. Studies document that
only a small percentage of patients require a pri-
mary pharyngeal fl ap or fl ap revision after
maxillary advancement. Articulatory distortions
resulting from malocclusion are also identi fi ed
by the speech pathologist, and cause-and-effect
relationships determined. The successful orth-
odontic and surgical correction of crossbites,
open bites, cleft-dental gaps, negative overjet,
and residual oronasal fi stulas represent the most
effective way to correct the identi fi ed articulation
distortions.
A thorough evaluation of the upper airway
in a cleft patient with a jaw deformity is con-
ducted by an otolaryngologist to assess for
areas of obstruction. A formal sleep study
(attended polysomnogram) is done if there is
suggestion of obstructive sleep apnea (OSA). If
indicated, simultaneous intranasal procedures
including: septoplasty, reduction of the inferior
turbinates, and recontouring of the nasal aper-
tures, fl oor of the nose, and anterior nasal spine
should be carried out at the time of orthognathic
surgery.
Discussion between the treating medical and
dental consultants and patient/family clari fi es the
need for and extent of orthognathic and intranasal
procedures. The overall plan for speech, jaw,
upper airway, dental rehabilitation, and the
enhancement of facial aesthetics is agreed to
prior to initiating treatment.
25.4
Timing of Orthognathic
Surgery
Correction of the cleft jaw deformity is best
carried out after skeletal maturity and prior to
the
individual’s
fi nishing
high
school.
Maxillofacial growth is generally complete
between the ages of 14 and 16 years in girls and
16 and 18 years in boys. However, skeletal
growth is variable and should be documented
by knowledge of the pubertal growth spurt and/
or sequential cephalometric radiographs taken
at intervals. The patient/family’s preferences
for timing of the operation based on psychoso-
cial and functional needs (i.e., speech, swal-
lowing, chewing, and breathing) are also taken
into account.
25.5
Residual Deformities in the
Adolescent Born with a Cleft
25.5.1 Unilateral Cleft Lip and Palate
Correction of residual skeletal, soft tissue, and
dental deformities in the UCLP adolescent chal-
lenges the ingenuity and skill of the orthognathic
surgeon and cleft team (Laspos et al. 1997a, b ;
Posnick 1997, 2000a, b, c, d, e ; Posnick and
Ricalde 2004 ; Posnick and Agnihotri 2011 ;
Sandham and Murray 1993 ; Stoelinga et al. 1990 ;
Tessier and Tulasne 1984 ; Turvey et al. 1996 ) .
The central deformity is maxillary hypoplasia,
but it is often combined with residual oronasal
fi stula, bony defects, intranasal obstruction, soft
tissue scarring, and velopharyngeal dysfunction.
In addition, the maxillary lateral incisor at the
cleft site is usually congenitally absent or
de fi cient, resulting in cleft-dental gap (Cassolato
et al. 2009 ; Robertsson and Mohlin 2000 ; Suzuki
and Takahama 1992a, b ) . Secondary deformities
of the nose, mandible, and chin region are also
common. The prevalence of these residual cleft-
ing deformities in mature patients with UCLP
varies widely depending on the primary cleft sur-
geon’s philosophy, available expertise (Nordquist
and McNeill 1975 ) , the individual’s intrinsic bio-
logic growth potential, and the family/patient’s
interest. Published clinical surveys of individuals
born with complete UCLP and treated at estab-
lished cleft centers indicate that despite best
efforts, a number of children will not make them-
selves available for mixed dentition (prior to
eruption of the cleft side canine) grafting
(Felstead et al. 2010 ; McIntyre 2010 ) . Also,
some of those that do will fail grafting and require
other means of reconstruction/dental rehabilita-
tion. A subgroup of UCLP patients will present

574
J.C. Posnick
at or after adolescence with multiple cleft-related
problems that may include:
1. Maxillary hypoplasia
2. Residual oronasal fi stula
3. Residual bony defects.
4. Cleft-dental gap
5. Chin dysplasia
6. Mandibular dysplasia
7. Nasal obstruction and sinus blockage.
8. Velopharyngeal dysfunction.
25.5.2 Bilateral Cleft Lip and Palate
The adolescent patient with BCLP often has sev-
eral residual deformities that can be challenging
to manage (Posnick 1997, 2000a, b, c, d, e ;
Posnick and Ricalde 2004 ; Posnick and Agnihotri
2011 ; Stoelinga et al. 1990 ) . The central defor-
mity is maxillary hypoplasia, but it is often com-
bined with residual oronasal fi stula, bone defects,
intranasal obstruction, soft tissue scarring, and
velopharyngeal dysfunction. In addition, the
maxillary lateral incisors are usually congenitally
absent or hypoplastic (93 % of the time), and the
patients often have cleft-dental gaps. Secondary
deformities of the nose, mandible, and chin
region are also common (Cassolato et al. 2009 ;
Robertsson and Mohlin 2000 ; Suzuki and
Takahama 1992a, b ) . The prevalence of these
residual deformities in mature patients varies
widely depending on the treating clinician’s phi-
losophy, available expertise, the individual’s
intrinsic biologic growth potential, and the fam-
ily/patient’s interest/motivation. Published clini-
cal studies indicate that a considerable number of
children with BCLP will either not make them-
selves available for mixed dentition grafting or
will fail the grafting procedure and require other
means of reconstruction/dental rehabilitation
(Felstead et al. 2010 ) . For all of these reasons, a
subgroup of BCLP individuals continues to
present at or after adolescence with multiple cleft-
related challenges that may include the following:
1. Maxillary hypoplasia
2. Residual oronasal fi stula.
3. Cleft-dental gap
4. Residual bony defects
5. Chin dysplasia
6. Mandibular dysplasia
7. Nasal obstruction and sinus blockage
8. Velopharyngeal dysfunction
25.5.3 Isolated Cleft Palate
The ICP adolescent/adult referred for orthog-
nathic evaluation will have an intact alveolar
ridge and is generally with a full complement of
teeth (Bell and Levy 1971 ; Posnick 1997, 2000a,
b, c, d, e ; Posnick and Ruiz 2000 ; Posnick and
Ricalde 2004 ; Posnick and Agnihotri 2011 ;
Stoelinga et al. 1987 ) . They may, however, pres-
ent with one or more of the following residual
cleft-related problems:
1. Maxillary dysplasia
2. Residual oronasal (palatal) fi stula
3. Chin dysplasia
4. Mandibular dysplasia
5. Nasal obstruction and sinus blockage
6. Velopharyngeal dysfunction
25.6
Orthodontic Considerations
in a Cleft Patient with a Jaw
Deformity
25.6.1 Unilateral Cleft Lip and Palate
The adolescent or adult UCLP patient that pres-
ents with maxillary hypoplasia and ineffective
bone grafting will have two maxillary segments
separated by a cleft. Each segment will have a
varied degree of dysplasia in all three planes in
space. From an orthodontic perspective, each
segment is treated individually in anticipation of
segmental repositioning. On the other hand, if the
individual has undergone effective bone grafting
in the mixed dentition, then the maxilla is in one
unit and the arch form can be evaluated as an
integrated unit.
There is great variability in the number of
permanent incisors and the amount of alveolar
bone in the anterior aspect of the UCLP maxilla.
A lateral incisor-like tooth frequently is found
along the edge of the cleft in the lateral segment.

575
25 Cleft Jaw Deformities and Their Management
When a poorly formed lateral incisor is present,
it should be extracted in the interest of long-term
function and dental rehabilitation. Cassolato et al.
have documented that in patients with complete
UCLP, the lateral incisor on the cleft side is nor-
mal and maintained in only 7 % of cases.
The decision to extract the fully erupted nor-
mally formed tooth (i.e., fi rst bicuspid) depends
on the volume and height of available alveolar
bone to house the dental roots adjacent to the
cleft and the degree of overall dental crowding
within the arch. It is preferred to extract a fi rst
bicuspid to ensure that there is adequate alveolar
bone for leveling and aligning the retained teeth
without irreversibly weakening the periodontal
support of the teeth adjacent to the cleft and
throughout the alveolus. Planning for extrac-
tions in the mandibular arch depends on alveolar
space requirements and on tooth movements
needed to position the incisors ideally over basal
bone. Mandibular extractions are generally not
required.
The potential disadvantage of closure of a
cleft-dental gap (whether carried out orthodonti-
cally or surgically) is that it shifts the preopera-
tive anterior dental gap (lateral incisor region) to
a posttreatment posterior gap (second molar
region). Articulated dental models with the max-
illa (maxillary segments) in the proposed postop-
erative positions are analyzed preoperatively to
con fi rm that the posterior maxillomandibular
occlusion will be acceptable. For this reason, the
maxillary second molar on the cleft side be
orthodontically included in the arch form.
Occasionally, there will be a nonimpacted (use-
ful) maxillary wisdom tooth that can be incorpo-
rated to oppose the mandibular second molar.
25.6.2 Bilateral Cleft Lip and Palate
The patient who has not had an effective bone
graft in the mixed dentition will have three sepa-
rate maxillary segments, each with a degree of
dysplasia in all three planes. If this is the case,
each segment should be treated individually by
the orthodontist in anticipation of segmental sur-
gical repositioning. Radiographic analysis is
essential before any orthodontic movement is ini-
tiated. A Panorex fi lm is useful for assessing
overall jaw and dental anatomy and tooth angula-
tion. A cone beam CT scan is preferred to assess
bone volume at each cleft site.
Both the number of permanent incisors and
the amount of dentoalveolar bone in the premax-
illa differ widely. Lateral incisor-like teeth are
frequently found along the edges of the premax-
illa of the lateral segments. These generally are
rudimentary with poor root form and are best
removed. An erupted supernumerary teeth
should be extracted either at the time of bone
grafting in the mixed dentition or prior to orthog-
nathic surgery. A useful lateral incisor at the
cleft site is only found in 7 % of patients and
should be assessed according to root, not crown,
morphology.
The decision to extract additional teeth (i.e.,
bicuspids) should depend on the width and height
of available alveolar bone and degree of dental
root crowding in the segments (arch). Extractions
may be preferred to ensure that there is adequate
bone for leveling and aligning teeth without irre-
versibly weakening the periodontal support of
the dental roots next to the clefts. Incorporation
of all erupted maxillary teeth including the sec-
ond molars into the orthodontic mechanics will
facilitate development of the desired postopera-
tive arch form and occlusion. Extractions in the
mandibular arch are generally not required, but
this depends on space requirements and on the
tooth movements needed to position the incisors
ideally over basal bone.
25.6.3 Isolated Cleft Palate
The primary goal of presurgical orthodontic treat-
ment in the teenager with an ICP jaw deformity is
to eliminate all existing dental compensations.
Instituting camou fl age treatment is likely to jeop-
ardize periodontal health, lead to dental relapse,
and may cause resorption. The need to retract the
upper incisors, upright the lower incisors, and
eliminate crowding, spacing, and rotations are all
important orthodontic considerations. The arch
form objectives are to achieve a satisfactory

576
J.C. Posnick
occlusion at operation which can be detailed
afterward. To eliminate dental compensations,
extractions within the maxillary arch may be
required. In the ICP patient, compared with the
UCLP or BCLP patient, treatment is simpli fi ed as
the alveolus is intact (no alveolar clefts), and
there is generally a full complement of teeth.
25.7
Immediate Presurgical
Reassessment
Two to six weeks before the planned operation,
the orthodontist places passive surgical wires and
con fi rms that the preoperative orthodontic objec-
tives have been met. The surgeon takes fi nal
records including alginate impressions of the
teeth, centric relation (CR) bite registration, face-
bow transfer, and direct facial measurements.
Past medical and dental records (e.g., radio-
graphs, reports, photographs, dental models, spe-
cial studies) are reviewed. CT scan views of the
cleft alveolus can be helpful to assess bone vol-
ume. Decisions are fi nalized concerning preferred
vector changes (reposition) of the jaw(s) and the
precise linear (mm) distances and angles to be
accomplished in each jaw for the desired result.
Model planning is carried out on the articulated
dental casts, and splints are fabricated. The splints
assist in achieving the precise occlusion and pre-
ferred facial aesthetics which have been decided
on preoperatively.
25.8
Orthognathic Surgical
Approach
25.8.1 Unilateral Cleft Lip and Palate
Historically, the literature warned of possible
complications with maxillary osteotomy in
patients with UCLP (Lanigan 1995 ) . Only lim-
ited and confusing descriptions of techniques
were provided to guide the orthognathic surgeon
in the performance of safe, reliable osteotomies
to solve these complex problems (Braun and
Sotereanos 1980, 1981 ; Des Prez and Kiehn
1974 ; Fitzpatrick 1977 ; Freihofer 1977a, b ;
Georgiade 1974 ; Gillies and Rowe 1954 ; Gillies
and Millard 1957 ; Jackson 1978 ; James and
Brook 1985 ; Kiehn et al. 1968 ; Poole et al. 1986 ;
Samman et al. 1994 ; Skoog 1965 ; Ward-Booth
et al. 1984 ; Westbrook et al. 1983 ) . As with other
aspects
of
orthognathic
surgery,
Hugo
Obwegeser’s milestone contributions to cleft
skeletal reconstruction are important (Drommer
1986 ; Obwegeser 1966, 1967, 1969a, b, 1971,
2007 ; Obwegeser et al. 1985 ) . By the late 1960s,
he succeeded in advancing the cleft maxilla to the
preferred location without the need for a compro-
mised mandibular setback approach. Early on,
Obwegeser gained experience to feel comfortable
with cleft maxillary advancement of up to 20 mm.
He realized that adequate mobilization of the
down-fractured maxilla was the key step in
advancing the jaw, whether cleft or noncleft. The
success of this approach, as initially carried out
by Obwegeser, was con fi rmed by Bell’s demon-
stration of the blood supply to these maxillary
segments in animal studies (Bell and Levy 1971 ;
Bell et al. 1995 ; Dodson et al. 1994 ; Dodson and
Neuenschwander 1997 ) . By the mid-1980s,
Posnick utilized and re fi ned Obwegeser’s tech-
niques of LeFort I osteotomy for treatment of the
UCLP deformity (Braun 1992 ; Posnick 1991a,
b, 1996 ; Posnick et al. 1994 ; Posnick and
Tompson 1992 ) . A key aspect was to use
Obwegeser’s circumvestibular incision which
permitted direct exposure for dissection, osteot-
omies, disimpaction, fi stula closure, septoplasty,
inferior turbinate reduction, piriform aperture
recontouring, bone grafting, and application of
plate and screw fi xation. This was consistently
found to be a reliable approach without signi fi cant
risk of circulation injury to the greater or lesser
dento-osseous-musculomucosal segments ( fl aps).

577
25 Cleft Jaw Deformities and Their Management
The visibility provided by the circumvestibular
incision made possible the incorporation of rou-
tine closure of the cleft-dental gap through dif-
ferential maxillary segmental repositioning
without necrosis of bone or loss of teeth. This
method also closes the cleft dead space and brings
together the labial and palatal fl aps without need
for subperiosteal undermining which permits
closure of recalcitrant oronasal fi stulas without
tension and the establishment of periodontal
health to the cleft-adjacent teeth (Fig. 25.6 ).
The extent of maxillary advancement car-
ried out by the surgeon is based on the pre-
ferred occlusion, airway needs, and facial
aesthetics determined preoperatively. The ideal
vertical dimension is also achieved intraopera-
tively based on the preoperative plan. The
maxillary osteotomy sites are fi xed in place
with titanium plates and screws at each zygo-
matic buttress and piriform aperture according
to the principles originally described by Luhr
(Champy 1980 ; Luhr 1968 , 1981 ) . An addi-
tional microplate is applied to stabilize each
interpositional corticocancellous (iliac) graft.
Mandibular and chin osteotomies to correct
secondary deformities and facial asymmetries
are also frequently required to achieve objec-
tives (Fig. 25.1 ).
Fig. 25.6 Illustrations of modi fi ed
LeFort I osteotomy in two segments as
carried out in a patient with UCLP
who has not undergone successful
bone grafting in the mixed dentition.
( a ) Frontal view of maxillofacial
skeleton before and just after LeFort I
osteotomy in two segments. The
inferior turbinates have been reduced,
and a submucous resection of the
deviated septum has been performed.
The nasal fl oor has been recontoured
with a rotary drill. Cancellous Iliac
bone graft has also been placed along
the nasal fl oor. Corticocancellous
(iliac) graft is also placed in gaps
along the anterior maxilla on each
side. ( b ) Illustration of circumvestibu-
lar and peri fi stula incisions for
exposure to complete osteotomies and
later fi stula closure
a
b

578
J.C. Posnick
c
d
e
Fig. 25.6 (continued)
( c ) Illustration of down-
fractured LeFort I osteotomy
in two segments after
submucous resection of
septum, reduction of inferior
turbinate through the nasal
mucosa opening, and
watertight nasal-side closure.
( d ) Illustration indicating
wound closure after
differential segmental
repositioning. ( e ) Palatal view
of bony segments before and
after repositioning (From
Posnick 1991b )

579
25 Cleft Jaw Deformities and Their Management
25.8.2 Bilateral Cleft Lip and Palate
Surgical attempts to correct the jaw dishar-
mony seen in patients with BCLP date back to
Steinkamm’s descriptions in 1938 (Steinkamm
1938 ) . The early literature mostly warned of pos-
sible complications with maxillary osteotomy in
patients with BCLP and offered only incomplete
descriptions of surgical techniques to guide the
surgeon in performing safe and reliable osteoto-
mies (Fitzpatrick 1977 ; Sinn 1980 ; Gillies and
Rowe 1954 ; Gillies and Millard 1957 ; Jackson
1978 ; Poole et al. 1986 ; Ward-Booth et al. 1984 ) .
Hugo Obwegeser’s early milestone contribu-
tions to cleft skeletal reconstruction are impor-
tant (Drommer 1986 ; Obwegeser 1966, 1967,
1969a, b, 1971, 2007 ; Obwegeser et al. 1985 ) .
Unfortunately, in the early days, very few clini-
cians shared his enthusiasm. In 1974, Willmar
reported on the complications associated with
LeFort I osteotomy in BCLP patients (Willmar
1974 ) . Of the eight patients he treated, one died
of airway complications, and the results on the
others were not reported favorably. By the mid-
1980s, Posnick clari fi ed the safety of the seg-
mental LeFort I osteotomy technique in patients
with a BCLP jaw deformity (Fig. 25.7 ) (Posnick
1996, 2000a, b, c, d, e ; Posnick and Tompson
1993 ; Posnick et al. 1994 ) . The documented
favorable results con fi rmed the importance of
Fig. 25.7 Illustrations of modi fi ed LeFort
I osteotomy in three segments. This is,
as carried out in a patient with BCLP who
has not undergone successful bone
grafting in the mixed dentition. ( a )
Illustrations of a patient with BCLP before
and after three-part maxillary osteotomies
with repositioning of the segments.
Septoplasty, inferior turbinate reduction,
and recontouring of the nasal fl oor are
also shown. ( b ) Palatal views of bone
segments before and after repositioning
for closure of cleft-dental gaps. Both
skeletal and soft tissue views are shown
a
b

580
J.C. Posnick
Labial
flaps
Palatal
flaps
c
d
( c ) Illustrations of incisions for modi fi ed LeFort I in three segments. ( d ) Illustrations of down-
fractured lateral segments demonstrating exposure for nasal-side closure of oronasal fi stula
Fig. 25.7 (continued)

581
25 Cleft Jaw Deformities and Their Management
( e ) Illustration of premaxillary osteotomy carried out on palate side (vomer osteotomy) using a
reciprocating saw. ( f ) Illustration demonstrating oral wounds sutured at end of procedure. (From Posnick 1991b )
Fig. 25.7 (continued)
Labial
flap
Vomar
osteotomy
Labial
flap
e
f

582
J.C. Posnick
following sound biologic principles. For exam-
ple, preservation of the labial soft-tissue mucosal
pedicle to the premaxilla in the unsuccessfully
grafted BCLP maxilla is essential. The validity
of this fl ap circulation was proven by Bell et al. in
rhesus monkeys (Bell and Levy 1971 ; Bell et al.
1995 ) .
The BCLP patient with an intact (successfully
grafted) alveolar ridge on one side essentially
presents to the surgeon with the same anatomy as
a nongrafted UCLP patient. The surgical approach
to the maxilla for this patient is the same as
described for the nongrafted UCLP patient. For
the BCLP patient presenting with a “three-
segment” maxillary deformity, the modi fi ed
LeFort I osteotomy (in three segments) should be
used. For the BCLP adolescent presenting with
an intact (successfully grafted) alveolar ridge on
each side, a standard LeFort I down fracture is
carried out (Fig. 25.4 ).
25.8.3 Isolated Cleft Palate
In general, the primary jaw deformity observed
in the ICP adolescent is maxillary hypoplasia/
dysplasia resulting from the original cleft defor-
mity and the subsequent surgical interventions.
The usual reconstructive procedure to consider is
a standard LeFort I maxillary osteotomy. Early
on, Obwegeser clari fi ed that full mobilization of
the down-fractured maxilla was essential to
achieving an orthognathic correction on the oper-
ating room table and to limit skeletal relapse over
time. Bell and others validated that the Obwegeser
LeFort I technique allowed adequate blood sup-
ply for routine satisfactory bone healing without
aseptic necrosis or dental injury (Fig. 25.5 ).
Any residual palatal oronasal fi stula in the ICP
patient at the time of orthognathic correction will
be dif fi cult to close simultaneously with the
LeFort I procedure. This is because elevation of
palatal fl aps is generally required to do so and
this would compromise the blood supply to the
down-fractured maxilla. Interestingly, if a
watertight nasal-side closure can be achieved
through the down-fracture prior to fi xing the
maxilla in its new location, then the residual pal-
atal-side mucosal separation will frequently heal
by secondary intention with fi stula closure.
25.9
Clinical Management After
Initial Surgical Healing
Managing details of the in-hospital and at-home
convalescence during initial healing are essen-
tial for a successful outcome. The surgeon is
responsible for seeing the patient through this
phase of treatment. Cephalometric and dental
radiographs and facial and occlusal photographs
are obtained at standard postoperative intervals
for documentation.
Orthodontic maintenance of the surgical result
and detailing of the occlusion are initiated after ini-
tial healing (5 weeks after surgery). The seamless
transition from the surgeon to the orthodontist for
ongoing care is essential.
Speech and VP function can be objectively
reassessed 6 months after surgery, and any
remaining issues can be addressed at that time.
We prefer to evaluate VP function using nasoen-
doscopic instrumentation when feasible. Further
cleft soft tissue procedures (e.g., cleft rhinoplasty,
lip scar revision, pharyngeal fl ap/ fl ap revision,
closure of residual palatal fi stula) can be carried
out as early as 6 months after orthognathic sur-
gery. Once the orthodontic appliances are
removed, any planned de fi nitive restorative dental
work can also be fi nalized.
25.9.1 Unilateral Cleft Lip and Palate/
Bilateral Cleft Lip and Palate
If segmental osteotomies were carried out to
correct arch width, curve of Spee, and/or for closure
of cleft-dental gaps, then the orthodontist sees the
patient within 24 h of splint removal (approxi-
mately 5 weeks after surgery) and replaces the
maxillary sectional arch wires with a rigid con-
tinuous one. The teeth are ligated together to
maintain the surgical dental gap closure, new
arch form, and transverse width. Active orth-
odontic maintenance and fi nishing are started at
that time. The use of a transpalatal wire or a

583
25 Cleft Jaw Deformities and Their Management
palatal plate may also be used to stabilize (main-
tain) the arch form. Close orthodontist monitor-
ing for skeletal and dental shifts during the fi rst
6 months after surgery is essential.
25.10 Cleft Orthognathic Surgery:
Results and Complications
25.10.1 Unilateral Cleft Lip
and Palate
Posnick and Tompson prospectively assessed
the cleft deformity and clinical results in 66
consecutive adolescents and young adults (age
range 15–25 years; mean 18 years) with UCLP
who underwent orthognathic surgery by one
surgeon (Posnick) using a single surgical proto-
col over a 6-year time frame (Posnick and
Tompson 1995 ) . All patients underwent periop-
erative orthodontic treatment and were judged
to be skeletally mature at the time of jaw sur-
gery. The clinical follow-up after maxillary
advancement ranged from 1 to 7 years (mean
40 months). These patients had their cleft lip/
palate repaired earlier in life by different sur-
geons using a variety of protocols. Many had
undergone multiple attempts at closure of resid-
ual oronasal fi stula and to fi ll alveolar clefts
with bone grafts. Seven of the 66 UCLP patients
had previously undergone orthognathic surgery
by another surgeon.
The basic orthognathic procedure carried out
included a modi fi ed LeFort I osteotomy in two
segments. All ( n = 66) had multiple residual
UCLP skeletal deformities, including residual
oronasal fi stula (100 %), negative overjet (97 %),
and congenitally missing lateral incisor (91 %).
Twenty-three of these patients needed simultane-
ous sagittal split ramus osteotomies to correct
facial asymmetry and disproportion. Thirty- fi ve
of the 66 underwent an osseous genioplasty (hor-
izontal advancement with variable vertical
reduction).
Sixty-one (92 %) of the 66 patients underwent
successful simultaneous oronasal fi stula closure.
Surgical cleft-dental gap closure was achieved
and maintained in all but 3 (5 %) of the 57
patients in whom it was attempted. In all of the
patients, keratinized mucosa was placed and
remained along the labial surface of the cleft-
adjacent teeth ( n = 132 teeth). The long-term
maintenance of overjet was measured directly
from the late (more than 1 year) postoperative
lateral cephalometric radiograph. All but two
patients maintained a positive overjet. The long-
term maintenance of overbite also was measured
directly from the late postoperative lateral cepha-
lometric radiograph. Sixty (91 %) of 66 patients
maintained a positive overjet. Four (6 %) shifted
to a neutral overbite, and two (3 %) relapsed into
a negative overbite.
Complications were few and generally not
serious. One patient who had undergone simulta-
neous septoplasty/inferior turbinate reduction
was returned to the operating room for nasal
packing to manage epistaxis (postoperative day 10).
In another patient, the maxilla was repositioned a
second time to reduce the vertical height (gingi-
val show) for improved facial aesthetics (postop-
erative day 3). No loss of segmental bone or teeth
occurred because of aseptic necrosis, infection,
or for any other reason.
25.10.2 Bilateral Cleft Lip
and Palate
Posnick and Tompson prospectively assessed the
clinical results of 33 consecutive adolescents (age
range 16–24 years; mean 18 years) with BCLP
who underwent orthognathic surgery by a single
surgeon (Posnick) over a 6-year period using the
modi fi ed LeFort I osteotomy (three segments)
(Posnick and Tompson 1995 ) . All underwent
perioperative orthodontic treatment and 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 patient’s surgeons earlier in life
varied as did the treatment protocols. Most had
undergone additional attempts to close the resid-
ual oronasal fi stulas and bone grafting to fi ll the
alveolar clefts.
All of the patients in this study group required
closure of residual bilateral labial and palatal

584
J.C. Posnick
fi stulas. The majority presented with a signi fi cant
negative overjet at the incisors (26–33) as an
indication of horizontal maxillary hypoplasia.
Thirty of the 33 patients had a cleft-dental gap on
each side. All 33 patients had a mobile premax-
illa indicating no bone bridging across the cleft
alveolar regions either side. Fifty-nine of the 66
cleft sites had congenitally absent/inadequate lat-
eral incisors. In addition to a modi fi ed LeFort I
osteotomy (three segments), ten of the patients
underwent simultaneous sagittal split ramus
osteotomies to correct secondary deformities
(asymmetry/disproportion). Fourteen of the 33
also underwent osseous genioplasty (vertical
reduction and horizontal advancement).
Twenty-six of the 33 patients underwent suc-
cessful one-stage complete fi stula closure and
full stabilization of the premaxillary segment to
the lateral segments as a result of the cleft orthog-
nathic procedure. Seven of the 33 patients retained
small fi stulas (all at the incisor foramen region)
and a degree of mobility of the premaxillary seg-
ment. Final fi stula closure using local fl aps with
additional bone grafting was then required to
attain complete fi stula closure and bony union of
the premaxilla to the lateral segments. All 33
patients successfully achieved the placement of
keratinized gingiva over the cleft side and cleft-
adjacent teeth on each side.
Five of the 33 patients bene fi ted from fi xed
prosthesis to either replace missing teeth or
improve the aesthetics of the incisors because
of poor enamel quality or congenital dyspla-
sia. The long-term maintenance of overjet and
overbite was measured directly for each patient
from the late (more than 1 year) postoperative
lateral cephalometric radiograph. The major-
ity of patients (31 of 33, 94 %) maintained a
positive overjet. Only 2 of the 33 patients
(6 %) relapsed into a negative overjet. Two of
the 33 patients (6 %) shifted into neutral over-
bite, and 4 of the 33 (12 %) relapsed into a
negative overbite.
There are no cases of infection requiring
extended use of antibiotics or drainage, and there
was no postoperative hemorrhage requiring return
to the operating room. None of the cleft-adjacent
teeth required root canal therapy. No teeth or
dentoalveolar segments were lost as a result of
aseptic necrosis, infection, or for any other
reason.
25.10.3 Isolated Cleft Palate
In a previously published study (Posnick and
Tompson), a consecutive series of ICP patients
( n = 14) who presented with a cleft jaw deformity
and underwent orthognathic correction by a single
surgeon (Posnick) were prospectively assessed
after surgery (Posnick and Tompson 1995 ) . The
14 skeletally mature ICP cleft jaw deformity
patients had undergone palate repair in infancy
and presented to this surgeon in adolescence with
maxillary dysplasia and malocclusion. All patients
underwent a standard one-piece LeFort I osteot-
omy. Simultaneous bilateral sagittal split ramus
osteotomies were also carried out in 4 of the 14
patients to further correct facial disproportion. All
subjects ( n = 14) underwent simultaneous osseous
genioplasty. Ten of the 14 underwent interposi-
tional iliac (hip) grafting to the horizontally
advanced and vertically lengthened maxilla.
As measured directly from the greater than
1 year postoperative cephalometric radiographs,
all patients maintained a positive overjet and
overbite at the incisor level. The mean horizon-
tal advancement initially achieved was 6.4 mm,
and that maintained at 1 year was 5.4 mm.
Perioperative morbidity was unremarkable with
reference to cardiopulmonary compromise,
maxillofacial infections, hemorrhage, aseptic
necrosis, loss of teeth, and/or need for root canal
therapy.
25.11 Controversies and Unresolved
Issues
25.11.1 Velopharyngeal Function After
LeFort I Advancement
Uncertainties about velopharyngeal function and
management of an in-place pharyngeal fl ap should
no longer be limiting factors when orthognathic
surgery is necessary in a patient with a cleft.

585
25 Cleft Jaw Deformities and Their Management
A nasoendoscopic-guided examination by a
speech pathologist and surgeon familiar with
cleft anatomy can reasonably predict current and
expected velopharyngeal function in a patient
scheduled for a LeFort I osteotomy. When post-
operative velopharyngeal deterioration is antici-
pated, the patient and family are counseled about
the sequencing of treatment and alternatives dis-
cussed. Clinical studies have now documented that
VP function will deteriorate in a similar fashion
whether either DO or standard Le Fort I osteot-
omy techniques are utilized (Chanchareonsook
et al. 2006, 2007 ; Guyette et al. 2001 ; Harada
et al. 2001 ; Janulewicz et al. 2004 ; Ko et al.
1999 ; Marrinan et al. 1998 ; McComb et al. 2011 ;
Phillips et al. 2005 ; Trindale et al. 2003 ; Witzel
and Munro 1977 ) . Despite the frequent need for
signi fi cant maxillary advancement to normalize
the skeleton, upper airway, and facial aesthetics
in patients with a cleft, we have not had or seen
an advantage to transecting an in-place pharyn-
geal fl ap to achieve maxillary mobilization and
the desired advancement. Our research and that
of others con fi rm that a pharyngeal fl ap in place
at the time of LeFort I does not increase compli-
cations nor does it result in a higher incidence of
relapse. De fi nitive reassessment of VP function
after cleft LeFort I advancement can be carried
out as early as 3 months after surgery. A primary
or revision pharyngeal fl ap can be safely carried
out by 6 months in conjunction with cleft rhino-
plasty and/or labial revision if indicated.
25.11.2 Mixed Dentition
LeFort I Osteotomy
By the mid-1980s, research clari fi ed that if jaw
surgery is undertaken in a growing cleft palate
patient, another procedure will likely be required
once skeletal maturity is reached. More recently,
several investigators have tested this theory by
preceding with mixed dentition LeFort I osteoto-
mies utilizing distraction (DO) techniques. All
research to date indicates that LeFort I advance-
ment carried out in the mixed dentition in the
cleft individual , whether by standard or distrac-
tion ( DO ) technique , results in no signi fi cant
further horizontal growth (Harada et al. 2006 ;
Huang et al. 2007 ; Molina et al. 1998 ; Polley and
Figueroa 1997, 1998 ; Suzuki et al. 2004 ; Wolford
1992 ; Wolford et al. 2001a, b, 2008 ) . As the
mandible continues to grow, an Angle Class III
malocclusion will occur with the need for either
additional LeFort I advancement or mandibular
setback.
25.11.3 Skeletal Relapse After
LeFort I Osteotomy
There are over 100 published articles reviewing
skeletal stability and relapse in cleft patients who
have had LeFort I advancement using either stan-
dard osteotomy or distraction osteogenesis (DO).
Clinical research data does not demonstrate
signi fi cant differences in relapse patterns between
the two techniques ( standard vs. distraction ( DO )
for Le Fort I advancement ) (Abyholm et al. 1981 ;
Al-Waheidi et al. 1998 ; Araujo et al. 1978 ; Aksu
et al. 2010 ; Chen et al. 2011 ; Cheung and Chua
2006 ; Cho and Kyung 2006 ; Cohen et al. 1997 ;
Dongmei 2010 ; Erbe et al. 1996 ; Escenazi and
Schendel 1992 ; Ewing and Ross 1993 ; Figueroa
et al. 1999, 2004 ; Freihofer 1976, 1977a, b ;
Garrison et al. 1987 ; Hathaway et al. 2011 ;
Hedemark and Freihofer 1978 ; Heidbuchel et al.
1994 ; Hirano and Suzuki 2001 ; Hochban et al.
1993 ; Houston et al. 1989 ; Hui et al. 1994 ; Kanno
et al. 2008 ; Mansour et al. 1983 ; McCance et al.
1997 ; Posnick and Ewing 1990 ; Posnick and
Dagys 1994 ; Posnick and Taylor 1994 ; Posnick
and Tompson 1995 ; Stoelinga et al. 1987 ;
Wiltfang et al. 2002 ) . Proponents of DO fre-
quently subjectively state that when greater than
10 mm of horizontal advancement is required,
the use of standard osteotomies with plate and
screw fi xation and bone graft may lead to a
greater degree of relapse. In perspective, it should
be noted that only 5 % of cleft patients undergo-
ing LeFort I advancement require greater than
10 mm of horizontal advancement at the incisors.
All clinicians agree that this subgroup of cleft
patients (5 %) is the most challenging. The rea-
sons for this go beyond the degree of horizontal
maxillary de fi ciency. These individuals are likely

586
J.C. Posnick
to also present with multiple residual end-stage
deformities and previously failed surgical
procedures.
Aksu et al. documented a horizontal maxil-
lary (skeletal) relapse of 22 % in cleft lip and pal-
ate patients after LeFort I using DO (Aksu et al.
2010 ) . This was at the 3-year follow-up in a series
of adult repaired cleft lip and palate patients who
presented with maxillary hypoplasia. He et al.
reported their results on adolescents with repaired
cleft lip and palate and maxillary hypoplasia who
then underwent LeFort I maxillary advancement
using an external distraction (DO) device (Aksu
et al. 2010 ) . The study patients ( n = 17) were
treated at one center between 2000 and 2006 and
had greater than 1 year of follow-up. Interestingly,
the fi rst four patients (two UCLP and two BCLP)
treated developed fi brous nonunion. All four
required reoperation and rigid (titanium plate and
screw) fi xation to achieve union. The authors then
extended the consolidation period to a minimum of
3 months for the remaining patients ( n = 13). They
were able to achieve bony union (13/17 = 76 %)
in this group. The mean horizontal relapse in this
group (13/17) was 11.9 % with 5 of 13 (38 %)
patients developing not better than an “end-to-
end” occlusion. A second orthognathic proce-
dure was necessary in this subgroup (5 of the 13,
38 %). Therefore, 9/17 (53 %) of the study patients
required two orthognathic procedures. Chen et al.
in 2011 reported a 30.7 % incidence of horizontal
(skeletal) relapse 1 year after LeFort I osteotomy
using DO techniques (RED device). This was in a
consecutive series of cleft patients that presented
with maxillary hypoplasia (Chen et al. 2011 ) .
Posnick et al. documented the degree
of horizontal relapse when using a standard LeFort
I osteotomy (in segments) in cleft jaw deformity
patients (as described in this chapter) (Posnick
and Tompson 1995 ) . They measured horizontal
change and stability from the greater than 1-year
postoperative cephalometric radiographs and
clinical examination. The results were reported
according to cleft type: UCLP (6.9 mm mean
advancement with 5.3 mm maintained) (Posnick
et al. 1994 ) , BCLP (94 % maintained a positive
overjet long-term) (Posnick and Tompson 1995 ) ,
and ICP (6.1 mm mean advancement with 5.1 mm
maintained) (Posnick et al. 1994 ) . Interestingly,
the degree of relapse documented by Posnick et al.
using standard techniques was less than generally
reported by clinicians using a DO approach (see
above). As Obwegeser stated in the 1960s and was
recon fi rmed by Precious et al., “relapse in cleft
patients after LeFort I advancement may well be
more related to failure to adequately mobilize the
maxilla and free it of abnormal soft tissue attach-
ments than anything inherent in the osteotomy or
the speci fi c diagnosis” (Obwegeser 2007 ) .
25.11.4 Staging of Maxillary
Reconstruction
25.11.4.1 Unilateral Cleft Lip and Palate
The described modi fi ed LeFort I (2-segmental)
osteotomy as a method of managing end-stage
oronasal fi stulas, alveolar defects, and cleft-den-
tal gaps in patients with UCLP who also have
maxillary hypoplasia is not intended to replace in
most cases standard techniques and accepted
sequencing of treatment (Fig. 25.5 ) (Harrison
1992 ; Lund and Wade 1993 ; Parel et al. 1986 ;
Perrott et al. 1994 ; Takahashi et al. 1997a, b ;
Turvey 1991 ; Verdi et al. 1991 ; Zachrisson and
Stenvik 2004 ) . We always prefer secondary bone
grafting in the mixed dentition with orthodontic
closure of the cleft-dental gap. However, the
method described does offer an alternative when
the opportunity for grafting in the mixed denti-
tion before the eruption of the permanent canine
tooth is lost and a jaw deformity also exists. A
two-stage approach to the adolescent or adult
with maxillary hypoplasia, residual alveolar
clefts, oronasal fi stulas, cleft-dental gap, and
nasal obstruction is not cost or time effective, and
in our experience, the potential overall morbidity
is increased. It is in these patients with UCLP that
a modi fi ed LeFort I osteotomy offers a reasonable
opportunity for the resolution of residual
end-stage problems (i.e., maxillary hypoplasia,
alveolar defect, residual fi stulas, cleft-dental
gap, nasal obstruction) in a safe and effective
way. The long-term bene fi ts to the patient of the

587
25 Cleft Jaw Deformities and Their Management
resulting
“low-maintenance”
(nonprosthetic)
dentition cannot be overstated.
25.11.4.2 Bilateral Cleft Lip and Palate
The described modi fi ed LeFort I (three-segmental)
osteotomy as a method for managing the maxillary
deformity in adolescent/adult BCLP patients that
also present with missing teeth, oronasal fi stulas,
alveolar defects, cleft-dental gaps, and nasal
obstruction is not intended to replace standard
techniques and accepted sequencing of treatment
(Fig. 25.7 ) (Harrison 1992 ; Lund and Wade 1993 ;
Parel et al. 1986 ; Perrott et al. 1994 ; Takahashi
et al. 1997a, b ; Turvey 1991 ; Verdi et al. 1991 ;
Zachrisson and Stenvik 2004 ) . This does, however,
offer an alternative once the opportunity for graft-
ing the alveolus in the mixed dentition before the
eruption of the permanent canine(s) is lost and a
jaw deformity coexists. A two-stage approach for
the adolescent with BCLP and maxillary hypopla-
sia, residual alveolar clefts, oronasal fi stulas, cleft-
dental gaps, mobile premaxilla, and nasal
obstruction is not cost or time ef fi cient, and there
may be increased morbidity. It is in these patients
with BCLP that a modi fi ed LeFort I osteotomy in
three segments with differential repositioning of
each segment offers a reasonable opportunity for
the resolution of residual problems.
25.11.5 Standard Versus DO Approach
to LeFort I Advancement
I agree with Obwegeser when he stated, “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 ef fi ciently, even when
requiring signi fi cant advancement, with a stan-
dard LeFort I type procedure as described.”
Usual thinking is for a surgeon to commit to
an approach (DO versus standard technique) for a
LeFort I advancement in a cleft patient prior to
arriving in the operating room. The surgeon then
“sticks to the plan” no matter what happens intra-
operatively. Based on review of the literature and
a 26-year personal experience as a cleft jaw sur-
geon, I make the following observations and
recommendations.
25.11.6 Observations Concerning
DO Approach
Distraction osteogenesis is always a patient’s
•
second choice compared to the standard
approach of LeFort I osteotomy with stable
(plate and screw) internal fi xation. The length
of convalescence after surgery using DO is
longer. It will be at least 3 months of limited
diet and physical activities. This generally is
followed by several additional months of face
mask therapy. The DO device is also awkward,
socially embarrassing, and typically blocks
the patient’s visual fi elds (e.g., red, blue, or
green external DO devices). Furthermore,
there is no overall reduction in the potential
for perioperative complications with DO com-
pared to a standard approach.
If the cleft maxilla is adequately down-fractured,
•
mobilized, and stabilized with interpositional
(bone) grafts and plate and screw fi xation,
there is a high probability of healing as planned
with a predictable and less extensive convales-
cence than DO.
An experienced cleft jaw surgeon is likely to
•
be more con fi dent with his ability to down-
fracture and fully mobilize the cleft maxilla
than a less experienced surgeon. Therefore,
the less experienced surgeon will more likely
use DO to avoid the uncertainty (personal
stress) of the intraoperative maxillary mobili-
zation process.
Even for the experienced cleft orthognathic
•
surgeon, there will be the occasional patient
where the extent of maxillary hypoplasia and
associated deformities (missing teeth, lack of
alveolar bone) will lead them to choose a DO
technique. Despite its protracted healing
requirements and limited versatility to correct
all the presenting cleft deformities, the DO
device’s gradual stretching ability can mobilize
even the most recalcitrant maxilla (Fig. 25.8 ).

588
J.C. Posnick
a
Fig. 25.8 A teenage boy born with ectodermal dysplasia
and complete UCLP. He underwent lip and palate closure
in infancy. There are multiple congenital missing teeth in
each arch. He was referred to this surgeon for evaluation
at 14 years of age. He retains only four long-term useful
teeth in the maxilla ( fi rst molars) and a badly displaced
right central and lateral incisor but with good roots and
periodontal attachment. The maxilla is vertically and hori-
zontally de fi cient. The mandible is with satisfactory sym-
metry and horizontal projection. He underwent evaluations
by specialists including orthodontist, prosthodontist, peri-
odontist, surgeon, speech pathologist, otolaryngologist,
and geneticist. Reconstruction/dental rehabilitation was
felt to require surgical repositioning of the maxilla fol-
lowed by an overdenture. In the mandible, crown and
bridge rehabilitation would be carried out. The prostho-
dontist requested 18-mm horizontal advancement and
14 mm of vertical lengthening of the maxilla. A two-stage
approach to maxillary reconstruction was undertaken.
Stage I surgery : (1) nasotracheal intubation, (2) LeFort I
osteotomy with disimpaction, (3) septoplasty/inferior tur-
binate reduction, (4) application of MED I external dis-
traction device, and (5) securing of MED I to prefabricated
chrome-cobalt maxillary appliance fi xed to dentition.
Successful outpatient distraction of maxilla to the pre-
ferred position was accomplished over a 10-day time
frame. Stage II surgery : return to the operating room for
(1) awake fi beroptic nasotracheal intubation, (2) removal
of MED I device, (3) harvesting of anterior iliac cortico-
cancellous graft, (4) reopening of circumvestibular inci-
sion, (5) securing a prefabricated splint to the maxilla and
then applying IMF, (6) autorotation of maxillomandibular
complex to achieve desired vertical dimension, (7) appli-
cation of plate and screw fi xation to maxilla, (8) crafting
and inset of corticocancellous grafts to the left and right
anterior maxilla, and (9) plate and screw fi xation of each
graft to native maxilla. After 6 weeks, the maxilla achieved
initial bone healing. He returned to a more regular diet and
sports activities. Six months postoperative, he underwent
a pharyngeal fl ap to achieve velopharyngeal competence
and an open rhinoplasty including a rib cartilage (caudal
strut) graft. Fixed bridge work in the mandibular arch and
overdenture construction for maxilla were accomplished.
( a ) Frontal and occlusal views at 14 years of age

589
25 Cleft Jaw Deformities and Their Management
( b ) CT scan views indicating
extent of maxillary hypoplasia. ( c ) Articulated dental
casts before and after model planning. ( d ) Facial and
occlusal views prior to surgery with prefabricated chrome-
cobalt appliance fi xed to maxillary dentition
Fig. 25.8 (continued)
15 mm
vertical lengthening
20 mm
horizontal adv.
c
d
b

590
J.C. Posnick
( e ) 10 days after LeFort I osteotomy with distraction of maxilla into preferred position accom-
plished. ( f ) CT scan views after securing maxilla in new location with bone graft and plate and screw fi xation
Fig. 25.8 (continued)
e
f

591
25 Cleft Jaw Deformities and Their Management
g
h
( g ) Frontal facial views in repose before and after reconstruction/rehabilitation. ( h ) Frontal views
with smile before and after reconstruction/rehabilitation
Fig. 25.8 (continued)

592
J.C. Posnick
( i ) Pro fi le views before and after reconstruction/rehabilitation. ( j ) Lateral cephalometric radio-
graphs before and after surgery
i
j
Fig. 25.8 (continued)

593
25 Cleft Jaw Deformities and Their Management
25.11.7 Recommendations
Concerning DO Approach
For most cleft patients with maxillary hypopla-
sia, standard surgical techniques, as described in
this chapter, are ef fi cient and effective. For those
rare circumstances, reserving DO as a “bailout”
when the down-fractured maxilla cannot be ade-
quately mobilized is the approach I recommend.
The occasional patient/family at risk can be
informed of this contingency plan in advance.
This approach allows the surgeon fl exibility to
make the right decision, at the right time, for the
patient in need, to achieve the most ef fi cient con-
valescence and favorable long-term results.
Conclusions
There are now convincing clinical studies which
document the high prevalence of jaw deformi-
ties in mature patients with repaired cleft palate
(i.e., UCLP, BCLP, and ICP). The methods
described to manage the adolescents/adults pre-
senting cleft jaw deformities, malocclusion,
and any residual oronasal fi stula, bony defects,
cleft-dental gaps, nasal obstruction, and aes-
thetic needs are generally safe and reliable
when performed by a dedicated orthognathic
surgeon and team. Successful cleft orthognathic
and intranasal procedures provide a stable foun-
dation on which fi nal soft tissue, lip, and nose
reconstruction may be carried out.
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