Cirugia Ortognatica Paladar 2

SECTION I • Clefts
28
Cleft and craniofacial orthognathic surgery
Jesse A. Goldstein and Stephen B. Baker
mities can also occur. Regardless of the etiology, patient

SYNOPSIS
examination and treatment-planning principles remain the
same. The goal of orthognathic surgery, therefore, is to estab-
■ Dentofacial deformities, in particular maxillary retrusion resulting in
lish ideal dental occlusion with the jaws in a position that
class III malocclusion, are typical of the cleft lip/palate population. Of
patients in this group, 25–30% have midface retrusion severe enough
optimizes facial form and function.
to require orthognathic surgery
■ Orthognathic surgery should ideally be performed after facial growth is
complete. If surgery is performed earlier, the likelihood is high that
Basic science
additional (though possibly less complicated) surgery may be required
when the patient reaches skeletal maturity Growth and development
■ Treatment should favor expansive movements (anterior and inferior
Timing of orthognathic surgery in the pediatric patient is key
repositioning) to achieve class I occlusion rather than contractile
to good and predictable outcomes and is mediated by the
movements (superior and posterior repositioning) in order to minimize
development and maturation of the craniofacial skeleton. The
premature aging.
foundation of maxillofacial growth relies on a complex
interplay between genetic processes and micro- and
macroenvironmental factors which must be understood to
Access the Historical Perspective section online at plan orthognathic procedures on patients with clefts and
http://www.expertconsult.com craniofacial disorders.
The osteogenesis of the maxillofacial skeleton occurs by
way of two well-understood processes: intramembranous
ossification and endochondral ossification. The cranial vault,
Introduction upper face, midface, and a majority of the mandible arise from
the former mechanism. Although there is a great amount of
Orthognathic surgery is the term used to describe surgical variability between individuals and genders, skeletal matura-
movement of the tooth-bearing segments of the maxilla and tion generally progresses in a cranial-to-caudal direction with
mandible. Candidates for orthognathic surgery have dentofa- the cranial vault reaching close to adult size in early adoles-
cial deformities that cannot be adequately treated with orth- cence, followed closely by the upper face in the early teen
odontic therapy alone. Children with cleft lip and palate as years, the maxilla in the mid-teens, and the mandible in the
well as certain craniofacial anomalies are especially prone to late teen years (Fig. 28.1).3
developing malocclusion. Indeed, where approximately 2.5% Dental eruption patterns proceed in a similar stepwise
of the general population have occlusal discrepancies that fashion, and the transition from mixed dentition (6–12 years
warrant surgical correction, 25–30% of patients who undergo of age) to permanent dentition (12–20 years of age) mirrors
surgical correction of cleft lip and palate in infancy will have the maturation of the maxillofacial skeleton. Indeed, midface
severe enough midface retrusion to require orthognathic and lower face development is, in part, mediated by the
surery.1 Maxillary hypoplasia resulting in class III malocclu- budding deciduous and permanent dentition, providing
sion is the typical deformity seen in patients with cleft and regional signals to the alveolus and stimulating bony deposi-
craniofacial deformities, but class II malocclusion, anterior tion. During this period, an alteration of tooth position can,
open bites, occlusal cants, and many other dentofacial defor- in turn, alter the direction of growth of both the maxilla and
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Historical perspective 660.e1
saw to the mandibular ramus took no more than 15 minutes

Historical perspective to perform.
Much has changed since those early surgeries. Perhaps the
The history of orthognathic surgery is complex, spanning greatest impact to the field was brought about by Hugo
two centuries and two continents and featuring some of Obwegeser, an Austrian-born dentist who is credited with
the innovators of the field of plastic surgery. Advances in modernizing the field of orthognathic surgery and introduc-
mandibular surgery preceded maxillary surgery by over ing it to the United States. Amongst his credits, the sagittal
50 years. Although the first mandibular osteotomy was split osteotomy for mandibular advancement and the intraoral
reported in 1846 by Hullihan, Blair and Kostecka together approach to the osseus genioplasty clearly advanced lower-
published the first large series of cases aimed at address- jaw surgery. But it was not until 1965, when Obwegeser2
ing mandibulofacial disproportion. These early cases were demonstrated that the maxilla could be completely mobilized
performed in a seated dental chair with simple ether sedation. in one procedure and reliably and stably repositioned, that
Blind osteotomies using transcutaneous application of a Gigli modern orthognathic surgery gained widespread appeal.
Diagnosis/patient preparation 661
surgeries increase the scar burden and may make maxillary

100%
advancement surgery difficult. With jaw asymmetries, a
history of hyperplasia or hypoplasia from syndromic, trau-
matic, postsurgical or neoplastic etiologies affects treatment
considerations. Each patient should be questioned regarding
symptoms of temporomandibular joint disease or myofascial
pain syndrome. Motivation and realistic expectations are
Cranial vault important for an optimal outcome. It is likewise important for
50% Maxilla patients to have a clear understanding of the procedure,
Mandible recovery, and anticipated result. In younger patients, a family
discussion in terms they can understand helps to alleviate
preoperative anxiety. Orthognathic surgery is a major under-
taking, and the patient and family must be appropriately
motivated to undergo necessary preoperative and postopera-
tive orthodontic treatment in addition to the surgery itself.
A complete physical exam should be performed on every
Birth 10 Years 20 Years
patient prior to surgery. The frontal facial evaluation begins
Fig. 28.1 Skeletal maturity of the cranial vault, the maxilla, and the mandible from with the assessment of the vertical facial thirds (trichion to
infancy to skeletal maturity (scaled to 100% of adult size). glabella, glabella to subnasale, and subnasale to menton) and
the horizontal facial fifths (zygoma to lateral canthus, lateral
to medial canthi, and intracanthal segment). The most impor-
tant factor in assessing the vertical height of the maxilla is the
mandible. Orthodontists take advantage of this active phase degree of “incisor show” while the patient’s lips are in repose.
of development through their use of braces, palatal expand- Males should show at least 2–3 mm, whereas as much as
ers, and various external devices to alter maxillary and 5–6 mm is considered attractive in females. If the patient
mandibular growth trajectories.4 For this reason, surgical shows the correct degree of incisor in repose, but shows exces-
intervention is usually delayed until skeletal maturity is sive gingiva in full smile, the maxilla should not be impacted.
reached and orthopedic movements are no longer effective. It is more important to have correct incisor show in repose
than in full smile. If lip incompetence or mentalis strain is
Diagnosis/patient preparation present, this can be an indication of vertical maxillary excess
or retrognathia/retrogenia.
The inferior orbital rims, malar eminence, and piriform
Preoperative evaluation areas are evaluated for the degree of projection. These regions
often appear deficient in cleft patients, and maxillary advance-
The cleft and craniofacial team ment is therefore indicated; if they are prominent, posterior
The chance of a favorable surgical outcome is optimized if repositioning may be necessary. The alar base width should
presurgical planning is performed in conjunction with a cleft/ also be assessed prior to surgery since orthognathic surgery
craniofacial team which includes plastic surgeons, otorhino- may alter this width; which, in turn, may accentuate any
laryngologists, dentists, geneticists, orthodontists, and many asymmetries associated with a cleft nasal deformity. Asym-
others. Speech pathologists, for example, play an integral role metries of the maxilla and mandible should be documented
in the evaluation of the velopharyngeal mechanism and the on physical examination, and the degree of deviation from the
potential effects that maxillary advancement may have facial midline noted.
on speech nasality and articulation. A preoperative video The profile evaluation focuses on the projection of the
fluoroscopy and/or nasoendoscopy has been shown to forehead and malar region, the maxilla and mandible, the
yield information that can aid in predicting postoperative nose, the chin, and the neck. An experienced clinician can
hypernasality. usually determine whether the deformity is caused by the
The orthodontist’s role in the preoperative evaluation and maxilla, the mandible, or both simply by looking at the
management is critical. Prior to surgery, the potential surgical patient. This assessment is made clinically and verified at
candidate requires a comprehensive work-up that includes an the time of cephalometric analysis. The intraoral exam should
analysis of the occlusal characteristics and the age of the facial begin with an assessment of oral hygiene and periodontal
skeleton, need for presurgical orthodontics, tooth extraction, health. These factors are critical for successful orthodontic
and possibly even palatal expansion. If orthognathic surgery treatment and surgery. Any retained deciduous teeth or
is attempted before the facial skeleton reaches maturity, the unerupted adult teeth are noted. The occlusal classification is
need for revision surgery will be increased because of contin- determined, and the degrees of incisor overbite and overjet
ued postoperative growth. are quantified. The surgeon should assess the transverse
dimension of the maxilla, as prior cleft palate repair will often
result in transverse growth restriction. If the mandibular third
The history and physical examination molars are present, they must be extracted 6 months prior to
It is important to obtain a thorough medical, dental, and sagittal split osteotomy. Any missing teeth or periapical
surgical history from every patient. Systemic diseases such as pathology should be noted, as should any signs or symptoms
juvenile rheumatoid arthritis, diabetes, and scleroderma can of temporomandibular joint dysfunction. These issues should
affect treatment planning. Multiple past cleft and craniofacial be addressed prior to proceeding with orthognathic surgery.
662 SECTION I CHAPTER 28 • Cleft and craniofacial orthognathic surgery
The term “dental compensation” is used to describe the ten-

dency of teeth to tilt in a direction that minimizes dental
malocclusion. For example, in a patient with an overbite
(Angle class II malocclusion), lingual retroclination of the S
upper incisors and labial proclination of the lower incisors
minimize the malocclusion. The opposite occurs in a patient
Or
who has dental compensation for an underbite (Angle class Po
III malocclusion). Thus, dental compensation, which is often Ar
MP PNS
the result of orthodontic treatment, will mask the true degree Ba Ptm ANS
of skeletal discrepancy. Precise analysis of the dental compen- A pt.
sation is done on the lateral cephalometric radiographs.
If the patient desires surgical correction of the deformity,
presurgical orthodontics will upright and decompensate the OP
occlusion, thereby reversing the compensation that has Go B pt.
occurred. This has the effect of exaggerating the malocclusion, Pg
but it also allows the surgeon to maximize skeletal move- Me
ments. If the patient is ambivalent or not interested in surgery, Gn
mild cases of malocclusion may potentially be treated by Fig. 28.2 The cephalometric radiograph is used to identify skeletal landmarks
further dental compensation, which may camouflage the used in determining the lines and angles that reflect facial development. These
deformity and restore proper overjet and overbite. The impor- measurements aid in determining the extent to which each jaw contributes to the
tance of a commitment to surgery prior to orthodontics lies in dentofacial deformity. S, sella turcica, the midpoint of the sella turcica; N, nasion,
the fact that dental movements for decompensation and the anterior point of the intersection between the nasal and frontal bones; A pt, “A
compensation are in opposite directions, so this decision point”, the innermost point in the depth of the concavity of the maxillary alveolar
process; B pt, “B point”, the innermost point on the contour of the mandible
needs to be made prior to orthodontic therapy.5 between the incisor tooth and the bony chin; Ba, basale, the most inferior point of
the skull base; Pg, pogonion, the most anterior point on the contour of the chin;
Patient selection Go, gonion, the most inferior and posterior point at the angle formed by the ramus
and body of the mandible; Po, porion, the uppermost lateral point on the roof of the
external auditory meatus; Or, orbitale, the lowest point on the inferior margin of the
Identifying the proper patient for orthognathic surgery is a orbit; PNS, posterior nasal spine, the most posterior point on the maxilla; ANS,
key step to ensuring satisfaction and successful outcomes. anterior nasal spine, the most anterior point on the maxilla; Gn, gnathion, the center
This includes amassing considerable data beyond a simple of the inferior contour of the chin; Me, menton, the most inferior point on the
history and physical exam and should be coordinated with mandibular symphysis; MP, mandibular plane, the line connecting the Go and the
other members of the cleft/craniofacial team. Gn; OP, occlusal plane.
Cephalometric and dental evaluation as a reference is that it allows the clinician to determine if one
A cephalometric analysis and comparison to normative values or both jaws contribute to a noted deformity. For example,
can help the surgeon plan the degree of skeletal movement a patient’s class III malocclusion (underbite) could develop
needed to achieve both an optimal occlusion and an optimal from several different etiologies: a retrognathic maxilla and
aesthetic result. A lateral cephalometric radiograph is per- a normal mandible as is common in cleft patients, a normal
formed under reproducible conditions so that serial images maxilla and a prognathic mandible, a retrognathic mandible
can be compared. This film is usually taken at the orthodon- and a more severely retrognathic maxilla, or a prognathic
tist’s office using a cephalostat, an apparatus specifically maxilla and a more severely prognathic mandible. All of these
designed for this purpose, and a head frame to maintain conditions yield a class III malocclusion, yet each requires a
consistent head position. It is important to be certain the different treatment approach. The surgeon can delineate the
surgeon and orthodontist can visualize both the bony and true etiology of the deformity by the fact that the maxilla and
soft-tissue features in order to facilitate tracing every land- mandible can be independently related to a stable reference,
mark. Once the normal structures are traced, several planes the cranial base. Next, cephalometric tracings are performed.
and angles are determined (Fig. 28.2). Cephalometric tracings give the surgeon an idea of how
The sella–nasion–subspinale (SNA) and sella–nasion– skeletal movements will affect one another as well as the
supramentale (SNB) are the two most important angles in soft-tissue profile. They also allow the surgeon to determine
determining the positions of the maxilla and mandible rela- the distances the bones will be moved to achieve the goals of
tive to each other as well as the cranial base. These angles are a specific procedure. Different tracing methods using acetate
determined by drawing lines from sella to nasion to “A point” paper are used for isolated maxillary, isolated mandibular, or
or “B point”, respectively. By forming an angle with the sella two-jaw surgeries. Much of the traditional hand cephalomet-
and nasion, this position is referenced to the cranial base. “A ric tracing, however, has given way to computer-aided cepha-
point” provides information about the anteroposterior posi- lometric analysis, which allows the surgeon to position the
tion of the maxilla. If the SNA angle is excessive, the maxilla maxilla and mandible electronically on the cephalogram
exhibits an abnormal anterior position relative to the cranium. while recording the soft-tissue changes and measuring the
If SNA is less than normal, the maxilla is posteriorly posi- degree of repositioning.
tioned relative to the cranial base. The same principle applies Complete dental records, including mounted dental casts,
to the mandible: “B point” is used to relate the mandibular are needed to execute preoperative model surgery and fabri-
position to the cranial base. The importance of the cranial base cate surgical splints. Casts allow the surgeon to evaluate the
Patient selection 663
occlusion both before and after articulation into proper posi- measured on the model block to determine the new three-
tions. Analysis of new occlusion gives the clinician an idea of dimensional position of the maxillary cast. The occlusal
how intensive the presurgical orthodontic treatment plan will portion of the maxillary cast is removed from its base using a
be. Casts also allow the clinician to distinguish between saw. As much plaster is removed from the cast as is necessary
absolute and relative transverse maxillary deficiency. Abso- to accommodate the new position of the maxilla. Once the
lute transverse maxillary deficiency presents as a posterior model block verifies the maxilla is in its new position, the cast
crossbite with the jaws in class I relationship. A relative maxil- is secured with sticky wax or plaster to the mounting ring.
lary transverse deficiency is commonly seen in a patient with Now it can be placed on the articulator. At this point, the
a class III malocclusion. A posterior crossbite is observed in surgeon has a mounting of the postoperative maxilla related
this type of patient, raising suspicions of inadequate maxillary to the preoperative mandible. An acrylic splint is made at this
width. However, as the maxilla is advanced or the mandible point. This splint is called the intermediate splint and is used
retruded, the crossbite is eliminated. Articulation of the casts in the operating room to index the new position of the maxilla
into a class I occlusion allows the surgeon to distinguish easily to the preoperative position of the mandible. A second mount-
between relative and absolute maxillary constriction. ing with the casts in the occlusion desired by the orthodontist
is used to make a final splint that represents the new position
Model surgery of the mandible to the repositioned maxilla. This is fabricated
in a manner similar to the splint for isolated mandibular
Using the cephalometric tracings as a guide, the next step is surgery. If the occlusion is good, intercuspal position can be
to reproduce the maxillary and/or mandibular movements on used to position the mandible without the splint.
articulated dental models. This allows for the fabrication of
occlusal splints to be used intraoperatively to guide jaw
repositioning in preparation for osteosynthesis. Model surgery 3D CT modeling
begins by obtaining accurate casts of the patient’s occlusion. There are several computer-assisted design (CAD) programs
If the surgeon does not have a dental laboratory, the ortho- that are now commercially available that can assist the surgeon
dontist will obtain the casts. The success of the technical with some or all of the preoperative patient preparation. A
portion of orthognathic surgery correlates directly with the computed tomography (CT) scan of the facial skeleton, as well
accuracy of the model surgery and splint fabrication. as updated dental casts, are obtained preoperatively. Although
conventional helical CT scans with fine cuts through the face
Isolated mandibular surgery are ideal, cone beam CT scans offer a comparable image
It should be noted that if isolated mandibular surgery is being quality with considerably less cost and radiation exposure
performed, the casts can be hand-articulated into the desired (50 µSv compared to 2000 µSv). The program then joins the CT
occlusion. The Galetti articulator is a useful tool that allows and the dental cast to render a complete three-dimensional
securing of casts with a screw mount. A universal joint allows model of the facial skeleton. A cephalometric analysis can
the casts to be set in the desired relationship. Surgical splints then be performed as well as simulated movements of the
can then be made from the articulator. If the maximum inter- jaws and chin in any dimension. Once the surgeon verifies the
cuspal position is the desired postoperative occlusion, a splint osteotomy movements, CAD/CAM (computer-aided manu-
may be unnecessary. The surgeon can osteotomize the man- facturing) technology is used to fabricate surgical splints for
dible and secure it into its new position using the maximum the patient. If necessary, 3D models of the patient can be made
intercuspal position as a guide to the new position. The showing the exact proposed movement (Fig. 28.3). Some
surgeon should always verify the desired postoperative occlu- systems can actually “wrap” a 2D digital image around the
sion with the orthodontist prior to surgery. soft-tissue envelope of the 3D CT image, thus replicating a 3D
image of the patient’s face in color.
In these authors’ experience, 3D CT modeling has demon-
Isolated maxillary and two-jaw surgery strated improved accuracy in diagnosis and treatment. The
A “face bow” is a device used to relate the maxillary model elimination of traditional model surgery saves the surgeon
accurately to the cranium on an articulator. If a maxillary time in patient preparation. Finally, the 3D aspect of this
osteotomy is being performed, one set of models should be treatment-planning approach enhances the surgeon’s ability
mounted on an articulator using the face bow. Two other sets to predict how osteotomies may affect soft tissue of the face.
of models are used in treatment planning. Next, an Erickson These advantages facilitate the ability of the plastic surgeon
model block is used to measure the current position of the to provide optimal care for these patients.
maxillary central incisors, cuspids, and the mesiobuccal cusp
of the first molar. The face bow-mounted maxillary cast is
placed on the model block. The maxillary model is then
Developing a treatment plan
measured to the tenth of a millimeter vertically, anteroposte- Once the data are obtained, the surgeon can determine which
riorly, and end-on. By having numerical records in three abnormalities the patient exhibits and the extent to which
dimensions, the surgeon can reproduce the maxillary cast’s these features deviate from the norm. The treatment plan is
exact location, as well as determine a new location. Reference the application of these data to provide the best aesthetic
lines are circumferentially inscribed every 5 mm around the result while establishing a class I occlusion. The goal is not to
maxillary cast mounting. The distances the maxilla will move “treat the numbers” in an attempt to normalize every patient.
in an anteroposterior, lateral, and vertical direction have been The appearance of the soft-tissue envelope surrounding the
determined from the previous cephalometric exam. These facial skeleton is the most crucial factor in determining the
numbers are added or subtracted from the current values aesthetic success of orthognathic procedures, and the jaws
Fig. 28.3 Three-dimensional computed tomography

reconstruction of patient with class III malocclusion
and anterior open bite. (A) Lateral preoperative view.
(B) Front preoperative view. (C) Three-dimensional
representation of computer-designed intermediate
D splint which is fashioned for intraoperative use.
(D) Lateral view after Le Fort I osteotomy has been
simulated with intermediate splint in place. (E) Lateral
postoperative view after Le Fort I and bilateral sagittal
split osteotomies have been simulated with correction
of class III malocclusion and anterior open bite.
E (F) Close-up view of predicted postoperative
occlusion.
should be positioned so they provide optimal soft-tissue of the jaws that will optimize the soft-tissue features of the
support. face. By reducing the emphasis on “normal” values and
Historically, skeletal movements that expanded the soft increasing the awareness of soft-tissue effects of skeletal
tissue of the face were less stable, so posterior and superior movements, it is realized that skeletal disproportion often
movements were preferred. Although these movements were leads to a more favorable result.6
more stable, they resulted in contraction of the facial skeleton
with the associated soft-tissue features of premature aging.
Since the introduction of rigid fixation systems, osteotomies Treatment/surgical technique
that result in skeletal expansion have been achieved with
a great degree of predictability. An attempt is made to General principles and pertinent anatomy
develop a treatment plan that will expand or maintain the
preoperative volume of the face. If a superior or posterior Several principles have broad application to jaw surgery.
(contraction) movement of one of the jaws is planned, an Blood loss can be substantial in maxillofacial surgery and
attempt should be made to neutralize the skeletal contrac- even small volumes can have significant clinical implications
tion with an advancement or inferior movement of the other in the pediatric population. Standard techniques of head eleva-
jaw or the chin. It is important to avoid a net contraction of tion, hypotensive anesthesia, blood donation, and the preop-
the facial skeleton as this may result in a prematurely aged erative administration of erythropoietin are useful adjuncts to
appearance. reduce blood loss, especially in the younger population.
A class I occlusion can be achieved with the jaws in a Before incisions are made, an antimicrobial rinse is helpful to
variety of positions. The goal in treatment planning is to use minimize the intraoral bacterial count. A topical steroid is
the data from the patient’s examination to predict the location applied to the lips to reduce pain and swelling associated with
Treatment/surgical technique 665
prolonged retraction. Intravenous steroids may also be useful The important mandibular structures that may be injured
to reduce postoperative edema. with the mandibular osteotomy are the mental nerve, the
The occlusion desired may not be the same as maximum inferior alveolar nerve, and the tooth apices. The third branch
intercuspal position. The splint is useful in maintaining the of the trigeminal nerve enters the mandibular foramen to
occlusion in the desired location when it does not correspond become the inferior alveolar nerve. It runs below the tooth
to maximal intercuspal position. It is easy for the orthodontist roots and exits at the level of the first and second premolars
to close a posterior open bite, but very difficult to close an through the mental foramen. The region where it is most
anterior open bite with orthodontic treatment. At the end of medial to the outer cortex is located near the external oblique
the case it is important to have the anterior teeth and the ridge. This is where the vertical portion of the sagittal split
canines in a class I relationship without an open bite. osteotomy is made because it affords the largest margin of
Guiding elastics are useful postoperatively to control the error.
bite. Class II elastics are placed in a vector to correct a class II
relationship (maxillary lug is anterior to the mandibular lug).
Class III elastics are applied to correct a class III discrepancy.
Le Fort I osteotomy
With rigid fixation, the elastics will not correct malpositioned The first step in any facial osteotomy is satisfactorily securing
jaws; they serve only to help the patient adapt to the new the nasal endotracheal tube; our preference is a nasal Ring–
occlusion. Minor malocclusions can be corrected with postop- Adair–Elwin (RAE) endotracheal tube. The vertical position
erative orthodontic treatment. of the maxilla is recorded by measuring the distance between
Certain skeletal movements are inherently more stable than the medial canthus and the orthodontic arch wire. These verti-
others. Stable movements include mandibular advancement cal measurements are absolutely critical. The maxillary vesti-
and superior positioning of the maxilla. Movements with bule is injected with epinephrine prior to patient preparation.
intermediate stability include maxillary impaction combined An incision is made with needle tip electrocautery 5 mm
with mandibular advancement, maxillary advancement com- above the mucogingival junction from first molar to first
bined with mandibular setback, and correction of mandibular molar. A periosteal elevator is then used to expose the maxilla
asymmetry. The unstable movements include posterior posi- around the piriform rim and infraorbital nerve. Obwegeser
tioning of the mandible and inferior positioning of the maxilla. toe-in retractors are held by the assistant at the head of the
The least stable movement is transverse expansion of the operating table. As the dissection extends laterally, it is impor-
maxilla. Long-term relapse with rigid fixation has not been tant to remain subperiosteal to avoid exposure of the buccal
demonstrated to be clearly superior to non-rigid fixation in fat pad. A Woodson elevator is used to initiate reflection of
single-jaw surgery. However, in two-jaw surgery, rigid fixa- the nasal mucosa, and a periosteal elevator is used to complete
tion results in less relapse. The judgment of the surgeon will the dissection of the nasal floor and lateral nasal wall. A
dictate the extent to which the facial skeleton can be expanded double-balled osteotome is used to release the septum from
without resulting in unacceptable relapse. the maxilla and a uniballed osteotome is used to release the
The maxilla is associated with the descending palatine lateral nasal wall. The surgeon can insert a finger on the
artery, the infraorbital nerve, the tooth roots, and the internal posterior palate to help feel when the cut is complete. A
maxillary artery. The internal maxillary artery runs about periosteal elevator is used to protect the nasal mucosa, and
25 mm from the pterygomaxillary junction, and the descend- then a reciprocating saw is used to make a transverse oste-
ing palatal artery descends into the posteromedial maxillary otomy from the piriform aperture laterally until the cut
sinus. The infraorbital nerve exits the infraorbital foramen descends just posteriorly to the last maxillary molar and
below the infraorbital rim along the mid pupillary line. The drops through the maxillary tuberosity. The cut should be
maxillary tooth roots extend within the maxilla in a superior made at least 5 mm above the tooth apices. This distance is
direction. The canine has the longest root and is usually visible determined from preoperative Panorex radiographs. If cuts
through the maxillary cortical bone. are complete, the maxilla is downfractured with manual pres-
The patient who presents with a cleft lip and/or palatal sure, or with Rowe disimpaction forceps which fit into the
anomaly will have several anatomic differences when com- piriform aperture and on the palate to provide increased
pared to an unaffected patient. The maxilla is typically defi- leverage for the downfracture. Pressure should be applied in
cient in both the anteroposterior and vertical dimensions. a slow, steady, controlled fashion, not in a series of quick
Because midface retrusion can be significant, it frequently movements. If the maxilla is not mobilized with relative ease,
appears that the mandible is prognathic, but it is rare that the the cuts are likely not complete and should be re-evaluated.
mandible demonstrates a true prognathia. It is a relative Scoring the posterior maxillary wall with a 10 mm osteotome
prognathia secondary to the maxillary deficiency. Finally, may be necessary to aid in downfracture and to prevent an
because of lesser-segment collapse, the dental midline is often uncontrolled fracture superiorly toward the cranial base.
deviated toward the cleft side. Once the downfracture is complete, a bone hook can be used
Despite having alveolar bone grafting performed, by the assistant to hold the maxilla down while any remaining
many cleft patients have deficient or missing bone in the bony interferences are removed. The descending palatine
region of the alveolus. Persistent palatal fistulas may be arteries will be seen near the posteromedial maxillary sinus.
present as well. The lateral incisor is frequently missing in These can be clipped prophylactically without compromising
these patients and closure of this space must be taken into the blood supply to the maxilla (Fig. 28.4). Any rents in the
consideration at the time of treatment planning. If a large nasal mucosa are repaired at this stage with chromic suture.
fistula is present in the alveolus, modifications of the Le The splint is then used to place the maxilla in its proper
Fort I procedure can be performed to facilitate a tension-free position in occlusion with the mandible. Mandibulomaxillary
alveolar closure. fixation (MMF) is then applied with 26-gauge wires around
Descending palatine artery
Nasopalatine artery Lesser palatine artery
Le Fort downfracture
Greater palatine artery
Maxillary artery
Ascending palatine artery

Ascending pharyngeal artery
Facial artery
External carotid artery
Fig. 28.4 Blood supply to maxilla before (left) and after (right) Le Fort I osteotomy and downfracture. After the nasopalatine and descending palatine arteries are transected,
perfusion of the maxillary segment occurs via the lesser palatine artery.
the surgical lugs. The amount the maxilla will be impacted or nasal spine. Separation is verified by activating the device.
elongated was determined in the treatment plan. This distance The maxilla is widened until the gingiva blanches and then
is added or subtracted from the medial canthal–incisor dis- is relaxed several turns to avoid ischemia. The SARPE offers
tance to determine the new vertical position of the maxilla. the best stability for maxillary expansion in the young adult
Four 2-mm plates, usually L-shaped, can be used to secure the and older patient. Transverse deficiencies of the mandible
maxilla. The MMF is released and occlusion verified prior to can be corrected with a similar technique, that of distraction
closure. If the alar base is wide, an alar cinch can be performed osteogenesis (DO).
to normalize the width. Lip shortening may also result from
closure. A V–Y closure at the central incisor can help alleviate Bilateral sagittal split osteotomy (BSSO)
this effect.
In patients who require increased cheek projection, a high The endotracheal tube placement and epinephrine injection
Le Fort I osteotomy can be performed. This differs in that the are carried out in a similar fashion to the Le Fort I osteotomy.
transverse osteotomy is made as high as the infraorbital nerve The mucosal incision is made with electrocautery about
will allow. If further cheek projection is necessary, bone grafts 10 mm from the lateral aspect of the molars and extends from
can be added. In the case of inferior or anterior positioning, the mid-ramus to the region of the second molar. If insufficient
gaps between the segments greater than 3 mm should be tissue is left on the dental side of the incision, closure is more
grafted with autogenous bone, cadaveric bone, or block difficult. A periosteal elevator is used to expose the lateral
hydroxyapatite. Finally, if simultaneous expansion of the mandible and the anterior coronoid process in a subperiosteal
maxilla is necessary, the maxilla can be split into two or more plane. As the coronoid process is exposed, placement of a
pieces to allow concurrent expansion. notched coronoid retractor may facilitate the dissection. A
curved Kocher forcep with a chain can be clamped to the
coronoid process and the chain secured to the drapes. To
Surgically assisted rapid palatal expansion optimize blood supply, subperiosteal dissection is limited to
Correction of transverse maxillary constriction is common in those areas required to complete the osteotomy. A J-stripper
patients with repaired cleft palates or those with craniofacial is used to release the inferior border of the mandible from
syndromes such as Apert or Cruzon syndrome. Such palatal the attachments of the pterygomasseteric sling. The eternal
constriction can be addressed in adolescence with non-surgical oblique ridge and inferior border of the mandible should be
orthodontic appliances. As the sutures begin to close during exposed. The medial aspect of the ramus is also dissected
late adolescence, relapse rates increase. A multiple-piece Le subperiosteally. The mandibular nerve should be identified.
Fort I osteotomy can be performed to provide simultaneous A Seldin elevator is inserted medial to the ramus to protect
maxillary expansion, but the degree of relapse is high. In the nerve. A Lindemann side-cutting burr is used to make a
the young adult, the preferred procedure is the surgically cut on the medial ramus that is parallel to the occlusal plane
assisted rapid palatal expansion (SARPE) procedure. The and extends about two-thirds of the distance to the posterior
orthodontist places a palatal expander prior to the proce- ramus.
dure. A Le Fort I osteotomy is performed to mobilize the The osteotomy proceeds from medial to lateral until the
maxilla completely from the upper face. A small osteotome burr is in the cancellous portion of the ramus. Mandibular
is used to make a thin cut between the roots of the central body retractors are then placed and a fissure burr, or a recip-
incisors, and a midline split is completed to the posterior rocating saw is used to make an osteotomy from the
mid-ramus down along the external oblique ridge, gently Two-jaw surgery
curving to the inferior border of the mandible. The cuts are
verified with an osteotome, and then large osteotomes are Moving the maxilla and the mandible in one procedure
inserted and rotated to separate the segments gently. The requires osteotomizing both jaws and precisely securing them
tooth-baring segment is referred to as the distal segment, and into position as determined by the treatment plan. If proper
the condylar portion as the proximal segment. treatment planning, model surgery, and splint fabrication are
The inferior alveolar nerve should be identified and found performed, each jaw should be able to be placed into its
in the distal segment. If part of the nerve is located within the desired position with precision. In a maxilla-first approach,
proximal segment, it should be gently released with a small the mandibular bony cuts are started first but terminated
curette. After both osteotomies are complete, the distal prior to osteotomy completion. The maxillary osteotomy is
segment is placed into occlusion and secured by tightening made, and the maxilla is placed into its new position using
26-gauge wire loops around the surgical lugs. If a surgical the intermediate splint. The splint is used to wire the teeth
splint is necessary to establish a required occlusion, it is placed into MMF, allowing for indexing the new position of the
between the teeth before MMF wiring. The proximal segments maxilla to the preoperative (uncorrected) position of the
are then gently rotated to ensure they are seated within the mandible. With the condyles gently seated, the maxilloman-
glenoid fossa. When each condyle is comfortably seated dibular complex is rotated so that the maxillary incisal edge
within the fossa, it is rotated to align the inferior borders of is at the correct vertical height. The maxilla is plated into
the two segments and secured into position with a clamp. position, the MMF is released, and the intermediate splint
Three lag screws are placed at the superior border of the removed. Next the mandibular osteotomies are completed,
overlapping segments on each side of the mandible. To ensure and the distal segment of the mandible is placed into the
that the transbuccal trocar will be placed properly, a hemostat desired occlusion using the final splint. If the teeth are in good
is placed at the proposed screw location and pointed toward occlusion without the splint, the final splint may not be neces-
the cheek. A small stab incision is made in the skin, and the sary to establish the desired occlusal relationship. Wire loops
trocar is placed through the tissue bluntly until the tip enters secure the occlusal relationship, and the rigid fixation is
the oral incision. The trocar is then exchanged for a drill completed as previously described.
guide, and the 2.0-mm and 1.5-mm drills are used in the lag
sequence to make three holes through the overlapping portion Genioplasty
of the proximal and distal segments. The screw lengths are Including a genioplasty in the treatment plan can be a power-
measured and the screws inserted. Alternatively, the Dal Pont ful adjunct to mandibular movements, either by offsetting
modification to the BSSO carries the buccal osteotomy anteri- soft-tissue collapse secondary to posterior mandibular repo-
orly to the level of the first mandibular molar creating a longer sitioning or by augmenting anterior mandibular movement.
proximal segment which can be fixated without a transbuccal When performed asymmetrically, a genioplasty may also
screw. Instead, 2.0-mm plates with monocortical screws are correct for minor mandibular asymmetries.
used to fixate the segments after the occlusal splint is placed. After adequate local anesthetic infiltration, the mucosa
The MMF is released, and the mandible is gently opened and is incised from canine to canine with needle tip electrocau-
closed to verify the occlusion. If a malocclusion is noted, the tery, 5 mm below the mucogingival junction. The mentalis
most likely etiology is that one or both condyles were not is transected, being sure to leave enough muscle cuff to
seated properly during application of fixation. The fixation allow for reapproximation during closure. Failure to do so
should be removed and replaced until the correct occlusion is can result in a ptotic soft-tissue envelope, or “witch’s chin”
established. The wounds are irrigated and closed with inter- deformity. Next, the dissection is carried out in a subperi-
rupted 4-0 chromic sutures. osteal fashion identifying and protecting the mental nerves
bilaterally. Using a reciprocating saw, the mandibular midline
Intraoral vertical ramus osteotomy is gently marked to aid in centric fixation. The transverse
osteotomy is made approximately 3 mm below the mental
A second technique for correcting mandibular prognathism
foramina in order to protect the intraosseous course of the
or asymmetry is the intraoral vertical ramus osteotomy. The
mental nerves and the canine tooth roots. The trajectory
incision is the same as described above. A subperiosteal dis-
of the osteotomy can be varied depending on the type of
section is performed from the lateral ramus, and a LeVasseur
correction required. The mobilized segment is then fixed
Merrill retractor is used to hold this tissue laterally. An oscil-
into the desired position with plates and screws, using the
lating saw is then used to make a vertical cut from the sigmoid
midline mark as a guide. The mentalis is then repaired and the
notch to the inferior border of the mandible. The osteotomy
mucosa closed.
must be made posterior to the mandibular foramen on the
medial side. The antilingula is a useful landmark, and is
found as an elevation on the lateral mandible, indicating the Cleft surgery
approximate location of the mandibular foramen. After both Orthognathic surgery in cleft lip/palate patients is done simi-
sides of the mandible are complete, the distal segment is larly to non-cleft patients with the exception of several
moved into occlusion, making sure that the proximal seg- important modifications that are necessary to maintain blood
ments remain lateral to the distal segments posteriorly. supply and assist in fistula closure.
Because rigid fixation is difficult to apply, a single wire, or no In a unilateral cleft lip patient, the standard maxillary inci-
fixation at all, is used, and the patient remains in MMF for 6 sion can be made with little jeopardy to the premaxillary
weeks. This osteotomy can be done from an external approach, blood supply (Fig. 28.5). Each side of the cleft has an incision
but this incision results in a scar on the neck. made similar to that of the alveolar bone graft incision. This
Fig. 28.5 (A) For patients with a unilateral cleft lip, the incision is made similar to a
standard Le Fort I osteotomy, except an alveolar dissection is used if supplemental
bone grafting or fistula closure is necessary. (B) The Le Fort osteotomy allows
compression of the maxillary segments if necessary to close a pre-existing fistula.
C (C) Fistula repairs are easier after compression of the segments and exposure of nasal
and palatal tissue.
allows for a two-layer closure of the palatal and nasal mucosa. mucosa. Since the vomer will be split, the majority of blood
If supplemental bone grafting needs to be done at this time, flow to the premaxilla must course from the premaxillary
harvested bone can be placed into the alveolar gap after fixa- buccal mucosa. A circumvestibular incision that violates this
tion has been applied. If a wide fistula is present, the surgeon mucosa will severely jeopardize the blood supply of the pre-
can compress the maxillary segments to reduce the size of the maxillary segment (Fig. 28.6). To minimize the risk of compli-
alveolar space. This ensures the soft-tissue closure is under cations, the incision is stopped just lateral to the alveolar cleft
minimal tension and the chance of fistula closure is optimized. on each side. One minimizes reflection of the mucosa from the
The canine may now be adjacent to the central incisor, but the premaxilla in order to preserve the blood supply. The oste-
restorative dentist can fabricate a prosthetic crown for the otomy of the premaxillary segment is made from a posterior
canine to make it look like a lateral incisor. approach just anterior to the incisive foramen. This allows
In the bilateral cleft patient, care must be taken not to make mobilization of the segment without violation of the buccal
the vestibular incision across the premaxilla. The premaxillary mucosa. Similar to the unilateral cleft maxilla, residual fistulae
blood supply originates from the vomer and the buccal and inadequate alveolar bone may be present. If either is
Fig. 28.6 (A) For patients with a bilateral cleft, care is taken to avoid incisions across
the premaxilla. (B) The premaxillary osteotomy is completed from a posterior
approach. (C) Fistula repairs or supplemental bone grafting can be done at this time.
(D) Compression of the maxillary segments can be performed if wide fistulas are D
present.
identified, it can be corrected by a two-layer mucosal closure Once the incision is made, the mucosa is reflected in a
and bone grafting into the alveolar defect. If large gaps are subperiosteal plane to expose the piriform aperture, the
present that may jeopardize fistula closure, the segments can zygomatic buttress, and the posterolateral maxilla. A recipro-
be compressed at the alveolar gaps to reduce tension of the cating saw is used to make a high Le Fort I osteotomy in most
repair. Postoperative orthodontics and prosthetic restorations cases. A high Le Fort I osteotomy is cut horizontally in a
of the teeth can correct almost any postoperative dental aes- lateral direct line from the piriform aperture to the zygomatic
thetic irregularities. buttress. One takes this line as high as possible while staying
at least 5 mm below the inferior orbital foramen. A vertical class II malocclusion, which is almost always caused by
cut is now made from the lateral edge of the horizontal cut mandibular retrognathia and is almost always best treated by
and taken to an area about 5 mm above the tooth root apices. mandibular advancement (Fig. 28.7). The mandible is small,
The lateral nasal walls are cut with a uniball osteotome and and forward positioning is an expansile movement that
mallet. The vomer and septum can be reached through the enhances facial form. If the maxilla is also slightly deficient or
lateral maxillary osteotomies so the mucosa remains pre- in an abnormal position, one may consider a bimaxillary
served. The pterygomaxillary junction can be separated with advancement to enhance further facial soft-tissue definition,
a 10-mm curved osteotome, or the maxillary tuberosity can be
cut posterior to the last molar in the arch. The latter choice
makes downfracture easier and results in fewer complica-
tions. Downfracture is now completed with either digital
pressure or application of the Rowe disimpaction forceps. If
a wide alveolar fistula is present, the greater and lesser seg-
ments can be compressed at the alveolus. The occlusion that
would result from segment compression would be evaluated
on the dental casts during preoperative model surgery. Any
deficiency of alveolar bone can be corrected with supplemen-
tal bone grafts after application of fixation, and fistulas can be
corrected as well.
The surgical splint is then placed to orient the new position
of the maxilla to the mandible. Wire loops (26-gauge) are used
to place the patient in maxillomandibular fixation. It is
extremely important to make sure the condyles are seated as
the maxillomandibular complex is rotated to its new vertical
dimension. Generally, cleft patients have vertical maxillary
deficiency in addition to the sagittal deficiency. This requires
the maxilla to be positioned inferiorly to its new position. If
vertical lengthening greater than 5 mm is required, bone
grafts are placed between the osteotomy segments to reduce
relapse. Rigid fixation is now used to secure the maxilla into
its new position. If any instability remains across the maxil-
lary segments, a small plate can be placed across the segments
to reduce mobility and maintain the bone graft. Because the
osteotomized cleft maxilla results in a multisegment maxilla,
the surgical splints are wired in place for 6–8 weeks in order
to allow for bone healing.
Distraction osteogenesis
Distraction osteogenesis (DO) is a useful technique to gain
large advancements reliably with relatively low rates of
relapse. This technique takes advantage of osteoinductive
properties of tension and stress across the osteotomy to
expand the mandibular or maxillary segment rapidly while
allowing the soft tissue to relax over time. Without the need
for anatomic reduction or rigid fixation at the time of surgery,
DO is often technically easier and faster than traditional
orthognathic surgery. Moreover, various methods of distrac-
tion allow for precise control in several different vectors to
position the osteotomized segment accurately in space with
relation to the cranial base and other dentofacial landmarks.
Basic approaches to commonly

encountered problems
The following paragraphs outline basic treatment approaches
to commonly encountered dentofacial deformities commonly
seen in orthognathic patients.
Skeletal class II malocclusion

Conditions such as Treacher Collins syndrome, Stickler syn- Fig. 28.7 Mandibular sagittal split osteotomies demonstrating mandibular
drome, and Pierre Robin sequence are often associated with advancement and mandibular setback.
Outcomes, prognosis, and complications 671
especially in more mature patients. If the malocclusion is Vertical maxillary excess

minimal and there is little pre-existing dental compensation,
one may choose to have the orthodontist intentionally com- Vertical maxillary excess is typically associated with lip
pensate the dentition to correct the occlusion and avoid incompetence, mentalis strain, and an excessive degree of
surgery. In contrast, if the malocclusion appears minimal but gingival show (long-face syndrome). The treatment approach
there is dental compensation, the skeletal discrepancy will be is to impact the maxilla to achieve the proper incisor show
more significant after the orthodontist decompensates the with the lips in repose. Impaction, however, may result in
dentition, and the patient may be a good surgical candidate skeletal contraction, so the surgeon must consider anterior
(Fig. 28.8). repositioning of the jaws to neutralize the associated adverse
soft-tissue effects. As the maxilla is impacted, the mandible
Skeletal class III malocclusion rotates counterclockwise (with respect to a rightward-facing
patient) to maintain occlusion. This rotation results in anterior
A class III malocclusion may be treated by advancing the positioning of the chin and is called mandibular autorotation.
maxilla, posteriorly positioning the mandible, or by combin- The opposite occurs if the maxilla is moved in an inferior
ing these procedures. It is important to consider the contribu- direction. In this case, the chin point rotates in a clockwise
tions of the mandible and the chin separately as each may direction, resulting in posterior positioning of the chin point.
require different treatments to achieve aesthetic goals. If some It is important to note these effects on the cephalometric
posterior positioning of the mandible is necessary, one may tracing during treatment planning because a genioplasty may
advance the maxilla to counteract the skeletal contraction be required to re-establish proper chin position.
produced from posteriorly positioning the mandible. Addi-
tionally, the patient may benefit from an advancement genio- Short lower face
plasty, counteracting any skeletal contraction occurring from
a mandibular setback. As in the class II patient, a minor A short lower face is marked by insufficient incisor show
malocclusion with minimal dental compensation may be cor- and/or a short distance between subnasale and pogonion.
rected with orthodontic treatment alone. In contrast, a minor Treatment is aimed at establishing a proper degree of incisor
malocclusion with dental compensation may become a sig- show. The facial skeleton should be expanded to the degree
nificant malocclusion after dental decompensation, and the that provides optimal soft-tissue aesthetics. As the maxilla is
patient will be a good surgical candidate. In cleft patients with inferiorly positioned, resulting clockwise mandibular rotation
class III malocclusion, where the maxilla may be scarred from leads to a posterior positioning of the chin. The surgeon needs
prior interventions, combined Le Fort I advancement and to assess the new chin position preoperatively on the cepha-
BSSO setback may be necessary even for relatively small lometric prediction tracing to determine if an advancement
degrees of negative overjet (unless maxillary DO is enter- genioplasty will be necessary to counter the effects of man-
tained) (Fig. 28.9). dibular clockwise rotation.
Maxillary constriction Postoperative care

Patients can present with a maxilla that is narrow in a trans-
Postoperative care of patients undergoing orthognathic
verse dimension. Maxillary constriction may occur as an iso-
surgery is paramount to a successful surgical outcome and a
lated finding or as one of multiple abnormalities. Up to about
satisfied patient and family. Close adherence to an oral hygiene
15 years of age, the orthodontist can usually expand the
regimen, including regular tooth brushing and chlorhexidine
maxilla non-surgically with a palatal expander. If orthopedic
mouth rinses, will minimize the risk of postoperative infec-
expansion cannot be done, a SARPE can be performed. If the
tion, as will a short course of antibiotics targeted toward
maxilla requires movement in other dimensions, a two-piece
common mouth flora. Additionally, steps taken to reduce
(or multipiece) Le Fort I osteotomy can be performed to place
swelling, including ice, head elevation, and anti-inflammatory
the maxilla in its new position while simultaneously achiev-
medication such as Solu-Medrol, will greatly improve patient
ing transverse expansion (Fig. 28.10).
comfort. A soft diet for at least the first 3 weeks postopera-
tively will help reduce the risk of malunion or hardware
Apertognathia failure. As well, guiding elastics are usually employed for the
An anterior open bite is caused by a premature contact of the first 2–3 weeks.
posterior molars and is commonly seen in patients with
syndromic craniosynostoses such as Apert or Crouzon syn-
dromes. The recommended treatment is a posterior impaction Outcomes, prognosis,
of the maxilla. By reducing the vertical height of the posterior and complications
maxilla, the mandible can come into occlusion with the
remaining mandibular teeth. Posterior maxillary impaction Accurate assessment of orthognathic surgical outcomes is
does not necessarily result in incisor impaction; the posterior essential to maintaining safe practices, maximizing patient
maxilla is simply rotated clockwise and upward using the satisfaction, and effectively evaluating an ever-changing field.
incisal tip as the axis of rotation. Therefore, incisor show Indeed, this importance is echoed in the ways investigators
should not be affected. If a change in incisor show is also have analyzed postoperative results. These range from mea-
desired, the posterior impaction is performed, and then the surement tools such as three-dimensional CT scanning and
whole maxilla can be inferiorly positioned or impacted to its volumetric analyses (used to evaluate postoperative changes
new position (Fig. 28.11). in bony and soft tissues immediately and over time) to
A B C
E
D
Fig. 28.8 (A–H) 17-year-old female with Treacher

H Collins syndrome. Pre- and postoperative views after
Le Fort I osteotomy with leveling and counterclockwise
G rotation, asymmetric BSSO advancement, and
advancement genioplasty.
A B C
D E
Fig. 28.9 (A–H) 19-year-old patient with unilateral cleft lip

G and palate. Pre- and postoperative views after Le Fort I
osteotomy and BSSO setback.
A B C
D E
Fig. 28.10 (A–E) Le Fort I osteotomies demonstrating maxillary lengthening, impaction, advancement, setback, and multipiece Le Fort.
questionnaires assessing patient-reported satisfaction scales Table 28.1 Comparison of preoperative and postoperative
and quality of life. While there is currently no universally speech variables
accepted tool to demonstrate patient outcomes after orthog-
nathic surgery accurately and reliably, with reasoned and Preoperative Postoperative
reasonable expectations on the part of the patient, family, and Total number of evaluation evaluation
surgeon alike, orthognathic surgery can result in high levels patients: 54 % (n) % (n)
of satisfaction from both a functional and aesthetic level. VP function: competent 42% (23) 18% (10)
Of particular importance to the cleft and craniofacial popu- VP function: borderline 36% (20) 40% (22)
lation is the effect of orthognathic surgery on speech. It is competent
generally accepted that the etiology of velopharyngeal insuf-
ficiency (VPI) in the cleft patient is due to the malalignment VP function: borderline 9% (5) 22% (12)
or shortening of the palatal musculature, as well as growth, incompetent
development, and/or surgical sequelae that can lead to VP function: complete VPI 13% (7) 20% (11)
abnormal structural relationships. Given the intricate attach- Normal nasality 40% (22) 40% (22)
ment of the muscular apparatus of the velum to the maxilla,
it follows that movement of the maxilla can change the pre- Mild hypernasality 18% (10) 29% (16)
operative velopharyngeal function. Moderate hypernasality 4% (2) 15% (8)
Janulewicz et al. performed a retrospective study of the Severe hypernasality 4% (2) 2% (1)
change in velopharyngeal function of 54 cleft lip and palate
patients who underwent maxillary advancement with or Hyponasality 33% (18) 15% (8)
without a mandibular setback procedure over a 21-year Reduced sibilant IOAPs 26% (14) 35% (19)
period.7 As summarized in Table 28.1, their study shows a Reduced fricative IOAPs 16% (9) 26% (14)
decline in competent velopharyngeal function (from 42% to
Reduced plosive IOAPs 6% (3) 22% (12)
18%), an increase in both borderline incompetence (from 9%
to 22%), and complete VPI (from 13% to 20%). The authors Anterior dentition errors 64% (35) 47% (26)
also noted that the quality of speech declined, as evidenced Mean speech score 2.46 4.24
by the increase in overall objective speech score from 2.46 to IOAP, intraoral air pressure; VP, velopharyngeal; VPI, velopharyngeal
4.24 (the higher the score, the worse the speech). In contrast, incompetence.
the authors noted that articulation defects improved, although (Reproduced from Janulewicz J, Costello BJ, Buckley MJ, et al. The effects of Le
the improvement did not achieve statistical significance. Fort I osteotomies on velopharyngeal and speech functions in cleft patients. J
Preoperatively 84% (46 patients) had at least one articulation Oral Maxillofac Surg. 2004;62:308–314.)
defect as compared to 73% (40 patients) postoperatively.

Other published studies have shown similar results or no
change in VPI function following jaw surgery. In their study,
Outcomes, prognosis, and complications 675
A
B
Fig. 28.11 (A) Anterior open bite. (B) The Le Fort osteotomy allows posterior impaction of the
C maxilla and clockwise rotation. (C) Counterclockwise mandibular autorotation closes the anterior open
bite.
Phillips et al.8 showed that the extent of anteroposterior move- assessment can predict postoperative speech and velopharyn-
ment of the maxilla is unrelated to velopharyngeal deteriora- geal function.
tion and is not a useful predictor. In their study of 26 cleft In summary, it appears that, while a positive effect on
patients (16 unilateral complete and 9 bilateral complete cleft articulation might be achieved by orthognathic surgery, it
lips and palates), Phillips et al. demonstrated that all patients might be at the expense of velopharyngeal function. Further
with perceived hypernasal speech preoperatively had hyper- prospective, controlled studies would be helpful in elucidat-
nasality after advancement. Furthermore, 9 of 12 patients who ing the relationships between maxillary advancement and
had preoperative nasopharyngoscopy showing borderline or speech.
inadequate VP closure developed postoperative VPI. Based Posnick and Tompson9 performed a retrospective study
on these results, Phillips et al. conclude that preoperative evaluating relapse in cleft patients who had undergone
orthognathic surgery between 1987 and 1990. They found that authors recommend a 2-mm overcorrection in inferior
there was no significant difference in outcome between positioning of the maxilla.
patients who had maxillary surgery alone and those who had 3. Rotation, clockwise or counterclockwise: The authors
operations on both jaws. Furthermore, the outcome did not report that most of their surgical rotation was lost and
vary significantly with the type of autogenous bone graft used relapse was seen in both clockwise and
or the segmentalization of the osteotomy. All 35 patients counterclockwise rotations. They suggest overcorrection
included in the study underwent a modified Le Fort I maxil- to mitigate the effects of relapse.
lary osteotomy with varied degrees of horizontal advance- 4. Type of cleft: Orthognathic surgery in a bilateral cleft
ment, transverse arch widening, and vertical change. Eleven patient was more likely to result in relapse, according to
of the 35 patients also required mandibular surgery, consisting their study. They attribute the increase in likelihood of
of sagittal split osteotomies. In 13 of 35 patients a pharyngo- relapse to increased scarring of palatal tissues and
plasty was in place at the time of maxillary Le Fort I osteotomy. multiple missing teeth.
The results of the study are summarized in Table 28.2. 5. Previous alveolar bone grafting: Although studies have
The mean horizontal advancement achieved for the group reported the value of alveolar bone grafting in
was 6.9 mm; 5.3 mm was maintained 1 year later (mean establishing stability of advancement and minimizing
relapse 1.6 mm). In 11 of the 35 patients the relapse was less relapse, the study by Hirano and Suzuki10 found no
than 1.0 mm. For the 13 patients who had a pharyngoplasty association between alveolar bone graft and the rate of
at the time of the Le Fort I osteotomy, the mean horizontal relapse in unilateral cleft lip and palate patients.
advancement was 8.2 mm immediately after the operation 6. Number of missing teeth: The study by Hirano and
and 6.5 mm 1 year later. Stability of the vertical displacement Suzuki10 also found no correlation between the number
was also evaluated. No maxillary vertical change was neces- of missing teeth and relapse although the authors stress
sary in 12 of 35 patients. The mean vertical displacement of that multiple missing teeth can compromise the stability
the maxilla in patients who underwent vertical displacement of the occlusion.
was 2.1 mm; 1.7 mm was maintained 1 year later. The authors
7. Type of orthognathic surgery: There was no difference
concluded that neither horizontal nor vertical relapse was
in the relapse rate between patients undergoing
related to the extent of movement. The overjet from the
maxillary surgery alone and those who underwent
cephalometric radiographs at the 1-year postoperative inter-
two-jaw surgery.
val was maintained in all patients, whereas a positive overbite
was maintained in only 30 of 35 patients (85%). While both relapse and worsening VPI can occur with the
Other investigators have found a correlation between movements performed in orthognathic surgery, they are a
relapse and the degree of advancement. To identify factors result of primary deficiencies in the soft tissue due to prior
associated with relapse after orthognathic surgery in the cleft scar formation as well as the underlying deformity and thus
lip/palate patient, Hirano and Suzuki10 performed a retro- are under only limited surgeon control. There are several
spective study on 58 cleft patients who underwent orthogna- complications, however, on which the surgeon can have a
thic surgery over a 10-year period. From their study, they direct effect.
identified the following factors related to relapse: Improper positioning of the jaws is noted by malocclusion
1. Horizontal advancement: In their series the mean or an obvious unaesthetic result. Special care must be taken
horizontal relapse was 24.1% of the mean advancement. to ensure proper condyle positioning during fixation of the
There was significant correlation between extent relapse mandibular osteotomy. If malocclusion results from improper
and advancement. The authors report that complete condyle position during fixation, it must be removed and
surgical mobilization of the maxilla is important in reapplied. The same is true for improper indexing of the
preventing relapse. splint. For this reason, it is wise to verify splint fit prior to
2. Vertical displacement (inferior positioning): In their surgery. Meticulous treatment planning prior to surgery
study the mean inferior vertical elongation was 3.0 mm minimizes splint-related problems.
with a relapse of 2.1 mm. Based on their study, the Measures to reduce the chance of an unfavorable mandibu-
lar split should always be employed. Removal of mandibular
third molars 6 months prior to the osteotomy allows time for
sockets to heal, decreasing the chance of a bad split. If the
Table 28.2 Patients with unilateral cleft lip and palate
segments do not appear to be easily separating, the surgeon
undergoing Le Fort I osteotomy with miniplate fixation: mean
should verify that the osteotomies are complete. Excessive
horizontal/vertical displacement and relapse
force that could increase the chance of an uncontrolled man-
Effective horizontal dibular split should be avoided. If an unfavorable split occurs,
Time after mean advancement Effective vertical the segments can be plated to re-establish normal anatomy,
surgery (mm) mean change (mm) and the proximal and distal segments can then be secured into
1 week 6.9 ± 2.6 2.1 ± 2.4 the desired position with rigid fixation.
Bleeding may occur from any area, but most commonly
6–8 weeks 6.3 ± 2.6 1.9 ± 2.1
from the descending palatine artery in the maxilla. This can
1 year 5.3 ± 2.7 1.7 ± 2.0 be stopped with packing or by placing a hemoclip on the
(Reproduced from Posnick JC, et al. Cleft-orthognathic surgery: the unilateral artery. Bone wax is useful for bleeding bony edges.
cleft lip and palate deformity. In: Craniofacial and Maxillofacial Surgery in Nerve damage is rare, but can occur. The nerves associated
Children and Young Adults, Vol. 2, Chapter 34. Philadelphia: WB Saunders; with these procedures are the infraorbital, inferior alveolar,
2001.)
and mental nerve. If a transaction is witnessed, coaptation
Secondary procedures 677
with 7-0 nylon suture is recommended. The patient should be 2. Obwegeser H. Surgery of the maxilla for the correction of
informed that there is approximately a 70% chance of some prognathism. SSO Schweiz Monatsschr Zahnheilkd. 1965;75:365–374.
paresthesia immediately after surgery, but permanent changes 3. Enlow EH. Craniofacial growth and development: normal and
deviant patterns. In: Posnick JC, ed. Craniofacial and Maxillofacial
are seen in only 25% of patients. Surgery in Children and Young Adults. Philadelphia: W B Saunders;
The incidence of nonunion or malunion is rare after surgery. 2000:22–35. In this comprehensive chapter, the author provides a detailed
If a malunion occurs, the jaw may need to be osteotomized account of the development of the craniofacial skeleton, under both normal
again to move it into proper position. A nonunion requires conditions and in disease states. It highlights the temporal relationship
secondary bone grafting to establish osseous continuity. between growth of the cranial skeleton and the facial skeleton as well as
the differences among genders and in specific conditions of craniofacial
abnormalities.
4. Mao JJ, Wang X, Kopher RA. Biomechanics of craniofacial sutures:
Secondary procedures orthopedic implications. Angle Orthod. 2003;73:128–135.
5. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations
The need for secondary procedures in orthognathic surgery is in orthognathic surgery. Int J Adult Orthodon Orthognath Surg.
uncommon, especially when careful patient selection and 1995;10:97.
preoperative evaluation are employed. However, orthogna- 6. Selber JC, Rosen HM. Aesthetics of facial skeletal surgery. Clin Plast
thic surgery rarely can completely resolve a significant Surg. 2007;34:437–445. This article highlights the changing paradigm in
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preoperative dentofacial deformity. Indeed, maxillary and analysis to one encompassing an evaluation of the aesthetic facial
mandibular movements, in addition to altering occlusal soft-tissue proportions.
relationships and skeletal proportions, may highlight features 7. Janulewicz J, Costello BJ, Buckley MJ, et al. The effects of Le Fort I
previously de-emphasized by malocclusion. In such cases, osteotomies on velopharyngeal and speech functions in cleft
procedures such as rhinoplasty, fat grafting, or malar augmen- patients. J Oral Maxillofac Surg. 2004;62:308–314.
tation may help restore facial harmony. 8. Phillips JH, Klaiman P, Delorey R, et al. Predictors of
It is important to realize that underlying issues related to velopharyngeal insufficiency in cleft palate orthognathic surgery.
Plast Reconstr Surg. 2005;115:681–686. This article is a retrospective
the primary cleft or craniofacial disorder may not be fully examination of 26 patients who underwent orthognathic advancement.
addressed with orthognathic surgery. For example, patients Assessments of speech and velopharyngeal function before and after
with repaired clefts who undergo orthognathic surgery to orthognathic surgery and the role of nasopharyngoscopy are detailed.
address a class III malocclusion may still need surgeries to 9. Posnick JC, Tompson B. Cleft-orthognathic surgery: complications
complete their dental rehabilitation. Bone grafting and ves- and long-term results. Plast Reconstr Surg. 1995;96:255–266. This
tibuloplasty may be as necessary after orthognathic surgery article is a retrospective evaluation of 116 patients with cleft palate who
underwent orthognathic surgery to correct malocclusion. The authors
as before.11 Likewise, in the setting of persistent edentulous report a mean follow-up of 40 months and describe common complications
spaces, osseointegrated implants which are resistant to ortho- and outcomes.
pedic movements should be utilized only after jaw surgery 10. Hirano A, Suzuki H. Factors related to relapse after Le Fort I
and postoperative orthodontics have determined final tooth maxillary advancement osteotomy in patients with cleft lip and
positions. palate. Cleft Palate Craniofac J. 2001;38:1–10. This article is a
retrospective study of 58 patients (42 unilateral cleft and 16 bilateral cleft)
who underwent orthognathic surgery to correct maxillary hypoplasia. The
References authors report a mean follow-up period of 2.5 years. Based on
cephalometric and statistical analyses, the authors elucidate factors related
1. DeLuke DM, Marchand A, Robles EC, et al. Facial growth and the to relapse after Le Fort I maxillary advancement.
need for orthognathic surgery after cleft palate repair: literature 11. Baker S, Goldstein JA, Seiboth L, Weinzweig J. Posttraumatic
review and report of 28 cases. J Oral Maxillofac Surg. 1997;55:694– maxillomandibular reconstruction: a treatment algorithm for the
697, discussion 7–8. partially edentulous patient. J Craniofac Surg. 2010;21:217–221.

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SECTION I • Clefts

mities can also occur. Regardless of the etiology, patient

saw to the mandibular ramus took no more than 15 minutes

surgeries increase the scar burden and may make maxillary

The term “dental compensation” is used to describe the ten-

Fig. 28.3 Three-dimensional computed tomography

Descending palatine artery

Nasopalatine artery Lesser palatine artery

Ascending palatine artery

Basic approaches to commonly

Skeletal class II malocclusion

especially in more mature patients. If the malocclusion is Vertical maxillary excess

Maxillary constriction Postoperative care

Fig. 28.8 (A–H) 17-year-old female with Treacher

Fig. 28.9 (A–H) 19-year-old patient with unilateral cleft lip

defect as compared to 73% (40 patients) postoperatively.

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