Orthognathic Surgery and Distraction Osteogenesis in Cleft Lip and Palate Patients with a Class III: What Should the Orthodontist Know? 

by Autelitano Luca

Maxillary hypoplasia is a common feature among cleft children. A consistent number of UCLP patients need final orthognathic surgery to obtain optimal facial aesthetics and a functional occlusion. The frequency of LFI varies among studies, ranging from 13% up to 70%. Conventional orthognathic surgery with Le Fort I osteotomy, is performed for the correction of maxillary hypoplasia. Le Fort I can be performed as a single piece or multi-piece osteotomy, depending on sagittal, vertical and transverse deficiency. The aim is to place the maxilla forward to obtain adequate occlusion, possibly with an overcorrection that could protect against the relapse (which is more frequent and consistent than in non-cleft patients), and to give a good support to the nose, upper lip and midface. When the sagittal discrepancy is large, and in case of heavy palatal scar tissue, distraction osteogenesis is preferred, with intraoral or extraoral devices. External devices allow to obtain more consistent advancement with higher predictability, allowing vertical increase. Once the desired position has been attained, the distraction device remains in situ, acting as rigid skeletal fixation system until completion of bone stabilization (typically 4 times the lengthening) The two major problems with maxillary advancement in cleft population are skeletal relapse and velopharyngeal insufficiency (VPI). Relapse was found to be greater in the osteotomic group than in the DO group, with higher relapse in the vertical than sagittal plane. Velopharyngeal function is impaired by maxillary advancement, with a direct proportion with sagittal lengthening. The relapse in cleft patients has to be considered at the moment of presurgical planning, an overcorrection of the vertical movement has to be performed in cleft patients. Velopharyngeal functionality has to be assessed before orthognathic surgery and if the risk of development of VPI is high, different options must be evaluated.

Learning Objectives

After this lecture, you will be able to define the techniques of treatment of maxillary hypoplasia in cleft patients
After this lecture, you will be able to evaluate the role of orthodontic and surgical coordination in treatment of maxillary hypoplasia
After this lecture, you will be able to evaluate the most relevant drawback with maxillary advancement in cleft patients