J Oral Maxillofac 50:666-675,

Surg

1992

Modification of the Maxillary Le Fort Osteotomy in Cleft-Orthognathic Surgery: I

The Unilateral Cleft Lip and Palate Deformity JEFFREY C. POSNICK, DMD, MD, FRCS(C), FACS,* AND BRIAN TOMPSON, DDSt Modifications of the Le Fort I osteotomy are described that allow for the simultaneous routine and safe management of maxillary hypoplasia, residual oronasal fistula, bony defects, soft-tissue scarring, and cleft-dental gap in adolescents with unilateral cleft lip and palate (UCLP). The results of this operation with 40 consecutive patients are presented, together with follow-up findings ranging from 15 months to 4 years 5 months. Parameters reviewed include cleft-dental gap closure, maintenance of attached gingiva at the cleft site, maintenance of a positive overjet and overbite, closure of residual oronasal fistula, the need for prosthetics to complete dental rehabilitation, and surgical morbidity. Thirteen of the patients also underwent simultaneous sagittal split osteotomies of the mandible, and 29 had a genioplasty performed. In 32 of the patients surgical cleftdental gap closure was planned, and was successfully executed in all but one. Thirtyseven patients underwent successful simultaneous oronasal fistula closure, but in three cases, small residual fistulas remained. In all cases, attached gingiva was maintained in the region of the cleft site and along the tooth-bearing surfaces. Almost all of the patients maintained a positive overjet (39 of 40) and 85% maintained a positive (34 of 40) or at least neutral (4 of 10) overbite. Complications were few and generally not serious.

The literature warns of the possible complications of maxillary osteotomy in these patients, but provides only limited descriptions of techniques to guide the orthognathic surgeon in the performance of safe, reliable osteotomies to solve these problems. Willmar,’ in 1974, reported on the complications associated with Le Fort I osteotomy. When this procedure was carried out in the patients with UCLP ( 17 of his 106 patients), he reported one patient with aseptic necrosis and partial loss of the lesser segment of the maxilla. In 1974, Georgiade2 suggested that a camouflage approach was often preferred to direct maxillary surgery. Completion of a mandibular osteotomy with setback was felt to improve the facial disproportion in the cleft patient. Kiehn et al3 and DesPrez and Kiehn,4 in recommending maxillary surgery in some cleft patients, warned of blood supply problems that might occur, but did not elaborate on specific surgical technique. In 1975, Henderson and Jackson5 reported combining cleft lip revision, anterior fistula closure, and maxillary osteotomy in a one-stage procedure. Although their concept was

Correction of the residual skeletal deformities of unilateral cleft lip and palate (UCLP) in the adolescent challenges the ingenuity and skill of the oral and maxillofacial surgeon. The central pathology in these patients is a degree of maxillary hypoplasia, often combined with residual oronasal fistula, bony defects, and soft-tissue scarring. In addition, the maxillary lateral incisor tooth at the cleft site usually is congenitally absent, resulting in a cleft-dental gap.

* Medical Director, Craniofacial Program, Division of Plastic Surgery, The Hospital for Sick Children, Toronto; Assistant Professor, Deoartment of Surgery, and Assistant Professor, Department of Dentistry, University oiToronto. t Head. Division of Orthodontics, Department of Dentistry, The Hdspital for Sick Children, Toronto; Associate Professor, Department of Dentistry, University of Toronto. Address correspondence and reprint requests to Dr Posnick: 555 University Ave, Toronto, Ontario, Canada M5G 1X8. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5007-0002$3.00/0

666

667

POSNICKAND TOMPSON innovative. the authors did not specify the details of the technique. In 1978, Jackson6 further described the Le Fort I procedure as it applied to the cleft patient. He said that if a large fistula was present that required extensive flap mobilization for closure, he preferred a staged approach with fistula closure and bone grafting followed later by osteotomy. In general, authors have been fearful of flap necrosis with loss of maxillary bone and teeth. These authors suggest that maxillary orthognathic surgery in the patient with UCLP involve only limited incisions, with subperiosteal tunnelling for exposure, osteotomies, and disimpaction, or a twostaged approach with fistula closure and bone grafting followed later by maxillary osteotomy.7-‘9 During the 1970s and 198Os, there was an explosion of new knowledge about flap circulation encompassing all tissue types and body regions.20 The basic knowledge and the clinical principles developed during this period now serve as a guide in this evolving field. In a study of particular importance to oral and maxillofacial surgery, Bell et al” examined the circulation to maxillary dento-osseous musculomucosal flaps and was the first to indicate that the Le Fort I osteotomy could be safely downfractured through direct incisions. He showed that intact greater palatine vessels resulted in an axial-pattern flap, whereas sacrifice of the greater palatine pedicles resulted in a random-pattern circulation, and that the downfractured maxilla survived as a random-pattern composite flap.” He further showed the safety of posterior segmental osteotomies of the maxilla.‘2 A rethinking of the circulatory needs of the Le Fort I osteotomy in the clefted maxilla suggested that safe flaps could be developed that allow more directly for the routine one-stage management of the residual deformities of the UCLP adolescent.23*24The purpose of this article is to review a consecutive series of patients with UCLP who underwent the modified Le Fort I osteotomy and present the long-term follow-up results. Material and Methods OPERATIVETECHNIQUE The operative technique has been previously outlined.25 It is illustrated and briefly described in the legend for Figure 1. For effective management of the UCLP maxilla, both the classic Le Fort I osteotomy and current techniques had to be modified. The principal modification consists of placement of soft-tissue incisions that allow direct exposure for dissection, osteotomies. disimpaction, fistula closure, bone grafting, and application of plate-and-screw fixation, but do not risk circulation injury to the dento-osseous musculomucosal flaps. With the increased visibility provided by these incisions, the routine surgical closure of the cleft-dental gap through differential maxillary segmental repositioning can be incorporated. This method of

approximating the maxillary segments for closure of the gap also closes the dead space where the cleft bony gap exists and approximates the labial and palatal flaps to allow for closure of recalcitrant oronasal fistula without tension. In anticipation of postoperative skeletal relapse, surgical overcorrection of several millimeters is planned in the horizontal and transverse dimensions. The exact amount will vary depending on the interdigitation of the teeth. Also, the jaws are rewired either at the end of the procedure or during the first few days, depending on perioperative airway needs, to give increased stability. Maxillomandibular fixation (MMF) is generally maintained for 6 weeks, with the prefabricated acrylic splint remaining ligated to the maxillary teeth for an additional 2 weeks. The segmental surgical archwires are then replaced by a continuous one, and orthodontic treatment is resumed. PATIENTDATA BetweenApril I987 and July 1990,40 of the authors’ patients with UCLP underwent orthognathic surgery at The Hospital for Sick Children, Toronto, using the modified Le Fort I osteotomy. The group included 19 males and 21 females ranging in age from 15 to 25 years. All underwent perioperative orthodontic treatment and were judged either by serial cephalometric radiographs or epiphyseal plate closure on hand radiographs to be skeletally mature at the time ofjaw surgery. Five of the 40 patients had previously undergone orthognathic surgery by another surgeon. Each of these five patients presented with residual maxillary hypoplasia. residual oronasal fistula, and a cleft-dental gap. Thirteen of the 40 patients also underwent simultaneous sagittal split osteotomies of the mandible, and 29 had a genioplasty performed. All but one patient had a residual perialveolar oronasal fistula of varied size and therefore underwent simultaneous fistula closure. The maxilla was segmented through the bony cleft site in all cases. Thirty-five of the patients presented with cleft-dental gaps, the other 5 having had successful gap closure through orthodontic treatment. Thirty-four of the 40 patients (85%) presented with a negative overjet at the central incisors. Thirty-seven of the 40 (92.5%) presented with both lateral (posterior) crossbites resulting from maxillary hypoplasia and a shift of the maxillary dental midline off the facial midline. The maxillary dental midline was also noncoincident with the mandibular dental midline in these 37 patients. Simultaneous differential repositioning of the maxillary segments was planned for all 40 patients. In 32 of the 35 patients presenting with cleft-dental gaps, surgical gap closure through segmental repositioning was also planned, whereas in 3 of the early cases, cleft-dental

CLEFT-ORTHOGNATHIC

SURGERY: UCLP

E FIGURE 1. Illustrations of modified Le Fort I osteotomy in two segments. A, Illustration of direct incisions for completion of osteotomies and fxstula closure. B, Frontal view of bony skeleton before and just after fixation of Le Fort I osteotomy in two segments. The inferior turbinates have been reduced, and a submucous resection of the deviated nasal septum has been performed. Iliac, cancellous bone graft has been placed along the nasal floor. A miniplate is placed vertically along each zygomatic buttress and pyriform aperature region while a microplate is placed horizontally across the segmental osteotomy site. C, Lateral view of maxillofacial skeleton before and just after osteotomies and fixation of modified Le Fort I osteotomy. D, Illustration of downfractured Le Fort I in two segments after submucous resection of septum, reduction of inferior turbinate through the nasal mucosa opening, followed by watertight nasal side closure. E. Palatal view of bony segments before and after repositioning. F, Illustration indicating oral-side wound closure on both labial and palatal aspects after differential segmental repositioning. (Reprinted with permission?5)

gap closure was not carried out and differential repositioning was performed to coordinate the arches. Despite the successful “orthodontic” cleft-dental gap closure in these 5 patients, surgical arch width and

coordination problems remained, necessitating segmental repositioning. All patients underwent simultaneous iliac cancellous bone grafting and fixation with four titanium mini-

669

POSNICK AND TOMPSON

plates and screws. Since 1990, a micro bone plate has also been used for placement across the cleft-dental gap closure sites. Use of a prefabricated acrylic splint wired to the maxillary teeth and MMF were also routine. A prophylactic antibiotic regimen consisted of intravenous (IV) penicillin and cloxicillin commencing intraoperatively just prior to the incision. On the second postoperative day when the IV fluids were discontinued, penicillin elixir was continued for a lo-day course. The postoperative parameters specifically reviewed for this study included surgical morbidity, closure of residual oronasal fistulas, cleft-dental gap closure, maintenance of attached gingiva at the cleft site, and maintenance of a positive overjet and overbite, as determined from the late postoperative cephalometric radiographs. Also reviewed was the need for prosthetics to complete the dental rehabilitation. Results The follow-up periods ranged from 15 months to 4 years and 5 months, with a mean of 24 months. Surgical cleft-dental gap closure was maintained in all but one of the patients in whom it was attempted. In this patient, the cleft-dental gap closure was initially achieved, but over the ensuing 6 months the lesser segment relapsed, with the opening of the gap, even though the fistula remained closed and the greater segment maintained good position. In 3 of the 40 patients, very early in the study when we were not yet convinced of the benefits of surgical cleft dental-gap closure, prosthetic replacement of cleft-related missing teeth was planned. Six patients required fixed bridgework to finalize their maxillary dental rehabilitation. In the three patients in whom the dental gap was intentionally left open and in another in whom the gap reopened due to relapse, prosthetic closure was required. In the other two patients requiring fixed bridgework, resurfacing of the incisor teeth because of chronic tooth decay and congenital dysplasia was the indication. In all cases, attached gingiva remained in the region of the cleft site and along the tooth-bearing surfaces. In many patients, gingiva along the distal aspect of the central incisor had receded over the years secondary to longstanding poor bony support and could not be much improved at the time of the orthognathic surgery. The long-term maintenance of overjet was measured directly from the late (greater than 1 year) postoperative lateral cephalometric radiograph in each patient; all but one patient (39 of 40) maintained a positive overjet; that patient shifted to a neutral overjet. The long-term maintenance of overbite was also measured directly from the late postoperative lateral cephalometric radiograph in each patient; 85% (34 of 40) maintained a positive overbite, 10% (4 of 40) shifted to a neutral

overbite, and 5% (2 of 40) relapsed into a negative overbite despite planned overcorrection and perioperative orthodontics. Thirty-seven patients underwent successful simultaneous oronasal fistula closure. In three cases, small residual fistulas required reclosure with standard mucogingival flaps as a secondary procedure, without the need for further bone grafting. Other complications were few and generally not serious. One patient had a significant nosebleed on the sixth postoperative day; it required anterior and posterior nasal packing, but no further sequelae occurred. In another patient, the maxillary vertical height was increased excessively, resulting in a gummy smile. The patient was returned to the operating room on the third postoperative day for repositioning of the maxilla for a more satisfactory appearance. In a third patient, a chronically decayed central incisor adjacent to the cleft site required root canal therapy 4 months after surgery. In a fourth patient, 9 months after surgery, the two maxillary central incisors showed enamel discoloration and a pulse Doppler study indicated early pulp necrosis; successful root canal therapy was carried out. There was no loss of bone or mobility of the teeth, and the long-term prognosis for the teeth is good. A fifth patient returned 3 weeks after surgery complaining of difficulty breathing. His MMF was released, thick mucus was suctioned from the nasopharynx, and his jaws were left unwired. The rest of his postoperative course was uneventful. In no circumstance was there segmental bone loss or loss of teeth. No infections occurred, nor was there any need for drainage procedures or extended use of antibiotics. None of the patients have yet required or requested removal of bone plates or screws. Case Reports Case 1 A 19-year-old boy born with complete cleft of the left lip and palate had undergone surgery for lip repair in infancy followed by cleft palate repair in early childhood (Fig 2). His residual clefting problems included maxillary hypoplasia with a class III malocclusion, a negative overbite and overjet with crossbite of the lesser maxillary segment, shift of the maxillary dental midline off the facial midline, a perialveolar oronasal fistula, and a cleft-dental gap resulting from a congenitally absent lateral incisor tooth. Orthodontic brackets had been placed at the age of 16 in preparation for orthognathic surgery, which was performed at the age of 19. Speech assessment, including nasendoscopy, confirmed inadequate velopharyngeal closure and sibilant distortions secondary to malocclusion. A modified maxillary Le Fort I osteotomy was carried out in two segments with differential repositioning to close the cleft-dental gap and perialveolar oronasal fistula, improve the bony and soft-tissue periodontal support of the teeth adjacent to the cleft, create a positive overbite and overjet, and correct lateral crossbites and class III malocclusion. Achievement of these improvements also required sag&al split osteotomies of the mandible and a vertical reduction and ad-

670

CLEFT-ORTHOGNATHIC

SURGERY: UCLP

FIGURE 2. A 19-year-old boy with UCLP undergoing a modified Le Fort I osteotomy in two segments is shown before surgery and 1 year later. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative lateral view. D, Postoperative lateral view. E. Preoperative occlusal view. F, Postoperative occlusal view. G. Preoperative palatal view. H, Postoperative palatal view.

FIGURE 2

(Cont’d).

vancement genioplasty. The septum of the nose was straightened and the inferior turbinates were reduced. Stabilization was accomplished with iliac bone grafts, titanium miniplate and screw fixation, the use of an interocclusal splint, and MMF. One and one-half years after surgery, the patient’s general appearance, smile, and profile are improved. He has undergone a veneer restoration of his left maxillary central incisor tooth because of congenital dental dysplasia. A pharyngeal flap and cleft rhinoplasty are planned.

A vertical reduction and advancement genioplasty was also performed. Stabilization was with an iliac bone graft, miniplate and screw fixation, acrylic splinting and MMF. One and one-half years after surgery. there was improved function and appearance, without the need for prosthetic rehabilitation. Speech reassessment confirmed the maintenance of adequate velopharyngeal closure and correction of sibilant distortions.

Case 2

Children with cleft lip and palate (CLP) are at risk for poor facial growth. ROSS~~noted that in approximately 25% of adult males with UCLP, orthognathic

An Oriental female was born with a complete cleft of the left lip and palate (Fig 3). She underwent lip and palate repair in infancy followed by cleft-lip nasal revision. These operations were done in Hong Kong. Her residual problems included maxillary hypoplasia with class III malocclusion, a negative overbite and overjet with crossbite of the posterior teeth, shift of the maxillary dental midline off the facial midline, labial, and palatal oronasal fistula, and a cleft-dental gap resulting from a congenitally absent lateral incisor tooth. There was also a palatally displaced supernumerary tooth on the right maxilla. Orthodontic brackets were placed in the patient 1% years before jaw surgery to level and align the teeth in each maxillary segment and the mandible in preparation for orthognathic surgery. Preoperative speech assessment, including nasendoscopy, confirmed adequate velopharyngeal function with articulation distortion in the anterior dentition. The patient underwent a modified Le Fort I osteotomy in two segments with differential repositioning to close the cleftdental gap, dead space, and oronasal fistula, and to correct her class III malocclusion and overjet and overbite problems.

Discussion

surgery would be necessary to permit an adequate functional relationship of the jaws. The criteria applied by ROSS~~in his study are those traditionally applied to determine maxillary development. The cephalometric criteria refer to the basic anteroposterior projection of the maxilla at the incisors, reviewed either in isolation or in relation to mandibular anteroposterior projection, and the basic anterior vertical maxillary height, also reviewed either in isolation or as a proportion of total facial height. These criteria may be sufficient to determine the incidence of horizontal and vertical maxillary hypoplasia at the incisors, but fail to identify completely the adolescents with UCLP who would benefit from orthognathic surgery. The prevalence of residual clefiing deformities in the adolescent varies widely, depending on a center’s policy

672

CLER-ORTHOGNATHIC

SURGERY: UCLP

C FIGURE 3. Seventeen-year-old girl with UCLP undergoing a modified Le Fort I osteotomy in two segments seen before and 1 year after surgery. A, Preopemtive frontal view. B, Postoperative frontal view. C, Preoperative profile view. D, Postoperative profile view. I?, Preoperative occlusal view. F, Postoperative occlusal view. G, Preoperative palatal view. H, Postoperative palatal view.

POSNICK

673

AND TOMPSON

FIGURE 3

in regard to the staging of reconstruction and on its available technical expertise. In addition, despite a center’s preferred method of management in infancy, childhood, and early adolescence, there will be a subgroup of patients with UCLP who present with multiple residual problems who would benefit from orthognathic surgery.26 Review of the literature on the Le Fort I osteotomy and its application to patients with UCLP shows an incomplete understanding of blood supply to the dentoosseous musculomucosal flaps. This has resulted in 1) use of camouflage procedures to avoid direct surgery on the maxilla2; 2) avoidance of direct incisions with only limited exposure, resulting in limited access for reconstruction9‘i9; or 3) staging of reconstructive procedures to limit complications.576S16 With refinements in hypotensive anesthesia, improved methods of airway management, and refinements in maxillary surgery, surgical camouflage procedures rather than direct osteotomy of the maxilla rarely are indicated. The tunnelling methods generally suggested for maxillary osteotomies result in poor visibility,9-l 1.14.16-19 increase the possibility of morbidity to adjacent teeth, limit soft-tissue dissection, and may result in ineffective placement of plate-and-screw fixation, with a greater tendency to relapse and a need

(Cont’d).

for external fixation. The alternative of staging the reconstruction by first bone grafting and closing the residual oronasal fistula, and later proceeding with a maxillary Le Fort I downfractured osteotomy, requires a second surgical procedure, often with the need for additional bone grafting, does not allow resolution of the cleft-dental gap problem by differential movement of the maxillary segments, and results in less satisfactory periodontal support to the adjacent teeth. This method of managing residual fistulas, alveolar defects, and cleft-dental gaps described25 is not intended to replace standard techniques. Rather, it offers an alternative once the golden opportunity is lost for grafting the alveolus in the mixed dentition before eruption of the permanent canine tooth. A two-stage approach for the cleft adolescent with maxillary hypoplasia and a residual alveolar cleft is not cost-effective. During the first stage, the patient must be hospitalized, undergo an operation with a general anesthetic, and autogenous bone graft is required for alveolar grafting and fistula closure. After 6 to 12 months of healing, the patient must return to the hospital for another anesthetic and operation, at which time jaw surgery is carried out, generally with the need for further interpositional autogenous bone grafting for osteotomy stabilization.8,‘2~‘3 Finally, once osteotomy healing has occurred and or-

674

thodontic treatment is complete, with demonstrated skeletal and dental stability, prosthetic rehabilitation is required to manage the cleft-dental gap. The onestage procedure described requires only a single anesthetic and operation, without the need for a second bone graft or prosthetic rehabilitation. Prosthetic options for the cleft-dental gap are available. These include a removable partial denture that can also cover residual fistulas. In the long term, however, a denture places significant stress on the natural dentition and fixed bridgework requires the cutting down of adjacent normal teeth. The fixed bridgework will also need replacement at intervals throughout the patient’s life, and demands ongoing meticulous oral hygiene to achieve long-term maintenance. Placement of an osseointegrated implant is an attractive third option in selected cases, but at present should be considered experimental when placed into a bone-grafted alveolar cleft region.27 The importance of bone grafting in the cleft patient undergoing maxillary osteotomy has been emphasized by Gillies and Rowe,’ Araujo et aL2’ and Tessier and Tulasne.29 Use of plate-and-screw fixation in the maxillofacial region was initially introduced in 1968 by Luhr,30 and further described by Champy,31 HBrster,32 Drommer and Luhr,33 and Beals and Munro.34 We combine autogenous bone grafting with plate-andscrew fixation in all cleft cases. Posnick and Ewing35 have shown that even with the use of plate-and-screw fixation, however, a degree of skeletal relapse may occur. For this reason, we generally overcorrect the maxilla in the horizontal and transverse planes by approximately 1 to 3 mm and also use acrylic splinting and MMF. Others will rely more on elastic traction as needed in the postoperative phase of treatment. This diversity in treatment reflects more the art than the science of cleft-orthognathic surgery. Proffit36 and Boyne37 recently described the advantages of cleft-dental gap closure by orthodontic anterior migration of the canine tooth when the lateral incisor tooth is congenitally absent. Successful fistula closure and alveolar bone grafting followed by successful orthodontic treatment, including gap closure initiated in the mixed dentition, is required. Proffit36 and Boyne37 identified the advantages of cleft-dental gap closure by canine tooth migration as follows: improved alveolar bone support to the dentition, increased projection to the anterior maxilla, and improved nasal sill support without the need for dental prosthetics. They pointed out that despite a general preference for the approach, orthodontic closure of the cleft-dental gap has not been achieved in many cleft patients. As adolescents, patients with cleft lip and palate often face residual problems of maxillary hypoplasia combined with residual oronasal fistula and a cleft-dental gap requiring treatment. Our one-stage approach is

CLEFT-ORTHOGNATHIC

SURGERY: UCLP

ideally suited to such patients. The disadvantages of shifting the teeth within the lateral segment anteriorly to close the gap created by the congenitally absent lateral incisor tooth would apply to either orthodontic or surgical gap closure, and have not proven to be clinically significant. The theoretical disadvantages relate to change in tooth contacts during dynamic lateral excursion of the mandible. More important, a posterior dental gap is created with anterior gap closure. Articulated dental models must be analyzed with the lateral segment dentition in the proposed advanced position to be certain that the posterior maxillomandibular occlusion will remain satisfactory. Uncertainties about velopharyngeal function and management of an in-place pharyngeal flap have been a limiting factor when cleft-orthognathic surgery is considered. Witzel and Munro3’ have shown that nasendoscopy combined with clinical examination is an excellent predictor of current and expected velopharyngeal function in the cleft patient scheduled for orthognathic surgery. When significant velopharyngeal deterioration is anticipated, informed consent can be obtained and alternatives discussed. At the time of maxillary osteotomy, it has not been necessary to transect an in-place flap to achieve the desired advancement. Flap modification in attempting to improve velopharyngeal function or the inset of a new flap at the time of osteotomy is not recommended. This manipulation might compromise circulation to the maxillary dento-osseous musculomucosal flaps. If the inset or revision of a pharyngeal flap is required, as established through preoperative nasendoscopy and clinical examination and confirmed at the 6- to 1Zmonth reassessment after surgery, it is carried out at that time as a secondary procedure, and may be combined with other necessary soft-tissue revisions to the cleft lip or nose.

Acknowledgment The authors wish to acknowledge and thank Drs A. Dagys, R.B. Ross, M. Taylor, D. Engel, and N. Shapera from the Division of Orthodontics, The Hospital for Sick Children, for their assistance with the surgical planning and orthodontic treatment of the patients presented, and Dr M. A. Witzel and her staff for providing the speech and articulation evaluations and treatment of the cleft patients.

References 1. Willmar K: On Le Fort I osteotomy: A follow-up study of 106 onerated natients with maxilla-facial deformity. Stand J Plast ReconstrSurg 1974 (suppl 12) 2. Georgiade NC? Mandibular osteotomy for the correction of facial disproportion in the cleft lip and palate patient. Symposium on Management of Cleft Lip and Palate and Associated Deformities. Am Plast Reconstr Surg 8:238, 1974 3. Kiehn CL, DesPrez JD, Brown F: Maxillary osteotomy for late correction of occlusion and appearance in cleft lip and palate patients. Plast Reconstr Surg 42:203, 1968 4. DesPrez JD, Kiehn CL: Surgical positioning of the maxilla.

675

THOMAS W. BRAUN

Symposium on Management of Cleft Lip and Palate and Associated Deformities. Am Plast Reconstr Surg 8222, 1974 5. Henderson D, Jackson IT: Combined cleft lip revision, anterior fistula closure and maxillary osteotomy; a one-stage procedure. Br J Oral Surg 13:33, 1975 6. Jackson IT: Cleft and jaw deformities. Symposium on Reconstruction of Jaw Deformity 16:113, 1978 7. Steinkamm W: Die Pseudo-Progenie und ihre Behandlung. Berlin, Inaug Diss, 1938 8. Gillies H, Rowe NL: L’ost6otomie du maxillaire superieur envisa&e essentiellement dans les cas de becde-lievre total. Rev Stomatol Chir Maxillofac 55:545, 1954 9. Fitzpatrick B: Mid-face osteotomy in the adolescent cleft patient. Aust Dent J 22~338, 1977 10. Tideman H, Stoelinga P, Gallia L: Le Fort I advancement with segmental palatal osteotomies in patients with cleft palates. J Oral Surg 38: 196, 1980 11. Sinn DP: Simultaneous maxillary expansion and advancement, repair of oronasal fistula, and bone grafting of the alveolar cleft, in Bell WH, Protlit WR, White RP (eds): Surgical Correction of Dentofacial Deformities. Philadelphia, PA, Saunders, 1980 12. Braun TW, Sotereanos GC: Orthognathic and secondary cleft reconstruction of adolescent patients with cleft palate. J Oral Surg 38:425, 1980 13. Braun TW, Sotereanos GC: Orthognathic surgical reconstruction of cleft palate deformities in adolescents. J Oral Surg 39:255, 1981 14. Westbrook MT Jr, West RA, McNeil RW: Simultaneous maxillary advancement and closure of bilateral alveolar clefts and oronasal fistulas. J Oral Maxillofac Surg 41:257, 1983 15. Ward-Booth. RP. Bhatia SN. Moos KF: A cenhalometric analvsis of the Le’Fort II osteotomy in the adult cleft patient. J Maxillofac Surg 12:208, 1984 16. James D, Brook K: Maxillary hypoplasia in patients with cleft lip and palate deformity-The alternative surgical approach. Em J Orthop 7:231, 1985 17. Poole MD, Robinson PP, Nunn ME: Maxillary advancement in cleft lip and palate patients. A modification of the Le Fort I osteotomy and preliminary results. J Maxillofac Surg 14: 123, 1986 18. Stoelinga PJ, vd Vijver HR. Leenen RJ, et al: The prevention of relapse after maxillary osteotomies in cleft palate patients. J Craniomaxillofac Surg 15:325, 1987 19. Stoelinga PJ, Haers PE, Lennen RJ, et al: Late management of secondarily grafted clefts. Int J Oral Maxillofac Surg 19:97, 1990 20. McGraw JB, Dibbell DG, Carraway JH: Clinical definition of independent myocutaneous vascular territories. Plast Reconstr Surg 60:341. 1977 2 1. Bell WH, Fonseca RJ, Kennedy JW III, et al: Bone healing and

J Oral Maxillofac 50:675-676.

22. 23.

24.

25.

26.

27.

28.

29. 30. 3 I. 32.

33.

34. 35.

36.

37.

38.

revascularization after total maxillary osteotomy. J Oral Surg 33:253, 1975 Bell WH, Levy BM: Revascularization and bone healing after posterior maxillary osteotomy. J Oral Surg 29:3 13, 197 I Posnick JC, Dagys Al? Refinements in orthognathic surgery in the cleft patient. Proceedings of the Sixth International Congress On Cleft Palate and Related Craniofacial Anomalies, Jerusalem, Israel. 1989, p 55 Posnick JC: Refinements in clefi orthognathic surgery through modification of the maxillary Le Fort I: Morbidity and long term results. Proceedings of the 44th Annual Meeting, Canadian Society of Plastic Surgeons, 1990, p 48 Posnick JC: Orthognathic surgery in the cleft patient, in Russel RC (ed): Instructional Courses, Plastic Surgery Education Foundation (~014). St Louis, MO, Mosby, 1991, pp 129- 157 Ross RB: Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Part 7: An overview of treatment and facial growth. Cleft Palate J 24:7 1, 1987 Pare1 SM, Branemark PI, Jansson T: Osseointegration in maxillofacial prosthetics. Part I: Intraoral applications. J Prosthet Dent 55:490, 1986 Araujo A, Schendel SA, Wolford LM, et al: Total maxillary advancement with and without bone grafting. J Oral Surg 36: 849. 1978 Tessier P, Tulasne JF: Secondary repair of cleft lip deformity. Clin Plast Surg 11:747, 1984 Luhr HG: Zur stabilen Osteosynthese bei Unterkieferfrakturen. Deutsch Zahnaerztl. Z 23:754, 1968 Champy M: Surgical treatment of midface deformities. Head Neck Surg 2:45 1, 1980 Horster W: Experience with functionally stable plate osteosynthesis after forward displacement ofthe upper jaw. J Maxillofac Surg 8:176, 1980 Drommer R, Luhr HG: The stabilization of osteotomized maxillary segments with Luhr mini-plates in secondary cleft surgery. J Maxillofac Surg 9: 166, 198 I Beals SP, Munro IR: The use of miniplates in craniomaxillofacial surgery. Plast Reconstr Surg 79:33, 1987 Posnick JC, Ewing M: Skeletal stability after Le Fort I maxillary advancement in patients with unilateral cleft lip and palate. Plast Reconstr Surg 85:706, 1990 Proffit WR: Orthodontic treatment of clefts: Yesterday, today, and tomorrow. Proceedings of the 48th Annual Meeting, American Cleft Palate-Craniofacial Association. Hilton Head. SC. March 199 I, p 32 Boyne PJ: Bone grafting in the reconstruction of alveolar and anterior palatal fistulas. Proceedings of the 48th Annual Meeting, American Cleft Palate-Craniofacial Association, Hilton Head, SC, March 1991, p 31 Witzel MA, Munro 1R: Velopharyngeal insufficiency after maxillary advancement. Cleft Palate J 14: 176, 1977

Surg

1992

Discussion Modification of the Maxillary Le Fort I Osteotomy in Cleft-Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity Thomas W. Braztn, DMD. PhD Utiiversity c$Pinsbwgh. Pittsburgh, PA The authors have discussed a complicated therapeutic problem using a surgical method that attempts to address multiple deformities simultaneously, specifically orthognathic surgical repositioning of the maxilla, elimination of the bony

defects and oronasal fistulae at the cleft site, and most interestingly, elimination of the cleft dental gap. This gap is the composite residual effect of the cleft, the paucity of bone. and the absence or malformation of adjacent teeth. The presentation of 40 patients consecutively treated by the modified Le Fort I osteotomy is notable. Twenty-nine patients underwent simultaneous genioplasty, which does not dilute the descriptive benefit of the maxillary procedure. Thirteen patients, however, underwent simultaneous bilateral sagittal osteotomies and repositioning of the mandible. In discussing relapse, it would be beneficial to know how many of these two-jaw cases may have experienced occlusal or skel-