Midfacial osteotomies in patients with cleft lip, alveolus and palate

Surgical/orthodontic strategies in patients with hypoplastic midfaces and cleft of lip, alveolus and palates after completion of skeletal growth are guided by cephalometric data, with the soft-tissue profile playing the most important role. The Le Fort I, the extended Le Fort I and, less frequently, the Le Fort II procedure depend on the extent of midfacial hypoplasia. Osteotomy planning should consider that in cleft patient's maxilla, the anterior nasal spine and A-point need to be advanced and caudally rotated to a larger extent than is necessary in non-cleft patients. A slight overcorrection of ANB-angle is necessary to achieve a harmonious and attractive soft-tissue profile since upper lip and nasal soft tissue require more bony support. In severe bimaxillary disturbances the midfacial advancement has to be combined with mandibular osteotomies. Stabilization after midfacial osteotomies should be done by corrosion-resistant Vitallium or titanium miniplates. This technique provides sufficient stability to restore early function immediately after surgery. Intermaxillary fixation following surgery is no longer necessary. Several decisive advantages are provided by this technique over the previously applied wire suspension concepts or wire suturing techniques. The most advantageous points are: No intermaxillary fixation is required immediately postoperatively; Normal soft food intake is resumed after 8-10 days when wound healing is completed; Rigid plate fixation leads to a considerable improvement in bone healing, while 'pumping-effects' induced by micromovements from the masticatory muscles are avoided; Plate fixation allows immediate functional 'antirelapse-treatment' against relapse tendencies, using functional treatment by means of soft intermaxillary elastics.