**7.4. Unfavorable conditions**

If maxillary deficiency accompanies with a wide alveolar cleft and/or fistula, it will be more challenging for both orthodontist and surgeon to treat growing patients [54] (**Figure 9**).

Late bone grafting or prolonged orthodontic treatment prior to bone grafting leads to loss of orthodontic control, marked instability of the premaxilla, and difficulty in maintaining

**Figure 9.** Wide alveolar cleft limits both orthodontic treatment and maxillary osteotomy. (a, b) intraoral views of a wide cleft, (c) 3D image of the case.

anteroposterior growth. In patients with BCLP, the unstable premaxilla with the small amount of maxillary bone attached to the vomer is usually incapable of being maintained with good stability without grafting.

When the premaxilla has been effectively grafted, any need to forward the maxilla at a later date can be accomplished by Le Fort osteotomy with a much diminished possibility of relapse [19].
