**9. Success of orthognathic surgery**

After orthognathic surgery, cleft patients have a higher than normal risk of relapse due to factors such as different soft tissue-bone relations and complex mobilization vectors. Fahradyan et al. [59] reported that, in comparison to class III malocclusion patients without clefts, more relapse was encountered in those with

**73**

improved.

CBCT study [67].

*Orthognathic Surgery in Cleft Lip and Palate Patients DOI: http://dx.doi.org/10.5772/intechopen.89556*

average [59].

is lower.

relapse [61].

**10. Complications**

**10.1 Airway problems**

clefts (1.25 mm or more on average), and there was a significant positive correlation between larger clefts and horizontal relapse. In their study, the mean relapse rate was similar among different types of clefts, and in the case of each 1 mm increase in maxillary advancement, horizontal relapse increased by 0.3 mm on

Richardson et al. [60] examined all relapse cases among individuals where more than 11 mm of maxillary advancement was applied, and they reported a horizontal relapse rate of 18.75%. Nevertheless, Bhatia et al. [61] concluded that relapse rates stayed the same even in maxillary advancement degrees of more than 15 mm (mostly in cleft patients). Yamaguchi et al. [62] reported in their systematic review that the mean values of horizontal and vertical relapse were, respectively, 17.9% and 35.4% in orthodontic surgery for cleft patients. This shows us that vertical stability

Although most studies focused on horizontal maxillary stability, Park et al. [63] reported that postoperative mandibular relapse in cleft patients had a strong positive correlation with mandibular clockwise rotation and setback amounts. Wong et al. [64] could not find a significant difference between the relapse rates of individuals who received two surgical operations and those who received maxillary advancement surgery only. Some researchers used bone grafts to increase horizontal or vertical stability [61, 63, 64]. It was reported that usage of grafts has a preventive effect on horizontal maxillary stability with an average of 1.72 mm less

Treatment of cleft patients with class III malocclusion that results out of the combination of maxillary hypoplasia and intermaxillary disorder is usually achieved by maxillary advancement, mandibular setback, and clockwise rotation of the maxillomandibular complex. While maxillary advancement is associated with increased upper airway cavity, in contrast, mandibular setback is associated with reduction of airways with outcomes such as postoperative airway blockage, snoring, hypopnea (slow respiration), and obstructive sleep apnoea [65, 66]. Additionally, a pharyngeal flap may contribute to the airway-related difficulties that are encountered during operation or in the postoperative period. When the three-dimensional (3D) pharyngeal airway cavity of cleft patients in their pre- or post-pubertal periods were compared to a control group, Karia et al. [66] found significantly smaller airway sizes in the cleft group. The total airway volume increased from the pre-pubertal to the post-pubertal periods in both groups, but the reason for this outcome in the cleft group was not anteroposterior growth as in the case of the control group, but in contrast, associated with vertical airway growth. Especially in bilateral cleft patients, significantly reduced pharyngeal airway cavity in comparison to individuals without clefts was also confirmed in a

A prospective study by Chang et al. [68] examined the airway changes in cleft patients who received maxillary advancement and mandibular setback treatments by not only CBCT but also polysomnographic examination. Regarding the airway changes after orthognathic surgery, it was found that there was no significant difference in sleep-related respiratory functions, but the snoring index was

*Orthognathic Surgery in Cleft Lip and Palate Patients DOI: http://dx.doi.org/10.5772/intechopen.89556*

*Current Treatment of Cleft Lip and Palate*

check the patient's recovery [17].

treatment [17].

**8. Post-surgery clinical management**

Management of the process at the hospital and at home during the initial recovery process of the orthognathic patient is highly important for a successful outcome. Cephalometric and dental radiographies and facial and occlusal photographs should be taken at certain intervals after the surgery in order to documentation and

Orthodontist should remove the splint and see the patient in the next 24 hours to replace the maxillary segmental arch wires or rigid continuous arch wires. The maxillary teeth are tied to each other to preserve the occlusion, sagittal advancement, and transversal dimension. After 2 months of surgery, active orthodontic treatment and finishing procedures can be continued. A trans-palatal appliance (wire or palatal appliance) is recommended to stabilize the new arch form. The orthodontist should closely monitor the patients throughout the 6 months following the surgery to follow up on skeletal and dental relapse and to maintain orthodontic

In routine and unproblematic cases, splint usage is abandoned in about 5–7 after the surgery. However, in patients with early skeletal relapse, that is, within the first 2–8 weeks, the teeth are forced in the buccolingual direction toward outside of the bone because the teeth are held in place due to splint despite the alveolar relapse, and severe gingival recessions may occur (**Figure 3**). Therefore, CLP patients should be observed every week, unlike other orthognathic surgical patients. It should be kept in mind that the relapse rates given in the literature are averages, and

Speech may be objectively assessed in 3–6 months after the surgery. A nasal endoscopy may be used for this. Exact cleft-soft tissue procedures (e.g., cleft rhinoplasty, revision of the labial scar, pharyngeal flap or flap revision) may be carried out in 6 months after the operation. After removal of orthodontic appliances,

After orthognathic surgery, cleft patients have a higher than normal risk of relapse due to factors such as different soft tissue-bone relations and complex mobilization vectors. Fahradyan et al. [59] reported that, in comparison to class III malocclusion patients without clefts, more relapse was encountered in those with

*Periodontal tissue loss due to relapse [25]. (a) Initial: Patient with UCLP, maxillary hypoplasia, severe crowding, missing lateral, and asymmetric arch form. (b) Pre-op: Periodontal problems after* 

*expansion and leveling. (c) Post-op: Both transverse and sagittal skeletal relapse occur while teeth are locked within the arch-wire and surgical splint, which deteriorates the periodontal condition. The midline was* 

it is possible to see more of these amounts in individual cases.

pre-planned restorative approaches may be implemented [17].

**9. Success of orthognathic surgery**

**72**

**Figure 3.**

*surgically corrected.*

clefts (1.25 mm or more on average), and there was a significant positive correlation between larger clefts and horizontal relapse. In their study, the mean relapse rate was similar among different types of clefts, and in the case of each 1 mm increase in maxillary advancement, horizontal relapse increased by 0.3 mm on average [59].

Richardson et al. [60] examined all relapse cases among individuals where more than 11 mm of maxillary advancement was applied, and they reported a horizontal relapse rate of 18.75%. Nevertheless, Bhatia et al. [61] concluded that relapse rates stayed the same even in maxillary advancement degrees of more than 15 mm (mostly in cleft patients). Yamaguchi et al. [62] reported in their systematic review that the mean values of horizontal and vertical relapse were, respectively, 17.9% and 35.4% in orthodontic surgery for cleft patients. This shows us that vertical stability is lower.

Although most studies focused on horizontal maxillary stability, Park et al. [63] reported that postoperative mandibular relapse in cleft patients had a strong positive correlation with mandibular clockwise rotation and setback amounts. Wong et al. [64] could not find a significant difference between the relapse rates of individuals who received two surgical operations and those who received maxillary advancement surgery only. Some researchers used bone grafts to increase horizontal or vertical stability [61, 63, 64]. It was reported that usage of grafts has a preventive effect on horizontal maxillary stability with an average of 1.72 mm less relapse [61].
