**5.3 Surgical approach**

*Current Treatment of Cleft Lip and Palate*

dental arch form to the existing basal bone.

functioning and better esthetics.

thic surgery (**Figure 2**).

Orthodontic treatment is carried out to both position the teeth perpendicular to the alveolar crest and level the alveolar segments using the teeth. Sometimes, it is not possible to achieve leveling of the bony segments, and it may be necessary to level the teeth into two separate segments, instead of a complete arch, and to prepare for leveling these segments by alveolar distraction osteogenesis or segmental orthogna-

In cases that present with sufficient bone grafting during the mixed dentition period, the maxilla is a single segment, and the orthodontist would only adapt the

There are substantial variations in the number of upper permanent incisors and

*UCLP patient [25]. A1-3: Before orthodontic preparation. Retrognathic and narrow maxilla, missing teeth (12, 22, 15 and 25), noticeable alveolar cleft, severe transverse and vertical dislocation of the smaller segment. B1-3: Orthodontic leveling of teeth in two separate segments. C1-3: Post-op continuous stainless-steel arch-wires. D1-3:* 

the alveolar bone amount in the premaxilla of UCLP patients. The lateral incisor tooth on the cleft side was found normal in only 7% of UCLP cases [6], more frequently, when present, there are shape anomalies. In the presence of a weakly formed lateral incisor tooth, these teeth might need extraction for long-term

**66**

**Figure 2.**

*Post-treatment vertical relapse to some extent.*

Due to the prevalence of maxillary osteotomy complications in UCLP patients [38], confusing and complicated orthognathic surgery techniques were proposed for these patients [39–41]. Moreover, as in other aspects of orthognathic surgery, Hugo Obwegeser also provided contributions that could be explained as breakthroughs for skeletally cleft reconstruction [35, 42–44]. Toward the end of 1960s, he managed to advance the cleft maxilla by up to 20 mm to a desired position without needing a complicated mandibular setback approach. Then, he noticed that downfracture and adequate mobilization of the maxilla, regardless of the presence or absence of a cleft, were the key in maxillary advancement [35]. The success of this approach achieved by Obwegeser was confirmed when Bell showed supply blood circulation to the down-fractured maxillae in their animal studies [45].

In the mid-1980s, Posnick used the Le Fort I techniques of Obwegeser for treatment of UCLP deformity and improved them [46]. The main issue was that the circumvestibular incision used by Obwegeser directly allowed dissection, osteotomies, disimpaction, fistula closure, septoplasty, inferior turbinate reduction, pyriform aperture recontouring, bone grafting, and application of plate and screw fixation. This was a reliable approach that did not have a circulation damage risk in smaller or larger flaps and had continuity [35]. Moreover, with the easiness of field of view provided by circumvestibular incision, it became possible to readily close the cleft-dental region by differential maxillary segmental repositioning without bone necrosis or loss of teeth. This method also closes the unoccupied space of the cleft, and at the same time, combines the labial and palatal flaps together without needing a subperiosteal undermining procedure, which allows closure of stubborn oronasal fistulae and establishment of periodontal health in the teeth adjacent to the cleft [35]. Today, although the surgical methods applied on UCLP patients differ depending on the success of grafting performed in the mixed dentition period, the main method are as follows:
