**7.3 Surgical approach**

In general, primary maxillomandibular deformity that is seen in ICP patients is maxillary hypoplasia that is caused by the cleft deformity and surgical interventions. The normal reconstructive procedure that needs to be considered in these patients is a Le Fort I maxillary osteotomy. Obwegeser stated that complete mobilization of maxilla that are down fractured is needed to achieve an orthognathic repair during surgery and decrease skeletal relapse [35]. Bell and Levy [45] confirmed that the Obwegeser Le Fort I technique allows sufficient blood diffusion for satisfactory bone recovery without aseptic necrosis or tooth injury.

It would be difficult to close any residual palatal oronasal fistula in an ICP patient at the same time with the Le Fort I procedure during orthognathic surgery. The reason for this is that elevation of the palatal flaps that is usually needed will threaten the blood supply for the down-fractured maxilla. Moreover, it was stated that, if an impermeable closure of the nasal side can be achieved following downfracturing before fixing the maxilla to its new position, the residual mucosal gap on the palatal side will usually be recovered secondarily by fistula closure [35].
