**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 check the patient's recovery [17].

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 treatment [17].

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

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

#### **Figure 3.**

*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 surgically corrected.*
