**3. Preparation for orthognathic surgery**

In orthognathic surgery in cleft patients, there are some issues that need to be considered before surgery like velopharyngeal situation, speech problems, hearing problems, the situation of alveolar cleft gap, and dental problems.

Speech pathologists play a critical role in terms of assessing speech and articulation problems and determine velopharyngeal function with nasal endoscopy before the surgery [18, 19]. The velopharyngeal sufficiency rarely remains the same after maxillary advancement surgery; more often, an insufficiency is created [20]. Surgical correction of cross-bites and open-bites and the repair of cleft-dental gaps and residual oronasal fistulae usually alleviate articulation disorders [19, 21].

Prevention and treatment of tympanic infection as well as comprehensive preventive and restorative dental care have been provided during early childhood and adolescence. Oral hygiene maintenance may be more difficult in CLP patients than in routine orthodontic treatment patients. Soft tissues may have a more retentive morphology due to scarring from previous operations: shallow buccal sulci, sometimes buccal flaps with mucosa or gingivae covering teeth. Furthermore, because of poor dental esthetics, CLP patients do not like their teeth and smile and have low motivation. Long treatment times reduce motivation further. Orthodontic preparation presents various challenges not only in terms of planning but also in terms of implementation. It may be difficult for the orthodontist to work in a narrow space with low visibility, since the elasticity of lips is low, mouth opening is limited, and the upper jaw is small and retrognathic. All surgical management of maxillo-mandibular deformities usually requires prior adjustment of the dental arches over the maxillary and mandibular basal bones via orthodontic treatment. The "surgery-first" protocol rarely applies to CLP patients. A major dilemma during

#### **Figure 1.**

*Teeth erupting from the palate [25]. (a) UCLP patient, permanent dentition. Missing lateral incisors, 15 and 23 erupting palatally, and 17 erupting excessively buccally. (b) Dental arch development through orthodontic leveling, occult fistula enlarged and became visible during dental leveling, 13 is just starting to erupt after 2.5 years of orthodontic treatment.*

**65**

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

palate usually takes a long time (**Figure 1**).

**4. Residual deformities in CLP patients**

potential, and the level of care of the family/patient.

**5. Orthognathic approach on UCLP deformities**

surgery needed in repaired UCLP patients was 48–59.3% [3, 8].

thic surgery cleft team [26, 31, 35].

consecutively [22–24].

gap [6, 28–30].

**5.1 Prevalence**

**5.2 Orthodontic approach**

alignment is the decision on the management of the cleft alveolar region, where often the lateral teeth are missing [6]. Surgical correction of septal and inferior respiratory pathologies is done only in severe obstructive sleep apnoea cases before orthognathic surgery, but rather scheduled to be performed simultaneously or

In most CLP cases, teeth are either missing, erupt late or ectopically located. Therefore, the alveolar bone base is not sufficiently developed, and this adds to the skeletal (transverse and sagittal) insufficiency. Leveling of teeth erupting in the

Patients with Isolated Cleft Palate (ICP) have a complete alveolar ridge and generally a complete set of teeth [13, 17, 26, 27]. The main deformity in unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) patients is maxillary hypoplasia, but oronasal fistula, bony defects, intranasal obstruction, soft tissue scarring, and velopharyngeal dysfunctions are also frequently encountered [27]. Additionally, the maxillary lateral incisor and often the second premolars in the cleft region are either congenitally missing, resulting in a cleft-dental

In addition to the existing deformities in UCLP and BCLP patients, nasal obstruction and sinus blockage and mandibular asymmetry and chin dysplasia are seen frequently as secondary deformities [27, 31]. The prevalence of these deformities varies significantly based on the surgical philosophy and experience of the surgeon who repaired the first cleft [32], the individual's unique biological growth

Published clinical research on individuals who were born with complete UCLP/ BCLP and treated at cleft centers showed that, despite the best efforts, the mixed dentition period would not be appropriate for grafting just before the canine tooth is erupted on the cleft side in some children [33, 34]. Additionally, although grafted appropriately, in some individuals, additional reconstruction is needed [33]. For these reasons, repairing residual skeletal and soft tissues and managing dental deformities in patients with CLP strains the proficiency and skills of the orthogna-

Studies have examined the need for orthognathic surgery in UCLP patients who underwent primary lip-palate repair procedures in childhood [3, 8, 36, 37]. Ross [37] stated that the midface is close to normal only in 25% of patients, and there is a need for orthognathic surgery in the remaining patients, with interventions at early stages worsening the situation. In other similar studies, the rate of orthognathic

In adolescent or adult UCLP patients with maxillary hypoplasia and deficient bone grafts, there are two maxillary segments separated by the cleft. Each segment has varying degrees of dysplasia on the sagittal, vertical, and horizontal directions. *Orthognathic Surgery in Cleft Lip and Palate Patients DOI: http://dx.doi.org/10.5772/intechopen.89556*

*Current Treatment of Cleft Lip and Palate*

**3. Preparation for orthognathic surgery**

Orthognathic surgery for treatment of maxillomandibular deformities is usually applied after completion of growth of the maxillomandibular structure [14–16]. Transverse, sagittal, and vertical growth of the maxilla and the mandible ends at different chronological ages, usually at the ages of 14–16 for female patients and 16–18 for male patients [17]. Mandibular growth has a normal pattern in most CLP patients [13]. However, since skeletal growth is variable, hand-wrist or cephalometric radiographs may help in determining the timing of skeletal maturation [17].

In orthognathic surgery in cleft patients, there are some issues that need to be considered before surgery like velopharyngeal situation, speech problems, hearing

Speech pathologists play a critical role in terms of assessing speech and articulation problems and determine velopharyngeal function with nasal endoscopy before the surgery [18, 19]. The velopharyngeal sufficiency rarely remains the same after maxillary advancement surgery; more often, an insufficiency is created [20]. Surgical correction of cross-bites and open-bites and the repair of cleft-dental gaps and residual oronasal fistulae usually alleviate articulation disorders [19, 21]. Prevention and treatment of tympanic infection as well as comprehensive preventive and restorative dental care have been provided during early childhood and adolescence. Oral hygiene maintenance may be more difficult in CLP patients than in routine orthodontic treatment patients. Soft tissues may have a more retentive morphology due to scarring from previous operations: shallow buccal sulci, sometimes buccal flaps with mucosa or gingivae covering teeth. Furthermore, because of poor dental esthetics, CLP patients do not like their teeth and smile and have low motivation. Long treatment times reduce motivation further. Orthodontic preparation presents various challenges not only in terms of planning but also in terms of implementation. It may be difficult for the orthodontist to work in a narrow space with low visibility, since the elasticity of lips is low, mouth opening is limited, and the upper jaw is small and retrognathic. All surgical management of maxillo-mandibular deformities usually requires prior adjustment of the dental arches over the maxillary and mandibular basal bones via orthodontic treatment. The "surgery-first" protocol rarely applies to CLP patients. A major dilemma during

*Teeth erupting from the palate [25]. (a) UCLP patient, permanent dentition. Missing lateral incisors, 15 and 23 erupting palatally, and 17 erupting excessively buccally. (b) Dental arch development through orthodontic leveling, occult fistula enlarged and became visible during dental leveling, 13 is just starting to erupt after* 

problems, the situation of alveolar cleft gap, and dental problems.

**64**

**Figure 1.**

*2.5 years of orthodontic treatment.*

alignment is the decision on the management of the cleft alveolar region, where often the lateral teeth are missing [6]. Surgical correction of septal and inferior respiratory pathologies is done only in severe obstructive sleep apnoea cases before orthognathic surgery, but rather scheduled to be performed simultaneously or consecutively [22–24].

In most CLP cases, teeth are either missing, erupt late or ectopically located. Therefore, the alveolar bone base is not sufficiently developed, and this adds to the skeletal (transverse and sagittal) insufficiency. Leveling of teeth erupting in the palate usually takes a long time (**Figure 1**).
