*6.3.3 Modified Le fort I osteotomy (three-segment)*

Unfortunately, a big part of patients who have BCLP maxillomandibular deformities are still observed to have alveolar clefts, residual oronasal fistulae, and mobile premaxilla. While carrying out a Le Fort I osteotomy procedure on a BCLP patient with non-grafted alveolar arches, accurate incisions has a critical importance for providing all three segments with blood circulation [17].

In the technique, on each side, a buccal (labiolateral) incision is made from the zygomatic buttresses (anterior and gingival levels of the parotid canal) in the depth of the vestibule extending toward the location of the residual oronasal fistula. Then, vertical incision continues according to mesial angle of the canine (or if the canine is missing, the most mesial tooth on each lateral segment). Without completely separating the premaxilla, an intermediate splint is placed to fix the lateral segments. The premaxilla is to be included to the vestibular incisions at the posterior with angular, vertical incisions in its labial direction, and to separate the oral and nasal mucosa of the fistulae even further, the incision continues downward along the distal line angle of the central incisor teeth on both sides. Attention should be paid to prevent deformation or incision of the mucosa in the premaxilla. Shavings are made from the segments to get the hard and soft tissues closer to each other. While doing this, one should be careful not to damage the lamina dura of the existing teeth. After completion of the premaxillary segment and other adjustments, the final splint is placed, and the segments are fixed with titanium plates and screws [17]. If there is grafting, an additional microplate is also needed to stabilize each cortico-cancellous (iliac) graft. To repair facial asymmetries, mandibular deformations, and secondary

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

**7. Orthognathic approach on ICP deformities**

otomy in BCLP patients.

**7.2 Orthodontic approach**

**7.3 Surgical approach**

bone and because all teeth are usually present.

**7.1 Prevalence**

deformities, mandibular surgery may also be needed in addition to Le Fort I oste-

It was reported that 20% of Caucasians with ICP who receive repairs in the period of infancy would experience maxillary hypoplasia in a way that would lead to malocclusions that do not respond to a conventional or compensatory orthodontic approach by itself [36]. Chen et al. [57] reported on the horizontal maxillary growth of both children and adults with ethnic origins of Eastern China who were operated/not operated. Accordingly, as an interesting finding, the results of the individuals with ICP who were not operated in the mixed dentition period showed an almost normal horizontal growth. In the patients who were operated (repaired cleft palate) in the mixed dentition period, there was a decrease in the clockwise rotation of the maxillomandibular complex. In addition to this, it was stated that, for an individual born with ICP, the prevalence of maxillomandibular deficiency is dependent on a combination of factors such as the internal structure of the primary cleft defect, secondary hypoplasia due to surgical repair at infancy, and functional factors (e.g., muscle effects – mastication, respiratory pattern, and mandibular resting posture) [58].

The main purpose of orthodontic treatment before surgery in ICP patients is to eliminate all existing dental compensations. This is because, conducting camouflage treatment in these patients threatens periodontal health and may cause to relapse and resorption in teeth. Inclination and angulation of the maxillary and mandibular teeth, crowding, gaps, and rotations are organized throughout the orthodontic treatment process. The targets related to achieving ideal arch forms and ideal occlusion may be detailed after the operation. Extractions may be needed in the maxillary arch to eliminate dental compensations. In comparison to UCLP or BCLP patients, treatment is simpler in ICP patients due to the intact nature of the alveolar

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

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].

satisfactory bone recovery without aseptic necrosis or tooth injury.

deformities, mandibular surgery may also be needed in addition to Le Fort I osteotomy in BCLP patients.
