Shahid R. Aziz

Rutgers University School of Dental Medicine, Camden, New Jersey, USA

A means of establishing maxillary form and function in the dentoalveolar cleft patient.

Indications

1. Restore facial symmetry
2. Establishment of a class 1 dental occlusion
3. Place the components of the craniofacial skeleton in an ideal aesthetic position
4. Provide stability to the clefted maxilla

Contraindications

1. Class 1 occlusion
2. Dental malocclusion not associated with dentofacial deformities
3. Medical contraindication to general anesthesia
4. Psychological instability

Technique: Modifications to Le Fort I Osteotomies for Unrepaired and Repaired Alveolar Clefts

1. In addition to the standard vestibular incision for a Le Fort osteotomy, extensions are made vertically along the alveolar cleft and oronasal fistula to the palatal aspect of the fistula, thus separating the oral and nasal mucosa. The palatal aspect of these incisions must be undermined to provide for a tension-free closure. However, the palatal mucosa must remain intact to avoid any interruption of blood flow.
2. Osteotomies and bony separation are completed in the same manner as in a traditional Le Fort I osteotomy. However, with an unrepaired unilateral alveolar cleft, once the Le Fort I osteotomy is completed, the maxilla is in two pieces.
3. Downfracture is done by hand with gentle digital pressure. Tessier retractors are placed posterior to the tuberosities, the maxillary soft tissue pedicle is carefully stretched, and the segments are mobilized. Tessier retractors are preferred over Rowe forceps in order to minimize potential trauma to the palatal mucosa.
4. The deviated nasal septum and vomer are trimmed. Bony interferences are removed.
5. The alveolar dental defect is closed by moving the two segments of the maxilla together with the aid of the surgical splint.
6. Cancellous bone grafting may be utilized to fill any residual defects within the alveolus and nasal floor. Cortico-
cancellous blocks can be utilized to fill voids within the Le Fort osteotomy.
7. The incisions are primarily closed with care to completely close the oronasal fistula in a watertight, tension-free fashion.
8. If there is a significant degree of bone grafting, some authors advocate keeping the patient in maxillomandibular fixation (MMF) for 4–6 weeks to minimize graft loss.

Technique: Modifications to Le Fort I Osteotomies for Bilateral Clefts

Bilateral cleft patients typically exhibit severe maxillary dysplasia with hypoplastic lateral segments. The premaxillary segment is frequently mobile, malpositioned, and associated with residual oronasal fistulae, bony defects, significant soft tissue scarring, and a tenuous vascular supply. Due to these circumstances, the following surgical modifications are recommended:

1. Vestibular incisions extend from the zygomatic buttress region to the alveolar defects. Within the region of the alveolar cleft, the incision is continued along the mesial line angles of the canine defects.
2. The premaxillary segment incisions are placed adjacent to the distal line angle of the incisor tooth on each side and co/>
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