With interest, we read about the comprehensive treatment approach of a patient with bilateral cleft lip and palate in the January 2015 issue of the Journal (Kokai S, Fukuyama E, Sato Y, Hau JC, Takahashi Y, Harada K, et al. Comprehensive treatment approach for bilateral cleft lip and palate in an adult with premaxillary osteotomy, tooth autotransplantation, and 2-jaw surgery. Am J Orthod Dentofacial Orthop 2015;147:114-26). We really appreciated the authors’ efforts for bringing up this new approach including premaxillary osteotomy combined with alveolar bone grafting and autotransplantation of a tooth with complete root formation to the grafted bone region. However, we have 2 concerns about the study, focusing on the necessity of the 2-jaw surgery.

First, the authors mentioned that “her facial profile was concave, with a flat nose and protrusion of the upper and lower lips” but failed to notice that the patient has a straight profile considering the N, Sn, and Pos points on the same line. The patient’s so-called concave profile is mostly due to her flat nose. Besides, from the pretreatment cephalometric measurements, the patient is skeletal Class I and has a normal angle. We don’t think it was necessary to do 2-jaw surgery, and we are curious about the effect of the 2-jaw surgery to dramatically improve the patient’s profile.

Second, from the facial photographs, the patient’s mandibular deviation is not obvious, and the upward canting of her occlusal plane is partly due to her posterior crossbite. The authors mentioned the mandibular deviation toward the right of approximately 8.0 mm before the treatment but failed to show the cephalometric analysis after surgery. What’s more, the authors only showed pretreatment radiographs, and readers might mistakenly think that facial asymmetry can’t be resolved without surgery. As shown in Figure 5, C and D , the asymmetrical midline of the mandibular arch was already improved to some extent. Was it really necessary to have 2-jaw surgery instead of camouflage? As a bilateral cleft lip and palate patient, she would have already undergone a series of surgeries in childhood, so is it really better for the patient?