Correction of jaw deformities in patients with cleft lip and palate

Acleft lip/palate deformity occurs in approximately one in every 700 live births in the USA (1). Jaw growth in the population of patients with unrepaired cleft lip and palate is generally favorable (2‐6). No significant difference exists between patients with and those without such deformities in the distribution of vertical or anteroposterior skeletal jaw relationships, except that posterior crossbites (deficiency in the width of the upper jaw, with the upper teeth biting inside the lower teeth) may be more common in patients with a cleft deformity. However, significant disturbances of growth of the jaws, particularly the maxilla (upper jaw), can occur in patients with cleft deformities as a result of surgical repairs of the cleft lip and palate or other factors. The maxilla can become underdeveloped, affecting the alveolus (bone supporting the teeth), dentition (teeth), and associated soft-tissue structures. The following surgical procedures, commonly performed during childhood, can have an unfavorable effect on facial growth: 1. Cleft lip repair. Commonly performed within the first 3 months of life, this procedure can adversely affect the anterior maxillary alveolar morphology, which is probably related to the discontinuity defect in the alveolar cleft and the extent of softtissue undermining and subsequent fibrosis. Other changes in the craniofacial complex are usually minimal (7‐12). 2. Cleft palate repair. These procedures can affect the vertical, anteroposterior, and transverse development of the maxilla and alveolar processes (13‐15). Periosteal stripping at the time of surgery and the resulting fibrosis are the most likely reasons for this response. 3. Alveolar cleft repair. Bone grafting of alveolar cleft defects, when performed in early childhood, can severely inhibit maxillary growth. Several authors have reported early and intermediate repairs using specific techniques that may have fewer unfavorable effects on craniofacial growth (16‐20). Bone grafting usually adversely affects vertical and horizontal growth of the maxilla. Ideally, alveolar cleft bone grafting should be delayed as long as possible, until just before the permanent cuspid teeth erupt into the cleft area (age 9 to 12 years), thus allowing more maxillary growth before surgical intervention (21). 4. Pharyngeal flap. With posterior pharyngeal flaps, a surgical procedure used to correct hypernasal speech problems, a tissue flap from the posterior pharyngeal wall is attached to the soft palate. This flap can have a profound effect on facial growth and development, decreasing the anteroposterior and transverse