Secondary Cleft Surgery
Surgery in the teenage and adult years for differences that can remain after cleft lip and palate repair in childhood: the position and width of the upper jaw, the shape of the nose, and the bone of the gum ridge.
Who it is for
Most children born with a cleft lip and palate have their lip and palate repaired in the first years of life. As they grow, some develop further differences that are addressed later. The scar tissue from the palate repair can limit the growth of the upper jaw, so that it sits behind the lower jaw and is narrower than it should be. There may also be a difference in the shape of the nose, a gap in the bone of the gum ridge, or an opening between the mouth and the nose.
Secondary cleft surgery is planned for each person individually and in coordination with the orthodontist and, where possible, the cleft team that has followed them since childhood.
Corrective jaw surgery for the upper jaw
A retruded, narrow upper jaw is common after cleft repair. It can cause an underbite (the lower front teeth in front of the upper), a crossbite of the back teeth, difficulty biting and chewing, and a flat appearance of the middle of the face.
Le Fort I advancement moves the upper jaw forward into a better relationship with the lower jaw. When the upper jaw is also too narrow, it can be divided into segments and widened in the same operation (segmental Le Fort I). In some patients the lower jaw is also repositioned. The movements are planned beforehand on a 3D model from a CT scan and transferred to the operating room with surgical splints or guides.
Jaw surgery is usually done once growth is complete, with orthodontic treatment before and after. Because moving the upper jaw forward can change how the soft palate closes during speech, speech is assessed before surgery and reviewed afterwards. See Corrective Jaw Surgery for planning, the procedure and recovery.
Cleft nasal deformity (secondary cleft rhinoplasty)
The nose on the side of the cleft is often flatter and wider at the nostril, the tip may be asymmetric, and the septum (the wall inside the nose) may be bent, which can make breathing through the nose harder. Secondary cleft rhinoplasty reshapes the nasal tip, nostril and septum, and may use cartilage grafts, most often from the septum and sometimes from the ear or a rib.
It is usually done after jaw surgery, because moving the upper jaw changes the support at the base of the nose.
Alveolar cleft bone grafting
The alveolar cleft is the gap in the bone of the gum ridge where the cleft passed. Bone grafting fills this gap, most often with bone from the hip. It supports the teeth next to the cleft and gives a path for the permanent canine to erupt. It also supports the base of the nose and can close an opening between the mouth and the nose. Later, it allows orthodontic tooth movement and dental implants in the graft.
It is most often done in childhood, before the permanent canine erupts, in coordination with the orthodontist. It can also be done in teenagers and adults who did not have it earlier, or when an earlier graft needs to be repeated.
Distraction osteogenesis
When the upper jaw needs to move a long way forward, the scar tissue from earlier surgery can resist the movement, and a large movement done all at once is more likely to drift back over time (relapse). Distraction osteogenesis is one option in that situation.
The bone is cut as in a Le Fort I operation, but instead of moving it into its final position in one step, a small device is attached. After a few days of healing, the device is adjusted a little each day, usually about a millimetre, so that the jaw moves forward gradually over several weeks. New bone forms in the gap and the soft tissues stretch along with it. The device then stays in place for some weeks while the new bone firms up, and is removed in a second, shorter procedure.
Distraction involves a longer treatment, regular visits for adjustments and a second procedure. Whether it or a conventional advancement is more suitable depends on the size of the movement, the scar tissue and speech, and is discussed at the consultation.
Order of treatment
The order and timing differ from person to person. Some patients come to us as adults who have had only part of this treatment; the plan starts from where they are.
Frequently asked questions
When is jaw surgery done after cleft repair?
Corrective jaw surgery is usually done once facial growth is complete, often in the late teens for young women and around the late teens to early twenties for young men. Growth is confirmed from records before a date is set.
Can moving the upper jaw affect speech?
It can. Moving the upper jaw forward can change how the soft palate closes during speech, and some patients notice more nasal-sounding speech. Speech is assessed before surgery, ideally with a speech-language pathologist, and reviewed again afterwards.
Why is the nose usually corrected after jaw surgery?
Moving the upper jaw changes the support at the base of the nose. Correcting the nose afterwards lets the nasal surgery be planned on the final skeletal position.
Can alveolar bone grafting be done as an adult?
Yes. It is most often done in childhood, before the permanent canine erupts, but it can be done later, for example before dental implants or before jaw surgery.
Do I need to involve my cleft team or orthodontist?
Yes. Secondary cleft care is planned together with your orthodontist and, where possible, your cleft team, speech-language pathologist and dentist, so that each step is done in a sensible order.
Your surgeons
Both surgeons perform corrective jaw surgery and secondary cleft surgery.
Youn Sagong, DDS
Oral and maxillofacial surgeon. Board-certified by the American Board of Oral and Maxillofacial Surgery. Residency and chief residency, Yale. Assistant Clinical Professor, UCI Medical Center; operating privileges at Hoag Hospital and UCI Medical Center.
Corrective jaw surgery and secondary cleft surgery.
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Andrei Marechek, MD, DDS
Oral and maxillofacial surgeon. Board-certified by the American Board of Oral and Maxillofacial Surgery. Residency, Case Western Reserve University. Assistant Clinical Professor, UCI Medical Center; operating privileges at Hoag Hospital and UCI Medical Center.
Corrective jaw surgery and secondary cleft surgery.
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