The modified “Wunderer” osteotomy for stabilization of the cleft-premaxilla – A new operative technique
Introduction
The bilateral cleft of lip, alveolus and palate is generally considered as the most severe congenital deformity of the upper jaw and the central part of the face. Its surgical correction is difficult and the results achieved are often not satisfying in regard to aesthetic and function. When upper lip and anterior palate are surgically closed the protruding premaxilla, that can even reach to tip of the nose (Fig. 1), is disturbing and prevents often a good aesthetic result. Certainly, the preoperative orthopaedic repositioning of the premaxilla makes the closure of the lip easier, but an unpleasant tightness and rigidity of the whole upper lip can remain. In former times some surgeons even recommended the resection of the protruding premaxilla however, it became soon obvious that this resulted in severe growth disturbances and mutilations of the middle part of the face (Fig. 2). Even after successful closure of lip and palate in cases of bilateral cleft lip and palate remains the problem of a mobile premaxilla due to the fact that the bony connection to the lateral process of the maxilla is missing. Quite often there are also remaining oro-nasal fistulae lateral or dorsal of the premaxilla that make a bone transplantation for its stabilization impossible. In addition the unfavourable position of the premaxilla can impede its alignment with the maxillary dental arch and therefore complicates a later prosthetic rehabilitation. Also problematic is the application of orthodontic forces for the alignment of the front teeth, because this may result in root resorption until to the loss of teeth. It was therefore obvious that already in the sixties of the past century different methods in the USA (Barsky et al., 1962) in Switzerland (Perko, 1966) and in Germany (Pfeifer, 1966) were developed for the stabilization of premaxilla with closure of the oro-nasal fistulae and simultaneous bone grafting.
In particular it was emphasized (Obwegeser and Perko, 1968) that in the same operation also the premaxilla can be osteotomized and repositioned. This procedure however, is technically difficult mainly due to the narrowness and the poor overview of the operation field. Above all the closure of the nasal muco-periosteum, which is essential for the success of the operation, must be carried out precisely. If there is any leakage the inserted bone graft is exposed to the nasal cavity with the consequence of infection and loss of the transplant. Another precondition for the success of the operation is the utilization of autogenous bone, preferably spongiosa from the iliac crest. Naturally the bone graft must also be covered from the oral side with a muco-periosteal or gingiva-periosteal flap from the vestibulum.
Section snippets
Material and method
The operative procedure which consists in the closure of oro-nasal communications, bilateral bone grafting, osteotomy and repositioning of the premaxilla and stabilization with a palatal splint is carried out in oral intubation. Nasal intubation is not recommendable because the identification of the nasal mucosa would be difficult. Local anaesthesia by adding a vasoconstrictor is applied to the palate and the vestibulum, but not to the region of the premaxilla for not disturbing the blood
Results
In the past the author has treated about a dozen patients with bilateral cleft lip and palate deformity with this operative method. The patients were in the age of 12–18 years. The operation was in all cases successful and without early postoperative complications. A follow-up investigation up to several years however, was only possible in a few patients. Among these patients no failure of the operation, like rejection of the bone graft, instability of the premaxilla, or reopening of oro-nasal
Discussion
The blood supply to the osteomized maxillary segment was probably the main concern when Wunderer developed his modification of the anterior maxillary osteotomy. He investigated the pattern of the blood vessels and stated that the blood flow from the buccal vestibulum, in particular from the superior labial artery in combination with the anterior ethmoidal artery is sufficient for keeping the segment, including the teeth, vital. Wunderer also stressed that the buccal mucosa and gingiva must
Conclusion
After the closure of lip and palate in bilateral cases remains the problem of the displaced premaxilla. In addition oro-nasal openings may remain which can influence speech and chewing function. For the correction of these deformities the stabilization of the premaxilla with bone grafts and the simultaneous closure of the oro-nasal communications is essential. The required surgical procedure is technically difficult due to the narrowness and poor vision of the operating field. To overcome this
Paper presented at
Annual Meeting Swiss Society of Oral and Maxillofacial Surgery, Zuerich Oct. 25–27, 2012.
Conflict of interest
The author has no conflicts of interest to declare.
Acknowledgement
I would like to express my thanks to my former co-worker Dr. Yu-Jian-min MD, DDS for his clear and informative drawings.
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