The modified “Wunderer” osteotomy for stabilization of the cleft-premaxilla – A new operative technique

Abstract

The operative closure of bilateral cleft lip and palate is a difficult procedure that requires in most cases secondary corrections. Besides aesthetic improvements of lip and nose also the rehabilitation of the teeth, in particular of the maxillary arch is important for the improvement of the chewing function and also for the well being of the patient. One of the most disturbing factors for the construction of any type of prosthetic devices, like removable denture, fixed bridge or dental implants is the mobility and often also malposition of the premaxilla. This problem can only be solved by the insertion of bone grafts into the bilateral gaps of the anterior maxillary arch. This procedure however, is difficult due to the narrowness and poor overview that complicates the closure of the nasal mucosa, which is the precondition for the success. For facilitating the operation the premaxilla is osteotomized and reflected anteriorly according to the method of Wunderer (1962). Then, after the much easier closure of the nasal mucosa the bony defects can be filled with autogenous cancellous bone and finally the oral mucosa can be closed. A preoperatively prepared palatal acrylic plate helps to protect the palatal tissue and also stabilizes the position of the premaxilla. The blood supply to the osteotomized premaxilla is secured by a sound soft tissue pedicle of the buccal muco-periosteum. The effectiveness of the blood supply of the premaxilla was examined in experimental studies by several authors. Also investigations of the growth impediments of the premaxilla and the midface revealed that early osteotomies will interfere with the development of this region. Therefore it is advisable to carry out this procedure not before the patient has reached the age of 12–14 years, which is also depending on the race and the gender of the patient.

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.