There was a special request to do a post on orthognathic surgery, or jaw alignment surgery, in cleft patients. So here we are! This can get pretty complicated, so I’m going to keep it as simple as possible! Let’s start with WHY this surgery is sometimes necessary for cleft patients.
It all started with the palate surgery…
The surgery that is done on the palate when the cleft patient is an infant leads to scar tissue forming on the upper jaw. Scar tissue is not as stretchy as normal tissue, so as the jaw tries to grow, the scar tissue pulls it back 
. At the same time, the lower jaw is growing normally. This leads to a discrepancy in size between the upper and lower jaws.
Some say that a delayed approach to palatal closure significantly decreases the chance of the patient having to undergo this operation.
Also, the severity of the cleft determines whether or not this surgery will be done. This is mostly due to the fact that the more severe the cleft, the more surgeries there will be, leading to more scar tissue. 
The upper jaw ends up being smaller than the bottom jaw.
This is one of the reasons cleft patients need palatal expanders as part of their orthodontic treatment. 
What this looks like:
From the patient’s profile, the lower jaw is protruding out while the middle of the face looks sunken in. While the palatal expander helps to align the jaw from left to right, the jaw from front to back is still out of alignment. This is called an anterior crossbite, or Class III malocclusion.
For some people, this can be fixed with braces, orthodontic rubber bands, and some tilting of the teeth. For others, the misalignment is too severe, and surgery is necessary. 
Why it’s important:
The dental malocclusion, or misalignment, can lead to speech and sleep obstruction issues.
It is also more difficult for the patient to eat with a misaligned jaw.
When it should be done:
The best time would be when the face is mature and before the patient finishes high school 
. This is between 14 to 16 in girls and 16 to 18 in boys. It is up to the patient and the doctors, though, when the surgery should be done.
It is preferable for the procedure to not be done until the secondary bone graft procedure is completed because there needs to be stability in the upper arch first. However, if a fistula remains, sometimes these procedures can be done at the same time. 
Let’s get into it, shall we? 
The procedure that is done is called a LeFort I osteotomy. The patient is being seen by the orthodontist at the time of surgery, who is responsible for creating an appliance that will guide the surgeon into the correct alignment of the jaws. 
The orthodontist knows how the bite should be, so the guide portrays how they would like the bite to be after the procedure. The guide is used by the oral surgeon during the operation to know where to place the jaw.
The upper jaw segment is separated during the surgery to allow it to be moved into the correct position. The incision is made right above the upper teeth. Bone is placed in the new space that is created.
Alternatively, there can be a device inserted into the upper jaw, and distraction can be done. What this means is the device will be adjusted, and the maxilla will slowly go into place as the device is activated each time, moving bones apart. As the bone is “distracted” and moved forward into the right position, new bone forms, creating stability. This is usually done when the jaw discrepancy is more severe, and it takes about 6-8 weeks. The device is removed by the surgeon at this time. 
The main difference between the two procedures is that one is done slowly while the other is done in one surgery and one step. Also, with the distraction procedure, a bone graft is not necessary.
After the surgery
The jaw is secured in place with metal plates and screws after the Le Fort I. A splint is used to hold the jaws in place for 6 weeks. You’ve probably heard of this as “jaws wired shut.” 
You will not be able to chew, so it’s important to make sure you get adequate nutrition through blended foods.
Try to aim for 2 or 3 nutrient-dense drinks per meal time. Avoid fizzy drinks, and try using a straw. That will help a lot. Good foods include milkshakes, smoothies, soups, juice, yogurt.
It is very important to use good oral hygiene still while healing. Use a small soft toothbrush to brush your teeth, and rinse your mouth with warm salt water.
After 6 weeks, start chewing slowly again. It will take a bit of time for it to feel normal again.
It will also be difficult to speak. Be patient, and bring a pen and paper with you everywhere! 
Complications
The side effects include:
- numbness in the face
- infection
- instability of jaw
- nasal blockage
- loss of teeth
- jaw returns to how it was before surgery
- this is more common with Le Fort I
The most common side effect by far is experiencing temporary numbness in the face. 
There are many nerves in this region of the face, so the surgery may affect some of those nerves. This is what causes the temporary numbness.
My story
I was lucky enough that I was part of the group of cleft patients who did not require orthognathic surgery. 
My Class III malocclusion (lower teeth in front of upper teeth) was corrected with braces and orthodontic rubber bands. My teeth were also tilted to be in front of my lower teeth.
I am so grateful for this, but I do remember when the orthodontist said “Let’s try to do this with just rubber bands, but if it doesn’t work, we will need to do jaw surgery.” Thankfully, I was diligent with my bands, and the surgery was not necessary.
I know this is one of the tougher surgeries for cleft patients, but the outcome is great and life-changing. 
Thanks for reading. Let me know if you have any questions!!