In<unk>  palate patients bone<unk>  during the mixed dentition has been widely accepted since the mid-1960s. The goals of surgery are to stabilize the maxilla, facilitate the healthy eruption of teeth that are adjacent the<unk> , improving the esthetics of the base of the nose, create a bone base for dental implants, and to close any oro-nasal fistulas. Pre-treatment monitoring and timing The incisors and first molars start to erupt between the ages of 6 to 8 years. Panorex xray showing defect (red arrow) in the alveolus with maxillary canine tooth erupting into the<unk>  about age 13 One of the most controversial topics in<unk>  is the timing of treatment, however, most centres recommend<unk>  around the ages of 6–8 years old as the lateral incisor and maxillary canine near the<unk>  site. This is referred to as secondary<unk>  during mixed dentition (after eruption of the maxillary central incisors but before the eruption of the canine). A smaller proportion recommend primary<unk>  around the age of 2, but success rates are lower, and fewer patients are good candidates. Late secondary<unk>  (after eruption of the canine) has also been advocated but has been largely abandoned due to the loss of tooth support. In secondary<unk> , the dental age of the patient needs to be closely monitored for the eruption of the first maxillary molars in unilateral cases around the age of 6, and in bilateral cases the eruption of central incisors about the age of 8. This timing is used because there is minimal growth of the upper jaw after ages 6–7, the patient is more compliant with orthodontics that is required prior to surgery for expansion, the donor site is better developed, and the<unk>  precedes the eruption of teeth into the site. In cases with a single<unk> , 35-60% of lateral incisors are congenitally missing, and cannot be relied on for timing. Instead, the eruption of the incisors and first molars is used as a queue to begin assessments. With bilateral cases, the premaxilla must be repositioned before<unk>  and special consideration must be given. During this time, the orthodontist must be wary of rotating teeth into the<unk>  site. Last, the size of the patient, defect, and social issues must all be taken into consideration and is best assessed with a CBCT scan as the patient enters the mixed dentition phase of dental development. Pre-surgery Orthodontics Fan rapid palatal expander in<unk>  palate prior to<unk>  In<unk>  lip and palate cases, the maxilla is typically narrow compared to the lower jaw and must be expanded outward. An expansion appliance is placed in the maxilla 6–9 months prior to correct any crossbite or upper arch constriction. This will widen the<unk>  size, and so that parents and patients need to be warned the symptoms such as fluid reflux may worsen, although some centres will expand the jaw after surgery is complete. In the case of double<unk> s, expansion is typically before surgery because the premaxilla needs to be repositioned forward, which cannot occur until the upper jaw is widened to allow room. Surgical correction Incisions used in<unk> . Red arrow marks oro-nasal fistula, blue lines mark incisions The goals of the surgery are to: # Close any fistulas between the mouth and the nose # Leave keratinized tissue around the tooth margins # Create enough bone to stabilize the maxilla and allow teeth to erupt without a bone defect At surgery, the gingiva is incised along the<unk>  margin to allow creation of pocket of tissue up towards the nose (recreating a nasal floor), and down towards the mouth (recreating a palate, and closing the palatal opening). The bony edges of the<unk>  are cleaned, and any extra teeth in the<unk>  are removed. The gingiva along the outside part of the upper jaw is raised, so that it can be drawn forward to close the<unk> . After creation of the pocket, but before suturing closed the gingiva a bone graft is placed into the bony defect. This is most commonly harvested from the anterior hip but can also be obtained from other sites, donor bone, or bioactive materials such as bone morphogenic proteins. Once packed the<unk>  is filled with bone material the gingiva is sutured closed to create a water tight closure between the mouth and the nose. Source of bone graft Location of the incision to harvest bone from the anterior iliac crest The most common source of the bone graft is from the iliac crest, harvested at the time of the<unk>  closure. Other sources such as the chin, and posterior iliac crest, or skull can also be used. Artificial grafts such as demineralized bone, recombinent bone morphogenic protein or a mix of harvested bone and artificial grafts have also been used. Insufficient data exists to show that one is beneficial over the other.
Alveolar cleft grafting
Rhinoplasty
Crown lengthening
Non-surgical rhinoplasty
Greyhound therapy
Facial implant
Clitoral hood reduction
Craniofacial prosthesis