Orthognathic Surgery Combined with Orthodontic

The incidence of cleft lip and palate is 8 in every 10,000 live births. A patient with this condition experiences a deficiency in maxillary growth. Maxillary hypoplasia leads to malocclusion and skeletal disharmony. Orthognathic surgery at skeletal maturity is the standard procedure at the end of the protocol to correct maxillary hypoplasia resulting in malocclusion not correctable with orthodontics alone. Case Presentation and Operation Technique: We report the result of orthognathic surgery performed on a 23 year old male with complete bilateral cleft lip, palate, and alveolus. We proceeded with bimaxillary surgery despite the alveolar cleft. We also recorded a neglected alveolar cleft in which he should have had undergone alveolar bone graft prior to the current procedure. The pre-maxillary segment was stabilized with miniplate followed by Le Fort 1 advancement and mandibular setback guided by an occlusal wafer. Malar augmentation was done by onlay bone grafts. Mandibulo-maxillary fixation was maintained. Postoperatively, a good occlusion and better facial harmony were achieved. He was planned to undergo a septorhinoplasty in the near future. Discussion:

left lip and palate is the most common congenital facial anomaly.In patients with bilateral cleft lip and palate, the posterior alveolar segments can be collapsed medially to a greater degree, which may result in an extremely narrow maxilla with bilateral posterior cross bite.It is well documented that patients with a history of C S yndactyly is a condition well documented both in textbooks and current literature mainly because it is the most common congenital hand defect. 1 Coming from the Greek word syn (meaning together) and dactyly (meaning digits), it describes an embryological failure of finger separation. 2 Commonly found in some species, Diana Murtiati Kusuma a , Iswinarno Doso Saputro a *, Sitti Rizaliyana a including birds and kangaroos, it has a large aesthetic and functional significance for humans born with the condition.It is believed to have a genetic component, and this has been the subject of research over the last decade. 1yndactyly is the failure of differentiation in which the fingers fail to separate into individual appendages, usually occurring during the 6-8 weeks of embryologic development.The etiology of syndactyly is approximately 10-60% familial genetic disorder and autosomal dominant.The most common congenital abnormality of the hand is more common in Caucasians with a rate of 1 per 2000-2500 births with male-to-female ratio of 2:1. 3 The operative management of this condition has been, aside from conservative approach, the only definitive care for these patients, but new options are becoming available as our understanding of the condition develops?. 1 The current mainstay for the treatment and management of syndactyly is surgery.The indications for surgery in general for hand anomalies including syndactyly are: degree of function required by the patient and whether delaying surgery may alter hand function and grip development. 4

CASE PRESENTATION AND OPERATION TECNIqUE
A 13-year old boy was admitteed, presenting with fusion of all right fingers at birth.There are no other co-morbidities and no family members suffer from similar anomaly.Prior to his current visit, he underwent partial separation of the right fingers at the age of 6 y.o. at local hospital.Following partial separation, the fingers did not grow normally (Figure 1).
Current X-ray showed atrophy and deviation the middle phalanx (Figure 4).We report separation between index and middle finger, and between fourth finger and small finger, performed in our hospital (Figure 2).
The dorsal and palmar skin flaps were outlined with a marker before dissection.(Figure .2).Interdigital webbings are released using local flap.For the reconstruction of first web, the skin flaps were altered.A rectangular flap with a broad base was elevated dorsally, whereas from the volar surface 2 rectangular flaps were elevated.These 2 volar flaps were laterallybased and their proximal side was dissected at the level at which the distal side of the dorsal flap was sutured volarly. 4he remaining raw surface is covered using full-thickness skin grafts.The full thickness skin graft was harvested from inguinal area and the remaining scar is perfectly sutured.
Associated malformations of the involved fingers were corrected during the separation of the digits in the majority of the patient.Priority was given to the separation of the second and fourth web whereas the third web was reconstructed at a later stage.The time interval between the separation of adjacent webs ranged from 3 to 6 months.Postoperatively, the hand was immobilized in a bulky dressing.Skin graft was evaluated on the fifth day.
On follow up visits, the patient showed good functional and aesthetic outcome.The functional outcome in hands with multiple syndactylies were impressive.Although the surgery did not return the hand to normal cosmetic appearance, the improvement in function made these hands useful for daily activities.He was able to write with his right hand with better coordination (Figure 5).

DISCUSSION
Complex syndactyly reconstruction is challenging.Syndactyly between digits with different length, such as the thumb and index or the ring and small fingers, should be corrected within the first year of life because the difference of length creates angular and rotational deformity to the longest finger, if left untreated for a long time. 1 In addition, the complex complicated syndactyly should be operated upon early in life to correct the bony and articular deformities and prevent further disturbance of the digital function. 2or psychological reasons, even simple syndactyly should be operated upon before the beginning of school life, that is, before the age of 5 years old. 1 The age of the patient during the separation of the webbed fingers is important and the basic criteria for the timing of operation are the complexity of the syndactyly as well as the length discrepancy between the involved fingers, especially in complete syndactylies.Common post surgical findings include rotational deformity, angular deformity and nail deformity.On deformity, finger is typically rotated away from and deviated toward the site of the previous complex syndactyly.We describe how we have altered our approach on these findings.
The patients who had complex complete syndactyly in digits of unequal length and came late for reconstruction, needed more surgeries to reach satisfactory results compared to patients that came early and correction of the syndactyly was done simultaneously with the correction of the skeletal deformities. 5n addition, the function of these digits were limited and remained so in cases of late correction.In some cases of complete syndactyly with a common nail, a minor rotational deformity of the distal phalanx of the longer digit was present in late followup visits.This could be explained either as natural evolution of the bone and soft tissue of the digits with syndactyly or by the pull of pigmented skin graft, which cannot follow the growth of the digit. 3

CONCLUSION
In conclusion, congenital syndactyly should be corrected early in life, taking into consideration the basic principles of web reconstruction and simultaneous correction the skeletal deformities that might coexist. 6Careful dissection using loupe magnification, the use of a dorsal rectangular flap in combination with 2 volar triangular flaps, and use of full thickness skin grafts ensure a satisfactory outcome and minimize the number of operations per web. 4

Figure 2 .
Figure 2. Local flap design for separation of syndactyly

Figure 1 .
Figure 1.Boy, 13 years old with abnormal growth of right fingers after partial separation

Figure 4 .
Figure 4. X-ray of the right hand of the patient (after partial separation)

Figure 5 .Figure 3 .
Figure 5.After 3 month full separation between index and middle finger, and between third finger and small finger