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

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.