Atlas of Operative Oral and Maxillofacial Surgery

Age	Procedure	Timing	Comments
3 months	Repair of cleft lip	3 months	Historically performed after 10 weeks, when weight is greater than 10 lbs. and hemoglobin is greater than 10 dl/mg. This “rule of tens” was originally based on anesthetic risk. Traditionally, however, most cleft lip repairs are undertaken around 3 months of age as no significant benefit has been identified with earlier repair.
7–18 months	Repair of cleft palate	7–18 months	The timing of palatal surgery must balance the need for normal speech development against potential growth disturbances encountered after early surgery. There is an increased risk for developing maxillary hypoplasia when palatal repair is performed prior to 9 months of age. However, by 18 months of age, most children will require an intact palate for normal speech development.
3–5 years	Pharyngoplasty	3–5 years	The diagnosis of velopharyngeal insufficiency (VPI) may not be possible before the age of 3 as a result of testing difficulties in such young children. In most cases, reliable testing can be accomplished between 3 and 5 years of age. Surgical intervention is based on the individual child's speech and phonemic age, however, rather than simply chronologic age.
6–9 years	Orthodontics	6–9 years (initiated)	Interceptive orthodontics may begin during the primary dentition stage, but it is more commonly started in mixed dentition, between 6 and 9 years of age, after the first molars have erupted. Traditional orthodontics typically begins after exfoliation of the primary dentition. Completion depends on the need for orthognathic surgery, dental arch maintenance and grafting, and restorative options.
6–9 years	Dentoalveolar cleft repair	6–9 years (based on dental development)	Although it remains a subject of controversy, secondary bone grafting of maxillary dentoalveolar clefts appears to be best accomplished in the stage of mixed dentition before canine eruption, ideally between ages 6–9 years. In addition, higher success rates have been achieved when grafting is performed prior to the eruption of the tooth located distal to the cleft.
14–16 years (F); 16–18 years (M)	Orthognathic surgery	14–16 years (female); 16–18 years (male)	Best accomplished after cessation of facial-skeletal growth to avoid complications with relapse. Most females undergo surgical correction between 14 and 16 years of age, whereas males typically undergo surgery between ages 16 and 18 years. Exact timing is based on individual growth characteristics.
16–18 years	Dental implant placement	16–18 years	Best accomplished after orthognathic surgery once the dentoalveolar arches have been established and facial-skeletal growth is complete. Additional bone grafting may be indicated prior to implant placement.
18–21 years	Rhinoplasty	18–21 years	Ideally, the dental arch should be established, skeletal maturity achieved, and maxillary hypoplasia corrected before surgical repair of most nasal deformities. As such, correction is typically performed after orthognathic surgery.
	Revision of cleft lip	Varies	Cleft lip and nasal revisions may be accomplished at any time after 5 years of age, as most lip and nasal growth is complete by this age. However, surgical revision may be attempted earlier when severe deformities exist. In addition, surgeries performed before 3 years of age have the advantage of being completed prior to the development of facial image and before the child has memory of the operations.

Note: References for Appendix 2 are located at the end of Chapter 25.