Striking the Balance: 

Sagittal Advancement Thresholds in Cleft Orthognathic Surgery

Midface hypoplasia (MFH) is a prevalent and challenging sequela of cleft lip and palate (CLP), attributed to both intrinsic growth restriction and iatrogenic scarring from prior surgical interventions. Orthognathic surgery is required in up to 65% of patients with CLP to reestablish functional occlusion and restore facial harmony. Techniques for maxillary advancement in this context include surgically-assisted maxillary protraction (SAMP), Le Fort I advancement (LF1), and distraction osteogenesis (DO). Despite technological advances in virtual planning and surgical fixation, skeletal relapse after maxillary advancement is reported as high as 64% among patients with CLP. The clinical and technical factors that predispose patients to relapse and reoperation, however, remain poorly understood. This study aims to identify predictors of skeletal relapse requiring reoperation across different surgical techniques, with an emphasis on procedural thresholds and patient-specific risk factors. By refining surgical risk stratification, we seek to inform individualized treatment planning and mitigate the cumulative burden of care in this high-risk cohort.