Cleft related facial skeletal surgery: an update

PURPOSE OF REVIEW: This review provides a comprehensive update on advancements and evolving paradigms in cleft-related facial skeletal surgery. It evaluates recent literature concerning the integration of artificial intelligence in surgical prediction, optimal orthognathic surgical sequencing, the utility of virtual surgical planning (VSP) and patient-specific implants (PSIs), strategies for managing skeletal surgery related velopharyngeal insufficiency (VPI) and airway patency, the evolution of alveolar bone grafting (ABG) techniques, and the increasing emphasis on patient-reported outcome measures (PROMs). RECENT FINDINGS: Recent studies demonstrate that machine learning models utilizing preadolescent cephalometric data can predict the need for orthognathic surgery with high accuracy (over 83%). The implementation of 3D VSP has validated the mandible-first surgical sequence and significantly improved occlusal accuracy while reducing preoperative planning time. While PSIs reduce skeletal relapse in large maxillary advancements (>10 mm), they carry a higher risk of hardware removal compared to conventional plates. Regarding speech and airway management, safe maxillary advancement thresholds have been established to minimize VPI risk, and preserving prior pharyngeal flaps during surgery, if possible, is highly recommended to prevent speech deterioration. In alveolar reconstruction, synthetic grafts and allografts combined with osteogenic agents (like rhBMP-2) are showing success rates comparable to traditional iliac cancellous autografts, with a marked shift toward earlier intervention (ages 4-8) and outpatient procedures. Finally, while orthognathic surgery significantly improves psychosocial well being and facial aesthetics, significant disparities in care access persist based on insurance status and geopolitical factors. SUMMARY: The landscape of cleft-related facial skeletal surgery is rapidly advancing through the integration of artificial intelligence, 3D digital planning, and novel biomaterials. These innovations allow for earlier, more accurate surgical predictions, reduced operative morbidity, and enhanced long-term skeletal stability. Balancing structural advancements with airway and speech preservation remains a delicate, patient-specific process. Ultimately, while surgical and technological refinements continue to optimize functional and aesthetic results, addressing socioeconomic barriers is critical to ensuring timely care and maximizing health-related quality of life for all cleft patients.