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Distraction osteogenesis has established itself as an accepted form of treatment in the management of midface deficiency in cleft patients. However, it is well known that some amount of relapse is inevitable in patients who undergo this procedure. Like most surgical techniques, it has its specific indications, limitations, and complications. The problems are amplified in some patients because of severe fibrosis resulting from previous palate and lip operations. This article reviews treatment planning, pre- and postoperative orthodontic management, operative technique, and mechanics of distraction. It also discusses long-term changes following distraction and protocols to optimize the results and minimize complications.