Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients

Comparison of Maxillary Distraction Osteogenesis and Conventional Orthognathic Osteotomy: A Systematic Review

Maxillary hypoplasia, affecting 0.3% of the US population and nearly 25% of patients with cleft lip and/or palate (CLP), often results in Class III malocclusion with significant functional and esthetic challenges. Treatment options include LeFort I distraction osteogenesis (DO) and conventional osteotomy (CO), but reported outcomes vary widely. A systematic review of PubMed, Embase, Scopus, and CINAHL identified 17 studies (6 randomized controlled trials, 11 retrospective cohort studies) from 5076 screened. Outcomes assessed included skeletal relapse, speech changes, velopharyngeal insufficiency (VPI), soft tissue adaptations, and complications. Study quality was evaluated using the Newcastle-Ottawa scale and Cochrane risk-of-bias tool. Findings showed no significant differences in skeletal relapse between DO and CO. Speech and VPI outcomes were comparable, with deterioration in 10% to 45% of DO patients and 22.2% to 81.8% of CO patients. DO provide superior soft tissue improvements, particularly in nasal and lip landmarks. Complication rates ranged from 5% to 20% for DO and 21% to 22.2% for CO. Overall, evidence comparing DO and CO remains limited and inconsistent, preventing definitive conclusions on skeletal stability, speech outcomes, VPI risk, and complications. While DO may offer better soft tissue outcomes, it shares high complication rates and patient dissatisfaction. Further research is essential.

Efficacy of modified anterior maxillary segmental distraction osteogenesis based on 3D visualisation for the treatment of maxillary hypoplasia among adolescents with cleft lip and palate

BACKGROUND

This study evaluates a three-dimensional (3D) visualisation design combined with customized surgical guides to assist anterior maxillary segmental distraction osteogenesis (AMSDO) in correcting maxillary hypoplasia in adolescents with cleft lip and palate (CLP), focusing on treatment outcomes, satisfaction and the validity of 3D planning.

METHODS

This retrospective cohort study was conducted at a single hospital in China. Between January 2020 and December 2023, 12 adolescents with CLP with maxillary hypoplasia were included. An advanced 3D simulation was used to convey the treatment strategy to the patients and their families. A customized surgical guide and distraction osteogenesis device were designed. Cephalometric analysis evaluated AMSDO changes and long-term stability. Patient satisfaction was assessed. The Chinese version of the Child Oral Health Impact Profile was used to evaluate the children's oral health-related quality of life before and after treatment. The postoperative outcomes were compared with the planned outcomes by superimposing the actual postoperative data onto the simulated soft tissue models and calculating the linear and angular differences between them.

RESULTS

One patient experienced postoperative gingivitis, yielding an 8.33% complication rate. Most patients (83.33%) were highly satisfied with the target position, with the rest content. Cephalometric analysis showed significant improvements in various indices post-traction. Quality-of-life scores significantly improved post-treatment. The discrepancies in facial soft tissue between the simulated and actual results were within clinically satisfactory ranges.

CONCLUSIONS

Digitally designed surgical guides effectively treat maxillary hypoplasia in adolescents with CLP, ensuring stability, reducing complications, reducing dependency on operator experience, and enhancing satisfaction and health outcomes. Although the simulated results were clinically acceptable, it is important to inform patients of potential variations in the predicted soft tissue.

Skeletal stability after maxillary distraction osteogenesis or conventional Le Fort I osteotomy in patients with cleft lip and palate: A superimposition-based cephalometric analysis

PURPOSE

The aim was to assess skeletal stability after maxillary advancement using either distraction osteogenesis (DO) or conventional Le Fort I osteotomy (CO) in patients with cleft lip and palate (CLP) or cleft palate (CP) utilising a new superimposition-based cephalometric method.

METHOD

This retrospective study included patients who were treated with DO (N = 12) or CO (N = 9). Sagittal and vertical changes after surgery, and skeletal stability at 18 months post-operatively were assessed with superimposition-based cephalometry, comparing lateral cephalograms performed pre-operatively (T0), post-operatively after CO or immediately after completed distraction in DO (T1), and at 18 months of follow-up (T2).

RESULTS

The mean sagittal movements from T0 to T2 in the DO and CO groups were 5.9 mm and 2.2 mm, respectively, with a skeletal relapse rate of 16% in the DO group and 15% in the CO group between T1 and T2. The vertical mean movement from T0 to T2 in the DO and CO groups was 2.8 mm and 2.0 mm, respectively, and the skeletal relapse rate between T1 and T2 was 36% in the DO group and 32% in the CO group.

CONCLUSION

Sagittal advancement of the maxilla was stable, in contrast to the vertical downward movement, which showed more-extensive relapse in both groups. Despite more-extensive maxillary advancement in the DO group, the rates of skeletal relapse were similar.

Updates in Cleft Care

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

Long-term speech outcome after anterior distraction osteogenesis of the maxilla in patients with cleft lip and palate

Advancement of the maxilla may increase the distance between the soft palate and the posterior pharyngeal wall in patients with cleft lip and palate, implying a risk of velopharyngeal dysfunction. The aim was to evaluate long-term speech outcome in a consecutive series of patients treated with distraction osteogenesis (DO). Fourteen out of the 16 patients agreed to participate. A long-term speech follow-up was performed 1.5 to 13.5 years after DO. For two participants, audio recordings before DO were missing, and for another one, it was incomplete. The percentage of consonants correct (PCC) based on phonetic transcription and perceived velopharyngeal competence rated on a three-point scale were assessed before and after DO by three independent judges, based on audio recordings of reading of standardised sentences. Also, the participants were asked how they perceived their speech after DO. Changes in PCC were insignificant. Four participants perceived deteriorated speech related to DO. In two cases, the subjective deterioration did not correlate to results from perceptual assessment. In two others, the subjective deterioration correlated with the perceptual assessment, and the velopharyngeal function was judged as being incompetent after DO. After secondary velopharyngeal surgery, velopharyngeal function improved to competent in one case and marginally incompetent in the other. The results need to be interpreted with caution due to methodological limitations but indicate that some patients develop deteriorated velopharyngeal function after DO. The impact on articulation needs to be further explored. It is important that patients are informed before treatment of the risk of velopharyngeal dysfunction after DO.

Using whole exome sequencing to identify susceptibility genes associated with nonsyndromic cleft lip with or without cleft palate

Cleft lip and palate is a common congenital birth defect in humans. Its incidence rate in China is as high as 1.82%, and is now a frequent deformity observed among the Chinese population; moreover, it varies across regions. Although the etiology of nonsyndromic cleft lip with or without cleft palate (NSCL/P) has been widely investigated, the results are inconsistent. The specific genes and mechanisms responsible for NSCL/P have not been fully understood. Whole exome sequencing (WES) is a new strategy for studying pathogenic genes. WES studies on NSCL/P have not been conducted in East China. Therefore, the aim of this study was to screen candidate genes of NSCL/P in East China using WES and analyze the temporal and spatial expressions of the candidate genes during embryonic palatal development. WES was performed in 30 children with NSCL/P from East China to screen candidate genes. A bioinformatics analysis was performed using commercially available software. Variants detected by WES were validated by immunohistochemistry and western blotting. After WES, 506,144 single-nucleotide variant sites were found. The results of database comparison, functional analysis, and mass spectrometry revealed that only the laminin alpha 5 (LAMA5) gene (site: rs145192286) was associated with NSCL/P. Immunohistochemistry results showed that LAMA5 expression in the medial edge epithelium changed with formation, lifting, and contact during palatogenesis. Almost no LAMA5 expression was detected in the palatal mesenchyme or after palatal fusion. Western blotting and immunohistochemistry results showed consistent trends. In conclusion, the WES results shows that the mutation at the site (rs145192286) of LAMA5 is associated with NSCL/P. The temporal and spatial expressions of LAMA5 during palatal development further demonstrate the involvement of this gene. Therefore, we speculate that LAMA5 is a new candidate pathogenic gene of NSCL/P. The identification of new pathogenic genes would help elucidate the pathogenesis of NSCL/P and provide a scientific basis for the prenatal diagnosis, prevention, and treatment of NSCL/P.

Starting a Swedish national quality registry for orthognathic surgery: a tool for auditing fundamentals of care

BACKGROUND

National quality registries (NQRs) provide open data for user-directed acquisition. National Quality Registry (NQR) data are often used to analyze the rates of treatment success and adverse events for studies that aim to improve treatment quality and patient satisfaction. Thus, NQRs promote the goal of achieving evidence-based therapies. However, the scientific literature seldom focuses on the complex process of initiating, designing, and implementing an NQR. Starting an NQR may be particularly challenging in a setting where specialized care is decentralized, such as orthognathic surgery in Sweden. The present study describes the initiation and early phases of a new NQR for orthognathic surgery in Sweden.

METHODS

The initial inventory phase included gaining knowledge on regulations, creating economic plans, and identifying pitfalls in existing NQRs. Next, a crude framework for the registry was achieved. Outcome measures were selected with a nation-wide questionnaire, followed by a Delphi-like process for selecting parameters to include in the NQR. Our inclusive process comprised a stepwise introduction, feedback-based modifications, and preparatory educational efforts. Descriptive data were collected, based on the first 2 years (2018-2019) of registry operation.

RESULTS

Two years after implementation, 862 patients that underwent 1320 procedures were registered. This number corresponded to a 91% coverage rate. Bimaxillary treatments predominated, and the most common were a Le Fort I osteotomy combined with a bilateral sagittal split osteotomy (n = 275). Reoperations were conducted in 32 patients (3.6%), and the rate of patient satisfaction was 95%.

CONCLUSIONS

A National Quality Registry should preferentially be started and maintained by an appointed task force of active clinicians. A collaborative, transparent, inclusive process may be an important factor for achieving credibility and high coverage, particularly in a decentralized setting.

Periodontal changes following distraction osteogenesis in patients with cleft lip and palate: a clinical trial

Objectives

To evaluate inflammatory mediator levels and periodontal changes following distraction osteogenesis (DO) in patients with cleft lip and palate (CLP) using mid-maxillary distraction (MMD).

Materials and Methods

A total of 20 healthy patients with CLP with Class III malocclusion were included. Segmental forward advancement of the anterior maxilla from the second premolars on both sides using DO was performed. A custom-made, tooth-borne distractor connecting buccal molar segments to the anterior maxilla was used for 7 days with 0.5-mm distraction for the first 2 days and then increased to 1 mm daily until overcorrection. Crevicular interleukin IL-1β and tumor necrosis factor TNF-α levels were measured during distraction. Periodontal clinical parameters and indices were recorded at baseline and 3 and 6 months postoperatively. Soft tissue healing was evaluated histologically at 2 and 4 weeks after distraction.

Results

The periodontal parameters remained stable during the follow-up periods. Insignificant increases in the level of inflammatory cytokines compared with the control were observed. Histological findings revealed mild inflammatory and structural changes in the gingiva immediately after distraction, whereas regeneration was noticed after 4 weeks.

Conclusions

MMD was an effective technique in treating patients with CLP, leading to new bone and soft tissue formation without significant detrimental effect on the periodontium of the adjacent teeth.

Long-term follow-up of mandibular dental arch changes in patients with complete non-syndromic unilateral cleft lip, alveolus, and palate

BACKGROUND

Treatment of cleft lip and palate (CLP) requires a comprehensive interdisciplinary approach and long-term follow-up. Only a few studies are available that reported on changes after treatment, which showed that in particular the transverse dimension, in patients with CLP is prone to changes after treatment. However, those studies did not pay attention to concomitant changes in the mandibular arch that occur after treatment.

OBJECTIVES

To evaluate mandibular transverse dental arch dimensions and interarch transverse changes in patients with complete non-syndromic unilateral cleft lip, alveolus, and palate (CUCLAP) up to five years after treatment.

MATERIAL AND METHODS

Retrospective longitudinal study in 75 consecutive patients with CUCLAP directly after comprehensive treatment (T0), two (T2), and 5 years after treatment (T5). Great Ormond Street, London and Oslo (GOSLON) scores were available for all patients. Three-dimensional scans of all dental casts were made. Inter premolar and intermolar distances between the mandibular contralateral teeth were measured. The modified Huddart Bodenham (MHB index) was applied to assess the transverse interarch relationship. Paired t-tests and ANOVA were used to analyze transverse and interarch transverse changes. Linear regression analysis was done to define contributing factors.

RESULTS

Paired t-tests showed a significant decrease of the mandibular inter first and second premolar distances (p < 0.05) and an increase of the inter second molar distance, whilst the MHB Index deteriorated at all time points for all segments and for the total arch score (p < 0.05). Linear regression showed no significant contributing factors on the decrease of the transverse distances. However, inter arch transverse relationship was significantly affected by age at the end of treatment, missing maxillary lateral incisor space closure, and the GOSLON Yardstick score at the end of treatment (p < 0.05), especially during the first two years after treatment.

CONCLUSIONS

Changes occurred in the mandibular arch expressed as changes in the transverse dimensions and interarch relationship measured by the MHB Index. A younger age at the end of treatment, space closure for a missing maxillary lateral incisor and a higher GOSLON score at the end of treatment negatively influence the interarch transverse deterioration especially in the first two years after treatment. For the transverse dimensional changes in the mandibular arch such influencing factors could not be determined.

A New Orthodontic-Surgical Approach to Mandibular Retrognathia

(1) Background: Mandibular deficiency is one of the most common growth disorders of the facial skeleton. Recently, distraction osteogenesis has been suggested as the treatment of choice for overcoming the limitations of conventional orthognathic surgery; (2) Methods: A new custom-manufactured dental-anchored distractor was built and anchored in the first molar and lower canine. It consists of a stainless-steel disjunction screw, adapted and welded to the orthodontic bands through two 1.2 mm diameter connector bars with a universal silver-based and cadmium-free solder; (3) Results: The distractor described can be a useful tool to correct mandibular retrognathia and is better tolerated by patients, especially in severe cases; (4) Conclusions: The dental-anchored distractor increases the anterior mandibular bone segment without affecting the gonial angle or transverse angulation of the segments and avoids posterior mandibular rotation, overcoming the limitations of conventional surgical treatment.

Combating Constraints of the Functional Matrix: The Importance of Overcorrection in Pediatric Craniofacial Surgery

Background:

To effectively manipulate the bone, particularly in the growing patient, the craniofacial surgeon must understand the principles related to bone-based reconstruction. A theory of craniofacial growth that is both biologically accurate and clinically relevant is thus needed.

Methods:

A historical review of major findings across various disciplines (including orthopedic surgery, anatomy, embryology, orthodontics, and cell biology) will be covered, as it pertains to the concept of the functional matrix of the craniofacial skeleton.

Results:

The functional matrix dictates the interplay between the soft tissue envelope and bone grafts, thus guiding donor site choice and inset methods. The soft tissue may also warrant the use of bony hypercorrection especially in cranial vault remodeling. Control of both bone and boundaries of the soft tissue functional matrix can be achieved via distraction osteogenesis.

Conclusion:

The soft tissue functional matrix must be accounted for during craniofacial bone grafting, mobilizing osteotomies, and distraction osteogenesis if optimal aesthetic results are to be obtained using the least amount of procedures.

Distraction Osteogenesis Versus Orthognathic Surgery: Demystifying Differences in Concepts, Techniques and Outcomes

Introduction

The popularity and interest evoked by orthognathic surgery and distraction osteogenesis are undisputed in the field of oral and maxillofacial surgery. However, questions regarding the individual identities of either of them with clarity in their concepts, techniques and outcomes have remained unanswered. The aim of this review is to shed light on these questions.

Methods

This review is structured as a narrative review of thirty years of literature available in the specialities of orthognathic surgery and distraction osteogenesis.

Conclusion

The authors present a review of existing literature combined with contrasting experience gained over the years in providing an overview of the merits and demerits of the two surgical techniques which will aid the clinician in justifying the use of one technique over the other.

Bone-anchored maxillary protraction long-term outcomes in UCLP

This case report presents a 12-year-old boy with unilateral complete cleft lip and palate and severe maxillary retrusion treated with bone-anchored maxillary protraction (BAMP) therapy followed by fixed appliances. The follow-up period extended until the end of growth. Initially, the patient demonstrated a Goslon 4 interarch relationship with an overjet of -3.5 mm and a Wits appraisal of -7.9 mm. Six months after the secondary alveolar bone graft, Bollard miniplates were fixed bilaterally at the infrazygomatic region in the maxilla and between the canines and lateral incisors in the mandible. Class III elastics were used bilaterally full time for 12 months. After treatment, the overjet increased 5.9 mm. Significant maxillary advancement (SNA +3.2°) and skeletal convexity improvement (NA-APo +12.4°) were observed. Retrusion of the anteroposterior position of the mandible was observed (SNB -2.1°). Comprehensive orthodontic treatment was performed after BAMP therapy with nighttime bone-anchored Class III elastics as active retention until the end of growth. Occlusion and facial esthetics were satisfactory at the end of orthodontic treatment and growth. Le Fort I surgery for maxillary advancement was not required. BAMP therapy demonstrated an adequate orthopedic outcome, preventing the need for orthognathic surgery in unilateral complete cleft lip and palate.

Pre-treatment Factors Affecting Post-treatment Velopharyngeal Incompetency in Patients with Unilateral Cleft Lip and Palate Treated with Maxillary Rigid External Distraction

Introduction: Maxillary advancement (MA) with rigid external distraction (RED) to correct mid-face deficiency in adult cases with cleft lip and palate (CLP) may trigger velopharyngeal incompetency (VPI) post-surgically.

Aim and objectives: To determine pre-treatment factors affecting worsening of post-surgical VPI in patients with repaired unilateral CLP who underwent MA with RED.

Material and methods: Treatment records of 10 patients with unilateral CLP who underwent MA with RED were selected from institutional archives. All patients underwent clinical evaluation of velopharyngeal function at T1 (1 week before surgery) and T2 (3 months after surgery). Based on post-surgical VPI status, patients were divided into 2 groups: group 1 (no change in VPI) and group 2 (worsened VPI). Lateral cephalograms were manually traced at T1 and T2 to determine the changes in length of soft palate (LSP) and pharyngeal depth (PD) at T2. The information regarding amount of MA and presence of pre-surgical VPI was obtained from case sheets of patients.

Results: Mean LSP and PD at T2 were higher compared to T1 ( p-value < .001). No significant difference was observed in mean pre-surgical age, gender, pre-surgical LSP, and pre-surgical PD between the study groups ( p-value > .05 for all). The worsened VPI post-surgically was significantly associated with the presence of VPI pre-surgically and also with the amount of MA ( p-value < .05 for both).

Conclusions: Amount of MA and presence of pre-surgical VPI are most important factors affecting post-surgical VPI. Prospective studies are recommended to validate the findings of this study.

Orthognathic Surgery Treatment Need in a Turkish Adult Population: A Retrospective Study

Objectives: Limited information exists on orthognathic procedures and respective dentofacial deformities in Turkey. This retrospective study assessed the orthognathic surgery procedures in two universities, using the Index of Orthognathic Functional Treatment Need (IOFTN), and compared the IOFTN grades according to gender as well as sagittal and vertical skeletal relationships. Material and Methods: Records of 200 consecutive patients (120 females, 80 males, mean age = 23.4 (SD: 5.4) years) who received orthognathic treatment (2014–2018) were analyzed. Sagittal (ANB angle) and vertical skeletal type (GoGnSN angle), osteotomies, and IOFTN scores were recorded. Results: Class III, II, and I malocclusions formed 69%, 17.5%, and 13.5% of the samples, respectively. Class III skeletal relationships (69%) and high-angle cases (64%) were the most prevalent (p < 0.05). IOFTN scores were unevenly distributed among genders (p < 0.05) and the prevalent scores were 5.3 (40.5%), 4.3 (15.5%), 5.4 (13%), and 5.2 (7.5%), with 94% scoring 4 or 5 (great and very great functional need). Bimaxillary osteotomies were the most prevalent (55%), followed by LeFort I (32%), and 26% had genioplasty. Conclusion: IOFTN is a reliable tool to identify patients in need of orthognathic surgery. Class III malocclusions and Class III sagittal skeletal relationships were more common in this sample. Comparatively, a higher number of patients had genioplasty as a part of their treatment.