Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

What is the Effectiveness of Premaxilla Surgical Repositioning and its Stabilization Methods in Mixed Dentition Patients With Bilateral Cleft Lip and Palate?

OBJECTIVE

Verify the effectiveness of surgical repositioning of the premaxilla and its stabilization methods in patients with bilateral cleft lip and palate during mixed dentition.

DESIGN

Systematic review.

MATERIAL AND METHODS

The search was conducted in 7 databases (eg, Medline via PubMed; Scopus; Central Cochrane; LILACS; Embase, Web of Science; and Sigle via OpenGrey until August 2021), using the descriptors "premaxilla", "cleft Palate", and "bone transplantation".

INCLUSION CRITERIA

Clinical trials and observational studies that have patients with bilateral cleft who had a need for superior/posterior repositioning of the premaxilla on mixed dentition; Studies in any language was evaluted whitout time restriction of publication.

RESULTS

From 5572 records, 6 studies were included in the review with a total sample of 212 patients. Regarding the type of stabilization used in the premaxilla, the hybrid method (rigid and complementary semi-rigid stabilization) predominated, being observed in 184 patients (86.8%). A total of 17 failures were identified related to the surgical repositioning of the premaxilla, corresponding to 8% of the total number of surgeries. A meta-analysis of prevalence was performed, only with the retrospective studies. It was observed that the effectiveness rate of premaxilla repositioning was 92%, with a CI between 0.04 and 0.13, with all included studies showing a similar failure rate (0.08-0.09). The included studies also showed great homogeneity in this analysis (I2 = 0%; P = .75).

CONCLUSION

Although there are several alternatives and techniques for repositioning and stabilizing the premaxilla, the statistical result did not differ between the different techniques.

A Custom Stabilizing Splint for the Management of BLCP with Protruding Premaxilla

A severely protruding premaxilla in a patient with bilateral cleft lip and palate prevents functional closure of the orbicularis oris muscle and acceptable reconstruction of the nasolabial components during primary cheiloplasty. This is typically corrected with vomerine osteotomy and premaxillary setback, followed by cheiloplasty and rhinoplasty. Due to the risk of vascular compromise to the prolabium and premaxillary segment, the lip and nose repair is often staged after the vomerine osteotomy and premaxillary setback has healed. Stabilizing the premaxillary segment to allow adequate healing has been a topic of interest. Several methods have been described, but each is associated with varying degrees of compromise of the blood supply to the premaxilla. To combat this, the authors created a custom oral splint that effectively maintained the position of the premaxilla with minimal impingement of the blood supply. The authors present two cases in which a two-stage premaxillary setback with a custom-stabilizing oral splint was performed, followed by primary cheiloplasty and rhinoplasty in an age-appropriate and delayed presentation of bilateral cleft lip and palate and protruding premaxilla.

Correction of a prominent premaxilla in a juvenile with a bilateral cleft lip and palate using a novel, hybrid function regulator, the FR-BCPPm, followed by preadjusted fixed appliances: A 20-year follow-up

A seven-year-old boy with a repaired bilateral cleft lip and palate, presented with a severe skeletal II base and an extremely prominent premaxilla. He had grossly incompetent lips with lower lip trapping, an 18.5-mm overjet, a deep overbite, markedly retroclined lower incisors, bilateral crossbites and 12-mm-wide alveolar gaps together with 6-mm vertical steps between the extruded premaxillary incisors and the posterior teeth. Before the eruption of the permanent canines, there was an urgency to approximate the opposing cleft alveolar margins and to level the split maxillary occlusal plane, in order to facilitate the successful insertion and subsequent consolidation of secondary alveolar bone grafts.A new functional appliance was therefore designed to achieve this objective, which drew components from Fränkel's FR I and FR III function regulators. Together with a couple of novel components, it created a hybrid appliance, namely the function regulator for juveniles with a bilateral cleft and a prominent premaxilla: the FR-BCPPm.The patient was treated with this appliance and a nocturnal headgear at 7-13 years, together with a concomitant quad helix appliance followed by a transpalatal arch and bilateral bone grafts. He was then treated non-extraction up to the age of 17 years with preadjusted fixed appliances to correct his residual, crowded Class II malocclusion.The marked improvement in his occlusion, dentofacial appearance and his perioral function after a decade of treatment was then followed up over 20 years, during which time mild relapse of the incisor overjet and moderate recurrence of the lower anterior misalignment was noted two years after treatment.While no further relapse was observed at the four-year post-treatment review, by 20 years after treatment, a little further misalignment of the lower anterior teeth was noted, half of which was deemed to be attributable to age-related maturation.

Repair Sequence and Management of the Premaxilla in Patients With Bilateral Cleft Lip and Palate: A Systematic Review of the Literature

BACKGROUND

Bilateral cleft lip and palate (BCLP) remains a difficult surgical problem due to the severely protruding premaxillary segment, with no consensus of optimal treatment sequence in older patients. A systematic review of the literature was performed to assess the current status of BCLP repair based on age.

METHODS

A PRISMA systematic review of the PubMed, Web of Science, and Embase databases was performed using a series of search terms related to BCLP. Studies were categorized based on the age of presentation, repair sequence, and technique.

RESULTS

The database search identified 381 articles. Of these, 72 manuscripts were ultimately included. The lip was repaired first in 1077 patients (86.0%), palate first in 161 patients (12.9%), and simultaneous lip and palate in 14 patients (1.1%). Patients less than 6 months old received lip repair first (n = 959, 98.6%), with complications of unaesthetic appearance (n = 86, 62.3%) and midface retrusion (n = 41, 34.1%) in younger patients and wound dehiscence (n = 8, 40%) in older patients. Primary lip repair was preceded by presurgical orthopedics (n = 760) or lip adhesion (n = 272) to reduce lip tension with nasoalveolar molding (n = 452, 62.9%) or the Latham device (n = 282, 37.1%). In older patients, the palate was repaired first or premaxillary setback (n = 222) was indicated in protruded premaxillae greater than 10 mm, but carried the risk of premaxilla mobility (n = 20, 37.7%) and midface retrusion (n = 10, 18.9%).

CONCLUSION

In younger patients, lip repair is performed first with preoperative orthopedics or lip adhesion. In older patients, the palate is more commonly repaired first compared with the lip; however, there is no difference in complication rate.

Interdisciplinary Approach for the Treatment of Complex Bilateral Cleft Lip and Palate With Missing Premaxilla

Complex craniofacial deformities such as complete bilateral cleft lip and palate require interdisciplinary approach for proper diagnosis and treatment. A severe skeletal discrepancy caused by bilateral cleft lip and palate and missing premaxilla was successfully managed with orthodontic preparation and distraction osteogenesis. Conventional prosthodontic treatment combined with orthodontic preparation was proven to be a viable option to manage multiple missing teeth in cleft lip and palate.

Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts

ABSTRACT

Management of residual clefts of the alveolus and maxilla requires the coordinated effort of multiple members of the craniofacial team including surgeon, orthodontist, and when teeth are hypoplastic or absent, the prosthodontist to achieve complete habilitation. Such cooperation among specialists begins early in the patient's life and continues through completion of care.Although numerous publications on this topic exist, few present definitive multidisciplinary reconstructive outcomes with longterm results. In this review paper, the authors present our comprehensive, multidisciplinary protocols, experience, and techniques as they have evolved with over 35 years of practice at our Craniofacial Center.Details of our updated protocols for each intervention and procedure, including our current thoughts on appropriate timing, follow up and advantages from the incorporation of current technologies are discussed. Close cooperation among specialists at all stages of care, the use of evolving technology, and adherence to, and modification where indicated, of time honored team protocols enables us to consistently achieve successful functional and esthetic outcomes, while minimizing complications.

Retrospective analysis of clinical outcomes in bilateral cleft lip and palate patients after secondary alveolar bone grafting and premaxilla osteotomy, using a new dento-maxillary scoring system

Evaluation of relevant clinical outcomes in patients with bilateral cleft lip and palate (BCLP) after secondary aveolar bone grafting (SABG) and premaxilla osteotomy (PMO), through the use of a new scoring system. Data were collected retrospectively from all patients with BCLP who were operated on between 2004 and 2014, at the end of follow-up. The treatment protocol consisted of SABG + PMO in patients aged between 9 and 13 years. At the end of follow-up, the following parameters were scored: (un)interrupted dental arch, skeletal sagittal relationship, bone height using the Bergland/Abyholm criteria, and the presence of postoperative fistula. These parameters were combined to produce a dento-maxillary scoring system, giving a final score between 1 and 10. For statistical analysis, the independent t-test was used. Of 55 children, 45 were suitable for analysis. The mean age at time of surgery was 12.0 years (8.9-16.4 yrs), and the mean follow-up time was 11.7 years (5.8-15.8 yrs). The average number of surgeries executed under general anesthesia was 6 (range: 3-11). The average dento-maxillary score in this patient cohort was 7.6 (1-10; median: 8). Among these patients, 31 had an uninterrupted dental arch; the average Bergland/Abyholm score was 2.07; 30 patients exhibited an Angle class I incisor relationship; and, in 38 cases, the oronasal communication was closed after SABG + PMO treatment. A significant effect of fistulas was seen on dento-maxillary score (p = 0.001). Specifically, a significant effect of fistulas was seen on interrupted dental arch (p = 0.002) and on Bergland/Abyholm score (p = 0.037). The proposed dento-maxillary scoring system is a straightforward tool that can be used to describe and analyze the amount of dento-maxillary rehabilitation at the end of the treatment. Persistence of oronasal fistulas in patients with BCLP has a significant impact on interruption of the dental arch, and can influence dental results at the end of the second decade.

Full arch monolithic zirconia prosthesis in a patient with bilateral cleft palate: A clinical report

Adult patients with bilateral cleft lip and palate present unique challenges for prosthodontic treatment because of mobility of the premaxillary segment, oral-nasal communication, multiple missing and malpositioned anterior teeth, unfavorable soft tissues, and scar tissue underneath the maxillary lip. This clinical report describes the prosthodontic treatment of an adult patient with a terminal maxillary dentition and bilateral cleft palate, by using 5 dental implants and a 1-piece complete-arch fixed implant-supported prosthesis made of monolithic zirconia. The zirconia prosthesis aided in rigidly splinting not only the implants but also in orthopedically splinting the mobile premaxillary segment to the maxilla. Additional surgical and prosthodontic considerations in splinting the mobile premaxilla as well as biomechanical principles involved in management of such patients are also presented in this article.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding

BACKGROUND

Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results.

METHODS

We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated.

RESULTS

We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils.

CONCLUSION

The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

Secondary correction of premaxilla in bilateral cleft lip and palate with lag-screw fixation

It is not unusual for the protruding premaxilla to attain an undesirable position after cleft lip repair. Such a premaxilla may lead to considerable problems in facial aesthetics, or oral functions, or both in early childhood. These abnormal premaxillas may produce difficulties in bone grafting and orthodontic treatment in late childhood. In such cases, surgical correction of the premaxilla in childhood is justified. From 2013 to 2018, 11 children, aged 2 to 11 years, had a secondary ostectomy of their premaxilla. A new stabilisation method (developed by us) was used to provide rigid fixation to the premaxilla. The follow up period ranged from 1 - 6 years. The results were satisfactory in all except for a few minor issues in three patients. There was significant improvement in their appearance, oral functions, and most importantly in their quality of life. The need for secondary osteotomy of the premaxilla should always be weighed against its potential complications. The fixation technique described by us, though, provides rigid fixation, but may potentially be associated with a few complications if not practised carefully.

Incidence and morphology of the incisive suture in CT scanning of young children and human fetuses

PURPOSE

Incisive suture is a suture classically described on the oral face of the palate in fetuses and young children. The aim of our study was to describe the evolution of the incisive suture in human fetuses and to evaluate the incidence of this suture in a population of young children under 4 years, to determine if there is a possibility of improving the anterior growth of the maxilla, by stimulation of this suture.

METHODS

One hundred and thirty CT scan images of patients aged from birth to 48 months have been studied and nine fetal palates aged from 18 to 26 weeks of development, have been scanned using high-resolution X-ray micro-computed tomography RESULTS: The CT scan images of patients showed that an incisive suture was present in 33/130 cases (25,4%). All the patients with a suture were under 2 years old. The fetal palate study showed that the suture was present in the inferior aspect of the palate (oral cavity) in all cases. The incisive suture increased from 18 to 24 weeks. At 26 weeks it stopped growing although the intercanine length increased. Considering the closure of the suture in a vertical plane, our study on fetuses has shown that the incisive suture is closing from its superior side (nasal side) to its inferior side.

CONCLUSIONS

Considering all these results it appears to us that the incisive suture is partially ossified after birth, it cannot be stimulated by orthodontic appliances.

Incidence of complications in secondary alveolar bone grafting of bilateral clefts with premaxillary osteotomy: a retrospective cohort study

OBJECTIVE

To evaluate factors affecting incidence of complications after secondary alveolar bone grafting with premaxillary osteotomy (SABG + PO) in children with complete bilateral cleft of lip and palate (BCLP).

MATERIALS AND METHODS

Data were collected from children with BCLP treated with SABG + PO from 2004 to 2014 at our institute. Preoperative parameters included age, donor site, race, gingival health, bone quality around cleft-related teeth, premaxilla position, graft timing, presence of canines in the cleft, and presence of deciduous teeth around the cleft area. Logistic regression and the chi-squared test were used to assess correlations and the incidence of complications.

RESULTS

In the 64 patients, a significant correlation was found between complication rate and timing of bone grafting with respect to early versus late SABG + PO (p = 0.041), age > 12 years (p = 0.011; odds ratio (OR) 5.9; 95% confidence interval (CI) 1.49-23.93), malposition of the premaxilla (p = 0.042; OR 3.3; 95% CI 1.04-10.13), and preoperative bone quality around cleft-related teeth (p = 0.005; OR 5.3; 95% CI 1.6-17.2).

CONCLUSIONS

The timing of SABG + PO is essential, as early SABG + PO is associated with fewer complications. A malpositioned premaxilla and poor bone quality around cleft-related teeth are associated with more complications. Therefore, preoperative orthodontic repositioning of the malpositioned premaxilla before SABG + PO should be considered.

CLINICAL RELEVANCE

Analysis of treatment protocols and complications for BCLP patients underscores that proper timing of SABG + PO and correct premaxilla repositioning help reduce complications.

Management of the protuberant premaxilla: where does it fit in?

PURPOSE OF REVIEW

To discuss multidisciplinary treatment options for the protuberant premaxilla associated with bilateral cleft lip and palate. Lessons have been learned throughout the years regarding the effect of growth restriction after early and aggressive therapy. Multiple surgical and orthodontic interventions are discussed. Recent literature will be highlighted and discussed.

RECENT FINDINGS

A paucity of long-term studies was noted. Recent literature revealed numerous studies introducing innovative presurgical orthopedic devices as less expensive and easier to use alternatives to nasoalveolar molding. Multiple approaches to premaxillary setback were presented, offering multiple approaches to improve success rates and minimize burden to the patient. Novel orthodontic and advanced microvascular procedures were discussed as additional tools for treatment of the malpositioned premaxilla once skeletal maturity is reached.

SUMMARY

Multidisciplinary team management of the protuberant premaxilla and bilateral cleft lip and palate is becoming increasingly embraced worldwide. Numerous surgical procedures and orthodontic treatments are required to optimally reposition the premaxilla; however, these interventions can inhibit growth, resulting in maxillary retrusion. Long-term follow-up studies are needed to determine what protocol is best. Studies should also include ways to overcome barriers to treatment success, such as late intervention, resource disparity, and limited access to care.

A Pristine Approach for the Prominent Premaxilla in Bilateral Cleft Lip and Palate (BCLP) Cases

OBJECTIVE

The neonate premaxilla in bilateral cleft lip and palate is often protruding and displaced laterally. Surgeons prefer the premaxilla to be repositioned and centralized to allow a tension-free primary lip repair. This report describes the fabrication of a premaxillary bonnet appliance with silicone material and its successful use in 2 cases of bilateral cleft lip and palate (BCLP).

PATIENTS, PARTICIPANTS

Two male BCLP patients of ages 34 days and 10 days, respectively.

INTERVENTIONS

Nonsurgical repositioning of the premaxillary segment using silicone cup-bonnet appliance.

RESULTS

The duration of active treatment by silicone appliance was 36 days in case 1 and 75 days in case 2. The retention period was 2 months and 3 months, respectively. The appliance made of room temperature vulcanizing (RTV) silicone is flexible and softer in comparison to the rigid conventional acrylic appliance and is therefore almost atraumatic. A gentler appliance resulted in enhanced compliance and acceptance by the neonates. There was a noticeable change in the position of the discernible asymmetric premaxilla. Analysis of frontal facial photographs revealed an angular change in the position of the premaxilla (C) by 12° in case 1 and 6° in case 2 in reference to the midfacial plane.

CONCLUSION

This silicone appliance provides enhanced compliance and improved retention compared to acrylic appliance since it is a more gentle, flexible, and less traumatic alternative to a rigid acrylic appliance. Further, the RTV silicone appliance can be 3-dimensionally printed for better accuracy following intraoral scanning and thus eliminating the need for impression making in cleft newborns.

Bilateral Cleft Lip and Palate, With Facial Dysplasia: Interdisciplinary Treatment and Long-Term Follow-Up

Bilateral complete clefts represent the result of an incomplete fusion with all the morphologic components present. It is well known that patients with bilateral cleft lip and palate have typical characteristics such as insufficient medial face development with an orthodontic class III tendency, flat nose and short columella with abnormal nasolabial angle, bilateral oronasal fistulas, alterations in the number and position of the lateral incisors, and agenesis or supernumerary teeth. Successfully solving these cases, results in a difficult challenge and studies showing extended follow-up are not frequent. Bilateral complete clefts, including medial facial dysplasia, are a rare condition, not only difficult to be included in any classification but also of complex solution. These patients require multiple surgical procedures throughout life, and long-term results are often still far from ideal. Due to surgical intervention and diminished intrinsic growth potential, surgical results may change from initially good into a progressively disappointing outcome. However, if the ideal timing and type of surgery are known, in combination with the intrinsic growth potential, these results could be ameliorated. A patient with complete bilateral cleft, presenting hypoplasia of philtrum and premaxilla, flat nose with rudimentary columella and septum, is reported. A description of her interdisciplinary treatment and long-term outcome with an adequate and stable result was observed. Being the intrinsic growth restriction mainly localized in the central mid-face, a protocol oriented to stimulate facial development during growth period could be essential to reduce the number of surgical procedures and prevent sequels. Early referral to a specialized center is mandatory to achieve a correct treatment and result.

Bilateral cleft lip repair with simultaneous premaxillary setback and primary limited rhinoplasty

Background

Functional closure of the orbicularis oris muscle and esthetic reconstruction of nasolabial components are impossible in patients with severely deformed premaxilla. Here, we review a surgical strategy for patients with unremedied premaxilla retrospectively.

Results

Vomerine ostectomy and premaxillary setback with nasolabial repair were performed in 12 patients with bilateral cleft lip and palate. The mean age of patients was 21.7 months. The extent of ostectomy varied between 3 and 11 mm. There were no serious complications from defective perfusion to the premaxilla or the philtral flap. The follow-up period ranged from 2 to 25 months. Proper positioning of the premaxilla and satisfactory nasolabial esthetics were achieved in all patients.

Conclusions

We performed nasolabial repair after premaxillary setback without jeopardizing the premaxillary segment or the philtral flap. Our surgical strategy could be recommended in poor socio-economic circumstances due to the cost effectiveness of limiting the number of surgeries.

Does a Premaxillary Setback and Lip Adhesion Have a Negative Impact on Lip Outcome in Bilateral Cleft Patients?

BACKGROUND

The early premaxillary setback and lip adhesion remains as a controversial maneuver in the treatment of bilateral cleft lip and palate patients. This study aimed to assess extent of preoperative deformity and lip outcomes during the first year after surgery in bilateral cleft patients who underwent premaxillary setback and lip adhesion and to compare to those with primary lip repair.

METHODS

A retrospective observational study was conducted of 16 nonsyndromic consecutive bilateral complete cleft lip patients (with and without Simonart band), who underwent primary cleft lip repair. Patients were allocated in group 1 without premaxillary setback and group 2 with premaxillary setback and lip adhesion. Preoperative and postoperative linear measurements were used for intergroup and intragroup comparisons.

RESULTS

Cutaneous lip height of patients in group 2 significantly (P < 0.05) improved after combined premaxillary setback and lip adhesion and primary cleft lip repair. There were no significant (all P > 0.05) differences in intragroup 1 comparisons, and in intergroup comparisons.

CONCLUSION

Bilateral cleft patients with a protruded and deviated premaxilla over 10 mm discrepancy of the lateral maxillary achieved noninferior lip symmetry 1 year postoperatively compared with patients with less severe original deformity.

Assessing agreement between preclinical magnetic resonance imaging and histology: An evaluation of their image qualities and quantitative results

One consequence of demographic change is the increasing demand for biocompatible materials for use in implants and prostheses. This is accompanied by a growing number of experimental animals because the interactions between new biomaterials and its host tissue have to be investigated. To evaluate novel materials and engineered tissues the use of non-destructive imaging modalities have been identified as a strategic priority. This provides the opportunity for studying interactions repeatedly with individual animals, along with the advantages of reduced biological variability and decreased number of laboratory animals. However, histological techniques are still the golden standard in preclinical biomaterial research. The present article demonstrates a detailed method comparison between histology and magnetic resonance imaging. This includes the presentation of their image qualities as well as the detailed statistical analysis for assessing agreement between quantitative measures. Exemplarily, the bony ingrowth of tissue engineered bone substitutes for treatment of a cleft-like maxillary bone defect has been evaluated. By using a graphical concordance analysis the mean difference between MRI results and histomorphometrical measures has been examined. The analysis revealed a slightly but significant bias in the case of the bone volume [Formula: see text] and a clearly significant deviation for the remaining defect width [Formula: see text] But the study although showed a considerable effect of the analyzed section position to the quantitative result. It could be proven, that the bias of the data sets was less originated due to the imaging modalities, but mainly on the evaluation of different slice positions. The article demonstrated that method comparisons not always need the use of an independent animal study, additionally.