Management of Cleft Lip and Palate and Cleft Orthognathic Considerations

Need for orthognathic surgery in cleft patients from Northern Finland

OBJECTIVE

Northern Finland has a unique distribution of clefts compared to the rest of Europe and Finland. This may reflect the need for orthognathic surgery among Northern Finland's patient pool. The aim of this study was to compare previously operated patients aged 18 years or older with cleft lip, cleft lip and alveolus, cleft lip and palate, cleft palate and to evaluate the need for orthognathic surgery in order to achieve a stable and functional occlusion.  Materials and methods: The study group consisted of all 18-years-old cleft patients treated in the Oulu Cleft Center. The total amount of patients was 110. The patients were compared retrospectively using patients' hospital records. The majority of patients did not have any cleft-associated syndrome. The need for maxillary or bimaxillary orthognathic or corrective-jaw surgery was evaluated by the Oulu Cleft Team. A descriptive and statistical analysis was used to determine the need for orthognathic surgery according to sex and cleft type.

RESULTS

There were nineteen patients of the total of 110 patients who met the criteria requiring corrective-jaw surgery (17,3%). In total 12 males (25,0%) and 7 females (11,3%) were evaluated for the need of orthognathic surgery. Sixteen of the 19 patients had palatal involvement of the cleft.

CONCLUSIONS

The need for orthognathic surgery was greater in the cleft lip palate and cleft palate patient groups compared to cleft lip alveolus or cleft lip groups. This study also found that males from Northern Finland need surgery more often than females.

One-Jaw versus Two-Jaw Orthognathic Surgery for Patients with Cleft: A Comparative Study Using 3D Imaging Virtual Surgical Planning

Whether a one-jaw or two-jaw design is used in orthognathic surgery for patients with cleft remains varied and controversial. This study aimed to compare the two approaches using 3-dimensional imaging surgical simulation. This study was conducted on 41 consecutive patients with complete unilateral cleft lip and palate treated in the craniofacial center. All patients had original two-jaw virtual planning and orthognathic surgery. Simulation of one-jaw LeFort I surgery was performed using the same final dental occlusion on 3-dimensional images. Cephalometric data and asymmetry index were collected and compared among the designs. Average advancement of the maxilla was 7.46 mm in one-jaw and 4.80 mm in two-jaw design. SNA, SNB, and A-N perpendicular were significantly greater and close to normative data in the one-jaw design. ANB angles were similar in both designs. The anterior and posterior occlusal plane cants, the deviation of midline landmarks, and the asymmetry index were more improved in the two-jaw approach. It is concluded that the two-jaw cleft orthognathic surgery could significantly improve facial midline and symmetry compared with the one-jaw approach. However, the two-jaw surgery with mandibular setback produced less protrusive facial contour although a harmonious relationship between the maxilla and mandible was achieved.

Is Cleft Lip or Palate a Risk Factor for Perioperative Complications in Orthognathic Surgery?

PURPOSE

Perioperative outcomes following cleft orthognathic surgery are not well established. The purpose of this study was to compare the incidence of orthognathic specific complications (OSCs) in patients with and without cleft lip and/or palate.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases were used to enroll patients undergoing orthognathic surgery. The primary predictor variable was a prior diagnosis of cleft lip and/or palate: cleft versus noncleft. The primary outcome variable was OSCs (yes/no) within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between cleft status and OSCs.

RESULTS

The study sample was composed of 1,149 subjects: 98 in the cleft group and 1,051 in the noncleft group. The incidence of OSCs was 6.1 and 4.7% for the cleft and noncleft groups, respectively (P = .461). After adjusting for age, cleft status, bone grafting, segmentation of the maxilla, and history of bleeding disorder, classification as American Society of Anesthesiologists (ASA) III (P = .002, odds ratio [OR] = 3.92, 95% confidence interval [CI] 1.63-9.40), ASA IV (P = .039, OR = 9.47, 95% CI 1.12-80.4), and isolated mandibular osteotomies (P = .006, OR = 3.23, 95% CI 1.40-7.48) were independent predictors of OSCs. Length of stay was 1.66 ± 1.14 days compared to 1.37 ± 3.74 days for the cleft and noncleft groups, respectively (P = .443).

CONCLUSIONS

There was no significant difference in the incidence of perioperative OSCs and length of hospital stay between cleft and noncleft patients. Cleft status was not an independent predictor of OSCs; instead, greater ASA classification and isolated mandibular osteotomies were the only predisposing factors. Patients with clefts undergoing orthognathic surgery do not have an increased risk of short-term OSCs within the limitations of this study.

Parental Perceptions Following Cleft Lip Repair in Their Children

OBJECTIVE

Cleft lip (CL) repair at 3 months is chosen mostly out of convention and offers minimal functional benefit. Potentially, a better cosmetic outcome is possible by delaying repair. This study examines parental perceptions around repair at 3 months to determine if current guidelines are appropriate.

DESIGN

Retrospective cross-sectional survey.

SETTING

Tertiary-care institution.

PARTICIPANTS

Parents of children with CL ± P under age 6 years who underwent CL repair from 2004 to 2011 at our center were surveyed (n = 64). Response rate was 61% (n = 37).

METHODS

Open-ended survey asked about various aspects of parental perceptions before and after repair. Qualitative data analysis is used to interpret survey responses.

STATISTICS

Fisher exact test using contingency tables to identify statistically significant results.

RESULTS

Nearly all (36/37) parents felt repair was important, citing reasons such as feeding, speech, and appearance. Most (28/37) felt surgery would fix the problem. A portion of parents (15/37) would delay repair if better aesthetics were possible later, but most would not (20/37). Most parents were satisfied with repair quality (33/37). On average, repair did not impact parent-child bonding, and eliminated negative interactions with strangers that parents found distressing.

CONCLUSIONS

Arguably, positive parental perceptions of their child's condition reflect favorably on the child's well-being, and may outweigh any future aesthetic benefit. Therefore, current recommendations should be upheld. However, given that some parents would consider delaying repair, they could be offered this option. Future efforts should examine cultural factors, and aesthetic and developmental outcomes of repair at different ages to determine optimal repair timing.

Virtual planning and CAD/CAM-assisted distraction for maxillary hypoplasia in cleft lip and palate patients: Accuracy evaluation and clinical outcome

The aim of this prospective study was to report the experience with a specific guided distraction protocol for the treatment of CLP patients with severe midface hypoplasia. From January 2016 to April 2019, six consecutive, non-growing, CLP patients with maxillary hypoplasia underwent a specific distraction protocol based on the use of VSP, CAD/CAM-generated surgical splints, cutting guides, prebent internal maxillary distractors, early removal of distractors, and acute callus manipulation and fixation. STL files for VSP, using multislice CT scans taken preoperatively (T0) and 3 months after distractor removal (T1) were superimposed using the free software 3D Slicer and Geomagic Wrap to evaluate the accuracy of maxillary repositioning and assess 3D bone changes. Clinical outcome was evaluated at the 1-year follow-up (T2). The patients and surgeon were satisfied with the occlusal and aesthetic outcomes. A maximum difference of 2 mm between the VSP and the actual surgical outcome was chosen as the success criterion for accuracy. The average linear difference for selected points was <2 mm in four patients and >2 mm in two patients. The average distance of the postoperative maxilla from the VSP model was 2.28 mm (median 1.85), while the average forward movement of the maxilla was 10.18 mm The protocol used is effective and accurate in the correction of severe maxillary hypoplasia in CLP patients. Early removal of the distractor and stabilization with plates reduces patient discomfort and does not jeopardize stability. This protocol should be reserved for complex cases due to the costs of the procedure, which are not negligible.

Skeletal and Dental Correction and Stability Following LeFort I Advancement in Patients With Cleft Lip and Palate With Mild, Moderate, and Severe Maxillary Hypoplasia

OBJECTIVE

This study evaluates skeletal and dental outcomes of LeFort I advancement surgery in patients with cleft lip and palate (CLP) with varying degrees of maxillary skeletal hypoplasia.

DESIGN

Retrospective study.

METHOD

Lateral cephalograms were digitized at preoperative (T1), immediately postoperative (T2), and 1-year follow-up (T3) and compared to untreated unaffected controls. Based on the severity of cleft maxillary hypoplasia, the sample was divided into 3 groups using Wits analysis: mild: ≤0 to ≥-5 mm; moderate: <-5 to >-10 mm; and severe: ≤-10 mm.

PARTICIPANTS

Fifty-one patients with nonsyndromic CLP with hypoplastic maxilla who met inclusion criteria.

INTERVENTION

LeFort I advancement.

MAIN OUTCOME MEASURE

Skeletal and dental stability post-LeFort I surgery at a 1-year follow-up.

RESULTS

At T2, LeFort I surgery produced an average correction of maxillary hypoplasia by 6.4 ± 0.6, 8.1 ± 0.4, and 10.7 ± 0.8 mm in the mild, moderate, and severe groups, respectively. There was a mean relapse of 1 to 1.5 mm observed in all groups. At T3, no statistically significant differences were observed between the surgical groups and controls at angle Sella, Nasion, A point (SNA), A point, Nasion, B point (ANB), and overjet outcome measures.

CONCLUSIONS

LeFort I advancement produces a stable correction in mild, moderate, and severe skeletal maxillary hypoplasia. Overcorrection is recommended in all patients with CLP to compensate for the expected postsurgical skeletal relapse.

What is the relapse after Le Fort I maxillary advancement in cleft lip and palate patients? A systematic review

Le Fort I osteotomy is the most common procedure for maxillary advancement in cleft patients, and a significant relapse is expected in the postoperative period. This study purpose is to evaluate the maxillary relapse and associated factors in cleft lip and palate (CLP) patients submitted to standard Le Fort I advancement. This systematic review sought studies in PubMed, SCOPUS, and Cochrane and included papers that evaluated the maxillary relapse with at least 1-year postoperative period. The quality assessment was adapted following PRISMA statement. The initial electronic search found 345 papers, and the final selection included 10 studies. In total, 275 CLP patients were evaluated 198 had unilateral CLP and 41 had bilateral CLP. Isolated maxillary advancement was performed in 166 patients, while 109 had bimaxillary surgery. The mean relapse in horizontal and vertical plane was 1.2 mm (19.7%) and 1.0 mm (29.4%), respectively. In conclusion, a relapse after maxillary advancement in patients with CLP is expected, being higher in vertical plane. Patients with UCLP and those who underwent bimaxillary surgery had a higher relapse rate. Due to the miscellaneous data and methodologies, future prospective clinical trials should apply rigorous selection of CLP patients sample and methods for variable analysis to obtain more accurate results.

Virtual Surgical Planning Assisted Management for Cleft-Related Maxillary Hypoplasia

Maxillary hypoplasia is a common developmental deformity affecting patients with cleft lip and palate. Various surgical techniques including conventional orthognathic surgery, total maxillary distraction osteogenesis, and anterior maxillary segmental distraction have been applied to address the deformity. With the evolution of 3D computed tomography imaging, the visualization of skeletal complexities in different perspectives is greatly enhanced and comprehensive surgical planning is achieved. Intraoperative efficiency is also improved with the fabrication of 3D-printed templates. The study aims to present different surgical techniques with virtual surgical planning (VSP) and 3D-printed surgical templates and the solution of representative cases. From January 2014 to January 2019, VSP was transferred to actual surgery or distraction precisely in 80 adult patients with cleft-related maxillary hypoplasia. The accuracy was analyzed and the relapse was also estimated and observed in 18 patients after 1-year follow-up. Based on our experience, VSP provides a more reliable and effective option to conventional model surgery. It facilitates the preoperative planning and accurately transfers the virtual plan to correct the cleft-related maxillary hypoplasia.

Reconstruction of Congenital Nose, Cleft Primary Palate, and Lip Disorders

Clefts of the primary palate in the dog are uncommon, and their repair can be challenging. The aims of this article are to provide information regarding pathogenesis and convey practical information for the repair of these defects.

Description of total population hospital admissions for cleft lip and/or palate in Australia

BACKGROUND

Orofacial clefts are a group of frequently observed congenital malformations often requiring multiple hospital admissions over the lifespan of affected individuals. The aim of this study was to describe the total-population hospital admissions with principal diagnosis of cleft lip and/or palate in Australia over a 10 year period.

METHODS

Data for admissions to hospitals were obtained from the Australian Institute of Health and Welfare National Hospital Morbidity Database (July 2000 to June 2010). The outcome variable was a hospital separation with the principal diagnosis of cleft palate, cleft lip or cleft lip and palate (ICD-10-AM diagnosis codes Q35-Q37 respectively). Trends in rates of admission and length of stay by age, gender and cleft type were investigated.

RESULTS

A total of 11, 618 admissions were identified; cleft palate (4,454; 0.22 per 10,000 people per year), cleft lip (2,251; 0.11) and cleft lip and palate (4,913; 0.25). Admission age ranged from birth to 79 years with males more frequently admitted. Most admissions occurred prior to adolescence in cleft palate and cleft lip and through to late teens in cleft lip and palate, declining for all groups after 25 years.

CONCLUSIONS

This study identified population level trends in hospital separations for orofacial cleft diagnosis in Australia.