Le Fort I osteotomy in cleft patients: Maxillary advancement and velopharyngeal function

Effect of maxillary advancement on velopharyngeal function in cleft lip and palate: 20 years of experience

This retrospective study aimed to investigate the impact of orthognathic surgery with maxillary advancement (MA) on the velopharyngeal function (VF) in individuals with cleft lip and palate (CLP). The study included 651 patients with repaired CLP, both sexes, aged over 18 years who underwent MA alone or in combination with nasal procedures and/or mandibular osteotomy, operated between 2000 and 2019. The main outcome measures were nasalance (nasal text-NT and oral text-OT) and velopharyngeal orifice area measurement (VA), determined by nasometry and pressure-flow technique, respectively. Preoperatively, mean nasalance scores for NT and OT indicated normality, and VA demonstrated borderline-inadequate velopharyngeal closure in all patients. Following MA, a significant increase in nasalance scores for NT and OT occurred (p < 0.001), revealing hypernasality in those undergoing MA combined with nasal procedure (MAN, N = 191), bimaxillary orthognathic surgery with nasal procedure (BON, N = 227) and bimaxillary orthognathic surgery (BO, N = 151). Conversely, nasalance scores remained within the normal range for those undergoing isolated maxillary advancement (IMA, N = 82). VA exhibited a significant increase leading to the classification of VF as inadequate in the BON and MAN groups. Overall, MA contributed to VF deterioration, resulting in the appearance of hypernasality and increased VA, particularly when combined with nasal procedures.

Occlusal and Cephalometric Outcomes of Cleft Orthognathic Surgery: A Retrospective Cohort Study

OBJECTIVES

Aberrant facial growth in individuals affected by orofacial clefts can result in maxillary retrusion and class III malocclusion, with a proportion requiring surgical correction at cessation of growth. This study aimed to evaluate occlusal and cephalometric outcomes of combined orthodontic-orthognathic treatment.

MATERIAL AND METHODS

Retrospective cohort study in a United Kingdom cleft center. Participants included twenty-seven patients (20 males, 7 females) with cleft (n = 16 UCLP :7 BCLP :4 ICP) who consecutively underwent combined surgical treatment for Class III malocclusion between January 2013 and December 2017. Records were collected pre-treatment (T0), pre-surgery (T1) and at debond (T2). Models were scored using the Peer Assessment Rating (PAR) index and cephalometric radiographs were traced and analyzed. Outcomes were assessed by an independent rater.

RESULTS

Mean age at surgery was 21.4 years (SD 4.9). Le Fort 1 advancement (mean 6.1 mm, SD 4.0) was performed in all cases. Additional procedures included mandibular setback (n = 2), cortico-cancellous bone grafting (n = 6) and genioplasty (n = 1). Mean T0 PAR score was 44.8 (SD 11.7), reducing to 3.6 (SD 2.0) at T2, indicating a mean % PAR score reduction of 91.6% (SD 4.7). Class III skeletal profiles improved from a mean T0 ANB of -2.1º (SD 2.2), to 2.8º (SD 1.6) at T2. Mean T0 overjet was -3.3 mm (SD 2.3), increasing to 2.6 mm (SD 1.3) at T2.

CONCLUSION

Cleft orthognathic surgery differs in complexity and approach to routine orthognathics, however, these results demonstrate that occlusal outcomes can still be comparable with non-cleft populations. Outcome data can be used for comparison with other centers providing cleft orthognathic treatment.

Evaluation of Posterior Superior Alveolar Canal in Individuals With Cleft Lip and Palate Using Cone Beam Computed Tomography

OBJECTIVE

To evaluate the posterior superior alveolar canal (PSAC) in individuals with cleft lip and palate (CLP) by comparing them with individuals with no cleft lip and palate (NC) using cone beam computed tomography (CBCT).

SETTING

This is a cross-sectional, analytical study with a prospective sample.

PATIENTS, PARTICIPANTS

CBCT scans of 29 individuals with no cleft and palate (Group I) and 29 individuals with cleft lip and palate (Group II) were used.

INTERVENTIONS

PSAC was evaluated and compared for its position, diameter, and distance between the individuals with CLP and NC using CBCT scans.

RESULTS

The mean age of individuals in Group I and II were 12.93 and 11.82 years, respectively. The distribution of individuals based on gender comprised of 51.7% males and 48.3% females in both the study groups. PSAC was present in both right and left maxillary sinus in 100% of the study subjects of Group I and Group II. The most prevalent position of PSAC in Group I and Group II was on the lower third and middle third of lateral wall of maxillary sinus, respectively. The mean diameter was higher in Group II (1.2962 mm) when compared to Group I (1.0897 mm) which showed statistically significant value (P = .008).

CONCLUSION

The promising results obtained from the present study demonstrates the importance of knowing the precise anatomical location of the PSAC in individuals with cleft lip and palate by using CBCT which is reliable, less time consuming and cost effective imaging tool.

Velopharyngeal Function Change after 2-Jaw Orthognathic Surgery in Patients with Cleft: A Study of 162 Consecutive Cases

BACKGROUND

Orthognathic surgery (OGS) is a common intervention used to correct midfacial hypoplasia in patients with cleft. Previous studies have reported that Le Fort I maxillary advancement may affect velopharyngeal function, but similar investigations focusing on 2-jaw OGS have not been conducted.

METHODS

A total of 162 consecutive patients with cleft lip and palate who underwent 2-jaw OGS between 2015 and 2020 were enrolled. Clinical data were collected, and preoperative and postoperative skeletal measurements were obtained from cephalometric images. Velopharyngeal function was evaluated using perceptual analysis and nasopharyngoscopy. A logistic regression model was used for risk factors associated with changes in velopharyngeal function.

RESULTS

After 2-jaw OGS, 82.1% of patients showed no change in velopharyngeal function, 3.7% experienced improvement, and 14.2% exhibited worsening of function. Changes in velopharyngeal function were statistically significant compared with velopharyngeal status before OGS. Multivariable logistic regression revealed that the amount of maxillary advancement independently predicted the deterioration of velopharyngeal function after OGS (odds ratio, 1.74; 95% CI, 1.20 - 2.52; P = 0.004). The receiver operating characteristic curve based on maxillary advancement demonstrated good discrimination, with an area under the curve of 0.727 (95% CI, 0.62 - 0.83; P = 0.001). The Youden index was 4.27 mm.

CONCLUSIONS

Despite the risk of velopharyngeal function deterioration in patients with cleft palate undergoing OGS, some individuals experienced improved function after 2-jaw OGS. The extent of maxillary advancement has a negative effect on velopharyngeal function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reshaping Faces, Redefining Risks: A Systematic Review of Orthognathic Surgery Outcomes in Cleft Lip and Palate Patients

Background: This study aims to determine a generalized outcome and risk profile for patients undergoing orthognathic surgery for the definitive treatment of cleft lip and palate. Furthermore, we hope to determine the key risk factors that cause increased risk for cleft lip and palate patients undergoing orthognathic surgery. Methods: This study includes a systematic review using PubMed, MEDLINE, Cochrane, and Scopus. Data curation utilized Covidence software, with dual-reviewer screening and conflict resolution by a third party, focusing on publications with the full texts available. Results: The initial search yielded 1697 articles. Following title, abstract, and full-text screening, a total of 62 articles were included in this review. A total of 70.9% of included articles had moderate bias, with the rest having low risk of bias. The sample consisted of 2550 patients with an average age of about 20 years and an average follow-up of 16.8 months. The most employed procedure was Le Fort I osteotomy (99%). In terms of velopharyngeal function, there were notable increases in insufficiency and severity scores, with an average 63% worsening score from the baseline. That being said, patients experienced an average 33% improvement in speech articulation. Furthermore, the average horizontal movement was reported to be 6.09 mm with a subsequent relapse of 0.98 mm overall. Conclusions: This systematic review distills data from 62 articles and 2550 patients. It highlights the efficacy of orthognathic surgery in addressing oropharyngeal and aesthetic deficits. This study identifies relapse and velopharyngeal insufficiency as recurrent complications. These insights inform surgical refinement and patient counseling, laying a foundation for enhanced clinical protocols.

Measuring the Change in Soft Palate Length and Shape Following Maxillary Advancement: A Cohort Study in Patients with Orofacial Clefts

OBJECTIVE

To evaluate a method of measuring the change in palatal length and shape following maxillary advancement using synchronous lateral videofluoroscopy and voice recording in order to understand how movement of the maxilla may affect VPI risk in patients with cleft lip and/or palate (CL/P).

DESIGN

Retrospective cohort study of children with cleft lip and/or palate.

SETTING

Single center, tertiary children's hospital.

PARTICIPANTS

Patients with cleft lip and/or palate who underwent maxillary advancement between 2016-21 inclusive.

INTERVENTIONS

Maxillary advancement surgery, including those who underwent concurrent mandibular procedures.

MAIN OUTCOME MEASURES

The length of the soft palate and the genu angle were measured throughout palatal dynamic range. Pre- and post-operative measurements were compared using a one sided T-test, with subgroup analysis for patients with clinical VPI.

RESULTS

Ten patients were examined. The mean distance of maxillary advancement was 10.5 mm. The average increase in pre-genu soft palate length was 2.8 mm in the resting position and 2.9 mm in the closed position. The genu angle decreased in the closed position by 16.3 degrees.

CONCLUSIONS

The soft palate showed limited ability to lengthen following maxillary advancement and this may explain the risk of VPI. There was partial compensation by the muscle sling of the palate as demonstrated by a more acute post-operative genu angle and this suggests one reason for the variability of VPI reported. Future research is required to investigate how length and shape changes measured using this method can predict VPI risk.

Does Distraction Lower Risk of VPI Compared to Conventional Maxillary Advancement? A Retrospective Cohort Study of Adolescents with Cleft Palate

OBJECTIVE

To determine whether method of maxillary advancement in adolescents with cleft palate with or without cleft lip (CP ± L) influences post-operative velopharyngeal function.

DESIGN

Retrospective cohort.

SETTING

Pediatric Tertiary Care Hospital.

PARTICIPANTS

One hundred and ninety-nine patients with CP ± L after LeFort I osteotomy for maxillary advancement at our institution between January 2007 and June 2019.

INTERVENTIONS

LeFort I osteotomy via distraction osteogenesis (DO) or conventional osteotomy (CO).

MAIN OUTCOME MEASURES

Patients who underwent DO or CO were compared for the presence of new velopharyngeal insufficiency (VPI), as measured by perceptual rating by a craniofacial speech-language pathologist.

Of the 199 patients who underwent maxillary advancement, 126 were available for analysis. The DO group was younger, male, and had more severe maxillary hypoplasia. Following surgery, 17/41 (41.5%) of the DO group had new VPI, compared to just 23/85 (27.1%) of the CO group. After adjusting for cleft type and predicted maxillary advancement, however, there was not sufficient evidence to reject the null hypothesis of no difference in risk of post-operative VPI between the two surgical groups (prevalence ratio [PR] 1.40, 95% CI 0.68-2.90). Increased prevalence of VPI after DO versus CO was primarily observed among patients with a pre-operative velopharyngeal need ratio < 0.8 (PR = 2.01, 95% CI 0.79-5.10) and patients with normal velopharyngeal function pre-operatively (PR = 2.86, 95% CI 0.96-8.50).

Our results suggest an increased rather than decreased risk of VPI following DO relative to CO. This association is primarily seen among those with a smaller velopharyngeal ratio or perceptually normal velopharyngeal function pre-operatively.

Rhinoplasty and Le Fort I Maxillary Osteotomy in Cleft Patients

INTRODUCTION

Cleft patients often need orthognathic surgery to correct maxillary hypoplasia and rhinoplasty to correct nasal deformity. Rhinoplasty can be performed as a staged procedure after orthognathic surgery or simultaneously with maxillary osteotomy.

AIM

The authors evaluated need for and complications of staged and simultaneous rhinoplasties in patients with different cleft types undergoing maxillary osteotomy.

PATIENTS AND METHODS

This retrospective study examined 99 (54 females) consecutive nonsyndromic patients with cleft lip/palate [23 bilateral cleft lip and palate (BCLP), 51 unilateral cleft lip and palate (UCLP), and 25 cleft palate (CP)] with a mean age of 17.8 (range: 11.5-45.3) years who had undergone Le Fort I maxillary advancement or bimaxillary osteotomy at the Cleft Palate and Craniofacial Center, Helsinki University Hospital, Finland, between 2002 and 2016. Medical charts were accessed through the hospital's archives and database.

RESULTS

Of patients who underwent maxillary osteotomy, 45% (45/99) needed rhinoplasty (14 BCLP, 27 UCLP, and 4 CP). A significant difference ( P <0.01) existed in the need for rhinoplasty between different cleft types, those with BCLP and UCLP needing the most operations (60% and 53%). In 20 patients (20%), rhinoplasty was performed simultaneously with maxillary osteotomy, and in 25 patients (25%) in a second operation after osteotomy. The overall complication rate was 14%. No difference existed in complication rate in patients with or without simultaneous rhinoplasty.

CONCLUSIONS

Of cleft patients who underwent maxillary osteotomy, 45% needed rhinoplasty. Patients with BCLP and UCLP needed rhinoplasty most often. Staged and simultaneous procedures were almost equally common with similar complication rates.

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.

Early experience of wafer-free Le Fort I osteotomy with patient-specific implants in cleft lip and palate patients

PURPOSE

The use of virtual surgical planning and patient-specific saw and drill guides combined with customized osteosynthesis is becoming a gold standard in orthognathic surgery. The aim of this study is to report preliminary results of the use of virtual surgical planning and the wafer-free PSI technique in cleft patients.

MATERIALS AND METHODS

Patient-specific saw and drill guides combined with milled patient-specific 3D titanium alloy implants were used in reposition and fixation in Le Fort I osteotomy of 12 cleft patients. Surgical information was retrieved from hospital records. Pre- and post-operative lateral cephalograms were analyzed.

RESULTS

In 10 of 12 cases, the implants fitted as planned to predesigned drill holes and bone contours with high precision. In one patient, the mobilization of the maxilla was too demanding for virtually planned advancement, and the implants could not be used. In another patient, PSI fitting was impaired due to an insufficient mobilization of maxilla and tension on PSI fixation with screws. After the surgery, the mean advancement of the anterior maxilla (point A) of all patients was 5.8 mm horizontally (range 2.7-10.1) and -3.1 mm vertically (range -9.2 to 3.4). Skeletal relationships of the maxilla and mandible could be corrected successfully in all patients except for the one whose PSI could not be used.

CONCLUSIONS

Virtual surgical planning combined with PSI is a possible useful clinical adjunct for the correction of maxillary hypoplasia in cleft patients. Large maxillary advancements and scarring may be cause problems for desired advancement and for the use of implants.

Speech assessment following microsurgical soft palate repair

The aim of this study was to analyze speech intelligibility of children, who had undergone microsurgical soft palate repair according to Sommerlad. Cleft palate patients were treated by closure of the soft palate according to Sommerlad at about 6 months of age. At the age of 11, their speech was evaluated through automatic speech recognition. Word recognition rate (WR) was used as the outcome parameter of automatic speech recognition. To validate automatic speech results, an institute for speech therapy evaluated the speech samples for perceptual intelligibility. The results of this study group were compared to an age-matched control group. A total of 61 children were evaluated in this study, 29 in the study group and 32 in the control group. Study group patients had a lower word recognition rate (mean 43.03, SD 12.31) compared to the control group (mean 49.98, SD 12.54, p = 0.033). The magnitude of the difference was considered small (95% CI of the difference 0.6-13.3). The study group patients received significantly lower scores in the perceptual evaluation (mean 1.82, SD 0.58) compared to the control group mean (mean 1.51, SD 0.48, p = 0.028). Again, the magnitude of the difference was small (95% CI of the difference 0.03-0.57). Within the limitations of the study it seems that microsurgical soft palate repair according to Sommerlad at the age of 6 months might be a relevant alternative to other well established surgical techniques.

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.

Oral Rehabilitation of Bilateral Cleft Lip and Palate Patient with Simultaneous LeFort I Osteotomy and Zygomatic Implants: A Case Report

The aim of this study is to evaluate Le Fort I Osteotomy and zygomatic implantation without any graft placement for management of a cleft lip and palate patient. This case report describes oral rehabilitation of a 33-year-old patient with bilateral cleft lip-palate and oronasal fistula and atrophic pre-maxilla. As treatment, the patient received simultaneous Le Fort I osteotomy, palatoplasty and two zygomatic implant insertions. The prosthetic superstructure included zygomatic implant-supported removable hybrid prosthesis on bar locator and metal-ceramic fixed bridges in the posterior region. As conclusion, this protocol can be promising for management of patients with cleft lip-palate and malocclusion.

Relapse-related factors of Le Fort I osteotomy in cleft lip and palate patients: A systematic review and meta-analysis

A systematic review search was based on the PICOS approach, as follows: population: cleft lip and palate patients; intervention: Le Fort I osteotomy; comparator: different surgical protocols; outcome: stability, recurrence or surgical complications; study designs: only case reports were excluded from the review. No restrictions were placed on language or year of publication. Risk of bias was analyzed, heterogeneity was assessed, and subgroup analysis was performed using a level of significance of 1% (p = 0.01). The search identified 248 citations, from which 29 studies were selected and a total of 797 patients enrolled. The level of agreement between the authors was considered excellent (k = 0.810 for study selection and k = 0.941 for study eligibility). Our results reported a mean maxillary advancement of 5.69 mm, a mean vertical downward/upward of 2.85/-2.02 mm and a mean clockwise rotation of 4.15°. Greater surgical relapse rates were reported for vertical downward movement (-1.13 mm, 39.6%), followed by clockwise rotation (-1.41°, 33.9%), sagittal (-0.99 mm, 17.4%) and vertical upward (0.11 mm, 5.4%) movements. No relevance was found regarding the type of cleft, the type of Le Fort I osteotomy, concomitant bone grafting, surgical overcorrection, postoperative rigid or elastic intermaxillary fixation, or retention splint. Study limitations were heterogeneity and the low number of high-quality studies. In spite of reported high relapse rates, Le Fort I osteotomy for maxillary reposition is the first-choice procedure for selected cleft lip and palate patients in whom extensive maxillary movements are not required, because of its safety and its three-dimensional movement versatility in one-step surgery. Otherwise, distraction osteogenesis should be considered as the gold standard treatment.

Precision Pharyngeal Flap: An Individualized, Patient-Specific Surgery for the Treatment of Velopharyngeal Insufficiency

BACKGROUND

The pharyngeal flap is one of the most common secondary surgeries for the correction of velopharyngeal insufficiency (VPI) for patients with cleft palate and/or cleft lip and palate. This study aimed to demonstrate the effectiveness of the precision pharyngeal flap surgery performed by the senior author.

MATERIALS AND METHODS

Children with VPI, who underwent precision pharyngeal flap, were retrospectively examined. All surgical procedures were performed by the senior author. The flap size was individually configured based on the patients' preoperative nasopharyngoscopic analysis and speech function evaluation. Pre- and post-operative velopharyngeal functions were assessed using perceptual speech evaluation and nasometric analysis; factors affecting surgical outcomes were determined.

RESULTS

Of 138 patients, 112 (women: 53, men: 59) were included in analyses, according to the inclusion and exclusion criteria. The median follow-up period was 21 months (range: 9-120). Postoperative perceptual speech evaluation revealed improved velopharyngeal function in 108 (96.4%). There were no reports of postoperative hyponasality (preoperative, 1.8% versus postoperative, 0%; P = 0.053). Other parameters of perceptual speech evaluation (hypernasality, nasal emission, articulation error, and intelligibility) showed significant improvement postoperatively (P < 0.01). Postoperative nasalance scores revealed sufficient postoperative resonance rating in 96% of patients. No patients experienced postoperative complications (bleeding, airway obstruction, and surgical wound dehiscence).

CONCLUSIONS

Individually configured pharyngeal flaps designed based on preoperative nasopharyngoscopic examination coupled with precise surgical techniques led to the high surgery success rate for VPI treatment.

Le Fort I Osteotomy in Cleft Patients: Maxillary Advancement and Articulation

BACKGROUND

Maxillary advancement may affect speech in cleft patients.

AIMS

To examine whether the amount of maxillary advancement and preoperativecephalometric skeletal and dentoalveolar relationships are associated with articulation errors of the Finnish alveolar consonants /s/, /l/, and /r/ in cleft patients.

MATERIALS AND METHODS

Fifty-seven nonsyndromic cleft patients who underwent Le Fort I or bimaxillary osteotomies were evaluated retrospectively. Pre- and post-operative lateral cephalometric radiographs and standardized speech video recordings were analyzed. The Aspin-Welch unequal variance t test, Student t test sign test, intraclass correlation and Kappa statistics were used in the statistical analyses.

RESULTS

The mean advancement of the maxilla (point A) was 4.65 mm horizontally (range -2.80 to 11.30) and -3.82 mm vertically (range -14.20 to 3.90). The overall articulation (especially the sounds /s/ and /l/) improved significantly postoperatively, but the amount of maxillary advancement did not affect the articulation. The preoperative mean percentages of /s/, /l/, and /r/ errors were 32%, 33%, 46% and the postoperative percentages 23%, 19%, 40%, respectively. Preoperative articulation errors of /s/ were related to palatal inclination of the upper incisors.

CONCLUSIONS

Orthognathic surgery may improve articulation errors. The amount of maxillary advancement is not related to the improvement.