Associated relaps factors in Le Fort I osteotomy. A retrospective study of 54 cases

Complications of orthognathic surgery in patients with cleft lip and palate: A systematic review

OBJECTIVE

Determine the main complications of orthognathic surgery in patients with cleft lip and palate.

METHODS

PubMed, LILACS, Cochrane, Embase, Scopus, and Google Scholar were systematically reviewed. Studies addressing the complications of orthognathic surgery in patients with cleft lip and palate were included. For the search, the strategy was used with the descriptors extracted from MeSH "Cleft Palate", "Orthognathic Surgery" and "Complications". The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the included studies. Patients of any sex, age, and ethnicity with cleft lip and palate submitted to orthognathic surgery were included in this systematic review. The study followed the PRISMA 2020 standards and was registered in PROSPERO with protocol CRD42020195927.

RESULTS

In the initial search, 1090 articles were found and after applying the inclusion and exclusion criteria, eleven studies were selected. The sample consisted of 629 patients who underwent Orthognathic Surgery, with an average age of 21.52 years. The majority of patients (390) presented unilateral transforamen proposals. In total, 150 complications were identified in the included studies, the most frequent being relapse of movement with 77 cases (51.3 %). Other reported, but less frequent, complications were gingival recession with root exposure, premaxillary mobility, intraoperative hemorrhage, fistulas and infection and velopharyngeal impairment. Most included studies did not have a control group, making meta-analysis unfeasible. Seven of the included studies presented a low risk of bias according to the NOS.

CONCLUSIONS

Orthognathic surgery in cleft patients is a safe procedure, however it presents particularities and more complications when compared to a non-cleft patient. In this study, the most common complication found was the relapse, and the surgeon must be aware of this complication and others, and try to minimize its negative effects on the patient. We strongly recommend further investigations with detailed methodologies, control groups, well-described criteria for reported complications, and comprehensive sample characteristics to provide higher-quality evidence.

A 3D dynamic finite element analysis of biomechanical behaviour of maxilla and fixative appliances following advancement Le Fort I surgery applied in different lengths

OBJECTIVES

Dynamic analysis of chewing impact on the stability of rigid fixation techniques following Le Fort I osteotomy has not been investigated in the previous literature. The aim of the present study was to evaluate segmental displacement and von Mises (VM) stress values on the fixation devices following different amounts of Le Fort I advancements under dynamic loading conditions.

MATERIALS AND METHODS

The 3D finite element models simulating 3, 5 and 8 mm advancement of maxilla at the Le Fort I level were generated using CBCT scan data. The models included two anterior L plates and two posterior I plates fixations bilaterally. Dynamic finite element analysis was performed to evaluate their biomechanical behavior against chewing cornflakes bio. Von Mises stresses and displacement values on three points were calculated.

RESULTS

Calculations were made in a time of 38, 40 and 40.5 ms for 3, 5 and 8 mm advancement models, respectively. As the advancement increased, stress values on the plates and displacement values in the D1 (intersection of the apex of the canine tooth with the osteotomy line), D2 (the most prominent point of zygomatic buttress on the osteotomy line), and D3 (intersection of the midline of the second molar tooth with the osteotomy line) points increased. The lowest stress and displacement values were found in the 3 mm advancement model. As advancement increased, the highest values were found in the I plates. The stress levels on the plates and screws remained within safe limits.

CONCLUSIONS

The von Mises stresses and displacement values tend to increase in according with the amount of advancement. More stress is transferred to posterior I plates and screws under dynamic forces.

Factors affecting the relapse of maxilla and soft tissues of nose, upper lip and velopharyngeal structures after maxillary advancement in cleft patients

The objectives of this study were to find the factors affecting the relapses after maxillary advancement in cleft patients. This retrospective study included 25 cleft patients. The serial lateral cephalograms were used for the evaluation of the maxilla and the soft tissue relapses in 1-year post-operative period. The skeletal relapse rate correlated with the amount of skeletal movement only in horizontal direction (r = 0.483, p = 0.015). The patients with significant skeletal relapse did not have different amount of soft tissue relapses when compared to the patients without significant skeletal relapse, except for the A' point. Relapses of the soft tissue parameters of the upper lip and nose were correlated with the upper incisor tip position horizontally and vertically. When comparing the patients who underwent maxillary distraction (DO) with the patients who underwent conventional orthognathic surgery (CO), the DO group had greater NLA relapse and increase of pharyngeal depth than the CO group.

Long-term vertical stability of horseshoe osteotomy for the correction of large vertical excess of the maxilla, a retrospective assessment in 15 patients

INTRODUCTION

Vertical stability after a Le Fort I (LF1) osteotomy with substantial upward movement can be compromised by the position and the volume of the inferior turbinate. A horseshoe (HS) osteotomy represents then an alternative as it preserves the hard palate and the intranasal volume. The aim of this study was to assess the vertical stability of the maxilla after HS osteotomy.

MATERIALS AND METHODS

Patients who underwent a HS osteotomy for the correction of long-face syndrome were retrospectively analyzed. The vertical stability was assessed on lateral cephalograms performed preoperatively (T0), immediately postoperatively (T1), and at the last follow-up (T2) by studying points C (the distal cusp of the first maxillary molar), point P (the prosthion, the lowest edge of the maxillary alveolus of the central incisor), and point I (the upper central incisor edge) in a coordinate system. Postoperative complications and aesthetics of the smile were also investigated.

RESULTS

Fifteen patients were included (7 females, 8 males, mean age 25.5 ± 9.8 yeras). The mean impaction ranged from 5 mm on point P to 6.1 mm on point C, with a maximal movement of 9.5 mm. A non-significant relapse of 0.8 ± 1.7, 0.6 ± 0.8, and 0.5 ± 1.8 mm was observed after a mean 20.7 months on point C, P, and I respectively. Smile parameters were significantly improved by the procedure, mainly regarding the correction of the gum smile.

CONCLUSION

HS osteotomy represents a good alternative to total LF1 osteotomy for substantial maxillary upward movement in long face syndrome deformities.

Stability of Le Fort 1 osteotomy in patients with bilateral cleft lip and palate: A retrospective study of 71 patients

The aim of this study was to evaluate the sagittal and vertical relapses after Le Fort 1 osteotomy in bilateral cleft lip and palate (BCLP) patients. Lateral cephalograms before surgery, immediately after the procedure, at one year, and at least two years (when available) after surgery were superimposed. The positions of five landmarks were studied in a coordinate system. Uni- and multivariate analyses investigated the effect of various factors on the relapse. Of the 71 patients included for a BCLP, 54 presented complete data at one year, and 30 patients were included for the long follow-up study (mean of 55 months). The mean maxillary advancement was 6.2 mm on the sub-spinal point (A). Sagittal relapse occurred at one year (mean of 1.1 mm on point A, 0.7 mm on point prosthion (P); p < 0.0001) and progressed by 0.5 mm and 1.0 mm, respectively, on the same points at the last follow-up. The mean vertical relapse was 0.5 mm on point A (p = 0.044), 0.6 mm on point P (p = 0.16) and 0.5 mm on incisor (I) (p = 0.056). The vertical relapse was correlated to the degree of vertical movement. Three factors were associated to the recurrence including a prior pharyngeal flap, an associated mandibular osteotomy and smoking habits.

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.

Comparing Surgical Advancement Outcomes of Retruded Maxilla in a Group of Egyptian Cleft Lip and Palate Subjects

BACKGROUND: Cleft lip and palate (CLP) is one of the most common congenital deformities involving intervention in several sub-specialties. AIM: The present study was conducted to investigate the amount of maxillary advancement obtained by three different methods. METHODS: A retrospective comparative study was conducted on 24 CLP patients who were treated with three surgical maxillary advancement techniques: Group A was treated with Le Fort I (LFI) orthognathic surgery with bone grafting and rigid fixation (LFI). Group B was treated with intraoral maxillary bone distraction (MIDO). Group C was treated with orthodontic traction by facemask (orthodontic facemasks [OFM]) plus corticotomy. All pre-operative data were collected, which included intraoral and extraoral clinical photos and dental casts. Pre-operative radiographic assessment was compared with post-operative values using digital panorama, multi-slice computed tomography and lateral cephalometric X-ray measuring Sella-nasion-A point; point A-nasion-point B points, with a follow-up period of 6 months. RESULTS: All approaches showed statistically significant success in maxillary advancement with p < 0.01. LFI has produced the highest advancement obtained with regard to the pre-operative advancement required (8.6 ± 1.4) and post-operative advancement achieved (7.8 ± 0.8). MIDO technique is an alternative method to LFI, but it gives less achieved post-operative maxillary advancement (6.25 ± 0.8) and is indicated for moderate cases. OFM gave the least advancement results; however, it has been the most convenient less-invasive method and was more suitable for unsevere cases. CONCLUSIONS: The three approaches produced satisfactory results in rehabilitating deficient maxilla in cleft patients, although each technique has limitations and indications. Future research is recommended to assess the technique’s long-term stability.

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.

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.

Long-term dentoskeletal side effects of mandibular advancement therapy in patients with obstructive sleep apnea: data from the Pays de la Loire sleep cohort

OBJECTIVES

Mandibular advancement devices (MADs) are the main therapeutic alternative to continuous positive airway pressure for obstructive sleep apnea. Our aim was to evaluate the long-term dentoskeletal side effects of MADs and to identify the predictive factors for these side effects.

MATERIALS AND METHODS

Patients from the Pays de la Loire cohort treated with a custom-made MAD for at least 1 year were included in this retrospective study. Digital cephalometric analyses were performed at baseline and at follow-up.

RESULTS

We included a total of 117 patients, treated with a MAD for a median [interquartile range] of 4.6 [2.6-6.6] years. The main significant side effects were a decrease in overbite (- 0.5 ± 1 mm), overjet (- 0.7 ± 1 mm) and maxillary incisor inclination (- 2.5 ± 2.8°) and an increase in mandibular incisor inclination (+ 2.2 ± 2.7°). Subjective side effects were not linked to the observed dentoskeletal changes. Current smokers were at higher risk of overjet modifications. A pre-existing anterior open-bite was associated with a greater decrease in overbite. Treatment duration was associated with a more pronounced mandibular incisor proclination. Propulsion was negatively associated with maxillary incisor retroclination.

CONCLUSIONS

Long-term dentoskeletal side effects were mainly moderate dental side effects. Some predictive factors were shown to be associated with more pronounced changes. Subjective side effects did not appear to be reliable tools to detect dentoskeletal side effects.

CLINICAL RELEVANCE

Regular follow-up with clinical examination and regular radiographs is mandatory. The predictive factors could be of interest for a better selection of patients and to individualize follow-up.

Dental discoloration following Le Fort 1 osteotomy, a systematic review

INTRODUCTION

This study was conducted to review current knowledge concerning factor and how to proceed with dental discoloration after Le Fort 1 osteotomy (LF1O).

MATERIAL & METHODS

A systematic search of the literature was performed in PubMed/Medline and Cochrane library until December 1, 2020 using the following key words: "dental discoloration and osteotomy", "dental discoloration and Le Fort", "dental discoloration and orthognathic", "dental discoloration and surgery", "tooth discoloration and osteotomy", "tooth discoloration and Le Fort", "tooth discoloration and orthognathic", "tooth discoloration and surgery".

RESULTS

705 studies were located by initial screening; 232 were duplicate, 468 did not meet the eligibility criteria, leaving 5 studies. The post-operative follow-up period of the included studies ranged from 6 months to 2 years.

CONCLUSION

The present revue found dental discoloration can occur after LF1O in 3.56% of the cases. The follow-up before treatment should be around one years. If the discoloration persisted and pulpal sensibility test is negative, the tooth should be treated. If the pulpal sensibility test is positive, follow-up should be carry on.

Comparison of the postoperative stability after repositioning of the maxilla with Le Fort I osteotomy using four- versus two-plate fixation

INTRODUCTION

Le Fort I osteotomy procedures requires miniplates fixation in both the aperture piriformis and zygomaticomaxillary buttress.

PURPOSE

The purpose of this study was to compare the postoperative stability of the Le Fort I osteotomy using four-plate versus two-plate fixation.

MATERIAL AND METHODS

This study involved 39 Class III patients who underwent one-piece Le Fort I osteotomy with bilateral sagittal split ramus osteotomy. In group I, four miniplates were placed at the apertura piriformis and the zygomaticomaxillary buttress, whereas, in group II, fixation was achieved with two miniplates bilaterally placed at the piriform apertura with no posterior fixation. Linear and angular measurements included maxillary sagittal and vertical positions. The primary outcome of this study was stability, as recorded by lateral cephalometric measurements of the preoperative, immediately postoperative and late postoperative periods.

RESULTS

Significant immediate postsurgical changes were found in both groups. In the late postoperative cephalometric measurements, all skeletal parameters showed significant stability in groups I and II. In terms of vertical and sagittal relapse, there was no significant difference between the four-plate and two-plate groups (p1=0.686 and p2=0.513, respectively).

CONCLUSION

A good postoperative stability can be obtained with a two-plate fixation after one-piece Le Fort I osteotomy.

Treatment of an adult skeletal class II patient with a modified surgery-first approach

This case report presents an 18-year-old female patient who had skeletal Class II relationship due to a mandibular retrognathia, decreased lower anterior facial height and proclined incisors with increased overjet and overbite. Her main complaints were protruding upper incisors and decreased distance between the tip of the nose and chin. A modified surgery-first approach was performed with two months of presurgical orthodontics to achieve 8mm mandibular advancement. The total treatment time was 11 months. Improved aesthetics, a balanced facial profile and a stable and functional occlusion were obtained in less treatment time due to accelerated tooth movement.