Les séquelles maxillaires dans les fentes labioalvéolopalatovélaires. Place de la distraction ostéogénique

[Improving the accuracy of the preoperative planning of mandibular osteogenic distraction by an external custom-made device]

PURPOSE

The aim of this study was to analyze the predictability of virtual surgical planning of mandibular reconstruction by osteogenic distraction (OD) with a custom-made osteogenic distraction device (DEOS) after ballistic trauma and to make recommendations to mitigate potential sources of discrepancy.

METHODS

This retrospective study involved 12 patients who were victims of facial mandibular ballistic trauma and were reconstructed with osteogenic distraction with a DEOS device. Postoperative images were compared to the planned situation by means of several measures made in two plans : distraction plane and frontal plane.

RESULTS

The mean bone loss was 54.2mm. The anteroposterior difference was systematically inferior or equal postoperatively (10.8mm). The interrami angle difference in the frontal plane was positive, with an average of 4.8°. There was a significant negative correlation in univariate analysis between the antero-posterior difference measurement and the difference of the interrami angle in distraction.

CONCLUSION

A significant difference between the planning and postoperative results was shown, explained by the device being too adjustable leading to the loosening of the locking screws of the device. A static analysis showed that there are significant rotational forces at the carriages, which can lead to the loosening of the locking elements. It is then proposed that the device be optimized by customization of some elements.

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

PURPOSE

The Le Fort I osteotomy (LFI) procedure is commonly used to restore morpho-functional balance. The goal of maxillofacial surgeons with this procedure is to achieve occlusal stability. To identify factors associated with relapse after maxillary advancement in cleft lip and palate patients, the one-year post-operative stability of Le Fort I osteotomy was evaluated.

METHODS

Horizontal and vertical relapse were analysed on lateral cephalograms by retrospectively using tracing paper in an orthonormal landmark in 54 patients undergoing unilateral cleft lip and palate surgery who were monitored at Nantes University Hospital. The lateral cephalograms were performed pre-operatively, immediately post-operatively, and after one year. Several variables were studied such as population data, intra-operative and post-operative surgical treatment, and surgical movement.

RESULTS

At point A, the subspinale point, the mean advancement during surgery was 4.2 mm, with a relapse of 0.8 mm (20.1%). The mean downward movement was 2.0 mm in 26 patients who had a clockwise rotation of the maxilla, with a relapse of 0.6 mm (28.4%). The mean upward movement was 2.3 mm in 27 patients who had a counterclockwise rotation, with a deterioration of 0.2 mm (7%). A 7-millimetre surgical advancement corresponded to the threshold value beyond which relapse appeared to be significantly greater but still less than two millimetres in 75% of cases.

CONCLUSION

The degree of advancement appears to be the only variable correlated with the amplitude of the relapse.

[Maxillary advancement osteotomy with sequelae cleft lip and palate: Dilemma between occlusion and aesthetic profile]

INTRODUCTION

Maxillary hypoplasia is a common sequela of cleft lip and palate. Its surgical treatment consists in a maxillary advancement by distraction or by conventional orthognathic surgery but morphological results are unpredictable. Our goal in this study was to see if the esthetical results (on the lip and the nose) of maxillary advancement were correlated to the preservation of lateral incisor space of the cleft side.

PATIENTS AND METHOD

This retrospective study included 38 patients operated between 2002 and 2013. Unilateral clefts were studied independently from bilateral clefts. Profile aesthetics was evaluated independently and subjectively by two surgeons and scored on an 8-point scale. The result was classified as "good" if the score was superior or equal to 6. The score was correlated to the following parameters: amount of maxillary advancement, upper incisor axis, preservation of the missing lateral incisor space.

RESULTS

In the "good result" group, the space of the lateral incisor was less often preserved. The nasolabial angle was more open and the upper central incisor axis more vertical. These results were more pronounced in bilateral clefts, but also found in unilateral clefts.

DISCUSSION

Under reservation of the subjective evaluation and of the small number of patients, it seemed that lateral incisor space closure improved the profile of patients treated by maxillary advancement for cleft lip and palate sequelae.

[Orthognathic surgery for patients with cleft lip and palate]

Patients with cleft lip and palate frequently develop dento-facial deformity requiring orthognatic surgery. The origin of this deformity is therapeutic and surgeons are currently trying to prevent this iatrogenicity. The maxillary dento-facial deformity in these patients is a retrognathia with infragnathia, associated with endognathia, obliquity of the occlusal plane, with deviation of the superior incisive midline in case of unilateral clefts. The difficulties in the treatment of these skeletal deformities are due to the palatal, labial, and pterygomaxillary scar tissue. Orthognathic surgery is most of the time bimaxillary with a 3-dimensional movement of the jaws including maxillary advancement. The aims of surgery are occlusal, esthetic, and functional improvement. The first step is gingivoperiosteoplasty (ideally performed during childhood), orthodontic treatment including, if necessary, transversal maxillary distraction to obtain enough space to replace the lateral incisor; extraction of premolars should be avoided if possible. Planning and performing the treatment are difficult for the orthodontist and for the surgeon. Maxillary advancement by distraction may be an interesting alternative to prevent partial relapse. Obtaining normal oro-facial functions are required for a stable result. These should be monitored after the primary treatment by the whole staff, surgeons, speech therapist, and orthodontists. Performing Le Fort 1 osteotomy is more difficult than in other patients because of scar fibrosis than needs to be released.

Therapeutic thoughts on the treatment of sequellae of labial-alveolar-palatal clefts in adult patients - Part 1

With a worldwide incidence of 1/750 live births, facial clefts rank as the second most frequent congenital malformation. The term "sequelae" is used here to designate the conditions, which follow and are the result of labial-alveolar-palatal clefts. Most sequelae stem in fact from primary treatment and not from the initial malformation. However, there is no consensus regarding a management protocol. Among the 201 European centers treating this type of malformation, 194 different protocols are used for unilateral facial clefts alone! Unfortunately, primary surgery can trigger a wide range of harmful consequences. It is for this reason that secondary surgery is called for, generally after the adolescent growth spurt. The aim is to correct the damage done by primary surgery, which can affect the nose, lips, teeth and jaws and impact functions such as speech, breathing and swallowing, as well as morphological and psychological development. Nonetheless, the children concerned are sometimes lost to treatment only to re-emerge in adulthood, aware of the presence of the resultant defects and looking for facial esthetic improvement. The sequelae of labial-alveolar-palatal clefts can take on very different clinical forms according to whether the cleft has been treated or not and the type and timing of the procedures performed. The surgeon's experience will be paramount in the management of such cases, which draws heavily upon dento-maxillo-facial orthopedics. In this context, we intend, in this paper, to propose modalities for the management of labial-alveolar-palatal clefts supported by information currently available in the literature. Management of labial-alveolar-palatal clefts requires an interdisciplinary rather than a multi- or pluridisciplinary, approach. The practitioner coordinating the management must, like an orchestra conductor, ensure both the rhythm and the tempo of the treatment. The rhythm will determine the choice of chronological protocol and the tempo will govern the timing and importance given to each of the specialists involved. Practices vary from country to country but the orthodontist may be called on to assume this responsibility.

[Maxillary distraction complications in cleft patients]

INTRODUCTION

Cleft lip and palate (CLP) patients often present with a class III malocclusion in connection with a three dimensional maxillary hypoplasia. Twenty-five to 60% of these patients require a maxillary advancement. Two solutions are possible: orthognathic surgery and maxillary distraction. The purpose of this study was to evaluate the complications of the maxillary distraction in CLP patients.

MATERIALS AND METHODS

Data was collected from the records of patients treated at our Surgery Unit between 2000 and 2007. Among the eight patients (four male and four female), five presented a bilateral CLP, two a unilateral CLP and one a unilateral cleft lip associated to a soft palate cleft. The average age at surgery was 17 years old. All had a Le Fort I osteotomy with a pterygomaxillary disjunction. The first two patients had external distractors and the six following internal ones. After a seven-day latency, activation was led to the rate of 1mm per day twice. The period of consolidation was four months on average. The maxillary advancement varied between 7 and 19 mm with an average of 12.6mm. The average follow-up was four years.

RESULTS

We encountered difficulties and/or complications in seven patients: one intraoperatively haemorrhage, one avulsion of a tooth fixed at the pterygoid process during the osteotomy, three device failures, two cases of significant pains during activation, one dissociation of the dental anchorage of an external system, two labial ulcerations and one maxillary sinusitis by migration of the 18.

DISCUSSION

Difficulties of maxillary distraction in CLP patients are very frequent. The majority is related to the distractors and did not interfere with the final result. But this frequency must be taken into account in the indication and in the choice of the material. Two types of complications can occur during distraction: those related to the osteotomy and those related to the material. The complications related to the osteotomy are in connection with the cicatricial ground of the CLP. They are not specific of the distraction. We especially managed complications related to the material. The social benefit of the internal distractors is undeniable, but the design of certain models must be reexamined to improve their tolerance.