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Wagner CS, Barnett SL, Romeo D, Morales CZ, Salinero LK, Barrero CE, Pontell ME, McKenna RA, Folsom N, Taylor JA, Swanson JW. Sociodemographic Factors Predict Long-Term Attrition from Multidisciplinary Cleft Clinic. Cleft Palate Craniofac J 2025; 62:1003-1010. [PMID: 38425129 DOI: 10.1177/10556656241234804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
ObjectiveIdentify and describe factors associated with retention and attrition of patients during longitudinal follow-up at multidisciplinary cleft clinic.DesignRetrospective cohort study.SettingSingle, tertiary care center.Patients, ParticipantsPatients born between 1995 and 2007 with a diagnosis of cleft palate with or without cleft lip attending multidisciplinary cleft clinic.InterventionsNone tested, observational study.Main Outcome Measure(s)Age at last clinical appointment with a multidisciplinary cleft team provider. Attrition was defined as absence of an outpatient appointment following 15 years of age.ResultsSix hundred seventy-eight patients were included. The average age at last appointment across the entire cohort was 13.1 years (IQR 6.6-17.2). Patients who were Black (HR 1.60, 95% CI 1.10-2.32, p = 0.014) and other races (HR 1.90, 95% CI 1.22-2.98, p = 0.004) were more likely to be lost to follow-up compared to white patients. Publicly insured patients were more likely to experience attrition than those who were privately insured (HR 1.30, 95% CI 1.03-1.65, p = 0.030). Estimated income was not significantly associated with length of follow-up (p = 0.259). Those whose residence was in the fourth quartile of driving distance from our center experienced loss to follow-up significantly more than those who lived the closest (HR 2.04, 95% CI 1.50-2.78, p < 0.001).ConclusionsThere is a high degree of follow-up attrition among patients with cleft lip and palate. Race, insurance status, and driving distance to our center were associated with attrition in a large, retrospective cohort of patients who have reached the age of cleft clinic graduation.
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Affiliation(s)
- Connor S Wagner
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Sarah L Barnett
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Dominic Romeo
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Carrie Z Morales
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Lauren K Salinero
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Carlos E Barrero
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Matthew E Pontell
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Rachel A McKenna
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Nancy Folsom
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Jesse A Taylor
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Jordan W Swanson
- Divsion of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Pennsylvania, PA
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Hattori Y, Pai BCJ, Saito T, Chou PY, Lu TC, Chang CS, Chen YR, Lo LJ. Outcome of Patients with Complete Cleft Lip and Alveolus: 20-Year Follow-Up. Plast Reconstr Surg 2025; 155:746e-757e. [PMID: 38991117 DOI: 10.1097/prs.0000000000011622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
BACKGROUND Patients with cleft have functional and aesthetic impairment, and typically require several interventions as they grow. Long-term evaluation following a treatment protocol is essential, but such reports on patients with complete cleft lip and alveolus (CLA) are sparse in the literature. METHODS A retrospective review was conducted of all patients with complete CLA born between January of 1995 and August of 2002 and treated at our center. Patients who received continuous multidisciplinary team care until 20 years of age were included, and patients with cleft palate and syndromic abnormalities were excluded. Facial bone growth was evaluated using cephalometric analysis. RESULTS Eighty-seven and 11 patients with unilateral and bilateral CLA, respectively, were included. All patients underwent one-stage cheiloplasty with primary rhinoplasty. Revision lip/nose surgery was performed in 21.8% and 27.3% during growing age, and in 51.7% and 72.7% after skeletal maturity, respectively. Orthognathic surgery was performed in 20.7% and 27.3%, respectively. Compared with unilateral CLA patients, bilateral CLA patients had more operations (3.0 versus 3.7; P = 0.03) and a higher chance of undergoing alveolar bone grafting twice (1.1% versus 36.4%; P < 0.01). Patients with complete CLA had less hypoplastic maxilla, and underwent fewer operations than those with complete cleft lip and palate. CONCLUSIONS Complete CLA is a less severe form of cleft, but the patients still require multiple interventions. This review revealed certain suboptimal results, and modifications have been made in the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.
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Affiliation(s)
- Yoshitsugu Hattori
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Betty Chien-Jung Pai
- Craniofacial Orthodontics
- Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Takafumi Saito
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Pang-Yun Chou
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
- Graduate Institute of Dental and Craniofacial Science, Chang Gung University
| | - Ting-Chen Lu
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Chun-Shin Chang
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Yu-Ray Chen
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Lun-Jou Lo
- From the Departments of Plastic and Reconstructive Surgery
- Craniofacial Research Center, Chang Gung Memorial Hospital
- Graduate Institute of Dental and Craniofacial Science, Chang Gung University
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Badiee RK, Ettinger RE, Kapadia H, Sheller B, Susarla SM. Does Surgical Sequencing Influence the Accuracy of Maxillary Positioning in Bimaxillary Cleft Orthognathic Surgery? Plast Reconstr Surg 2025; 155:758e-766e. [PMID: 39046832 DOI: 10.1097/prs.0000000000011634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND The purpose of this study was to evaluate whether the sequence of osteotomies influences the accuracy of maxillary positioning in patients with cleft palate with or without cleft lip undergoing bimaxillary orthognathic surgery (OGS). METHODS This was a prospective study of patients with Veau II through IV clefts who underwent bimaxillary OGS at a tertiary-care children's hospital over a 3-year period. The primary predictor variable was the sequence of osteotomies (maxilla first versus mandible first). The primary outcome of interest was the concordance between the planned and achieved maxillary position, as assessed using linear and angular measurements. Secondary study predictors were demographic and surgical variables. Differences between groups were compared using nonparametric independent samples tests for continuous measures (data reported as median and interquartile range) and chi-square tests for categorical measures. For all analyses, P ≤ 0.05 was considered significant. RESULTS Participants who underwent maxilla-first ( n = 15) and mandible-first ( n = 16) operations were comparable with regard to age, sex, cleft type, skeletal classification, segmental maxillary osteotomy, and magnitude of maxillary movement ( P ≥ 0.09). The planned sagittal and vertical positions of the maxilla were similarly accurate between the 2 groups ( P ≥ 0.68). Angular accuracy was also comparable ( P ≥ 0.56) between the study groups. CONCLUSION In patients with cleft palate with or without cleft lip undergoing bimaxillary OGS, use of mandible-first sequencing, when compared with maxilla-first sequencing, does not affect the accuracy of maxillary positioning in the immediate postoperative period in well-selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Ryan K Badiee
- From the Craniofacial Center, Seattle Children's Hospital
- Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine
| | - Russell E Ettinger
- From the Craniofacial Center, Seattle Children's Hospital
- Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine
| | - Hitesh Kapadia
- From the Craniofacial Center, Seattle Children's Hospital
| | | | - Srinivas M Susarla
- From the Craniofacial Center, Seattle Children's Hospital
- Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine
- Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry
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Maia SÉDS, Seixas DR, Fukushiro AP, Trindade IEK, Silva ASCD, Araújo BMAM, Yamashita RP. Effect of maxillary advancement on velopharyngeal function in cleft lip and palate: 20 years of experience. J Craniomaxillofac Surg 2025; 53:30-36. [PMID: 39490347 DOI: 10.1016/j.jcms.2024.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/06/2024] [Accepted: 10/13/2024] [Indexed: 11/05/2024] Open
Abstract
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.
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Affiliation(s)
- Sérgio Éberson da Silva Maia
- Postgraduate Program in Rehabilitation Sciences, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Sao Paulo, Brazil
| | - Déborah Rocha Seixas
- Postgraduate Program in Rehabilitation Sciences, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Sao Paulo, Brazil
| | - Ana Paula Fukushiro
- Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Sao Paulo, Brazil; Department of Speech-Language Pathology and Audiology, Bauru School of Dentistry, University of Sao Paulo, Bauru, Sao Paulo, Brazil
| | - Inge Elly Kiemle Trindade
- Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Sao Paulo, Brazil; Department of Biological Sciences, Bauru School of Dentistry, University of Sao Paulo, Bauru, Sao Paulo, Brazil
| | | | | | - Renata Paciello Yamashita
- Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Sao Paulo, Brazil.
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Varidel A, Padwa BL, Britt MC, Flanagan S, Green MA. Patient-Specific Le Fort I Osteotomy Plates Are More Stable than Stock Plates in Patients with Cleft Lip and Palate. Plast Reconstr Surg 2025; 155:152e-159e. [PMID: 38546729 DOI: 10.1097/prs.0000000000011433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2024]
Abstract
BACKGROUND There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plate fixation. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate and determine stability differences between patient-specific and stock plates. METHODS Consecutive patients with cleft lip and palate who underwent isolated LFI by one surgeon (B.L.P.) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (nasion to A point) and horizontal planes (basion to A point) at 1 year after LFI using 3-dimensional cone beam computed tomography. Statistical analysis included independent samples t , Mann-Whitney U , Fisher exact, and chi-square tests. Values of P < 0.05 were significant. RESULTS The sample included 63 subjects; 23 in the patient-specific group (36.5%) and 40 in the stock group (63.5%). Groups were comparable by sex, race, age at surgery, cleft type, presence of pharyngeal flap, and magnitude of horizontal movement ( P > 0.136 for all). Subjects who underwent patient-specific plate fixation were less likely to have greater than or equal to 1-mm change at 1 year in the horizontal (4.3% versus 50.0%; P < 0.001) and vertical planes (4.3% versus 65.0%; P < 0.001) compared with stock plates. For patients who had greater than 10-mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific plates, 0.105 ± 0.317 mm; stock plates, 1.888 ± 1.125 mm; P = 0.003). CONCLUSION Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after 1 year than stock plates. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | | | | | | | - Mark A Green
- From the Department of Plastic and Oral Surgery
- Boston Children's Hospital
- Harvard Medical School
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Verzella AN, Alcon A, Schechter J, Shetye PR, Staffenberg DA, Flores RL. LeFort I Horizontal Osteotomy: Defining the Feasibility of the "High Osteotomy". Cleft Palate Craniofac J 2025; 62:63-68. [PMID: 37885216 DOI: 10.1177/10556656231202595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE To define "high osteotomy" and determine the feasibility of performing this procedure. DESIGN Single institution, retrospective review. SETTING Academic tertiary referral hospital. PATIENTS, PARTICIPANTS 34 skeletally mature, nonsyndromic patients with unilateral CLP who underwent Le Fort I osteotomy between 2013 and 2020. Patients with cone-beam computed tomography (CBCT) scans completed both pre- (T1) and post-operatively (T2) were included. Patients with bilateral clefts and rhinoplasty prior to post-operative imaging were excluded. INTERVENTIONS Single jaw one-piece Le Fort I advancement surgery. MAIN OUTCOME MEASURES Measurements of the superior ala and inferior turbinates were taken from the post-operative CBCT. RESULTS The sample included 26 males and 8 females, 12 right- and 22 left-sided clefts. The inferior turbinates are above the superior alar crease at a rate of 73.53% and 76.48% on the cleft and non-cleft sides, respectively. One (2.9%) osteotomy cut was above the level of the cleft superior alar crease, and no cuts were above the level of the non-cleft superior ala. On average, the superior ala was 2.63 mm below the inferior turbinates. The average vertical distances from the superior alar crease and the inferior turbinates to the base of the non-cleft side pyriform aperture were 12.17 mm (95% CI 4.00-20.34) and 14.80 mm (95% CI 4.61-24.98), respectively. To complete a "high osteotomy," with 95% confidence, the cut should be 20.36 mm from the base of the pyriform aperture. CONCLUSIONS A "high" osteotomy is not consistently possible due to the relationship between the superior alar crease and the inferior turbinate.
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Affiliation(s)
- Alexandra N Verzella
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Andre Alcon
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jill Schechter
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Pradip R Shetye
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - David A Staffenberg
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
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Stonehouse‐Smith D, Abd Rahman AN, Beale V, Bellardie H. Occlusal and Cephalometric Outcomes of Cleft Orthognathic Surgery: A Retrospective Cohort Study. Clin Exp Dent Res 2024; 10:e70019. [PMID: 39497347 PMCID: PMC11534636 DOI: 10.1002/cre2.70019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 09/11/2024] [Accepted: 09/21/2024] [Indexed: 11/08/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - Victoria Beale
- North West England, The Isle of Man and North Wales Cleft NetworkRoyal Manchester Children's HospitalManchesterUK
| | - Haydn Bellardie
- Faculty of DentistryUniversity of the Western CapeCape TownSouth Africa
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Schechter J, Alcon A, Verzella A, Shetye P, Flores R. Change in Lower Lip Position After Le Fort I Advancement in Patients with Bilateral vs. Unilateral Cleft Lip and Palate. Cleft Palate Craniofac J 2024; 61:1836-1844. [PMID: 38836361 DOI: 10.1177/10556656231184975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
To compare lower lip changes after Le Fort I advancement surgery in patients with a cleft. Single institution, retrospective review. Academic tertiary referral hospital. Skeletally mature patients with a cleft who underwent one-piece Le Fort I advancement surgery who had a lateral cephalogram or cone-beam computed tomography (CBCT) scan preoperatively and at least 6 months postoperatively. Patients who underwent concomitant mandibular surgery or genioplasty were excluded. 64 patients were included: 45 male and 19 female, 25 with BCLP and 39 with UCLP. The mean age at surgery was 18.4 years. Single jaw one-piece Le Fort I advancement surgery. Standard lateral cephalometric landmarks of the bony skeleton and soft tissue were compared before and after Le Fort I advancement. Pearson correlation coefficients (r) were calculated to measure the correlation between lower lip position and other soft and hard tissue changes. After comparable maxillary advancements [BCLP: 7.2 mm (95% CI: 6.2-8.3 mm), UCLP: 6.4 mm (95% CI: 5.7-7.0 mm)] the horizontal upper-to-lower lip discrepancy significantly improved in both groups. The lower lip became thinner and more posteriorly positioned. Changes in lower lip position correlated strongly with mandibular bony landmarks and moderately with upper lip position, but poorly with maxillary landmarks. Le Fort I advancement results in posterior displacement of the lower lip and better lip competence, thereby improving facial harmony. This lower lip change is not predictable by degree of maxillary advancement, and does not differ in patients with BCLP vs. UCLP.
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Affiliation(s)
- Jill Schechter
- Hansjorg Wyss Department of Plastic and Reconstructive Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Andre Alcon
- Hansjorg Wyss Department of Plastic and Reconstructive Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Alexandra Verzella
- Hansjorg Wyss Department of Plastic and Reconstructive Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Pradip Shetye
- Hansjorg Wyss Department of Plastic and Reconstructive Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Roberto Flores
- Hansjorg Wyss Department of Plastic and Reconstructive Surgery, NYU Langone Medical Center, New York, NY, USA
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Haj M, Ombashi S, Strabbing EM, Bouter AR, Kootstra TJM, van der Tas JT, Wolvius EB, van de Lande LS. Orthognathic surgery in cleft care: Challenges in monitoring outcomes. Curr Probl Surg 2024; 61:101581. [PMID: 39266127 DOI: 10.1016/j.cpsurg.2024.101581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/13/2024] [Accepted: 07/14/2024] [Indexed: 09/14/2024]
Affiliation(s)
- Mona Haj
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Saranda Ombashi
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Elske M Strabbing
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Anisha R Bouter
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Thomas J M Kootstra
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Justin T van der Tas
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Eppo B Wolvius
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Lara S van de Lande
- Department of Maxillofacial Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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May A, Richards C, Moore M. Measuring the Change in Soft Palate Length and Shape Following Maxillary Advancement: A Cohort Study in Patients with Orofacial Clefts. Cleft Palate Craniofac J 2024; 61:1526-1531. [PMID: 37170555 DOI: 10.1177/10556656231175860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew May
- Cleft and Craniofacial South Australia, The Women's and Children's Hospital, Adelaide, South Australia
| | - Christina Richards
- Cleft and Craniofacial South Australia, The Women's and Children's Hospital, Adelaide, South Australia
| | - Mark Moore
- Cleft and Craniofacial South Australia, The Women's and Children's Hospital, Adelaide, South Australia
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Lasky S, Moshal T, Jolibois M, Roohani I, Manasyan A, Husain F, Harris S, Nagengast ES, Urata MM, Magee WP, Hammoudeh JA. Orthognathic Surgery Rates in Furlow Double-Opposing Z-Plasty Versus Straight-Line Repair: A Review of Three Decades of Experience. Cleft Palate Craniofac J 2024:10556656241277395. [PMID: 39150018 DOI: 10.1177/10556656241277395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
OBJECTIVE The influence of different surgical techniques on maxillary growth remains unclear. This study investigates the long-term impact of Furlow double-opposing Z-plasty versus straight-line repair (SLR) techniques on midface growth and subsequent orthognathic surgery. DESIGN Retrospective cohort study. SETTING Tertiary children's hospital. PATIENTS/PARTICIPANTS This study evaluated patients who underwent primary palatoplasty with Furlow or SLR techniques from 1994-2023. Patients were >14 years old at their most recent follow-up. INTERVENTIONS No interventions were performed. MAIN OUTCOME MEASURE(S) Primary outcomes were orthognathic surgery and orthognathic surgery recommendation rates to correct midface hypoplasia (MFH). Cephalometrics at the time of orthognathic surgery recommendation were traced to validate MFH. RESULTS In total, 1857 patients underwent palatoplasty, of which 335 met inclusion criteria (49 SLR, 286 Furlow). Average age at last follow-up was 18.5±2.6 years. Patients who underwent Furlow versus SLR showed no significant difference in orthognathic surgery rates (p=0.428) or recommendation for orthognathic surgery rates (p=0.900). Patients recommended to undergo orthognathic surgery had more negative ANB angles (p<0.001) and smaller SNA angles (p<0.001) than patients not recommended for orthognathic surgery, demonstrating maxillary hypoplasia. Upon multivariate regression, patients with Veau III and IV clefts had an increased need for orthognathic surgery, p=0.047 and p=0.008, respectively. CONCLUSIONS Our findings suggest that higher cleft severity contributes to future orthognathic surgery. However, palatoplasty technique did not influence orthognathic surgery rates. Our results provide valuable data when surgeons are considering the impact of palatoplasty technique on sagittal growth restriction.
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Affiliation(s)
- Sasha Lasky
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tayla Moshal
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marah Jolibois
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Idean Roohani
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Artur Manasyan
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Fatemah Husain
- Department of Orthodontics, Kuwait University, Jabriya, KW, USA
| | - Samuel Harris
- Division of Dentistry, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Eric S Nagengast
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Mark M Urata
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - William P Magee
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jeffrey A Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
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12
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Ko J, Urata MM, Hammoudeh JA, Yamashita DD, Yen SLK. Reverse Engineering Orthognathic Surgery and Orthodontics in Individuals with Cleft Lip and/or Palate: A Case Report. Bioengineering (Basel) 2024; 11:771. [PMID: 39199729 PMCID: PMC11352120 DOI: 10.3390/bioengineering11080771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/27/2024] [Accepted: 07/28/2024] [Indexed: 09/01/2024] Open
Abstract
This case report presents a virtual treatment simulation of the orthodontic treatment and surgery-first orthognathic surgery employed to treat a patient with a repaired unilateral cleft lip and alveolus with Class III malocclusion and lower third facial asymmetry. The patient exhibited a negative overjet of 9 mm, a missing lower right second premolar, and a 5 mm gap between the upper right central and lateral incisors with midline discrepancy. The three-dimensional virtual planning began with virtual pre-surgical orthodontics, followed by the positioning of the facial bones and teeth in their ideal aesthetic and functional positions. The sequence of steps needed to achieve this outcome was then reverse-engineered and recorded using multiplatform Nemostudio software (Nemotec, Madrid, Spain), which facilitated both surgical and orthodontic planning. The treatment included a two-piece segmental maxillary osteotomy for dental space closure, a LeFort I maxillary advancement, and a mandibular setback with bilateral sagittal split osteotomy to correct the skeletal underbite and asymmetry. A novel approach was employed by pre-treating the patient for orthognathic surgeries at age 11, seven years prior to the surgery. This early phase of orthodontic treatment aligned the patient's teeth and established the dental arch form. The positions of the teeth were maintained with retainers, eliminating the need for pre-surgical orthodontics later. This early phase of treatment significantly reduced the treatment time. The use of software to predict all the necessary steps for surgery and post-surgical orthodontic tooth movements made this approach possible. Multi-step virtual planning can be a powerful tool for analyzing complex craniofacial problems that require multidisciplinary care, such as cleft lip and/or palate.
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Affiliation(s)
- Jaemin Ko
- Craniofacial and Special Care Orthodontics, Division of Dentistry, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA;
| | - Mark M. Urata
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (M.M.U.); (J.A.H.)
| | - Jeffrey A. Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (M.M.U.); (J.A.H.)
| | - Dennis-Duke Yamashita
- Division of Oral and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA;
| | - Stephen L.-K. Yen
- Craniofacial and Special Care Orthodontics, Division of Dentistry, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA;
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13
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Ghanim K, Alsabee WM, Al-Rawee RY, Tawfeeq BAG. Nasal Deformity Correction in Cleft Lip and Palate Patients by Secondary Rhinoplasty: Patients Satisfactions. J Craniofac Surg 2024:00001665-990000000-01777. [PMID: 39037227 DOI: 10.1097/scs.0000000000010476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/17/2024] [Indexed: 07/23/2024] Open
Abstract
AIM OF THE STUDY To evaluate the degree of patient satisfaction postsecondary rhinoplasty, specifically in cleft patients in Mosul city. METHODOLOGY A retrospective comparison questionnaire study was conducted between March and April 2024 among cleft patients who underwent surgical secondary rhinoplasty in Mosul City of Nineveh Province. All cleft patients aged 18 to 40 who underwent secondary rhinoplasty are included in the study. Forty participants respond to a specific questionnaire in 3 time periods (before surgery 3 and 6 months after). Basic demographic information (age, gender, cause of visit, diagnosis, and treatment) is recorded. Questionnaire which conflict the patient's perception presurgery and postsurgery also. The improvement rate and reduction rate of improvement are calculated according to a special equation.Thanks for such comment. The sentences changed as requested with (Six standard questions applied to evaluate the patients' satisfaction postsurgery. Responses are assessed statistically by special equation to detect the improvement rate). RESULTS According to age groups, the age between 26 and 30 years have the highest incidence between the cases with 37.5%. Females are highest with (55%). Esthetics are the most common cause. Effective or improvement rate shows positive except for question 6 ( median: 4%). The reduction rate shows positive results. CONCLUSIONS Despite being a complicated surgical operation, cleft rhinoplasty can yield symmetry, improved esthetics, and enhanced functioning, including improved breathing, which can be life-changing for patients and fulfilling for the surgeon. Its difficulty stems from the fact that it has required several surgical phases throughout the years, each of which calls for a comprehensive surgical team with a variety of specializations to be addressed for optimal outcomes.
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Affiliation(s)
- Khalid Ghanim
- Specialist ENT (Iraqi Board), Al-Salam Teaching Hospital
| | | | - Rawaa Y Al-Rawee
- Department of Oral and Maxillofacial Surgery, Al-Salam Teaching Hospital, Mosul, Iraq
- Ministry of Health, Iraq
- RCPS Glasgow
- BAMOS
- ACPA
- IUU, AADI
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14
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Schraad F, Schwahn C, Krey KF, Doberschütz PH. Craniofacial morphological variability in orthodontic patients with non-syndromic orofacial clefts: an approach using geometric morphometrics. Clin Oral Investig 2024; 28:409. [PMID: 38954126 PMCID: PMC11219447 DOI: 10.1007/s00784-024-05796-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 06/20/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES Orofacial clefts are complex congenital anomalies that call for comprehensive treatment based on a thorough assessment of the anatomy. This study aims to examine the effect of cleft type on craniofacial morphology using geometric morphometrics. MATERIALS AND METHODS We evaluated lateral cephalograms of 75 patients with bilateral cleft lip and palate, 63 patients with unilateral cleft lip and palate, and 76 patients with isolated cleft palate. Generalized Procrustes analysis was performed on 16 hard tissue landmark coordinates. Shape variability was studied with principal component analysis. In a risk model approach, the first nine principal components (PC) were used to examine the effect of cleft type. RESULTS We found statistically significant differences in the mean shape between cleft types. The difference is greatest between bilateral cleft lip and palate and isolated cleft palate (distance of means 0.026, P = 0.0011). Differences between cleft types are most pronounced for PC4 and PC5 (P = 0.0001), which together account for 10% of the total shape variation. PC4 and PC5 show shape differences in the ratio of the upper to the lower face, the posterior mandibular height, and the mandibular angle. CONCLUSIONS Cleft type has a statistically significant but weak effect on craniofacial morphological variability in patients with non-syndromic orofacial clefts, mainly in the vertical dimension. CLINICAL RELEVANCE Understanding the effects of clefts on craniofacial morphology is essential to providing patients with treatment tailored to their specific needs. This study contributes to the literature particularly due to our risk model approach in lieu of a prediction model.
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Affiliation(s)
- Franca Schraad
- Department of Orthodontics, University Medicine Greifswald, Fleischmannstraße 42-44, 17475, Greifswald, Germany.
| | - Christian Schwahn
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, Fleischmannstraße 42-44, 17475, Greifswald, Germany
| | - Karl-Friedrich Krey
- Department of Orthodontics, University Medicine Greifswald, Fleischmannstraße 42-44, 17475, Greifswald, Germany
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15
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Haj M, Hakkesteegt S, Poldermans H, de Gier H, Versnel S, Wolvius E. Speech Outcomes after Delayed Hard Palate Closure and Synchronous Secondary Alveolar Bone Grafting in Patients with Cleft Lip, Alveolus and Palate. Arch Plast Surg 2024; 51:378-385. [PMID: 39034979 PMCID: PMC11257747 DOI: 10.1055/s-0044-1787002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/09/2024] [Indexed: 07/23/2024] Open
Abstract
Background The best timing of closure of the hard palate in individuals with cleft lip, alveolus, and palate (CLAP) to reach the optimal speech outcomes and maxillary growth is still a subject of debate. This study evaluates changes in compensatory articulatory patterns and resonance in patients with unilateral and bilateral CLAP who underwent simultaneous closure of the hard palate and secondary alveolar bone grafting (ABG). Methods A retrospective study of patients with nonsyndromic unilateral and bilateral CLAP who underwent delayed hard palate closure (DHPC) simultaneously with ABG at 9 to 12 years of age from 2013 to 2018. The articulatory patterns, nasality, degree of hypernasality, facial grimacing, and speech intelligibility were assessed pre- and postoperatively. Results Forty-eight patients were included. DHPC and ABG were performed at the mean age of 10.5 years. Postoperatively hypernasal speech was still present in 54% of patients; however, the degree of hypernasality decreased in 67% ( p < 0.001). Grimacing decreased in 27% ( p = 0.015). Articulation disorders remained present in 85% ( p = 0.375). Intelligible speech (grade 1 or 2) was observed in 71 compared with 35% of patients preoperatively ( p < 0.001). Conclusion This study showed an improved resonance and intelligibility following DHPC at the mean age of 10.5 years, however compensatory articulation errors persisted. Sequential treatments such as speech therapy play a key role in improvement of speech and may reduce remaining compensatory mechanisms following DHPC.
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Affiliation(s)
- Mona Haj
- Department of Maxillofacial Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - S.N. Hakkesteegt
- Department of Maxillofacial Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - H.G. Poldermans
- Department of Maxillofacial Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - H.H.W. de Gier
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - S.L. Versnel
- Department of Plastic and Reconstructive Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - E.B. Wolvius
- Department of Maxillofacial Surgery, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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16
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Stanton E, Kondra K, Jimenez C, Shakoori P, Yen S, Urata MM, Hammoudeh JA, Magee WP. Premaxillary Setback in Bilateral Cleft Lip and Palate Repair. Cleft Palate Craniofac J 2024; 61:416-421. [PMID: 36448087 DOI: 10.1177/10556656221130166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE The aim of this study is to evaluate surgical outcomes and maxillofacial growth in patients undergoing primary lip repair with or without premaxillary setback. DESIGN Retrospective review. SETTING Children's Hospital of Los Angeles, California. PATIENTS AND PARTICIPANTS Patients with bilateral cleft lip ± palate (BCLP) who underwent lip repair with or without premaxillary setback from January 1975 to September 2021. INTERVENTIONS No intervention was performed. MAIN OUTCOME MEASURE(S) Patient demographics, comorbidities, and syndromic status were obtained. Indications for premaxillary setback, incidence of midface hypoplasia, orthodontic and/or orthognathic treatments, follow-up, complications, and revisions were recorded and analyzed. Comparisons among long-term outcomes, particularly the development of midface hypoplasia were made between groups. RESULTS Thirty-one patients who underwent BCLP repair with premaxillary setback (BCLP + PS) and 31 matched control patients who underwent BCLP repair without premaxillary setback (BCLP - PS) were included. Among the 2 groups, multiple logistic regression demonstrated that when controlling for comorbidities, syndromic status, timing of lip repair, and timing of palate repair, premaxillary setback was neither significantly associated with the development of midface hypoplasia (P = .076) nor the timing of midface hypoplasia development (P = .940) in those that ultimately acquired this facial dysmorphology. CONCLUSIONS While a high incidence of midface hypoplasia was seen in both BCLP ± PS and BCLP - PS, our findings demonstrate no difference in midface hypoplasia irrespective of premaxillary setback in the setting of BCLP. Future prospective studies investigating the downstream ramifications of our suggested selection criteria for premaxillary setback are warranted.
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Affiliation(s)
- Eloise Stanton
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Katelyn Kondra
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Christian Jimenez
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Pasha Shakoori
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
| | - Stephen Yen
- Division of Oral and Maxillofacial Surgery, University of Southern California, Los Angeles, CA, USA
| | - Mark M Urata
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
- Division of Oral and Maxillofacial Surgery, University of Southern California, Los Angeles, CA, USA
- Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey A Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
- Division of Oral and Maxillofacial Surgery, University of Southern California, Los Angeles, CA, USA
- Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - William P Magee
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA
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17
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Harjunpää R, Grann A, Saarikko A, Heliövaara A. Rhinoplasty and Le Fort I Maxillary Osteotomy in Cleft Patients. J Craniofac Surg 2024; 35:473-477. [PMID: 37983115 DOI: 10.1097/scs.0000000000009873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 10/09/2023] [Indexed: 11/21/2023] Open
Abstract
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.
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Affiliation(s)
- Roni Harjunpää
- Department of Plastic Surgery, Cleft Palate and Craniofacial Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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18
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Applebaum SA, Aronson S, Termanini KM, Gosain AK. Evidence-Based Practices in Cleft Palate Surgery. Plast Reconstr Surg 2024; 153:448e-461e. [PMID: 38266141 DOI: 10.1097/prs.0000000000011035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.
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Affiliation(s)
- Sarah A Applebaum
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Sofia Aronson
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Kareem M Termanini
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Arun K Gosain
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
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19
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Saito T, Tu JCY, Chou PY, Lo LJ. Primary rhinoplasty in patients with bilateral cleft lip: Longitudinal results and comparison between closed and semi-open approaches. J Plast Reconstr Aesthet Surg 2024; 89:117-124. [PMID: 38176136 DOI: 10.1016/j.bjps.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty. METHODS Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed. RESULTS In the comparative analysis at preschool age, semi-open rhinoplasty significantly improved the typical nasal deformities, including transversely oriented wide nostrils, short columella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age. CONCLUSION This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.
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Affiliation(s)
- Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Junior Chun-Yu Tu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
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20
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Celie KB, Wlodarczyk J, Naidu P, Tapia MF, Nagengast E, Yao C, Magee W. Sagittal Growth Restriction of the Midface Following Isolated Cleft Lip Repair: A Systematic Review and Meta-Analysis. Cleft Palate Craniofac J 2024; 61:20-32. [PMID: 35876322 DOI: 10.1177/10556656221116005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate repair, and is poorly understood. No study has examined the aggregate data on sagittal growth restriction of the midface following repair of the lip, but not palate, in these patients. A systematic review of 3780 articles was performed. Twenty-four studies met inclusion criteria and 11 reported cephalometric measurements amenable to meta-analysis. Patients with Veau class I-III palatal clefts were included so long as they had undergone only lip repair. Groups were compared against both noncleft and unrepaired controls. Cephalometrics were reported for 326 patients (31.3% female). Noncleft controls had an average SNA angle of 81.25° ± 3.12°. The only patients demonstrating hypoplastic SNA angles were those with unilateral CLP with isolated lip repair (77.4° ± 4.22°). Patients with repaired CL had SNA angles similar to noncleft controls (81.4° ± 4.02°). Patients with unrepaired CLP and CL tended toward more protruding maxillae, with SNA angles of 83.3° ± 4.04° and 87.9° ± 3.11°, respectively. Notably, when comparing SNA angles between groups, patients with CLP with isolated lip repair had significantly more hypoplastic angles compared to those with repaired CL (P < .0001). Patients with CLP with isolated lip repair were also more hypoplastic than noncleft controls (P < .0001). In contrast, there was no significant difference between the SNA of patients with repaired CL and controls (P = .648). We found that cleft lip repair only appeared to contribute to MFH in the setting of concurrent cleft palate pathology, suggesting that scarring from lip repair itself is unlikely to be the predominant driver of MFH development. However, studies generally suffered from inadequate reporting of timing, technique, follow-up time, and cleft severity.
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Affiliation(s)
- Karel-Bart Celie
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jordan Wlodarczyk
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | | | - Eric Nagengast
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Caroline Yao
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Operation Smile Incorporated, Virginia Beach, VA, USA
- Shriners Hospital for Children, Pasadena CA, USA
| | - William Magee
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Operation Smile Incorporated, Virginia Beach, VA, USA
- Shriners Hospital for Children, Pasadena CA, USA
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21
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Mathews AT, Dammling CW, Waite PD, Kinard BE. Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction? Cleft Palate Craniofac J 2023; 60:1572-1577. [PMID: 35733371 DOI: 10.1177/10556656221109413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The rigid external distraction (RED) device is reported to have the ability to three-dimensionally reposition the maxilla. The purpose of this study is to assess the ability of RED to intentionally alter the maxillary pitch. Retrospective cohort study. Institutional practice. A retrospective chart review was completed over the past 12 years and a total of 50 patients met the inclusion criteria. Cephalometric changes and alteration in palatal plane angle. Cephalometric analysis of standardized landmarks was completed on calibrated, standardized lateral cephalograms. Pre-distraction and post-consolidation variables were compared via a two-tailed paired t-test. The mean age at surgery of 12.2 ± 3.2 years. Through distraction osteogenesis (DO), the maxilla was moved anteriorly with a mean distraction distance of 8.4 ± 4.8 mm. The mean change in the angles sella-nasion-A-point angle (SNA), sella-nasion-B-point angle (SNB), and A-point-nasion-B-point angle (ANB) were 10.2 ± 4.8, 0.9 ± 2.7, and 9.3 ± 4.1, respectively. The mean change in the palatal plane angle was -4.4 ± 3.7. The mean change in the vertical position of the anterior nasal spine (ANS) and posterior nasal spine (PNS) in relation to the Frankfort horizontal (FH) were -2.0 ± 4.1 mm and 1.7 ± 3.8 mm, respectively. This study documents short-term findings of RED in a large cleft lip and palate (CLP) population. Despite positioning of distraction eyelets superior to the theoretical center of resistance, a counterclockwise (CCW) rotation of the palatal plane occurred. This suggests that adjunctive methods of vector control should be considered if clockwise (CW) rotation of the palatal plane is intended with the RED device.
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Affiliation(s)
- Alexander T Mathews
- University of Alabama at Birmingham School of Dentistry, Birmingham, AL, USA
| | - Chad W Dammling
- University of Alabama at Birmingham School of Dentistry, Birmingham, AL, USA
| | - Peter D Waite
- University of Alabama at Birmingham School of Dentistry, Birmingham, AL, USA
| | - Brian E Kinard
- University of Alabama at Birmingham School of Dentistry, Birmingham, AL, USA
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Prada Madrid JR, Gómez Prada DC, Gutierrez Rodríguez EP, Zarate Ardila A, Pérez Quintero JC. Lefort I Osteotomy With and Without Osteogenic Distraction in Cleft Lip and Palate Patients: Experience at Hospital Universitario Infantil De San José. J Craniofac Surg 2023:00001665-990000000-01244. [PMID: 37994847 DOI: 10.1097/scs.0000000000009837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/30/2023] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Cleft lip and cleft palate (CLP) are congenital diseases that lead to several secondary craniofacial anomalies, such as hypoplasia of the middle third of the face, which can be treated with different surgical techniques to help improve functional and esthetic alterations associated with the maxilla. This article reports the results of patients managed with LeFort I osteotomy in the same craniofacial surgery center for 10 years. OBJECTIVE To determine the postoperative results regarding recurrence rates, malocclusion, and speech status after surgical treatment, in patients with retrusion of the midface with CLP, who underwent LeFort I osteotomy with or without osteogenic distraction (OD). METHODS A descriptive cohort study was performed at the Hospital Infantil Universitario de San José in Bogotá, Colombia, between 2010 and 2020, evaluating 38 patients with CLP who met the inclusion criteria, all managed by LeFort I osteotomy with and without OD. The authors reported the sociodemographic information, as well as data related to speech before and after surgery, recurrence, complications, and cephalometric characteristics. The recurrence of the patients was described at 6 and 12 months after the surgical procedure. RESULTS A total of 43 patients met the inclusion criteria, of which 20 patients were managed with conventional LeFort I osteotomy, and 23 with LeFort I osteotomy with OD; 5 patients were excluded due to lack of data in the medical records, with a final sample of 38 patients. The distribution based on sex was: 57.8% men and 42.1% women. Regarding laterality, we have 7 patients with right CLP (18.42%), 11 patients with left CLP (28.9%), and 20 patients with bilateral CLP (52.63%), 100% of patients with a class III bite in Angle's classification. In group 1 (OD), 55% of the patients did not present changes in speech before surgery, 30% presented improvement in speech, and 15% worsened it. In group 2 (conventional advancement), 66% of the patients did not present changes in speech, 5.5% presented improvement, and 27.7% presented worsening of speech based on the preoperative condition, with a clinical recurrence at 6 months of 15% for group 1 and of 33% for group 2, and at 1 year of 20% for group 1 and 16% for group 2. CONCLUSIONS Osteogenic distraction is a safe method that can be applied in patients with CLP depending on the clinical characteristics. According to what is described in the literature, those patients who require advancement of up to 6 mm treated without OD have obtained good results, showing esthetic improvement by increasing the projection of the middle third of the face, without worsening of velopharyngeal insufficiency and achieving an adequate occlusal class (Angle I) in the immediate postoperative period or after the postoperative orthodontic management. However, in patients who require advances ≥7 mm, it is clear that OD is the best option, given its association with a lower recurrence rate, minimal changes in the speech, achieving occlusion edge-to-edge at the end of the distraction or Angle's class I, which is corroborated by the results obtained in this study.
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Affiliation(s)
- Jose Rolando Prada Madrid
- Craniofacial Surgery Unit, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital Infantil Universitario de San José
| | - Diana Carolina Gómez Prada
- Craniofacial Surgery Unit, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital Infantil Universitario de San José
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital Infantil Universitario de San José, Center for Children With Cleft Lip and Palate (FISULAB)
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Chaisiri S, Arayasantiparb R, Boonsiriseth K. Factors affecting the relapse of maxilla and soft tissues of nose, upper lip and velopharyngeal structures after maxillary advancement in cleft patients. PLoS One 2023; 18:e0294059. [PMID: 37939044 PMCID: PMC10631644 DOI: 10.1371/journal.pone.0294059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/14/2023] [Indexed: 11/10/2023] Open
Abstract
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.
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Affiliation(s)
- Sirada Chaisiri
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Nakhon Pathom, Thailand
| | - Raweewan Arayasantiparb
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Mahidol University, Nakhon Pathom, Thailand
| | - Kiatanant Boonsiriseth
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Nakhon Pathom, Thailand
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Surgical Correction of Maxillofacial Skeletal Deformities. J Oral Maxillofac Surg 2023; 81:E95-E119. [PMID: 37833031 DOI: 10.1016/j.joms.2023.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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25
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Mansour NM, Kim YC, Lee JY, Choi JW. Differences in the stability of the lesser and greater maxillary segments after cleft orthognathic surgery: A retrospective study using 3D analysis. J Craniomaxillofac Surg 2023; 51:416-426. [PMID: 37423789 DOI: 10.1016/j.jcms.2023.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/05/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023] Open
Abstract
The aim of this study was to determine whether significant differences in postoperative stability exist between the lesser and the greater maxillary segments after cleft orthognathic surgery in patients with and without residual alveolar cleft. A retrospective study of orthognathic patients with unilateral cleft was conducted. The patients were divided into two groups according to maxillary status before surgery, with group 1 comprising single-piece maxilla and group 2 comprising two-piece maxilla. Four maxillary points were used for intra- and intergroup comparisons of movements and relapses between the two maxillary segments. In total, 24 patients were included. The intragroup comparison showed significant differences in vertical relapses between lesser and greater segments in both group 1 (anterior, p = 0.004 and posterior, p = 0.01) and group 2 (posterior, p = 0.013). With regard to intergroup comparison, the lesser segments in the two groups differed in transverse movements (anterior, p = 0.048) and relapses (posterior; p = 0.04), while the greater segments differed in transverse movements (anterior, p = 0.014 and posterior, p = 0.019), with significant differences in relapses anteriorly (vertical, p = 0.031 and sagittal, p = 0.036) and posteriorly (transverse, p = 0.022). Maxillary changes following cleft orthognathic surgery showed significant differences between the lesser and the greater segments. These findings imply that 3D images should be used to assess each maxillary segment separately with regard to planning and outcome evaluation.
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Affiliation(s)
- Nabil Mokhter Mansour
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Young Chul Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Jong Woo Choi
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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26
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Mafféïs J, Odri GA, Mercier JM, Loin J, Perrin JP, Joly A, Letelier C, Corre P, Bertin H. Stability of Le Fort 1 osteotomy in patients with bilateral cleft lip and palate: A retrospective study of 71 patients. J Craniomaxillofac Surg 2023; 51:407-415. [PMID: 37550117 DOI: 10.1016/j.jcms.2023.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/13/2023] [Accepted: 06/25/2023] [Indexed: 08/09/2023] Open
Abstract
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.
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Affiliation(s)
- Julia Mafféïs
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France.
| | - Guillaume Anthony Odri
- Service de chirurgie Orthopédique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, 4, rue Ambroise-Paré, 75010, Paris, France; INSERM UMR 1132, Biologie de l'os et du Cartilage (BIOSCAR), Lariboisière Hospital, UFR de Médecine, Faculté de Santé, Université de Paris, 75010, Paris, France.
| | - Jacques-Marie Mercier
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France.
| | - Justine Loin
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France.
| | - Jean-Philippe Perrin
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France.
| | - Aline Joly
- Service de Chirurgie Maxillo-Faciale, Plastique et Brulés, Hôpital Trousseau, CHU de Tours, Tours, France.
| | - Claudia Letelier
- Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Universidad de Chile, Avenida Independencia 939, Santiago de Chile, Chile.
| | - Pierre Corre
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France; Nantes Université, Oniris, UnivAngers, CHU Nantes, INSERM, Regenerative Medicine and Skeleton, RMeS, UMR 1229, F-44000, Nantes, France.
| | - Hélios Bertin
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France; Nantes Université, UnivAngers, CHU Nantes, INSERM, CNRS, CRCI2NA, F-44000, Nantes, France.
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Kormi E, Peltola E, Lusila N, Heliövaara A, Leikola J, Suojanen J. Unilateral Cleft Lip and Palate Has Asymmetry of Bony Orbits: A Retrospective Study. J Pers Med 2023; 13:1067. [PMID: 37511680 PMCID: PMC10381611 DOI: 10.3390/jpm13071067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Facial asymmetry is common in unilateral clefts. Since virtual surgical planning (VSP) is becoming more common and automated segmentation is utilized more often, the position and asymmetry of the orbits can affect the design outcome. The aim of this study is to evaluate whether non-syndromic unilateral cleft lip and palate (UCLP) patients requiring orthognathic surgery have asymmetry of the bony orbits. Retrospectively, we analyzed the preoperative cone-beam computed tomography (CBCT) or computed tomography (CT) data of UCLP (n = 15) patients scheduled for a Le Fort 1 (n = 10) or bimaxillary osteotomy (n = 5) with VSP at the Cleft Palate and Craniofacial Center, Helsinki University Hospital. The width, height, and depth of the bony orbit and the distance between the sella turcica and infraorbital canal were measured. A volumetric analysis of the orbits was also performed. The measurements were tested for distribution, and the cleft side and the contralateral side were compared statistically with a two-sided paired t-test. To assess asymmetry in the non-cleft population, we performed the same measurements of skeletal class III patients undergoing orthognathic surgery at Päijät-Häme Central Hospital (n = 16). The volume of bony orbit was statistically significantly smaller (p = 0.014), the distance from the infraorbital canal to sella turcica was shorter (p = 0.019), and the anatomical location of the orbit was more medio-posterior on the cleft side than on the contralateral side. The non-cleft group showed no statistically significant asymmetry in any measurements. According to these preliminary results, UCLP patients undergoing orthognathic surgery show asymmetry of the bony orbit not seen in skeletal class III patients without a cleft. This should be considered in VSP for the correction of maxillary hypoplasia and facial asymmetry in patients with UCLP.
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Affiliation(s)
- Eeva Kormi
- Päijät-Häme Joint Authority for Health and Wellbeing, Department of Oral and Maxillofacial Surgery, Päijät-Häme Central Hospital, 15850 Lahti, Finland
| | - Elina Peltola
- HUS Diagnostic Center, Radiology, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Niilo Lusila
- Päijät-Häme Joint Authority for Health and Wellbeing, Department of Radiology, Päijät-Häme Central Hospital, 15850 Lahti, Finland
| | - Arja Heliövaara
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Junnu Leikola
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Juho Suojanen
- Päijät-Häme Joint Authority for Health and Wellbeing, Department of Oral and Maxillofacial Surgery, Päijät-Häme Central Hospital, 15850 Lahti, Finland
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital, 00029 Helsinki, Finland
- Clinicum, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
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28
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Kamata M, Sakamoto Y, Ogata H, Sakamoto T, Ishii T, Kishi K. Influence of Lip Revision Surgery on Facial Growth in Patients With A Cleft Lip. J Craniofac Surg 2023; 34:1203-1206. [PMID: 36727767 DOI: 10.1097/scs.0000000000009191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 10/10/2022] [Indexed: 02/03/2023] Open
Abstract
Although patients with cleft lip and palate often present with poor maxillary growth because of intrinsic and iatrogenic factors, the surgical influence of lip revision surgery, palatal fistula repair, and pharyngeal flap procedures remains uncertain in contrast to that of primary cleft lip repair and palatoplasty. Therefore, this study aimed to reveal factors inhibiting maxillary growth and inducing later orthognathic surgery. A retrospective analysis was conducted on the data of patients with cleft lip and palate who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on patient sex, cleft type, number and timing of lip revision surgery, the incidence of palatal fistulae, history of pharyngeal flap procedures, and timing of a repeat bone graft, and reviewed whether these patients underwent orthognathic surgery later in life. Multivariate analysis was conducted using binary logistic regression to extract factors affecting later orthognathic surgery. A total of 52 patients were included in this study. Results showed that revision surgery conducted more than twice was the highest statistically significant predictor of later orthognathic surgery in patients with a cleft lip and palate ( P <0.05, odds ratio=43.3), followed by palatal fistula occurrence after cleft palate repair ( P <0.05, odds ratio=22.3). Therefore, primary surgical procedure is most important for these patients.
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Affiliation(s)
- Masafumi Kamata
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo , Japan
| | - Yoshiaki Sakamoto
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo , Japan
| | | | - Teruo Sakamoto
- Department of Orthodontics, Tokyo Dental College, Chiba, Japan
| | - Takenobu Ishii
- Department of Orthodontics, Tokyo Dental College, Chiba, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo , Japan
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Martin SV, Van Eeden S, Swan MC. Secondary surgery techniques to optimise functional and aesthetic outcomes in orofacial clefting. Br Dent J 2023; 234:899-905. [PMID: 37349438 DOI: 10.1038/s41415-023-6001-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 06/24/2023]
Abstract
Although the goal of primary surgery is to avoid the need for secondary surgery, in a proportion of patients this is not always possible. Secondary, or revisional, surgery is frequently undertaken in patients with orofacial clefts and may present a complex and challenging problem for the multidisciplinary team. There are a broad range of functional and aesthetic issues that secondary surgery might aim to address. These include palatal fistulae (that may be symptomatic for air, fluid or food), velopharyngeal insufficiency (typically manifesting with decreased intelligibility or nasal regurgitation), suboptimal cleft lip scars (that can significantly impact upon the psychosocial wellbeing of the patient), and nasal asymmetry (that is frequently accompanied by nasal airway concerns). Unilateral and bilateral clefts are each associated with a characteristic nasal deformity that requires a tailored surgical approach. Suboptimal maxillary growth in repaired orofacial clefts may impact negatively on both appearance and function; surgical correction through orthognathic surgery can be transformational for the patient. The general dental practitioner, cleft orthodontist and restorative dentist all play a critical role in this process.
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Affiliation(s)
- Serena V Martin
- Cleft Fellow, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom
| | - Simon Van Eeden
- Consultant Cleft and Maxillofacial Surgeon, Alder Hey Children´s Hospital and Aintree University Hospital, Liverpool, L14 5AB, United Kingdom
| | - Marc C Swan
- Consultant Cleft and Plastic Surgeon, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom.
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30
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Martin SV, Van Eeden S, Swan MC. The role of primary surgery in the management of orofacial clefting. Br Dent J 2023; 234:859-866. [PMID: 37349432 DOI: 10.1038/s41415-023-6002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 06/24/2023]
Abstract
Primary cleft surgery refers to the planned surgical procedure(s) necessary to reconstruct an orofacial defect according to a specified protocol; in the context of a unilateral cleft lip and palate, this would include lip repair (with vomer flap closure of the hard palate), subsequent repair of the residual soft palate cleft and finally, the alveolar bone graft. This paper will provide an overview of the goals of primary surgical reconstruction, including the utility of pre-surgical orthopaedic techniques, including nasoalveolar moulding. The surgical methods of primary lip repair in both unilateral and bilateral clefts will be outlined and the concept of a primary rhinoplasty will be introduced. The principal techniques of cleft palate reconstruction will be delineated for a variety of cleft phenotypes. The final element of the primary reconstructive sequence is the alveolar bone graft using cancellous bone harvested from the iliac crest at approximately 8-10 years of age. The role of optimising oral hygiene prior to bone grafting cannot be over-emphasised and the utility of pre-surgical orthodontic arch expansion is also discussed. In the UK, bone graft outcomes are audited using the Kindelan score, which is evaluated from the six-month postoperative upper standard occlusal radiograph.
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Affiliation(s)
- Serena V Martin
- Cleft Fellow, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom
| | - Simon Van Eeden
- Consultant Cleft and Maxillofacial Surgeon, Alder Hey Childrens Hospital and Aintree University Hospital, Liverpool, L14 5AB, United Kingdom
| | - Marc C Swan
- Consultant Cleft and Plastic Surgeon, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom.
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Hattori Y, Pai BCJ, Saito T, Chou PY, Lu TC, Chang CS, Chen YR, Lo LJ. Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study. Int J Surg 2023; 109:1656-1667. [PMID: 37073546 PMCID: PMC10389451 DOI: 10.1097/js9.0000000000000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature. PATIENTS AND METHODS A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis. RESULTS A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient. CONCLUSION Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.
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Affiliation(s)
- Yoshitsugu Hattori
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Betty C.-J. Pai
- Department of Craniofacial Orthodontics and Craniofacial Research Center, Chang Gung Memorial Hospital, Kwei Shan, Taoyuan, Taiwan
| | - Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Ting-Chen Lu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Yu-Ray Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
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Drilleaud A, Corre P, Perrin JP, Loin J, Durand T, Salagnac JM, Delaire J, Mercier JM, Bertin H. Surgical Repositioning of the Premaxilla: Incidence, Indications and Growth Study About a 189 Bilateral Cleft Lip ± Palate Population. Cleft Palate Craniofac J 2023; 60:159-167. [PMID: 35068212 DOI: 10.1177/10556656211056807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the rate of patient requiring Surgical Repositioning of the Premaxilla in a population carrying BCL ± P, retrieve age and operative indication. Our secondary objective was to present further facial growth characteristics. SETTINGS This was a retrospective, single-center cohort study conducted in Nantes University Hospital, Oral and Maxillofacial Surgery department, tertiary cleft center. PATIENTS Patients with BCL ± P born between 1980 and 2019 treated at Nantes University Hospital were included. MAIN OUTCOME MEASURE Our primary outcome measure was the rate of patient requiring SRP. RESULTS Over the whole period, 189 patients with BCL ± P were identified. Three patients (1,58%) underwent SRP. Patients who underwent SRP all had BCLP. SRP was performed during their primary dentition period. The indication for surgical repositioning was always premaxilla vertical overgrowth with an overbite over 10 mm. Facial growth features in the three patients were mostly comparable with a population carrying BCLP who had no premaxillary surgery. CONCLUSION Our results showed a low incidence of SRP. No SRP was necessary during early infancy (ie, before lip repair) or during adulthood. Surgical repositioning of the premaxilla is beneficial for patient with orthodontically uncorrectable vertical premaxillary excess, even more since facial development compared with other patients with BCLP appears comparable.
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Affiliation(s)
- Adrien Drilleaud
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Pierre Corre
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, 26922faculty of dentistry, Nantes, France
| | - Jean-Philippe Perrin
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Justine Loin
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Thomas Durand
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Jean-Michel Salagnac
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Jean Delaire
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Jacques-Marie Mercier
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
| | - Helios Bertin
- Maxillofacial Surgery and Stomatology Department, 27045Nantes University Hospital, Nantes Cedex 1, France
- Osteogenic Sarcomas and Calcified Tissues Remodeling Laboratory (PhyOs, UMR 1238), Medecine Faculty, Nantes Cedex, France
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33
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Merta M, Heliövaara A, Leikola J, Suojanen J. Early experience of wafer-free Le Fort I osteotomy with patient-specific implants in cleft lip and palate patients. J Plast Reconstr Aesthet Surg 2023; 77:78-86. [PMID: 36563638 DOI: 10.1016/j.bjps.2022.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 06/21/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Minna Merta
- Päijät-Häme Joint Authority for Health and Wellbeing, Department of Oral and Maxillo-Facial Surgery, Lahti, Finland
| | - Arja Heliövaara
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Junnu Leikola
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Juho Suojanen
- Päijät-Häme Joint Authority for Health and Wellbeing, Department of Oral and Maxillo-Facial Surgery, Lahti, Finland; Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital and Helsinki University, Helsinki, Finland.
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Eldesouky R, Elbarbary A. Definitive Rhinoplasty and Orthognathic Surgery for Patients with Cleft Lip Palate. Oral Maxillofac Surg Clin North Am 2022; 35:127-137. [DOI: 10.1016/j.coms.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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The Accuracy of Jaws Repositioning in Bimaxillary Orthognathic Surgery in Patients with Cleft Lip and Palate Compared to Non-Syndromic Skeletal Class III Patients. J Clin Med 2022; 11:jcm11092675. [PMID: 35566801 PMCID: PMC9102274 DOI: 10.3390/jcm11092675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/26/2022] [Accepted: 04/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The present study aims to compare the accuracy of jaw repositioning in bimaxillary orthognathic surgery using digital surgical planning in cleft lip and palate patients and in non-syndromic skeletal class III patients in order to investigate if orthognathic surgery achieves different results in the first group of patients. Method: This study included 32 class III adult patients divided into 2 groups: cleft lip and palate (A, n = 16) and non-cleft (B, n = 16). For each patient, a 2D pre-surgical visual treatment objective was performed by the surgeon to predict hard tissue changes, and the surgical outcome was compared with that planned by using cephalometric measurement (ANB, SNA, SNB, Ar-Go-Me, S-Ar-Go). The statistical analysis showed equivalence between obtained and planned results for each measurement both in group A and in group B, but the difference between the planned and the obtained result was smaller in group B regarding ANB angle. Conclusions: Digital surgical planning ensures better predictability of the surgical results and higher accuracy of surgery in complex patients, such as those with cleft lip and palate.
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Ruschasetkul S, Liao YF, Chang CS, Lu TC, Chen YA, Yao CF, Chen PKT, Chen YR. Comparison of stability and outcomes of surgery-first bimaxillary surgery for skeletal class III deformity between unilateral and bilateral cleft lip and palate. Clin Oral Investig 2022; 26:3665-3677. [DOI: 10.1007/s00784-021-04336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 12/04/2021] [Indexed: 11/25/2022]
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Abstract
PURPOSE To determine the true need for orthognathic surgery in patients with repaired cleft lip and/or palate (CL/P) at a high-volume craniofacial center. METHODS An institutional retrospective review of patients with CL/P born between 1975 and 2008 was performed. Patients with adequate documentation reflecting cleft care who were ≥ 18 years at the time of last craniofacial/dentistry follow-up were included. Patients with non-paramedian clefts or a comorbid craniofacial syndrome were excluded. Primary outcome variable was the total proportion of patients with CL/P who either underwent or were referred for orthognathic surgery Le Fort I (LF1) to correct midface hypoplasia. Secondary outcome variables were associations between cleft phenotype, midface hypoplasia severity, and number of cleft related surgeries with the eventual LF1 referral/recipiency. RESULTS One hundred seventy-seven patients with CL/P met inclusion criteria. A total of 90/177 (51%) patients underwent corrective LF1; however, 110/177 (62%) of patients were referred for surgery. Patients with secondary cleft palate involvement were referred for and underwent LF1 at significantly greater rates than those without secondary palate involvement (referred: 65% versus 13%, P = 0.001; underwent: 55% versus 0%, P < 0.001). Patients with bilateral cleft lip/palate were referred for and underwent LF1 at significantly higher rates than those with unilateral cleft lip/palate (referred: 71.0% versus 50.4%, P= 0.04; underwent: 84% versus 71%, P = 0.02). Number of secondary palate surgeries was positively correlated with increased LF1 referral (P = 0.02) but not LF1 recipiency (P = 0.15). CONCLUSIONS The incidence of orthognathic surgery redundant in patients with repaired CL/P was 51% at our institution, marginally above the higher end of previously reported rates. However, this number is an underrepresentation of the true requirement for LF1 as 62% of patients were referred for surgical intervention of midface hypoplasia. This distinction should be considered when counseling families.
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Vomer Flaps Support Velopharyngeal Competency, Fistula Free Repair, and 3D Construction of Normal Anatomy in Patients with Cleft Palate. Plast Reconstr Surg Glob Open 2021; 9:e3968. [PMID: 34881136 PMCID: PMC8647874 DOI: 10.1097/gox.0000000000003968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/06/2021] [Indexed: 11/26/2022]
Abstract
Cleft palate repair comprises the surgical creation of a congenitally nonexistent normal anatomy, to establish physiological function by moving tissues into their normal anatomical positions. In patients with isolated incomplete (IICP) or submucous (SMCP) cleft palate, the vomer is usually not completely attached to the palatal plate in the midline. This condition, which is visible through surgical access radiologically or via endoscope, is often disregarded during hard palate repair. This can lead to "hypernasality" despite a well-functioning velopharyngeal mechanism. The general practice of hard palate repair by suturing merely the nasal layers together separates the oral and nasal cavities. However, without incorporation of the vomer, it is impossible to build two separate nasal floors on the left and right sides. We consider that achieving normal speech and separation of the nasal cavities are mutually dependent and have to be considered equally. Methods We described hard palate repair involving the vomer for construction of both nasal floors. We presented the occlusal relationship, hypernasality, and fistula rates in 37 patients operated on between January 1, 2017 and June 30, 2018. Results One child presented minimal hypernasality; all others had normal resonance/voice. Fistula rate was zero, and no cross bites were observed. Conclusions The implicit connection between the inner nose, resonance/voice, and prevention of fistulae has not yet been acknowledged. The correct usage of vomer flaps in IICP and SMCP creating separate nasal floors supports the velopharyngeal competency, avoids fistula formation, and should be incorporated regularly, like in other cleft forms.
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Intra-Lesional Injection of Triamcinolone to Palatoplasty Scar to Aid Reversal of Transverse Maxillary Relapse after Orthognathic Surgery. J Craniofac Surg 2021; 33:e416-e418. [PMID: 34753867 DOI: 10.1097/scs.0000000000008347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT A 32-year-old female with a repaired right unilateral cleft lip and palate underwent several surgical and orthodontic procedures during the rehabilitation process of her condition. Nine years after this extensive treatment she underwent transverse relapse of her maxilla and requested a consultation for its correction as she felt her speech and chewing were negatively affected. She presented with a transverse maxillary arch collapse on the cleft side with significant palatal scarring secondary to multiple palate procedures. A course of maxillary expansion and dental alignment with fixed orthodontic appliances was carried out. In addition, she had 2 triamcinolone injections 7 months apart while undergoing orthodontic treatment and one 10 months after completion to soften the scarred palatal tissues. The maxillary arch was successfully expanded and aligned. She was retained with a removable chrome cobalt palatal frame to be used full-time and assure stability of the correction. She has been followed for 4 years with no clinical evidence of relapse. Triamcinolone injection into significant palatal scarring in cleft palate patients with a decreased transverse maxillary dimension can be considered an adjunct procedure in conjunction with orthodontic treatment.
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Posnick JC. Enhanced Cleft Lip and Palate Team Care. J Oral Maxillofac Surg 2021; 80:588-589. [PMID: 34856160 DOI: 10.1016/j.joms.2021.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jeffrey C Posnick
- Professor Emeritus, Plastic and Reconstructive Surgery & Pediatrics, Georgetown University School of Medicine, Washington, DC; Professor of Orthodontics, University of Maryland, College of Dental Surgery, Baltimore, MD; Professor of Oral and Maxillofacial Surgery, Howard University College of Dentistry, Washington, DC.
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Midface Growth Potential in Unoperated Clefts: A Systematic Review and Meta-Analysis. J Craniofac Surg 2021; 33:774-778. [PMID: 34690318 DOI: 10.1097/scs.0000000000008296] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
ABSTRACT Competing hypotheses for the development of midface hypoplasia in patients with cleft lip and palate include both theories of an intrinsic restricted growth potential of the midface and extrinsic surgical disruption of maxillary growth centers and scar growth restriction secondary to palatoplasty. The following meta-analysis aims to better understand the intrinsic growth potential of the midface in a patient with cleft lip and palate unaffected by surgical correction. A systematic review of studies reporting cephalometric measurements in patients with unoperated and operated unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (ICP) abstracted SNA and ANB angles, age at cephalometric analysis, syndromic diagnosis, and patient demographics. Age and Region-matched controls without cleft palate were used for comparison. SNA angle for unoperated UCLP (84.5 ± 4.0°), BCLP (85.3 ± 2.8°), and ICP (79.2 ± 4.2°) were statistically different than controls (82.4 ± 3.5°), (all P ≤ 0.001). SNA angles for operated UCLP (76.2 ± 4.2°), BCLP (79.8 ± 3.6°), and ICP (79.0 ± 4.3°) groups were statistically smaller than controls (all P ≤ 0.001). SNA angle in unoperated ICP (n = 143) was equivalent to operated ICP patients (79.2 ± 4.2° versus 79.0 ± 4.3° P = 0.78). No unoperated group mean SNA met criteria for midface hypoplasia (SNA < 80). Unoperated UCLP/BLCP exhibit a more robust growth potential of the maxilla, whereas operated patients demonstrate stunted growth compared to normal phenotype. Unoperated ICP demonstrates restricted growth in both operated and unoperated patients. As such, patients with UCLP/BCLP differ from patients with ICP and the factors affecting midface growth may differ.Level of Evidence: IV.
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Tsang JMK, Yu WS, Tuomainen J, Sell D, Lee KYS, Tong MCF, Pereira VJ. The Impact of Maxillary Osteotomy on Fricatives in Cleft Lip and Palate: A Perceptual Speech and Acoustic Study. Folia Phoniatr Logop 2021; 74:271-283. [PMID: 34644700 PMCID: PMC9501750 DOI: 10.1159/000520080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/19/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Abnormal facial growth is a recognized outcome in cleft lip and palate (CLP), resulting in a concave profile and a class III occlusal status. Maxillary osteotomy (MO) is undertaken to correct this facial deformity, and the surgery can impact speech articulation, although the evidence remains limited and ill-defined for the CLP population. AIMS The aim of the study was to investigate the impact of MO on the production of the fricatives /f/ and /s/, using perceptual and acoustic analyses, and to explore the nature of speech changes. METHODS Twenty participants with CLP were seen 0-3 months pre-operatively (T1) and 3 months (T2) and 12 months (T3) after MO. A normal group (N = 20) was similarly recruited. Perceptual speech data was collected according to a validated framework and ratings made on audio and audio-video recordings (VIDRat). Spectral moments were centre of gravity (CG), standard deviation (SD), skewness (SK) and kurtosis (KU). Reliability studies were carried out for all speech analyses. RESULTS For the CLP group, VIDRat identified dentalization/interdentalization as the main type of pre-operative error for /s/ with a statistically significant improvement over time, χ2(2) = 6.889, p = 0.032. Effect sizes were medium between T1 and T3 (d = 0.631) and small between T2 and T3 (d = 0.194). For the acoustic data, effect sizes were similarly medium between T1 and T2 (e.g., SK, /f/ d = 0.579, /s/ d = 0.642) and small between T1 and T3 across all acoustic parameters. Independent t tests showed mainly statistically significant differences between both groups at all time points with large effect sizes (e.g., T2 CG, t = -4.571, p < 0.001, d =1.581), indicating that /s/ was not normalized post-operatively. For /f/, differences tended to be at T1 with large effect sizes (e.g., CG, t = -2.307, p = 0.028, d = 0.797), reflecting normalization. CONCLUSIONS AND IMPLICATIONS This is the first speech acoustic study on /f/ for individuals with CLP undergoing MO. The surgery has a positive impact on /f/ and /s/, which appear to stabilize 3 months post-operatively. Speech changes are an automatic and a direct consequence of the physical changes brought about by MO, effecting articulatory re-organization. The results of the study have direct clinical implications for the clinical care pathway for patients with CLP undergoing MO.
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Affiliation(s)
- Joy M K Tsang
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
| | - Wilson S Yu
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
| | - Jyrki Tuomainen
- Speech, Hearing and Phonetic Sciences, Division of Psychology and Language Sciences, University College London, London, United Kingdom
| | - Debbie Sell
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Kathy Y S Lee
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China.,Institute of Human Communicative Research, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
| | - Michael C F Tong
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China.,Institute of Human Communicative Research, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
| | - Valerie J Pereira
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China.,Institute of Human Communicative Research, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
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Relapse-related factors of Le Fort I osteotomy in cleft lip and palate patients: A systematic review and meta-analysis. J Craniomaxillofac Surg 2021; 49:879-890. [PMID: 34538538 DOI: 10.1016/j.jcms.2021.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 06/27/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Powell KK, Lewis P, Sesanto R, Waite PD. Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate? Cleft Palate Craniofac J 2021; 59:1279-1285. [PMID: 34514855 DOI: 10.1177/10556656211042789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine if secondary alveolar bone grafting (SABG) timing in patients with cleft lip and palate (CLP) influences the future need for additional maxillary advancement procedures, particularly Le Fort I osteotomy with rigid external distraction (RED). DESIGN Retrospective cohort study. Groups were separated by SABG timing: early mixed dentition (ages 68 years) or late mixed dentition (ages 9-11 years). The criterion for RED was negative overjet ≥8 mm, and sufficient dental development for RED. SETTING Single tertiary care institution. PATIENTS Patients with CLP that underwent SABG from 2010 to 2015. Exclusion criteria included syndromic conditions, SABG surgery at age >12 years, current age <12 years, and <2 years follow-up. 104 patients were included. MAIN OUTCOME MEASURES The number of RED candidates and treated patients. RESULTS There was no statistical difference in the number of RED candidates (P = .0718) nor treated patients (P = .2716) based on SABG timing; stratification by laterality was also insignificant. Early SABG is associated with higher odds of being a RED candidate (pooled, unilateral, bilateral) and treated patient (pooled and unilateral); however, there were no statistically significant associations between SABG timing and the number of RED candidates and treated patients as determined by logistic regression models. CONCLUSION There is no statistically significant association between SABG timing and the odds of being a RED candidate or treated patient. Future prospective studies are recommended to assess the relationship between SABG timing and maxillary growth in patients with CLP.
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Affiliation(s)
- Kathlyn K Powell
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paul Lewis
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rae Sesanto
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter D Waite
- School of Dentistry, 83488University of Alabama at Birmingham, Birmingham, AL, USA
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The Relationship Between Dental Agenesis and Maxillary Hypoplasia in Patients With Cleft Lip and Palate. J Craniofac Surg 2021; 32:2012-2015. [PMID: 33840758 DOI: 10.1097/scs.0000000000007555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Both dental agenesis and maxillary growth restriction are well-recognized sequelae in patients with unilateral cleft lip and palate, but their etiology remains controversial. The aim of this study was to evaluate the relationship between hypodontia and maxillary volume. A retrospective review of patients age 6 to 9 with Veau III (unilateral) cleft palate who underwent Cone Beam Computer Tomography in preparation for alveolar bone grafting at 2 major Children's Hospitals between 2010 and 2016 was conducted and serial panoramic radiographs were reviewed. Thirty-eight patients were identified that met inclusion criteria and had adequate imaging. Group 1 ("poor growers") consisted of the bottom 50% of Sella-Nasion-A point minus Sella-Nasion-B point (ANB) angles and Group 2 ("good growers") consisted of the top 50% of ANB angles. Group 1 had a significantly higher mean number of missing teeth (1.58 ± 0.28 missing teeth) compared to Group 2 (0.74 ± 0.23 missing teeth), and significantly lower maxillary volume (12.88 ± 0.61 cm3 versus 15.24 ± 0.88 cm3, respectively). The severity of maxillary hypoplasia in cleft patients increases with increased dental agenesis. These data indicate that intrinsic factors play a significant role in maxillary growth restriction in cleft patients, independent of the sequelae of surgical intervention.
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Abstract
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.
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Abstract
BACKGROUND In severe cases of maxillary hypoplasia, Le Fort I distraction may be required for treatment. This study describes our experience with internal distraction devices and assesses our outcomes in patients with a negative overjet on average >15 mm. METHODS A retrospective review of patients with a history of cleft lip and/or palate who underwent Le Fort I distraction at our institution from 11/2007-11/2017 was performed. Data regarding demographics, procedural details and outcomes were collected and analyzed. RESULTS Twenty patients, 13 (65.0%) male and 7 (30.0%) female, were included. All (100%) patients had a history of cleft lip and/or palate and 2 (10.0%) of them had associated syndromes. All 20 patients underwent internal distraction. The average age at surgery was 17.8 years (range 15.2-20.7, SD 1.6 years). The average preoperative negative overjet was 19.27 mm (range 10-30, SD 5.63 mm). The mean total distraction length was 15.3 mm (range 0-30, SD 6.72 mm). There were no intraoperative complications, however, there were a total of 4 (20.0%) postoperative complications, 2 of which required reoperation due to device malfunction or displacement. 14 (70.0%) patients had repeat procedures to complete occlusal correction or correct relapse. CONCLUSIONS Maxillary distraction alone was insufficient for correction of maxillary discrepancies averaging >15 mm. Instead, it's utility may be in positioning the maxilla for a more viable final advancement and fixation procedure, rather than being solely responsible for achieving normal occlusion during distraction.
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Early Prediction of the Need for Orthognathic Surgery in Patients With Repaired Unilateral Cleft Lip and Palate Using Machine Learning and Longitudinal Lateral Cephalometric Analysis Data. J Craniofac Surg 2021; 32:616-620. [PMID: 33704994 DOI: 10.1097/scs.0000000000006943] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The purpose of this study was to determine the cephalometric predictors of the future need for orthognathic surgery in patients with repaired unilateral cleft lip and palate (UCLP) using machine learning. This study included 56 Korean patients with UCLP, who were treated by a single surgeon and a single orthodontist with the same treatment protocol. Lateral cephalograms were obtained before the commencement of orthodontic/orthopedic treatment (T0; mean age, 6.3 years) and at at least of 15 years of age (T1; mean age, 16.7 years). 38 cephalometric variables were measured. At T1 stage, 3 cephalometric criteria (ANB ≤ -3°; Wits appraisal ≤ -5 mm; Harvold unit difference ≥34 mm for surgery group) were used to classify the subjects into the surgery group (n = 10, 17.9%) and non-surgery group (n = 46, 82.1%). Independent t-test was used for statistical analyses. The Boruta method and XGBoost algorithm were used to determine the cephalometric variables for the prediction model. At T0 stage, 2 variables exhibited a significant intergroup difference (ANB and facial convexity angle [FCA], all P < 0.05). However, 18 cephalometric variables at the T1 stage and 14 variables in the amount of change (ΔT1-T0) exhibited significant intergroup differences (all, more significant than P < 0.05). At T0 stage, the ANB, PP-FH, combination factor, and FCA were selected as predictive parameters with a cross-validation accuracy of 87.4%. It was possible to predict the future need for surgery to correct sagittal skeletal discrepancy in UCLP patients at the age of 6 years.
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Osteotomy of the Premaxilla in Bilateral Cleft Lip: A Useful Technique Following Failure of Primary Lip Closure. J Craniofac Surg 2021; 32:472-476. [PMID: 33704963 DOI: 10.1097/scs.0000000000006911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Successful aesthetic repair of the bilateral cleft lip and palate (BCLP) is one of the most challenging cases encountered by a surgeon. This challenge is heightened when the premaxilla is anteriorly protruded in relation lateral maxillary segments. Our aim is to demonstrate a useful technique for reducing the cleft size before secondary lip repair. We use a premaxillary osteotomy to posteriorly reposition the premaxilla between the lateral segments. METHODS Six patients with BCLP underwent repositioning of the protruded premaxilla. Five patients had previous primary lip closure procedures with unsatisfactory results. The cleft size was reduced by premaxillary osteotomy from nasal septum and partial removal of the vertical vomer. The osteotomized premaxilla was then repositioned, fixed with a custom-made orthodontic appliance. Following this procedure, the lip was closed in a traditional fashion. RESULTS All patients demonstrated satisfying lip closure without tension. In each case, the premaxilla was vital and exhibited partial stabilization during follow-up. CONCLUSIONS In this study the authors demonstrate the usefulness of a premaxillary segment setback as an adjunct to improved function and aesthetics in bilateral lip repair. This method serves as useful technique for previously unsuccessful closure of BCLP.
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Posnick JC, Susarla SM. Improving Cleft Outcomes: A Retrosynthetic Analysis Approach. J Oral Maxillofac Surg 2021; 79:2392-2395. [PMID: 34171225 DOI: 10.1016/j.joms.2021.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Jeffrey C Posnick
- Professor Emeritus, Plastic and Reconstructive Surgery & Pediatrics, Georgetown University School of Medicine, Washington, DC; Professor of Orthodontics, University of Maryland, Baltimore, College of Dental Surgery, Baltimore, MD; Professor of Oral and Maxillofacial Surgery, Howard University College of Dentistry, Washington, DC; Owner, Posnick MD Consulting, LLC, Potomac, MD.
| | - Srinivas M Susarla
- Associate Professor, Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA; Associate Professor, Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA
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