Long-term skeletal stability after maxillary advancement with distraction osteogenesis in cleft lip and palate patients

Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?

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.

Evidence Mapping and Quality Analysis of Systematic Reviews on Various Aspects Related to Cleft Lip and Palate

BACKGROUND

Management of cleft lip and palate is interdisciplinary. An evidence-mapping approach was envisaged to highlight the existing gaps in this field, using only the highest level of evidence.

OBJECTIVES

To conduct evidence mapping and quality analysis of systematic reviews and meta-analyses related to any aspect of cleft lip and palate.

SEARCH METHODS

The cleft lip and palate field was divided into 9 domains and 50 subdomains and a method of categorization of systematic reviews was established. A comprehensive search strategy was carried out in seven databases along with the search of gray literature and references of included articles.

SELECTION CRITERIA

Systematic reviews related to any aspect of cleft lip and palate, conducted by a minimum of two reviewers, with a comprehensive search strategy and adequate quality analysis were included.

DATA COLLECTION AND ANALYSIS

A self-designed, pre-piloted data-extraction sheet was used to collect information that was analyzed through an expert group discussion. Quality analysis was performed using ROBIS-I, AMSTAR 2, and the PRISMA checklist.

RESULTS

A total of 144 systematic reviews published between 2008 and 2022 were included. The largest number of these could be categorized in the therapeutic domain (n = 58). A total of 27% of the studies were categorized as inconclusive, 40% as partially conclusive, and 33% as conclusive. As per ROBIS-I, 77% of reviews had high risk of bias while 58% were graded as critically low in quality as per AMSTAR 2. The majority of systematic reviews showed low reporting errors.

CONCLUSIONS

The majority of systematic reviews related to cleft lip and palate relate to therapeutic and prognostic domains and show high risk of bias and critically low quality regardless of the source journal. The results of this paper might serve as a starting point encouraging authors to carry out high-quality research where evidence is lacking.

REGISTRATION

A multidisciplinary expert-group formulated an a priori protocol, registered in Open Science Framework (DOI 10.17605/OSF.IO/NQDV2).

The Last 40 Years of Orthognathic Surgery: A Bibliometric Analysis

PURPOSE

Bibliometric analyses provide information on the effectiveness, performance, trends, and various other characteristics of research by using mathematical and statistical analysis methods for data related to scientific publications. This study aims to determine the focus of studies in the field of orthognathic surgery, map it, and present the results in a simplified manner through a comprehensive bibliometric analysis of the relevant literature.

METHODS

In this bibliometric analysis study, orthognathic surgery publications from 1980 to 2022 were retrieved from the Web of Science Core Collection database. The independent variables were co-citations, while the outcome variables included cross-country collaboration analysis, keyword analysis, co-citation analysis, and cluster analysis of the co-citation network. Covariates were the number of publications, number of citations, year range, centrality value, and silhouette value. The bibliometric analysis was conducted using CiteSpace, VOSviewer, and R-Studio software.

RESULTS

A total of 7,135 publications and 75,822 references were included in the analysis, and the annual growth rate of publications was 9.52%. The co-citation clustering analysis revealed that the orthognathic surgery literature was organized into 16 subject headings. Patient satisfaction was found to be the most widely published topic. The youngest clusters, representing new topics in the field, were virtual planning and examination of condylar changes after orthognathic surgery.

CONCLUSION

Bibliometric analysis methods were used to evaluate the 40-year history of the orthognathic surgery literature. The analysis identified the most influential publications, the topics in which the literature is divided, and hot spots in the field. By conducting similar bibliometric research studies in the future, the progress and future direction of the literature can be monitored based on evidence.

Multidisciplinary Presurgical Education: Clinical Impact on Children With Orofacial Clefts Undergoing Maxillary Distraction via Rigid External Distraction

OBJECTIVE

Treatment of severe maxillary hypoplasia is commonly addressed via distraction osteogenesis with a rigid external device (RED). While effective, this method can be socially stigmatizing in an already vulnerable patient population. To prepare children and their caregivers for life with a RED and decrease peri-operative anxiety, we instituted a multidisciplinary pre-surgical education session (MPES). This educational team involves our cleft care coordinator, child life specialist, orthodontist and plastic surgeon 2 weeks prior to surgery. We reviewed the impact of this intervention by examining clinical outcomes before and after its implementation.

DESIGN

From February 2017 to February 2020, a retrospective chart review was performed to include patients with orofacial clefts and maxillary hypoplasia who underwent maxillary distraction osteogenesis with RED at our center before (28 patients) and after (29 patients) the implementation of MPES.

RESULTS

MPES was associated with a significantly shorter length of stay compared to controls who did not receive MPES (3.6 vs 3.1 days, p < 0.03) and significantly decreased usage of inpatient narcotic pain medication compared to controls (16.8 morphine equivalents vs 31.8 morphine equivalents, p < 0.02). Our intervention also demonstrated a trend towards decrease in minor complications but did not achieve statistical significance p = 0.32).

CONCLUSIONS

Multidisciplinary presurgical education is a beneficial adjunct in the care of patients with orofacial clefts and maxillary hypoplasia undergoing maxillary advancement with a RED.

A Comparative Study of Skeletal and Dental Outcome between Transcutaneous External Maxillary Distraction Osteogenesis and Conventional Rigid External Device in Treating Cleft Lip and Palate Patients

Background: Traditional distraction osteogenesis (DO) with the tooth-borne rigid external device (RED) system was regularly used in treating patients with cleft-related maxillary hypoplasia. However, the bone-borne RED system with miniplates and bone screws has currently become an effective treatment. This retrospective study was to compare bone-borne RED with traditional tooth-borne RED in distraction effectiveness, blood loss, operative time, and long-term stability. Methods: Twenty-two growing patients who underwent RED therapy were divided into two groups: eleven patients utilizing the bone-borne RED system with the transcutaneous wire attached with skeletal anchorage; another eleven patients using the traditional tooth-borne RED system with the intra-oral device attached with dental anchorage. Serial lateral cephalograms were analyzed for comparing treatment outcomes and stability in 1 month, 6 months, and 1.5 years after distraction. Results: In bone-borne RED group, the maxilla was advanced by 19.98 mm with slight clockwise rotation of 0.40° and minimal palatal inclination change of incisor by −3.94°. In traditional tooth-borne RED group, the maxilla showed less advancement by 14.52 mm, with significant counter-clockwise rotation of −11.23° and excessive palatal inclination change of incisor by −10.86°. Although operative time was longer in the bone-borne RED group by 38.4 min, this did not bring about greater blood loss. Conclusions: the bone-borne RED via transcutaneous wire system provides an easy, simple, and comfortable procedure as well as favorable long-term stability in maxillary distraction.

Camouflage orthodontic treatment combined with genioplasty distraction osteogenesis for skeletal class II relationship secondary to osteosarcoma excision surgery

OBJECTIVE

The treatment of orthodontic patients who survive head and neck tumors is challenging because of dentoskeletal deformities and other unexpected dental and facial complications. This case report describes the case of a 26-year-old woman who presented with mandibular retrognathia after survival from osteosarcoma.

CLINICAL CONSIDERATIONS

Camouflage orthodontic treatment was chosen instead of combined orthodontic-orthognathic surgery after primary reconstructive surgery with an iliac bone graft. Genioplasty distraction osteogenesis (DO) was performed to achieve an optimal facial profile. Although unexpected condyle dislocation and epithelial hyperplasia occurred during treatment, a favorable facial profile and optimal skeletal and dental relationships were accomplished after 32 months of treatment.

CONCLUSIONS

The patient underwent genioplasty DO and experienced unexpected left condyle dislocation. However, the treatment achieved esthetic goals after intermaxillary elastics were applied.

Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate?

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.

A systematic review of therapeutic outcomes following treatment of squamous cell carcinoma of the retromolar trigone

Squamous cell carcinoma (SCC) of the retromolar trigone (RMT) is a rare but potentially fatal disease that carries a poor prognosis due to its unique anatomic position. RMT SCCs tend to spread to vital nearby structures, including the tonsillar pillar, masticatory muscles, and underlying mandibular bone, even in their early stages, and aggressive treatment is often warranted. This systematic review appraises and qualitatively analyzes all available literature regarding the survival outcomes and prognosis of RMT SCC. Four databases were searched to identify all eligible articles published since January 1980. Of the 1,248 studies, a total of 15 studies representing 4,838 cases met the inclusion criteria. The evaluated patients had a high rate of advanced tumor stage (T3 or T4: 61.4%), lymph node metastasis (38.8%), and mandibular bone invasion (24%) at the time of diagnosis. Aggressive surgical treatments such as lip-splitting (92%), segmental mandibulectomy (61.1%), radical neck dissection (44.1%), and reconstruction using free flaps (49.5%) was undertaken for 92% of the pooled patient population. The mean rates for local, regional, and systemic recurrence were 23.40%, 8.40%, and 8.50%, respectively. The mean 5-year overall survival rate was 38.90%. Osteonecrosis was noted in 11.6% of the 328 patients who received radiotherapy. In conclusion, RMT SCC is generally associated with high recurrence, low survival, and high postoperative complication rates. Early diagnosis and aggressive treatment are thus warranted. However, significant methodological problems hamper current knowledge. Future studies of this topic that use randomized or cohort designs are thus needed.

Cleft Lip and Palate Midfacial Hypoplasia: Criteria to Choose the Treatment

ABSTRACT

A series of skeletal and dentoalveolar/occlusal criteria were proposed for choosing the treatment modality for the management of midface hypoplasia in cleft lip/palate patients, focusing on functional improvement, aesthetics, and minimizing the risk of recurrence and secondary alterations. For which, 42 patients with nonsyndromic cleft lip/palate, all with previous primary lip/palate surgeries and without previous osteotomies, were analyzed. Orthognathic surgery (OS) (n = 24) and maxillary distraction osteogenesis (n = 18) with anterior segmental osteotomies (segmental distraction osteogenesis [SD]), alveolar transport disc (TD), and midface total distraction osteogenesis (TDO) by modified Le Fort III osteotomy was done.The average of maxillary advancement for OS was 5.58 ± 0.83 mm, for SD 9.4 ± 0.89 mm, for TD 8.00 ± 1.00 mm, and for TDO was 8.13 ± 1.55 mm.In the presence of infraorbital and/or zygomatic hypoplasia, TDO was performed using skeletal anchorage, with the requirement of occlusal stability in dental cast in occlusion. In short maxillary arch without dental cast feasibility in occlusion, hypodontia/agenesis or absence of premaxilla, TD and SD was performed. There was only 1 mm of recurrence in 1 patient of each group. Changes in speech were detected in 2 patients in the OS group (8.3%). Orthognathic surgery can be indicated for advancements ≤7 mm not requiring orbito-zygomatic advancement, whereas distraction osteogenesis can be indicated for advances >8 mm with or without the need for orbito-zygomatic advancement, in addition with other dentoalveolar factors and velopharyngeal function.

Cleft Lip and Palate: Le Fort I Distraction Using an Internal Device

Maxillary hypoplasia is a commonly seen dentofacial anomaly in patients with cleft lip and palate after surgical repair of the cleft anomaly. To facilitate large horizontal movements of the maxilla, distraction osteogenesis is used to slowly stretch the soft tissue envelope with the skeletal advancement preventing tissue recoil and skeletal relapse. Internal distraction devices have the advantage of reducing the amount of physical and psychological stress placed on patients, families, and caregivers. The technique has been successful in producing stable results for large advancements of the facial skeleton when compared with conventional Le Fort I advancement and fixation of the maxilla.

Bone-anchored maxillary protraction long-term outcomes in UCLP

This case report presents a 12-year-old boy with unilateral complete cleft lip and palate and severe maxillary retrusion treated with bone-anchored maxillary protraction (BAMP) therapy followed by fixed appliances. The follow-up period extended until the end of growth. Initially, the patient demonstrated a Goslon 4 interarch relationship with an overjet of -3.5 mm and a Wits appraisal of -7.9 mm. Six months after the secondary alveolar bone graft, Bollard miniplates were fixed bilaterally at the infrazygomatic region in the maxilla and between the canines and lateral incisors in the mandible. Class III elastics were used bilaterally full time for 12 months. After treatment, the overjet increased 5.9 mm. Significant maxillary advancement (SNA +3.2°) and skeletal convexity improvement (NA-APo +12.4°) were observed. Retrusion of the anteroposterior position of the mandible was observed (SNB -2.1°). Comprehensive orthodontic treatment was performed after BAMP therapy with nighttime bone-anchored Class III elastics as active retention until the end of growth. Occlusion and facial esthetics were satisfactory at the end of orthodontic treatment and growth. Le Fort I surgery for maxillary advancement was not required. BAMP therapy demonstrated an adequate orthopedic outcome, preventing the need for orthognathic surgery in unilateral complete cleft lip and palate.

Skeletal stability in patients with clefts after large maxillary advancements using intraoral distraction

Maxillary hypoplasia is a common outcome in patients with cleft lip and palate after surgical and orthodontic interventions, and maxillary distraction osteogenesis has become a useful procedure for patients with extensive maxillary deformities. The aim of this study was to evaluate long term (two years) stability after maxillary advancement of more than 10mm by distraction osteogenesis in cleft patients using internal devices. We organised a retrospective study on 42 patients with cleft lip and palate using cephalometric analysis before and after maxillary distraction osteogenesis and evaluated them for 24 months. Postoperative measurements showed a marked advancement with an increase of 13.3mm and 10.8° in the length of the maxilla (Co-A) and SNA, respectively, including a shift from Angle class III to class I in dental relations. Follow-up observations showed preservation of maxillary length with a relapse of only 6.0 % (mean (SD) 0.8 (0.7) mm) and 10% relapse in SNA angle (mean (SD)1.1 (1.4) °) one year postoperatively and a negligible regression at the two years' follow up. This large-scale study shows stable results of skeletal advancement using distraction osteogenesis, indicating safe and reliable outcomes among patients with cleft lip and palate.

How Is the Created Alveolar Space Finally Restored After Maxillary Anterior Segmental Distraction Osteogenesis?

OBJECTIVE

Maxillary anterior segmental distraction osteogenesis (MASDO) for cleft and palate patients is the alternative treatment option to correct malocclusion with maxillary arch deficiency and severe crowding. After MASDO, prosthetic considerations are crucial for patients with cleft lip and palate because it is related to facial esthetics and occlusal function. The objectives of this study were to investigate the final restoration type for created alveolar space by MASDO.

METHODS

Thirteen patients with cleft lip and palate who underwent MASDO and orthodontic treatment from the years 2000 to 2010 in Yonsei University were examined. Final restorations are classified as dental implants, conventional prosthesis, and orthodontic space closure. The relationship between the distracted areas and final restoration type was investigated. The authors evaluated lateral cephalograms obtained at predistraction osteogenesis (pre-DO; T1), postdistraction osteogenesis (post-DO; T2), and debond (T3), and measured changes from T1 to T2 and from T2 to T3.

RESULTS

There was no significant difference of final restoration percentage of dental implants, conventional prosthesis, and space closure with orthodontic treatment. However, dental implants and conventional prostheses were applied more frequently in the posterior area and in the anterior area, respectively. The relapse rate was observed as 36.7% and 22.4% in the values of N-A distance and ANB angulation in T2-T3 stage.

CONCLUSION

The MASDO site should be decided, based on final restoration goal. Among the created alveolar spaces, implants were applied mainly to the posterior site and the conventional prostheses were mostly restored to the anterior site. For space closure by orthodontic approach, the area could be both anterior or posterior.

Transversal Maxillary Distraction in Patients with Cleft Lip and Palate

OBJECTIVE

The aim of this study is to describe the importance of osteodistraction with transpalatal distractors for treating transversal maxillary hypoplasia in patients with cleft and lip palate.

METHODS

The participants were 17 patients (9 females and 8 males) with cleft lip and palate. Among these, 10 presented unilateral cleft lip and palate, 4 bilateral cleft lip and palate, and 3 cleft palate only.

RESULTS

All patients experienced a satisfactory palatal expansion and crossbite correction. The mean lengthening was 12.7 mm. The average increase of intercanine distance, intermolar distance, maxillary transverse dimension (MTD), facial transverse dimension (FTD) was 12.16, 8.45, 1.77, and 1.67 mm, respectively. The clinical follow-up was 29.7 months (range: 6-61 months).

CONCLUSION

Palatal distraction is a safe and successful alternative for treating maxillary transversal alterations in patients with cleft lip and palate. This technique facilitates the establishment of an adequate transverse dimension of maxillary, and consequently a proper dental occlusion.

Long-term stability after multidisciplinary treatment involving maxillary distraction osteogenesis, and sagittal split ramus osteotomy for unilateral cleft lip and palate with severe occlusal collapse and gingival recession: A case report

In this report, we describe a case involving a 34-year-old woman who showed good treatment outcomes with long-term stability after multidisciplinary treatment for unilateral cleft lip and palate (CLP), maxillary hypoplasia, severe maxillary arch constriction, severe occlusal collapse, and gingival recession. A comprehensive treatment approach was developed with maximum consideration of strong scar constriction and gingival recession; it included minimum maxillary arch expansion, maxillary advancement by distraction osteogenesis using an internal distraction device, and mandibular setback using sagittal split ramus osteotomy. Her post-treatment records demonstrated a balanced facial profile and occlusion with improved facial symmetry. The patient's profile was dramatically improved, with reduced upper lip retrusion and lower lip protrusion as a result of the maxillary advancement and mandibular setback, respectively. Although gingival recession showed a slight increase, tooth mobility was within the normal physiological range. No tooth hyperesthesia was observed after treatment. There was negligible osseous relapse, and the occlusion remained stable after 5 years of post-treatment retention. Our findings suggest that such multidisciplinary approaches for the treatment of CLP with gingival recession and occlusal collapse help in improving occlusion and facial esthetics without the need for prostheses such as dental implants or bridges; in addition, the results show long-term post-treatment stability.

Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients

BACKGROUND

Cleft lip and palate is one of the most common birth defects and can cause difficulties with feeding, speech and hearing, as well as psychosocial problems. Treatment of orofacial clefts is prolonged; it typically commences after birth and lasts until the child reaches adulthood or even into adulthood. Residual deformities, functional disturbances, or both, are frequently seen in adults with a repaired cleft. Conventional orthognathic surgery, such as Le Fort I osteotomy, is often performed for the correction of maxillary hypoplasia. An alternative intervention is distraction osteogenesis, which achieves bone lengthening by gradual mechanical distraction. This review is an update of the original version that was published in 2016.

OBJECTIVES

To provide evidence regarding the effects and long-term results of maxillary distraction osteogenesis compared to orthognathic surgery for the treatment of hypoplastic maxilla in people with cleft lip and palate.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 15 May 2018), Embase Ovid (1980 to 15 May 2018), and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; from 1982 to 15 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing maxillary distraction osteogenesis to conventional Le Fort I osteotomy for the correction of cleft lip and palate maxillary hypoplasia in non-syndromic cleft patients aged 15 years or older.

DATA COLLECTION AND ANALYSIS

Two review authors assessed studies for eligibility. Two review authors independently extracted data and assessed the risk of bias in the included studies. We contacted trial authors for clarification or missing information whenever possible. All standard methodological procedures expected by Cochrane were used.

MAIN RESULTS

We found six publications involving a total of 47 participants requiring maxillary advancement of 4 mm to 10 mm. All of them related to a single trial performed between 2002 and 2008 at the University of Hong Kong, but not all of the publications reported outcomes from all 47 participants. The study compared maxillary distraction osteogenesis with orthognathic surgery, and included participants from 13 to 45 years of age.Results and conclusions should be interpreted with caution given the fact that this was a single trial at high risk of bias, with a small sample size.The main outcomes assessed were hard and soft tissue changes, skeletal relapse, effects on speech and velopharyngeal function, psychological status, and clinical morbidities.Both interventions produced notable hard and soft tissue improvements. Nevertheless, the distraction group demonstrated a greater maxillary advancement, evaluated as the advancement of Subspinale A-point: a mean difference of 4.40 mm (95% CI 0.24 to 8.56) was recorded two years postoperatively.Horizontal relapse of the maxilla was significantly less in the distraction osteogenesis group five years after surgery. A total forward movement of A-point of 2.27 mm was noted for the distraction group, whereas a backward movement of 2.53 mm was recorded for the osteotomy group (mean difference 4.8 mm, 95% CI 0.41 to 9.19).No statistically significant differences could be detected between the groups in speech outcomes, when evaluated through resonance (hypernasality) at 17 months postoperatively (RR 0.11, 95% CI 0.01 to 1.85) and nasal emissions at 17 months postoperatively (RR 3.00, 95% CI 0.14 to 66.53), or in velopharyngeal function at the same time point (RR 1.28, 95% CI 0.65 to 2.52).Maxillary distraction initially lowered social self-esteem at least until the distractors were removed, at three months postoperatively, compared to the osteotomy group, but this improved over time and the distraction group had higher satisfaction with life in the long term (two years after surgery) (MD 2.95, 95% CI 014 to 5.76).Adverse effects, in terms of clinical morbidities, included mainly occlusal relapse and mucosal infection, with the frequency being similar between groups (3/15 participants in the distraction osteogenesis group and 3/14 participants in the osteotomy group). There was no severe harm to any participant.

AUTHORS' CONCLUSIONS

This review found only one small randomised controlled trial concerning the effectiveness of distraction osteogenesis compared to conventional orthognathic surgery. The available evidence is of very low quality, which indicates that further research is likely to change the estimate of the effect. Based on measured outcomes, distraction osteogenesis may produce more satisfactory results; however, further prospective research comprising assessment of a larger sample size with participants with different facial characteristics is required to confirm possible true differences between interventions.

A case of cleft lip and palate with severe maxillary retrognathism treated by distraction osteogenesis and custom made intraoral rapid maxillary expansion appliance: A 2-year follow-up of retention

Herewith, a case is reported of an adolescent female patient with maxillary retrognathism due to restricted growth arising out of the previous cheiloplasty and palatoplasty surgeries treated for cleft lip and palate. She also presented an oroantral fistula in the scarred tissues of the palatal region. There was anterior crossbite and distorted occlusion in the anterior segment with crowding and open bite. There is maxillomandibular discrepancy of 6 degrees°. The distraction osteogenesis was performed so as treat the maxillary hypoplasia. This allows undermanding adaptation of the soft-tissue structures to the modification in the skeletal structures as a result of surgical procedures and ensures long-term stability. A custom made intraoral rapid maxillary expansion device was prepared utilizing the hyrax screw for the distraction of the bony segments. At the end of the treatment and a retention period of 24 months, the patient exhibited improved facial profile and hence esthetics.

Marginal or segmental mandibulectomy: treatment modality selection for oral cancer: a systematic review and meta-analysis

Surgery is the most well established mode of initial definitive treatment for the majority of oral cancers. The most important decision in terms of tumour ablation in oral cancers when the jaws are potentially involved is the management of the mandible. The aim of this study was to explore the differences in survival rate and disease control between patients undergoing marginal mandibulectomy and patients undergoing segmental mandibulectomy using a systematic review and meta-analysis approach. A total of 15 cohort studies, including 1672 participants, were identified. Meta-analysis provided weak evidence in favour of segmental mandibulectomy for local control. Segmental mandibulectomy gave 73% better disease-free survival than marginal mandibulectomy when the marrow was invaded (P=0.04). The overall survival rate was evaluated, and no statistically significant difference was found between the two different mandibulectomy approaches, although the results showed a trend in favour of segmental mandibulectomy which could increase the overall survival by 23%. Based on these findings regarding the survival rate and efficacy of disease control, this study indicates that a marginal mandibulectomy may be recommended for cases with no invasion or superficial invasion of the mandibular cortex, and a segmental mandibulectomy may be a more reasonable choice for patients with extensive mandibular cortex invasion or medullary invasion.

Profile Changes and Stability following Distraction Osteogenesis with Rigid External Distraction in Adult Cleft Lip and Palate Deformities

OBJECTIVES

The objective of this study is to analyze the hard and soft-tissue profile changes as well as the upper airway changes after distraction osteogenesis (DO) using rigid external distraction device in adult cleft lip and palate (CLP) patients. The study also evaluates the stability of the surgical result.

MATERIALS AND METHODS

Three lateral cephalometric radiographs were taken: Predistraction (T1), postdistraction (T2), and 1 year after distractor removal (T3). The treatment changes (T1 vs. T2) and the stability (T2 vs. T3) were analyzed. The overall treatment changes after 1 year were also evaluated (T1 vs. T3). The lateral cephalograms were digitally analyzed with the help of software named Dolphin.

STATISTICAL ANALYSIS USED

Wilcoxon Signed-Ranks test was used, and the probability value (P value) of 0.05 was considered as statistically significant level.

RESULTS

Eleven adult patients with CLP were retrospectively analyzed. After distraction, there was a significant mean maxillary advancement of 14 mm (P < 0.01) from a T1 value of 73.54 ± 10.38 to a T2 value of 88.2 ± 10.49. The lower facial height and the incisor exposure were significantly increased. The nasolabial angle had a significant improvement of 24.5° (P < 0.01) from a T1 value of 56.6 ± 21.03 to a T2 value of 81.18 ± 14.4.The upper airway was significantly improved by 3.7 mm (P < 0.01) with a T1 value of 13.5 ± 3.8 to a T2 value of 17.2 ± 3.66. After 1-year follow-up, there was a significant maxillary relapse of 3.20 mm (P < 0.05) from a T2 value of 8.29 ± 6.84 to a T3 value of 5.09 ± 5.59. However, the soft-tissue profile and upper airway remained stable.

CONCLUSION

The clinician should have an understanding of the related hard and soft tissues as well as airway changes which may assist him when planning for maxillary advancement for CLP patients with DO. There were significant improvements immediately after distraction, but during the 1-year follow-up, some relapse was seen. This stressed on the need for overcorrection of about 35%-40% for adult CLP patients.

Root resorption during orthodontic treatment with self-ligating or conventional brackets: a systematic review and meta-analysis

Background

The aim of this study was to compare the external apical root resorption (EARR) in patients receiving fixed orthodontic treatment with self-ligating or conventional brackets.

Methods

Studies comparing the EARR between orthodontic patients using self-ligating or conventional brackets were identified through electronic search in databases including CENTRAL, PubMed, EMBASE, China National Knowledge Infrastructure (CNKI) and SIGLE, and manual search in relevant journals and reference lists of the included studies until Apr 2016. The extraction of data and risk of bias evaluation were conducted by two investigators independently. The original outcome underwent statistical pooling by using Review Manager 5.

Results

Seven studies were included in the systematic review, out of which, five studies were statistically pooled in meta-analysis. The value of EARR of maxillary central incisors in the self-ligating bracket group was significantly lower than that in the conventional bracket group (SMD −0.31; 95% CI: −0.60–−0.01). No significant differences in other incisors were observed between self−ligating and conventional brackets.

Conclusions

Current evidences suggest self-ligating brackets do not outperform conventional brackets in reducing the EARR in maxillary lateral incisors, mandible central incisors and mandible lateral incisors. However, self-ligating brackets appear to have an advantage in protecting maxillary central incisor from EARR, which still needs to be confirmed by more high-quality studies.

Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients

BACKGROUND

Cleft lip and palate is one of the most common birth defects and can cause difficulties with feeding, speech and hearing, as well as psychosocial problems. Treatment of orofacial clefts is prolonged; it typically commences after birth and lasts until the child reaches adulthood or even into adulthood. Residual deformities, functional disturbances, or both, are frequently seen in adults with a repaired cleft. Conventional orthognathic surgery, such as Le Fort I osteotomy, is often performed for the correction of maxillary hypoplasia. An alternative intervention is distraction osteogenesis, which achieves bone lengthening by gradual mechanical distraction.

OBJECTIVES

To provide evidence regarding the effects and long-term results of maxillary distraction osteogenesis compared to orthognathic surgery for the treatment of hypoplastic maxilla in people with cleft lip and palate.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 16 February 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 1), MEDLINE Ovid (1946 to 16 February 2016), Embase Ovid (1980 to 16 February 2016), LILACS BIREME (1982 to 16 February 2016), the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) (to 16 February 2016), and the World Health Organization (WHO) International Clinical Trials Registry Platform (to 16 February 2016). There were no restrictions regarding language or date of publication in the electronic searches. We performed handsearching of six speciality journals and we checked the reference lists of all trials identified for further studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing maxillary distraction osteogenesis to conventional Le Fort I osteotomy for the correction of cleft lip and palate maxillary hypoplasia in non-syndromic cleft patients aged 15 years or older.

DATA COLLECTION AND ANALYSIS

Two review authors assessed studies for eligibility. Two review authors independently extracted data and assessed the risk of bias in the included studies. We contacted trial authors for clarification or missing information whenever possible. All standard methodological procedures expected by Cochrane were used.

MAIN RESULTS

We found six publications involving a total of 47 participants requiring maxillary advancement of 4 mm to 10 mm. All of them related to a single trial performed between 2002 and 2008 at the University of Hong Kong, but not all of the publications reported outcomes from all 47 participants. The study compared maxillary distraction osteogenesis with orthognathic surgery, and included participants from 13 to 45 years of age.Results and conclusions should be interpreted with caution given the fact that this was a single trial at high risk of bias, with a small sample size.The main outcomes assessed were hard and soft tissue changes, skeletal relapse, effects on speech and velopharyngeal function, psychological status, and clinical morbidities.Both interventions produced notable hard and soft tissue improvements. Nevertheless, the distraction group demonstrated a greater maxillary advancement, evaluated as the advancement of Subspinale A-point: a mean difference of 4.40 mm (95% CI 0.24 to 8.56) was recorded two years postoperatively.Horizontal relapse of the maxilla was significantly less in the distraction osteogenesis group five years after surgery. A total forward movement of A-point of 2.27 mm was noted for the distraction group, whereas a backward movement of 2.53 mm was recorded for the osteotomy group (mean difference 4.8 mm, 95% CI 0.41 to 9.19).No statistically significant differences could be detected between the groups in speech outcomes, when evaluated through resonance (hypernasality) at 17 months postoperatively (RR 0.11, 95% CI 0.01 to 1.85) and nasal emissions at 17 months postoperatively (RR 3.00, 95% CI 0.14 to 66.53), or in velopharyngeal function at the same time point (RR 1.28, 95% CI 0.65 to 2.52).Maxillary distraction initially lowered social self-esteem at least until the distractors were removed, at three months postoperatively, compared to the osteotomy group, but this improved over time and the distraction group had higher satisfaction with life in the long term (two years after surgery) (MD 2.95, 95% CI 014 to 5.76).Adverse effects, in terms of clinical morbidities, included mainly occlusal relapse and mucosal infection, with the frequency being similar between groups (3/15 participants in the distraction osteogenesis group and 3/14 participants in the osteotomy group). There was no severe harm to any participant.

AUTHORS' CONCLUSIONS

This review found only one small randomised controlled trial concerning the effectiveness of distraction osteogenesis compared to conventional orthognathic surgery. The available evidence is of very low quality, which indicates that further research is likely to change the estimate of the effect. Based on measured outcomes, distraction osteogenesis may produce more satisfactory results; however, further prospective research comprising assessment of a larger sample size with participants with different facial characteristics is required to confirm possible true differences between interventions.

Does Medullary Versus Cortical Invasion of the Mandible Affect Prognosis in Patients With Oral Squamous Cell Carcinoma?

PURPOSE

Whether mandibular involvement by oral squamous cell carcinoma (OSCC) could be identified as a factor for cancer staging and prognosis prediction remains a subject of debate. In addition, the influence of different types of mandibular invasion (cortical or medullary invasion) on patients' prognosis remains unclear. The aim of this systematic review was to establish whether mandibular invasion or its subset should be considered an independent prognostic factor for patients with OSCC.

MATERIALS AND METHODS

The search for eligible studies was performed according to the predesigned inclusion criteria for a systematic review. Mandibular invasion and invasion depth were considered the primary and secondary predictor variables, respectively. The electronic search was performed using 12 databases. Manual searching covered 14 related journals and references of the included studies were scanned. The risk of bias assessment was evaluated by 2 reviewers using risk-of-bias assessment tools recommended by Saltaji et al (Angle Orthod 82:1115, 2012). Two reviewers extracted the data in duplicate. RevMan 5.2 was used for meta-analysis to assess the primary outcomes (disease-free survival and overall survival) and the secondary outcomes (2- and 5-year survival rate and local control).

RESULTS

Eighteen studies (total, 3,756 participants) were included and used as the study sample. Among these included studies, 7 had an unclear risk of bias and the remaining showed a high risk. The results of the meta-analyses showed a significant relation between mandibular invasion and overall survival (P = .04) and, most importantly, that medullary involvement (P = .0001), but not cortical involvement (P = .66), could decrease overall survival. When focusing on disease-specific survival, mandibular medullary involvement predicted a poor disease-specific survival (P < .0001), but cortical involvement showed no effect (P = .66).

CONCLUSION

This review showed that OSCC mandibular medullary invasion, and not mandibular invasion or mandibular cortical invasion, could be an independent prognostic factor for patients.

Perpendicular serial maxillary distraction osteogenesis in cleft lip and palate patients

BACKGROUND

Cleft lip and palate patients often have a retruded maxilla with a severely narrowed deficient maxillary arch. This report aims to describe the management of severe maxillary retrusion and constriction in cleft lip and palate patients using distraction osteogenesis applied in serial sequence in two directions perpendicular to each other.

MATERIALS AND METHODS

Two adult male cleft lip and palate patients were treated with maxillary distraction osteogenesis in two stages. In the first stage, surgically assisted rapid palatal expansion with a tooth-borne device was performed to significantly expand the maxillary arch in the transverse dimension. After the teeth were orthodontically aligned, the horizontal distraction of the maxilla was made by two internal maxillary distraction devices.

RESULTS

In the first patient, the maxilla was initially widened by 11 mm and then distracted forward by 20 mm. Despite the breakage of the shaft of one of the two distractors at the end of distraction, a satisfactory occlusion was found at the time of distractor device removal. The maxillary position has remained stable through 8 years of follow-up. In the second patient, the palate was widened by 14 mm and the maxilla was distracted forward by 22 mm. The maxillary position has remained stable through 3 years of follow-up.

CONCLUSION

Sequential serial distraction of maxilla in two planes perpendicular to each other is a safe and stable approach for the treatment of cleft lip and palate patients with severe transverse and anteroposterior discrepancies.

Stability after Cleft Maxillary Distraction Osteogenesis or Conventional Orthognathic Surgery

OBJECTIVES

To compare stability of maxillary advancements in patients with cleft lip and palate following distraction osteogenesis or orthognathic surgery.

MATERIAL AND METHODS

INCLUSION CRITERIA

1) cleft lip and palate, 2) advancement > 8 mm. Eleven patients comprised the distraction osteogenesis group (DOG). Seven patients comprised the orthognathic treatment group (CONVG). Skeletal and soft tissue points were traced on lateral cephalograms: T1 (preoperatively), T2 (after surgery), T3 (follow-up). Group differences were analyzed using Students t-test.

RESULTS

At T1-T2, advancement of 6.98 mm (P = 0.002) was observed in DOG. Horizontal overjet increased 11.62 mm (P = 0.001). A point-nasion-B point (ANB) angle increased 8.82° (P = 0.001). Aesthetic plane to upper lip was reduced 5.44 mm (P = 0.017) and the naso-labial angle increased 16.6° (P = 0.001). Vertical overbite (VOB) increased 2.27 mm (P = 0.021). In T2-T3, no significant changes were observed in DOG. In T1-T2, horizontal overjet increased 8.45 mm (P = 0.02). The ANB angle, 9.33° (P = 0.009) in CONVG. At T2-T3, VOB increased, 2.35 mm (P = 0.046), and the ANB angle reduced, 3.83° (P = 0.003). In T2-T3, no parameters changed in CONVG. At follow-up (T3), VOB increased in CONVG compared with DOG, (P = 0.01). Vertical position of A point differed between the groups (P = 0.04). No significant intergroup differences between soft tissue parameters occurred.

CONCLUSIONS

Distraction osteogenesis resulted in a stable position of the maxilla and movement upwards in vertical plane, however in case of orthognathic treatment sagittal relapse and a continued postoperatively downward movement was registered.

Distraction osteogenesis and orthognathic surgery for a patient with unilateral cleft lip and palate

Maxillary deficiency is a common feature in patients with repaired cleft lip and palate. Orthognathic surgery has been the conventional approach for the management of cleft-related maxillary hypoplasia. However, for patients with a severe maxillary deficiency, orthognathic surgery alone has many disadvantages, such as high relapse rates of 25% to 40%, instability, limited amount of advancement, and a highly invasive surgical technique. As an alternative treatment method, distraction osteogenesis has been used successfully in the distraction of the mandible, the maxilla, the entire midface, and the orbits as well as the cranial bones, with stable outcomes. The type of distraction device, either external or internal, can be chosen based on the surgical goals set for the patient. In this study, we report on the use of a rigid external distraction device for maxillary advancement in a 22-year-old woman with a repaired unilateral cleft lip and palate and severe maxillary hypoplasia. After the distraction osteogenesis, 2-jaw surgery was performed to correct the maxillary yaw deviation and the mandibular prognathism.

Biomechanical comparison of two intraoperative mobilization techniques for maxillary distraction osteogenesis: Down-fracture versus non-down-fracture

Purposes:

The purpose of this study was to compare the distraction forces and the biomechanical effects between two different intraoperative surgical procedures (down-fracture [DF] and non-DF [NDF]) for maxillary distraction osteogenesis.

Materials and Methods:

Eight patients were assigned into two groups according to the surgical procedure: DF, n = 6 versus NDF, n = 2. Lateral cephalograms taken preoperatively (T1), immediately after removal of the distraction device (T2), and after at least a 6 months follow-up period (T3) were analyzed. Assessment of distraction forces was performed during the distraction period. The Mann–Whitney U-test was used to compare the difference in the amount of advancement, the maximum distraction force and the amount of relapse.

Results:

Although a significantly greater amount of maxillary movement was observed in the DF group (median 9.5 mm; minimum-maximum 7.9-14.1 mm) than in the NDF group (median 5.9 mm; minimum-maximum 4.4-7.6 mm), significantly lower maximum distraction forces were observed in the DF (median 16.4 N; minimum-maximum 15.1-24.6 N) than in the NDF (median 32.9 N; minimum-maximum 27.6-38.2 N) group. A significantly greater amount of dental anchorage loss was observed in the NDF group. Moreover, the amount of relapse observed in the NDF group was approximately 3.5 times greater than in the DF group.

Conclusions:

In this study, it seemed that, the use of the NDF procedure resulted in lower levels of maxillary mobility at the time of the maxillary distraction, consequently requiring greater amounts of force to advance the maxillary bone. Moreover, it also resulted in a reduced amount of maxillary movement, a greater amount of dental anchorage loss and poor treatment stability.

Submandibular Gland Transfer for the Prevention of Postradiation Xerostomia in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis

<b><i>Background:</i></b> Submandibular gland transfer has been widely used to prevent postradiation xerostomia in head-and-neck cancers. However, there are still some controversies. <b><i>Methods:</i></b> Six databases were searched, data extraction was performed and the risk of bias was assessed by 2 reviewers independently. The meta-analysis was performed using Review Manager, version 5.2. <b><i>Results:</i></b> A total of 7 trials (12 articles) and 369 participants were included. <b><i>Conclusions:</i></b> The present clinical evidence suggests that submandibular gland transfer might be highly effective to prevent postradiation xerostomia in head-and-neck cancers without serious adverse events. However, more randomized controlled trials are still needed to confirm this conclusion.

Orthodontic considerations for maxillary distraction osteogenesis in growing patients with cleft lip and palate using internal distractors

The orthodontist plays a key role in the selection of the optimal treatment for patients followed by a craniofacial team. For patients with cleft lip and palate, the need for multidisciplinary treatment planning and sequentially staged treatment is essential for successful patient outcomes. The technique of Le Fort I distraction osteogenesis of the maxilla using an internal device is potentially a predictable, stable, and convenient option for the correction of severe maxillary hypoplasia. It is an alternative option for treatment of maxillary hypoplasia in growing patients. In this article, the authors describe the orthodontist's approach to the management of cleft patients with severe maxillary deficiency with the use of an internal distraction device. The information is presented with a focus on the clinical aspects of treatment, using case illustrations and appropriate literature.

Analysis of genetic regulation and cytokine expressions of distraction osteogenesis reconstruction for cleft palate

Because cleft palate (CP) is one of the most common congenital deformities, surgeons have tried for longtime to achieve an ideal reconstruction of the palatal bone defects and restoration of muscle attachments. In this study, a new CP model on rhesus was established and corrected by an approach of distraction osteogenesis (DO), and then quantitative studies of regulation of osteogenesis genes and expression of alkaline phosphatase (ALP), insulin-like growth factor-I (IGF-I), osteopontin (OPN), and osteocalcin (OC) in different phases of new bone formation were preformed. The CP models (23 animals) were established surgically. In the experimental group (21 animals), the tissue defects were repaired by means of DO at the rhythm of 0.4 mm twice per day. The specimens were retrieved in 1, 2, 4, 6, 8, 12, and 24 weeks (3 animals each) after completion of distraction. The IGF-I, ALP, OPN, and OC messenger RNA (mRNA) were detected by real-time reverse transcription polymerase chain reaction, and their proteins were then analyzed by enzyme-linked immunosorbent assay tests. The results are compared with those of the experimental control and empty control groups (2 animals each). In the distraction gap, the mRNA and protein expressions levels of IGF-I and ALP were both highly upregulated and reaching apex in the early phase of new bone formation. Otherwise, the mRNA and protein expressions of OPN and OC demonstrated high level during intermediate and later remodeling stages. These results suggest that the reconstruction of CP bone defect by means of DO could get definitely intramembraneous new bone formation and eventually quite normal bone structure via consecutive remodeling in situ.

LeFort I Osteotomy

The LeFort I osteotomy is one of the most commonly used procedures to correct midface deformities. It allows for correction in three dimensions including advancement, retrusion, elongation, and shortening. It is indicated, often in conjunction with mandibular surgery, for class II and III malocclusion, facial asymmetry, obstructive sleep apnea, and maxillary atrophy. Before surgery, proper orthodontics and surgical planning should be undertaken to ensure adequate outcomes. Overall, the surgery is widely used due to its low complication profile and reliable long-term results.

Treatment of midfacial hypoplasia in syndromic and cleft lip and palate patients by means of a rigid external distractor (RED)

INTRODUCTION: Distraction Osteogenesis (DO) became an alternative for the treatment of severe craniofacial skeletal dysplasias. The rigid external distraction device (RED) is successfully used to advance the maxilla and all the maxillary-orbital-frontal complex (monobloc) in children, adolescents and adults. This approach provides predictable and stable results, and it can be applied alone or with craniofacial orthognathic surgical procedures. OBJECTIVE: In the present article, the technical aspects relevant to an adequate application of the RED will be described, including the planning, surgical and orthodontic procedures.