Maxillary Advancement With Conventional Orthognathic Surgery in Patients With Cleft Lip and Palate: Is It a Stable Technique?

PhD Graduate Student, Orthodontic Graduate Program, University of Alberta Faculty of Medicine and Dentistry, Edmonton, AB, Canada.
Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons (Impact Factor: 1.58). 06/2012; 70(12). DOI: 10.1016/j.joms.2012.03.009
Source: PubMed

ABSTRACT PURPOSE: To evaluate the long-term skeletal stability after maxillary surgical advancement with conventional Le Fort I osteotomy in patients with cleft lip and palate by a systematic review of the published data. MATERIALS AND METHODS: Electronic databases, "gray literature," and reference list searches were conducted. The inclusion criteria were the stability of maxillary surgical advancement with conventional Le Fort I osteotomy fixed with plates and assessed at the post-treatment follow-up 1 year or more postoperatively in patients with cleft lip and/or palate. Full reports were retrieved from abstracts or titles that appeared to meet the inclusion criteria or lacked sufficient detail for immediate exclusion. Once full reports were collected, they were again reviewed, considering more detailed inclusion criteria for a final selection decision. A methodologic quality assessment tool was used. The quantity and quality of the obtained data precluded a meta-analytic approach. RESULTS: A total of 25 abstracts/titles met the initial search criteria, and 10 studies were finally selected. The overall methodologic quality scores were high for only 1 randomized clinical trial. After maxillary advancement with Le Fort I in patients with cleft lip and palate, the long-term horizontal relapse at the A-point was 20% to 30% in 4 studies and 30% to 40% in 3 studies. In addition, vertical relapse was more than 50% in 4 studies. The study judged as a high-quality study reported a 37% rate of horizontal relapse and a 65% rate of vertical relapse at the A-point. CONCLUSIONS: Current evidence suggests maxillary surgical advancement with conventional Le Fort I osteotomy in patients with cleft lip and palate appears to show a moderate relapse rate in the horizontal plane and a high relapse rate in the vertical plane.

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    ABSTRACT: Patients with cleft lip and palate frequently develop dento-facial deformity requiring orthognatic surgery. The origin of this deformity is therapeutic and surgeons are currently trying to prevent this iatrogenicity. The maxillary dento-facial deformity in these patients is a retrognathia with infragnathia, associated with endognathia, obliquity of the occlusal plane, with deviation of the superior incisive midline in case of unilateral clefts. The difficulties in the treatment of these skeletal deformities are due to the palatal, labial, and pterygomaxillary scar tissue. Orthognathic surgery is most of the time bimaxillary with a 3-dimensional movement of the jaws including maxillary advancement. The aims of surgery are occlusal, esthetic, and functional improvement. The first step is gingivoperiosteoplasty (ideally performed during childhood), orthodontic treatment including, if necessary, transversal maxillary distraction to obtain enough space to replace the lateral incisor; extraction of premolars should be avoided if possible. Planning and performing the treatment are difficult for the orthodontist and for the surgeon. Maxillary advancement by distraction may be an interesting alternative to prevent partial relapse. Obtaining normal oro-facial functions are required for a stable result. These should be monitored after the primary treatment by the whole staff, surgeons, speech therapist, and orthodontists. Performing Le Fort 1 osteotomy is more difficult than in other patients because of scar fibrosis than needs to be released.
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    Journal of Craniofacial Surgery 10/2014; 25(6). DOI:10.1097/SCS.0000000000001098 · 0.68 Impact Factor
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    ABSTRACT: Cleft lip and palate affects roughly 1 in 600 children and predisposes patients to a lifetime of functional and esthetic discrepancies. Disparities in access as well as quality of care exist worldwide, with many children in developing countries unable to receive treatment. In the late 20th century, humanitarian medical missions emerged as a means of delivering surgical expertise to patients in resource-limited settings. These early missions took on a patient-centered approach focused solely on cleft repair, with little emphasis on treating the dental abnormalities that arose after the initial surgery. However, modern cleft care is characterized by a multidisciplinary, team-based approach with significant dental involvement. Recent cleft lip and palate endeavors have shifted from a mission-based approach to a developmental approach facilitating growth of an independent care center. This strategy focuses on creating an institution with expanded access to dental services, thus facilitating the long-term treatment inherent in modern cleft care. One clinic in a developing country that has experienced successful transitioning from a mission site to an independent craniofacial clinic is Operation Smile's Cleft Comprehensive Care Clinic in Guwahati, India. This article will summarize the rationale and planning of the clinic, underscore the team-based approach required in longitudinal treatment of cleft lip and palate, and demonstrate how treatment methodology may differ in resource-limited settings by outlining the therapeutic considerations of each provider in the Guwahati Clinic.
    Journal of Craniofacial Surgery 08/2014; 25(5). DOI:10.1097/SCS.0000000000001118 · 0.68 Impact Factor


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May 27, 2014