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

Article (PDF Available)inJournal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 70(12) · June 2012with129 Reads
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.
J Oral Maxillofac Surg
70:2859-2866, 2012
Maxillary Advancement With Conventional
Orthognathic Surgery in Patients With Cleft
Lip and Palate: Is It a Stable Technique?
Humam Saltaji, DDS, MSc Ortho,*
Michael P. Major, DMD, GPR,†
Hussam Alfakir, DDS, MSc Ortho,‡
Mohammed A.Q. Al-Saleh, BDS, MSc, (TMD/OFP),§ and
Carlos Flores-Mir, DDS, Cert Ortho, DSc, FRCD(C)
Purpose: To evaluate the long-term skeletal stability after maxillary surgical advancement with con-
ventional 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 conven-
tional 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.
© 2012 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 70:2859-2866, 2012
Orthognathic surgery is usually the final phase of
treatment for patients with cleft lip and palate (CLP).
More than 25% of patients with CLP develop a signif-
icant maxillary hypoplasia that requires surgical inter-
vention, and maxillary osteotomy is, therefore, most
commonly performed for these patients.
1,2
The tradi-
tional surgical procedure for correcting associated
maxillary retrusion is a Le Fort I osteotomy.
3
The treatment of maxillary hypoplasia in patients
with CLP is challenging, because conventional maxil-
*PhD Graduate Student, Orthodontic Graduate Program, Univer-
sity of Alberta Faculty of Medicine and Dentistry, Edmonton, AB,
Canada.
†MSc Graduate Student, Orthodontic Graduate Program, Univer-
sity of Alberta Faculty of Medicine and Dentistry, Edmonton, AB,
Canada.
‡Certified Specialist in Orthodontics, Edmonton, AB, Canada.
§PhD Graduate Student, Orthodontic Graduate Program, Univer-
sity of Alberta Faculty of Medicine and Dentistry, Edmonton, AB,
Canada.
Associate Professor and Head, Division of Orthodontics, Univer-
sity of Alberta Faculty of Medicine and Dentistry, Edmonton, AB,
Canada.
Address correspondence and reprint requests to Dr Saltaji: Orth-
odontic Graduate Program, University of Alberta Faculty of Medi-
cine and Dentistry, 5528 Edmonton Clinic Health Academy, Edmon-
ton, AB T6G 1C9 Canada; e-mail: saltaji@ualberta.ca
© 2012 American Association of Oral and Maxillofacial Surgeons
0278-2391/12/7012-0$36.00/0
http://dx.doi.org/10.1016/j.joms.2012.03.009
2859
lary osteotomy might not be stable.
4
Surgical relapse
is more frequent in patients with cleft than in those
without cleft owing to the increased soft tissue ten-
sions caused by scar contracture.
5
The possibility of
incomplete surgical success or postoperative relapse
is significant, because it could complicate the opera-
tive results and return the patient to an unacceptable
functional and esthetic result.
1,2
Although some studies have reported a high rate of
horizontal skeletal relapse after Le Fort I osteot-
omy,
1,6,7
a data review of cleft maxillary osteotomy
and distraction osteogenesis found that the Le Fort I
osteotomy had good short-term stability and achieved
a pronounced improvement in velopharyngeal func-
tion and speech.
8
To evaluate the effectiveness of any technique, it
is important to assess not only the immediate
postintervention effects, but also the long-term ef-
fects and occurrence of relapse. Although a data
review of cleft maxillary osteotomy has already
been published,
8
that review assessed the postint-
ervention effects but did not consider the long-term
stability. Additionally, it was published in 2006;
thus, new data might have become available that
could challenge its conclusions. The objectives of
the present report were, therefore, to systemati-
cally review the long-term skeletal stability after
maxillary surgical advancement with conventional
Le Fort I osteotomy fixed with plates in patients
with CLP and to update previous evidence-based
recommendations with new findings.
Materials and Methods
The research design of our report was a system-
atic review of the published data. The reporting of
this systematic review was based on the Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement for reporting system-
atic reviews of studies that evaluate health care
interventions.
9
No ethics approval was required for
this research, because there was no human or ani-
mal intervention.
DATA SOURCES AND SEARCHES
Electronic searches up to December 12, 2011, were
conducted using the following electronic biblio-
graphic databases: PubMed (1966 to December 2011,
week 2), MEDLINE (1980 to 2011, week 52); EMBASE
(1980 to 2011, week 52); ISI Web of Science (1965 to
December 9, 2011); Evidence-Based Medicine Re-
views–Cochrane Central Register of Controlled Trials
(1991 to fourth quarter of 2011); All Evidence-Based
Medicine Reviews, comprising the Cochrane Data-
base of Systematic Reviews, American College of Phy-
sicians Journal Club, Database of Abstracts of Reviews
of Effects (1991 to fourth quarter of 2011); and Health
STAR (1966 to November 2011). The key words used
in the search were “cleft,” “maxillary osteotomy,” “Le
Fort osteotomy,” “relapse,” “stability,” “recurrence,”
and “follow-up studies.” The details of the specific
search terms and combinations used in each individ-
ual database are listed in Table 1.
The electronic searches were developed with the
assistance of a librarian specializing in health science
databases. In addition, the data search also involved
searches through the bibliographies of the relevant
publications. No restrictions were applied regarding
publication year or language. The references resulting
from the searches were entered in EndNote X4, and
within this program, duplicates were electronically
removed. When additional information was needed,
efforts were made to contact the investigators.
STUDY SELECTION
The appropriate studies to be included fulfilled the
following predefined inclusion criteria:
Population: Patients with Cleft lip and/or palate
Intervention: Surgical therapy of maxillary hypopla-
sia with conventional Le Fort I osteotomy fixed with
plates
Outcome: Stability of the outcome assessed at least
12 months after treatment
Study design: Randomized and nonrandomized con-
trolled clinical trials, clinical trials, case series studies,
and prospective and retrospective studies were in-
cluded; however, case reports with 5 or fewer sub-
jects, animal studies, systematic reviews, meta-analy-
ses, and editorials were excluded
Two researchers independently reviewed the list of
titles and abstracts for inclusion. Once potentially
adequate abstracts were selected, the full reports
were retrieved in a second final selection process. If
the abstract was judged to contain insufficient infor-
mation for a decision of inclusion or exclusion, the
full report was obtained and reviewed before a final
decision was made. Any discrepancies in the inclu-
sion of reports between researchers were addressed
through discussion until a consensus was reached.
DATA EXTRACTION AND METHODOLOGIC
QUALITY ASSESSMENT
To perform an analysis of the included studies, the
data were collected for each selected study for the
following items: study design, age, sample size, cleft
type, fixation, follow-up period, and mean movement
and mean relapse in the horizontal and vertical dimen-
sions (Table 2). In addition, to evaluate the methodo-
logic quality of each study, a methodologic quality
assessment was performed by analyzing the study
design, study measurements, and statistical analysis
for each selected study (Table 3). The scoring process
2860
MAXILLARY ADVANCEMENT AND CLEFT LIP/PALATE
was a modified version of a previously developed
checklist used in a systematic review published by 1
of us.
10
Each study was scored by the same 2 investi-
gators, and discrepancies were resolved by discussion
until a consensus was reached. The maximum quality
score possible was 19. A meta-analysis was planned if
the quality of the information retrieved warranted a
meaningful statistical combination.
Results
The search strategy returned 221 potential studies
for inclusion. The search results from different elec-
tronic databases are listed in Table 1.
Of the 221 abstracts, 25 full studies were retrieved
for a more detailed evaluation. Of the 25 full reports
retrieved, only 10 studies
1,6,7,11-17
fulfilled the final
Table 1. SEARCH STRATEGIES AND RESULTS FROM DIFFERENT ELECTRONIC DATABASES
Database Keywords Results
PubMed 1. Relaps* OR recurr* OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
178
MEDLINE 1. Relaps$ OR recurr$ OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
22
Embase 1. Relaps$ OR recurr$ OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
17
ISI Web of Science 1. Relaps$ OR recurr$ OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
65
EMB Reviews-Cochrane Central Register of
Controlled Trials
1. Relaps$ OR recurr$ OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
2
EMB Reviews-Cochrane Database of
Systematic Reviews, Database of Abstracts
of Reviews of Effects, and American College
of Physicians Journal Club
1. Relaps$ OR recurr$ OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
0
HealthSTAR 1. Relaps$ OR recurr$ OR stability OR follow-up
studies
2. Maxillary osteotomy OR Le Fort osteotomy OR Le
Fort I osteotomy
3. Cleft OR cleft palate OR cleft lip palate
4. 1 AND 2 AND 3
19
Total Electronic Databases Searches 303
Duplicates 82
Final 221
Abbreviation: EBM, evidence-based medicine.
Saltaji et al. Maxillary Advancement and Cleft Lip/Palate. J Oral Maxillofac Surg 2012.
SALTAJI ET AL 2861
Table 2. DESCRIPTION OF STUDIES INCLUDED IN FINAL SELECTION
Study
Study Design,
Age (yr)
Sample Size,
Cleft Type Fixation
Postoperative
Follow-Up
Horizontal Dimension Vertical Dimension
Mean Movement Mean Relapse Mean Movement Mean Relapse
Randomized clinical trial
Chua et al,
12
2010 P, RCT
16 yr
25 Plates and IMF 5 yr Anterior, 6.8 mm
Posterior, 6.9 mm
Anterior, 37% (2.5 mm)
Posterior, 35.5% (2.45
mm)
Anterior, 1.6 mm
Posterior, 0.9 mm
Anterior, 65.5%
(0.8 mm)
Posterior, 156.8%
(1.4 mm)
Clinical trials
Daimaruya et al,
11
2010
P, CT
21.1 yr
(range 19.6-23)
7(4M,3F)
7 UCLP
Plates 1 yr Anterior, 5.8 mm
SNA, 5.3°
Anterior, 25.5%
(1.6 mm)
SNA, 24.6% (1.3°)
Anterior, 3.3 mm Anterior, 50.4%
(1.7 mm)
Kumar et al,
13
2006 R, CT G1 (10 mm), 20
G2 (10 mm), 11
Plates 1 yr G1: Anterior, 5 mm
SNA, 5.1°
G2: Anterior, 7.2 mm
SNA, 5.7°
G1: Anterior, 2%
(0.1 mm)
SNA, 13.7% (0.7°)
G2: Anterior, 19.4%
(1.4 mm)
SNA, 21.1% (1.2°)
G1: Anterior, 0.5
mm
G2: Anterior, 0.4
mm
G1: Anterior, 0%
(0 mm)
G2: Anterior,
50% (0.2 mm)
NR G1, 16 UCLP, 2 BCLP,
2CP
G2, 8 UCLP, 3 BCLP
Case Series Studies
Thongdee and
Samman,
1
2005
R, CS
18 yr
(range 14-28)
30 (9 M, 21 F)
30 UCLP
Plates 62.7 mo (range
12-66)
Anterior, 5.6 mm
Posterior, 3.1 mm
SNA, 3.9°
Anterior, 31.5%
Posterior, 13.2%
SNA, 45%
Anterior, 4.4 mm
Posterior, 2.3 mm
Anterior, 52.3%
Posterior, 33.9%
Heliövaara et al,
14
2002
R, CS
BCLP, 23.7 yr CP,
27.2 yr
BCLP, 11 (9 M, 2 F)
CP, 14 (11 F, 3 M)
11 BCLP, 14 CP
Plates 1 yr CP, 4.7 mm
CP (SNA), 4.8°
BCLP, 5.3 mm
BCLP (SNA), 4.8°
CP, 8.5% (0.4 mm)
CP, SNA, 6.3% (0.3 mm)
BCLP, 9.4% (0.5 mm)
BCLP, SNA, 16.7% (0.8
mm)
CP, 3.6 mm
BCLP, 7.3 mm
CP, 16.7% (0.6
mm)
BCLP, 17.8% (1.3
mm)
Heliövaara et al,
15
2001
R, CS
23.7 yr
(range 16-40)
40 (27 M, 13 F)
40 UCLP
Plates 1 yr Anterior, 3.9 mm
SNA, 4.2°
Anterior, 20.5% (0.8
mm)
SNA, 16.7% (0.7°)
4.5 mm 22.2% (1 mm)
Hirano and Suzuki,
16
2001
R, CS
19.8 yr
(range 15-37)
58 (30 M, 28 F)
42 UCLP, 16 BCLP
Plates and IMF 2.5 yr (range
1.5-8.5)
6.9 mm 24.1% (1.5 mm) 3 mm 70% (2.1 mm)
Erbe et al,
7
1996 R, CS
19 yr
(range 14-36)
11 (7 M, 4 F)
9 UCLP, 2 BCLP
Plates 59 mo (range
39-110)
SNA, 3.6° SNA, 38.9% (1.4°) NR NR
Ayliffe et al,
17
1995 R, CS
19.5 yr
61 (34 M, 27 F)
46 UCLP, 15 BCLP
Extraoral frame
and IMF, 25
Plates, 36
28 mo (range
12-48)
6.1 mm 5% (0.3 mm) 5.7 mm 21% (1.2 mm)
Posnic and Dagys,
6
1994
R, CS
18 yr (range 14-25)
35 UCLP Plates 1 yr 6.9 mm 23% (1.6 mm) 2.1 mm 19% (0.4 mm)
Abbreviations: R, retrospective study; P, prospective study; CS, case series; CT, clinical trial; RCT, randomized clinical trial; BCLP, bilateral cleft lip and palate; UCLP, unilateral
cleft lip and palate; CP, cleft palate; SNA, sella-nasion-A point; IMF, intermaxillary fixation; NR, not reported; F, female; M, male.
Saltaji et al. Maxillary Advancement and Cleft Lip/Palate. J Oral Maxillofac Surg 2012.
2862 MAXILLARY ADVANCEMENT AND CLEFT LIP/PALATE
selection criteria and were included in the study. No
reports were found during the gray literature searches
or reference list searches. A flow diagram of the data
search is given in Figure 1.
Of the 25 full studies initially selected, 6 were
excluded because no long-term follow-up was provid-
ed,
18-23
4 because of an incomplete report of the
data,
24-27
3 because they used wire fixation,
28-30
1
because Class III patients were included,
31
and 1
because it was a literature review.
8
We attempted to
contact the investigators of the studies with an incom-
plete data report, but no responses were obtained.
The 15 excluded studies and the reasons for their
exclusion are listed in Table 5.
Ultimately, only 10 studies fulfilled all the inclusion
criteria.
1,6,7,11-17
A summary of the study design, pa-
tient age, sample size, cleft type, surgical procedure,
latency period, device, rate of distraction, consolida-
tion period, follow-up period, mean movement, and
mean relapse in the horizontal and vertical dimen-
sions is listed in Table 2. A meta-analysis was not
possible owing to the heterogeneity of the outcome
measures. The methodologic quality assessment of
the finally selected studies resulted in scores ranging
FIGURE 1. Flow diagram of published data search.
Saltaji et al. Maxillary Advancement and Cleft Lip/Palate. J Oral
Maxillofac Surg 2012.
Table 4. METHODOLOGIC SCORE OF SELECTED STUDIES
Study
Study Design
Study
Measurements
Statistical
Analysis
TotalABC D EFG H I J K LM N
Daimaruya et al,
11
2010 ✓✓ XX X ✓✓✓✓ X X X 10 (52.6)
Chua et al,
12
2010 ✓✓ ✓✓✓ ✓✓ X X ✓✓16.5 (86.8)
Kumar et al,
13
2006 ✓✓XXX ✓✓ XX⫽⫽ XX 9 (47.4)
Thongdee and
Samman,
1
2005
✓✓✓✓ ✓✓ X ✓✓X X 13 (68.5)
Heliövaara et al,
14
2002 ✓✓✓✓ ✓✓ X ✓✓XX ✓✓ 13 (68.5)
Heliövaara et al,
15
2001 ✓✓✓✓ ✓✓ X ✓✓XX ✓✓ 13 (68.5)
Hirano and Suzuki,
16
2001
✓✓✓✓ X X ✓✓XXX X 10 (62.5)
Erbe et al,
7
1996 ✓✓ X X X ✓✓ XXX X 8 (42.1)
Ayliffe et al,
17
1995 ✓✓✓✓ X X ✓✓ X X ✓✓ 11 (57.9)
Posnic and Dagys,
6
1994
⫽⫽ XX X XXX X 7 (36.8)
Letters A to N indicate methodologic criteria listed in Table 3; check indicates study satisfactorily fulfilled the methodologic
criteria (1 check); equal sign with slash indicates study partially fulfilled the methodologic criteria (0.5 check); X indicates
study did not fulfill the methodologic criteria (0 check).
Saltaji et al. Maxillary Advancement and Cleft Lip/Palate. J Oral Maxillofac Surg 2012.
Table 3. METHODOLOGIC SCORE FOR INCLUDED
STUDIES (MAXIMUM NUMBER OF CHECKS 19)
Study Design (11 )
A. Objective—Clearly defined ()
B. Population—Adequately described ()
C. Sample size—Considered adequate ()
D. Selection criteria—Clearly described (), adequate ()
E. Randomization or consecutive selection—Stated ()
F. Follow-up length—Clearly described ()
G. Timing—Prospective design ()
H. Type of study—RCT (✓✓✓), CT (✓✓), CS ()
Study Measurements (4 )
I. Measurement method—Mentioned (), Appropriate ()
J. Blinding—Stated ()
K. Reliability—Described ()
Statistical analysis (4 )
L. Dropouts—Accounted ()
M. Statistical analysis—Appropriate ()
N. Presentation of data—Exact P value stated (),
variability measures (SD or CI) stated ()
Abbreviations: RCT, randomized clinical trial; CT, clinical
trial; CS, case series; SD, standard deviation; CI, confidence
interval.
Saltaji et al. Maxillary Advancement and Cleft Lip/Palate. J Oral
Maxillofac Surg 2012.
SALTAJI ET AL 2863
from 34% to 87% of the possible total maximum. The
methodologic scores are summarized in Table 4.
Discussion
Patients with CLP usually develop significant max-
illary retrusion, which requires orthognathic surgery
procedures. These procedures aim to achieve esthetic
and functional results by advancing the maxilla.
4
Max-
illary surgical advancement using conventional Le
Fort I maxillary osteotomy is the standard surgical
procedure for correcting maxillary retrusion but is
more prone to postoperative relapse in patients with
cleft than in those without cleft.
5
In the present sys-
tematic review, all the clinical trials and case series
that examined the long-term skeletal stability of Fort I
maxillary osteotomies were included. For the pur-
poses of our review, the postoperative posterior and
superior changes of the maxilla were considered re-
lapse, because the treatment direction is usually an
anterior and inferior movement of the maxilla.
12
Ten studies were finally selected. The designs of
these studies were as follows: 1 prospective random-
ized clinical trial,
12
1 prospective clinical trial,
11
1
retrospective clinical trial,
13
and 7 retrospective case
series studies.
1,6,7,14-17
The mean follow-up time was
more than 3 years in 4 studies. The mean age of the
treated patients was 18 years or older in 9 studies.
More than 4 times as many patients with unilateral
CLP were treated as patients with bilateral CLP (233
vs 49). In the 10 included studies, maxillary osteot-
omy was stabilized by internal fixation using plates
and screws, considered the standard procedure for
fixation. Three studies were excluded from our study
because they had used wire fixation.
28-30
Only 1 randomized controlled clinical trial was
found of the 10 studies finally selected. That clinical
trial compared the long-term stability of distraction
osteogenesis and Le Fort I osteotomy and reported
that patients receiving Le Fort I osteotomy showed
significant relapse in both horizontal and vertical
planes, with a trend toward occurring within the first
postoperative year. After 5 years of follow-up, the
maxilla had relapsed backward and upward in the Le
Fort I group and had advanced more downward and
forward in the distraction osteogenesis group. The
relapse rate was greater in the Le Fort I osteotomy
group than in the distraction osteogenesis group (37%
vs 8.24%).
12
All the finally included studies demonstrated less
than 8 mm maxillary advancement, as indicated by
the change in the A-point. The mean horizontal move-
ment was 3 to 6 mm in 5 studies
1,11,12,14,15
and6to8
mm in 4 studies.
6,13,16,17
Most of the included studies revealed that maxillary
surgical advancement with Le Fort I osteotomy tech-
nique showed moderate relapse rates in the patients
with CLP. The horizontal relapse in A-point was 20%
to 30% in 4 studies
6,11,15,16
and 30% to 40% in 2
studies.
1,12
Similarly, the horizontal relapse in sella-
nasion-A point angle was more than 35% in 2 stud-
ies
1,7
and 20% to 30% in 2 studies.
11,13
The report
judged as a high-quality study reported 37% horizontal
relapse in the A-point.
12
Regarding the vertical dimension, the movement
was less than 3 mm in 3 studies
6,12,13
and3to6mm
in 6 studies.
1,11,14–17
The vertical relapse in the A-
point was more than 50% in 4 studies.
1,11,12,16
The
report judged as a high-quality study reported 65%
vertical relapse in the A-point.
12
The relapse after maxillary advancement with Le
Fort I osteotomy in patients with CLP can be ex-
plained by the presence of scarred palatal and lip
tissues. Soft tissue scarring is known to be 1 of the
greatest challenges facing the surgical management of
patients with CLP and has been suggested as an etio-
Table 5. STUDIES NOT SELECTED FROM INITIAL
ABSTRACT SELECTION LIST AND REASONS
FOR EXCLUSION
Study Reason for Exclusion
Felemovicius and Taylor,
31
2009
Class III patients included in
sample
Chong et al,
25
2009 No or incomplete report of
data
Li et al,
27
2009 No or incomplete report of
data
Kok-Leng Yeow and Por,
24
2008
No or incomplete report of
data
Wolford et al,
29
2008 Used wire fixation
Baek et al,
18
2007 No long-term follow-up
reported
Figueroa and Polley,
26
2007
No or incomplete report of
data
Cheung and Chua,
8
2006 Review
Cheung et al,
19
2006 No long-term follow-up
reported
Landes et al,
20
2006 No long-term follow-up
reported
Ewing and Ross,
21
1993 No long-term follow-up
reported
Eskenazi and Schendel,
28
1992
Used wire fixation
Posnic and Ewing,
30
1990 Used wire fixation
Houston et al,
22
1989 No long-term follow-up
reported
Garrison et al,
23
1987 No long-term follow-up
reported
Saltaji et al. Maxillary Advancement and Cleft Lip/Palate. J Oral
Maxillofac Surg 2012.
2864 MAXILLARY ADVANCEMENT AND CLEFT LIP/PALATE
logic cause of the greater incidence of mid-face defi-
ciency in CLP populations. The patients with CLP
have typically undergone numerous craniofacial sur-
geries for correction of the palatal and/or lip cleft
before Le Fort I maxillary advancement. Soft tissue
scarring might not only be the potential cause of the
midface deficiency, but also the cause of surgical
relapse, restricting the surgical movement of the max-
illa and pulling it back to the preadvanced posi-
tion.
4,32
In addition, posterior pharyngeal flaps from a
previous surgery and disharmony of occlusion are
expected to be additional reasons for relapse after Le
Fort I osteotomy in patients with CLP.
12,32
In addition to the Le Fort I osteotomy technique,
maxillary advancement using the distraction osteo-
genesis technique has become a reliable and clinically
effective technique.
4
In the randomized controlled
trial conducted by Chua et al,
12
they reported maxil-
lary advancement with distraction osteogenesis in pa-
tients with CLP was 7 mm, and the relapse rate was
8.24% (0.6 mm) after 5 years of follow-up. The find-
ings of our systematic review suggest that maxillary
surgical advancement with Le Fort I osteotomy in
patients with CLP can be expected to relapse about
25% to 30% (1.5 to 2 mm) after 5- to 6-mm of hori-
zontal movement. Owing to the gradual movement of
the maxilla in the distraction osteogenesis technique,
it is expected that the rate of relapse is lower in the
distraction osteogenesis technique than in the Le Fort
I technique. More evidence is needed to determine
the stability and effectiveness of both techniques.
In conclusion, the conventional Le Fort I maxillary
osteotomy technique can effectively move the maxilla
forward and downward in moderate maxillary retru-
sion. Maxillary surgical advancement in patients with
CLP using Le Fort I osteotomy appears to show a
moderate relapse rate in the horizontal plane and a
high relapse rate in the vertical plane.
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2866 MAXILLARY ADVANCEMENT AND CLEFT LIP/PALATE
    • "La récidive concerne la dimension sagittale et la dimension verticale. Pour Saltaji et al. [13] , dans leur revue de la littérature de 2012, la récidive sagittale dans un sens de recul du maxillaire est de 20 a ` 40 % après une propulsion de moins de 8 mm. Quant a ` la récidive de la dimension verticale, cette revue de la littérature montre des récidives allant de 50 % a ` 65 %. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Jul 2014 · Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons
  • [Show abstract] [Hide abstract] ABSTRACT: 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. 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.
    Full-text · Article · Aug 2013
  • [Show abstract] [Hide abstract] ABSTRACT: It has been debated whether the Le Fort III procedure using distraction osteogenesis (LFIII-DO) reduces the risk of postintervention relapse compared with conventional Le Fort III (LFIII) osteotomy in the correction of syndromic midfacial hypoplasia. Our objective was to evaluate the short- and long-term stability of the bony structures after midfacial advancement using conventional LFIII osteotomy versus LFIII-DO in patients with syndromic midfacial hypoplasia. We performed a systematic review of the published data. An electronic search of 10 databases was performed from their inception through June 2012. The reference lists of the relevant publications were also reviewed. Studies were considered for inclusion if they were longitudinal clinical studies with follow-up periods of at least 1 year after surgery (LFIII group) or at the end of the consolidation period (LFIII-DO group). Study selection, risk of bias assessment, and data extraction were performed in duplicate. The methodologic and clinical heterogeneity across the studies precluded combining the findings using meta-analyses. A total of 57 reports met the initial search criteria, and 12 reports were finally selected. The studies demonstrated a mean midfacial advancement of 8 to 12 mm in the LFIII group and 9 to 16 mm in the LFIII-DO group. For the LFIII group, horizontal short-term follow-up showed a maximal rate of relapse of 8.7 to 11.9% in 2 studies, with 1 study demonstrating a far more severe rate of maximal relapse of 50%. For the LFIII-DO procedure, the horizontal short-term relapse rate was 14.4% in 1 study, with the remainder demonstrating a rate of relapse of less than 10%. Moreover, 3 studies even showed additional advancement without any rate of relapse. Current evidence suggests that conventional LFIII and LFIII-DO techniques can effectively advance the midface forward in patients with syndromic midfacial hypoplasia and have good to excellent stability, with a mild rate of relapse. However, the LFIII-DO technique appears to achieve a greater amount of advancement with a lower rate of relapse compared with the conventional LFIII technique.
    Full-text · Article · Oct 2013
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