Relapse-related factors of Le Fort I osteotomy in cleft lip and palate patients: A systematic review and meta-analysis

Nasal or Submandibular Intubation for Anesthesia in Orthognathic Surgery to Correct Jaw Deformities Secondary to Cleft Lip and Palate: Which One Is the Optimal Choice?

The aim of this retrospective study is to investigate the optimal airway management of orthognathic surgery anesthesia for correcting jaw deformity secondary to cleft lip and palate (CLP) by comparing the differences between nasal and submandibular intubation. Preoperative (T0), 1 week postoperatively (T1), and 6 months postoperatively (T2) CT scans and vital signs after oral intubation (S0), before reconnection of the submandibular tracheal catheter (S1), and after reconnection (S2) were collected from 54 patients who received nasal intubation (Group I) and submandibular intubation (Group II). The results were evaluated using 3D reconstruction and analysis in Mimics. During the follow-up, all patients demonstrated satisfactory facial shape and stable occlusion and no significant complications were observed. In Group II, maxillary operation duration and blood loss were significantly reduced (P < 0.001), and nasal septum deviation was distinctly improved (P < 0.001). Both groups exhibited increased nasal alar width, but Group I particularly females showed greater changes (P < 0.05). Only 2 patients (6%) in Group II developed hypertrophic scars 6 months postoperatively. This study demonstrates that submandibular intubation anesthesia represents a straightforward, safe and less complicated technique in orthognathic surgery for CLP patients. Nevertheless, this method should be carefully chosen for patients with scar constitution. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictors of Reoperation After Orthognathic Surgery in Patients With Cleft Palate: Two Decades of Insight

Orthognathic surgery represents a critical intervention within the continuum of care for patients with cleft lip and palate (CLP). Postoperative relapse is a significant complication and often necessitates reoperation. This study assesses risk factors for reoperation due to relapse following cleft orthognathic surgery. A retrospective review was conducted of patients with CLP who underwent orthognathic surgery for correction of class III malocclusion between 2005 and 2024, excluding those with under 6 months of follow-up. Maxillary advancement techniques included surgically assisted maxillary protraction (SAMP), LeFort I advancement (LF1), and distraction osteogenesis (DO). The outcome of interest was reoperation for late relapse. Overall, 133 patients met the inclusion criteria. The median age at surgery was 18.4 years, and the median follow-up was 2.1 years. Sixteen patients (12.0%) underwent SAMP, 101 (76.9%) LF1, 7 (5.3%) DO, and 9 (6.8%) staged DO followed by LF1. Bilateral sagittal split osteotomy (BSSO) for mandibular setback was performed in 48.4%. The incidence of reoperation was 13.5%. Maxillary advancements >8.5 mm were 6.3 times more likely to require reoperation (P<0.001). Multivariable regression identified bilateral CLP (P=0.038) and multiple prior maxillary operations (P=0.009) as significant predictors of reoperation, while BSSO was associated with decreased odds of reoperation (P=0.027). Patients with bilateral CLP and multiple prior maxillary operations were significantly more likely to require reoperation for late relapse. Limiting sagittal movements to <8.5 mm or performing concurrent BSSO may mitigate the risk of reoperation.

Patient-Specific Le Fort I Osteotomy Plates Are More Stable than Stock Plates in Patients with Cleft Lip and Palate

BACKGROUND

There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plate fixation. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate and determine stability differences between patient-specific and stock plates.

METHODS

Consecutive patients with cleft lip and palate who underwent isolated LFI by one surgeon (B.L.P.) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (nasion to A point) and horizontal planes (basion to A point) at 1 year after LFI using 3-dimensional cone beam computed tomography. Statistical analysis included independent samples t , Mann-Whitney U , Fisher exact, and chi-square tests. Values of P < 0.05 were significant.

RESULTS

The sample included 63 subjects; 23 in the patient-specific group (36.5%) and 40 in the stock group (63.5%). Groups were comparable by sex, race, age at surgery, cleft type, presence of pharyngeal flap, and magnitude of horizontal movement ( P > 0.136 for all). Subjects who underwent patient-specific plate fixation were less likely to have greater than or equal to 1-mm change at 1 year in the horizontal (4.3% versus 50.0%; P < 0.001) and vertical planes (4.3% versus 65.0%; P < 0.001) compared with stock plates. For patients who had greater than 10-mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific plates, 0.105 ± 0.317 mm; stock plates, 1.888 ± 1.125 mm; P = 0.003).

CONCLUSION

Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after 1 year than stock plates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Surgical Occlusion Setup and Skeletal Stability of Correcting Cleft-Associated Class III Deformity Using Surgery-First Bimaxillary Surgery

BACKGROUND

This study aimed to assess the 3-dimensional quantitative characteristics of the surgical occlusion setup in surgery-first cleft orthognathic surgery, and to evaluate its influence on postsurgical skeletal stability.

METHODS

This prospective study was composed of 35 patients with unilateral cleft lip and palate and class III deformity who consecutively underwent 2-jaw surgery with the surgery-first approach. Digitized dental models were analyzed to quantify the 3-dimensional characteristics of the final surgical occlusion setup. Cone-beam computed tomography was used to measure the 3-dimensional surgical skeletal movement and postsurgical skeletal stability. The correlation between skeletal stability and surgical occlusal contact or surgical skeletal movement was also evaluated.

RESULTS

Patients treated with the surgical occlusion setup had a large incisor overjet and positive overbite, as well as buccal cross-bite and open bite on second molars. Occlusal contact on 3 segments was present in 51.4% of the patients, and the average number for tooth contact was 4.3 teeth. No correlation was found between maxillary or mandibular stability and surgical occlusal contact. However, a significant correlation was found between maxillary and mandibular stability and the surgical skeletal movement.

CONCLUSIONS

The surgical occlusion for correction of cleft-associated class III deformity using the surgery-first approach was characterized by large overjet and positive overbite, along with posterior cross-bite and open bite. On average, there was occlusal contact on 4 to 5 teeth; half of surgical occlusion setups had contact on 3 segments. The postsurgical skeletal stability was related not to the surgical occlusal contact but to the surgical skeletal movement.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Assessing postoperative maxillary advancement stability in patients with cleft lip and palate

This study aims to evaluate the post-surgical stability of patients with cleft lip and palate that underwent maxillary advancement surgery. The study was conducted by means of cephalometric analysis of the soft tissues in digital radiographs acquired preoperatively, immediate postoperatively and six months after surgery using Dolphin Imaging 11.5 software. The effective sample consisted of 87 patients, among whom 50 (57.4%) were male and 37 (42.6%) were female. The mean age of the patients was 23.1 years, the minimum age was 17 years, and the maximum age was 37 years. Patients underwent maxillary advancement with cephalometric analysis during the preoperative and postoperative period, which was around six months. The results revealed a significant tendency for relapse in the vertical direction with instability of the occlusal plane. In the postoperative period, counterclockwise movement of the maxillomandibular complex was observed, leading to height reduction of the lower third of the face and increased facial angle. The observed changes were not correlated with the extent of the sagittal advancement.

Efficacy of the maxillary anterior segmental distraction osteogenesis in patients with cleft lip and palate

BACKGROUND

Cleft lip and palate (CLP) is one of the most common birth defects worldwide. It typically results in significant maxillary dysplasia, causing severe oral function problems and substantially affecting the patient's facial aesthetics. Maxillary anterior segmental distraction osteogenesis (MASDO) has gained popularity in recent years as an effective treatment for correcting maxillary dysplasia. However, the evaluation of its effectiveness in patients with CLP varies across different studies. Our research was aimed at providing evidence of the effects of MASDO among CLP patients.

METHODS

A meta-analysis covered Medline, Web of Science, Embase, Scopus, and Cochrane Library. Controlled clinical trial studies published before February 2024 and analyzed changes in maxillary cephalometric landmarks before and after MASDO among patients with maxillary hypoplasia and CLP were included.

RESULTS

Our meta-analysis included 10 papers in total. One study was at low risk of bias, seven were at medium risk, and two were at serious risk. MASDO significantly increased the maxillary length. The mean SNA angle increased by 6.43° (95% CI, 4.11° to 8.74°) and A-McNamara rose by 7.29 mm (95% CI, 6.21 mm to 8.37 mm). The maxilla also showed a slight counterclockwise rotation; however, this reached no statistical significance. The mandibular position did not vary remarkably. Moreover, a significant increase in upper anterior tooth tipping and overjet, a decrease in overbite, and an improvement in nasolabial soft tissue were observed.

CONCLUSIONS

MASDO might be a valid therapy option for CLP patients. It causes a significant increase in the maxillary length, anterior tooth crossbite, and nasolabial soft tissue were also greatly improved.

Three-dimensional Analysis of Skeletal Stability in Cleft Lip and Palate Patients Undergoing Bimaxillary Surgery With Le Fort I Osteotomy and Intraoral Vertical Ramus Osteotomy

Orthognathic surgery in patients with lip and palate clefts is challenging owing to scar tissue from primary repairs and severe deformities. In this study, we evaluated the stability of Le Fort I osteotomy with intraoral vertical ramus osteotomy (IVRO) in patients with cleft lip and palate using 3-dimensional (3D) analysis. This retrospective study comprised 14 cleft lip and palate patients (3 females, 11 males; the average age at surgery: 23.8 y) who underwent bimaxillary orthognathic surgery involving Lefort I osteotomy and IVRO. Cone-beam computed tomography (CBCT) images were obtained at preoperative (T0), 1-month postoperative (T1), and 1-year follow-up (T2) periods. The 3D analysis assessed the transitions and rotations of the maxilla and mandible using a virtual triangle. The maxilla showed stability in all directions at the 1-year follow-up with minimal relapse. The distal segment of the mandible exhibited clinically acceptable anterior (1.15 mm relapse) movements and pitch rotation (2.88° counterclockwise relapse) during the first year postoperatively. The proximal mandibular segment underwent anterior-inferior transition (1.21 and 2.01 mm, respectively) and lateral-outward rotation (4.90° and 7.51°, respectively) postsurgery, remaining unchanged 1 year postoperation. Le Fort I osteotomy with IVRO provides skeletal stability in patients with cleft lips and palates. This study demonstrated a minimal maxillary relapse and clinically acceptable movements in the distal mandibular segment during the first postoperative year. The proximal mandibular segment moved anteriorly and inferiorly, rotated laterally and outward after surgery, and remained unchanged at the 1-year follow-up.

Skeletal stability after maxillary distraction osteogenesis or conventional Le Fort I osteotomy in patients with cleft lip and palate: A superimposition-based cephalometric analysis

PURPOSE

The aim was to assess skeletal stability after maxillary advancement using either distraction osteogenesis (DO) or conventional Le Fort I osteotomy (CO) in patients with cleft lip and palate (CLP) or cleft palate (CP) utilising a new superimposition-based cephalometric method.

METHOD

This retrospective study included patients who were treated with DO (N = 12) or CO (N = 9). Sagittal and vertical changes after surgery, and skeletal stability at 18 months post-operatively were assessed with superimposition-based cephalometry, comparing lateral cephalograms performed pre-operatively (T0), post-operatively after CO or immediately after completed distraction in DO (T1), and at 18 months of follow-up (T2).

RESULTS

The mean sagittal movements from T0 to T2 in the DO and CO groups were 5.9 mm and 2.2 mm, respectively, with a skeletal relapse rate of 16% in the DO group and 15% in the CO group between T1 and T2. The vertical mean movement from T0 to T2 in the DO and CO groups was 2.8 mm and 2.0 mm, respectively, and the skeletal relapse rate between T1 and T2 was 36% in the DO group and 32% in the CO group.

CONCLUSION

Sagittal advancement of the maxilla was stable, in contrast to the vertical downward movement, which showed more-extensive relapse in both groups. Despite more-extensive maxillary advancement in the DO group, the rates of skeletal relapse were similar.

Effect of bimaxillary surgery on the stress distributions in patients with mandibular retrognathia under unilateral molar clenching

To investigate the effect of bimaxillary surgery on the stress distribution of the temporomandibular joint (TMJ) in patients with mandibular retrognathia under unilateral molar clenching (UMC). Five patients with mandibular retrognathia (preoperative group) and ten asymptomatic subjects (control group) were recruited. In addition, patients treated with bimaxillary surgery were considered as the postoperative group. The muscle forces corresponding to UMC were applied. The results showed that the discal stresses in the postoperative group were significantly greater than those in the preoperative and control groups. Bimaxillary surgery plus UMC had a detrimental effect on the TMJ.

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).

Stability of Le Fort 1 osteotomy in patients with bilateral cleft lip and palate: A retrospective study of 71 patients

The aim of this study was to evaluate the sagittal and vertical relapses after Le Fort 1 osteotomy in bilateral cleft lip and palate (BCLP) patients. Lateral cephalograms before surgery, immediately after the procedure, at one year, and at least two years (when available) after surgery were superimposed. The positions of five landmarks were studied in a coordinate system. Uni- and multivariate analyses investigated the effect of various factors on the relapse. Of the 71 patients included for a BCLP, 54 presented complete data at one year, and 30 patients were included for the long follow-up study (mean of 55 months). The mean maxillary advancement was 6.2 mm on the sub-spinal point (A). Sagittal relapse occurred at one year (mean of 1.1 mm on point A, 0.7 mm on point prosthion (P); p < 0.0001) and progressed by 0.5 mm and 1.0 mm, respectively, on the same points at the last follow-up. The mean vertical relapse was 0.5 mm on point A (p = 0.044), 0.6 mm on point P (p = 0.16) and 0.5 mm on incisor (I) (p = 0.056). The vertical relapse was correlated to the degree of vertical movement. Three factors were associated to the recurrence including a prior pharyngeal flap, an associated mandibular osteotomy and smoking habits.

Application of 3-Dimensional White-Light Scanning to Observe the Lip and Nose Morphology of Chinese Children

OBJECTIVE

To establish a database and study the growth and development of Chinese children's nasolabial units by 3-dimensional (3D) white-light scanning technology.

MATERIALS AND METHODS

From January 2018 to January 2019, 528 patients were selected preoperatively in our hospital, without cranial or maxillofacial deformities. The patients were placed in supine positions in a state of sedation, and the authors used a 3D white-light scanner to scan the children's faces to measure the 3D morphological structure of their nasolabial areas. The results were presented with Graphpad Prism 8.0.2 to explore correlations and analyze trends.

RESULTS

The selected Chinese children consisted of 356 males (67.4%) and 172 females (32.6%). All nasolabial subunits grew fastest at 0 to 2 years old and at a slower rate from 2 to 15 years old, whereas the relevant growth of different sex was similar among contemporaries.

CONCLUSIONS

Three-dimensional white-light scanning can quickly and accurately gain 3D imaging of nasolabial soft tissue to build a normal morphology database. Furthermore, every nasolabial subunit grows fastest at the age of 0 to 2 years.