The Likelihood of Orthognathic Surgery After Orofacial Cleft Repair

What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review

OBJECTIVE

Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes.

DESIGN

A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

SETTING

All study designs were included. Non-English articles were excluded.

PATIENTS AND PARTICIPANTS

Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula.

INTERVENTIONS

Free tissue transfer for a palatal fistula repair.

MAIN OUTCOMEE MEASURES

Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained.

RESULTS

Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies.

CONCLUSIONS

Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

Orthognathic Surgery Rates in Furlow Double-Opposing Z-Plasty Versus Straight-Line Repair: A Review of Three Decades of Experience

OBJECTIVE

The influence of different surgical techniques on maxillary growth remains unclear. This study investigates the long-term impact of Furlow double-opposing Z-plasty versus straight-line repair (SLR) techniques on midface growth and subsequent orthognathic surgery.

DESIGN

Retrospective cohort study.

SETTING

Tertiary children's hospital.

PATIENTS/PARTICIPANTS

This study evaluated patients who underwent primary palatoplasty with Furlow or SLR techniques from 1994-2023. Patients were >14 years old at their most recent follow-up.

INTERVENTIONS

No interventions were performed.

MAIN OUTCOME MEASURE(S)

Primary outcomes were orthognathic surgery and orthognathic surgery recommendation rates to correct midface hypoplasia (MFH). Cephalometrics at the time of orthognathic surgery recommendation were traced to validate MFH.

RESULTS

In total, 1857 patients underwent palatoplasty, of which 335 met inclusion criteria (49 SLR, 286 Furlow). Average age at last follow-up was 18.5±2.6 years. Patients who underwent Furlow versus SLR showed no significant difference in orthognathic surgery rates (p=0.428) or recommendation for orthognathic surgery rates (p=0.900). Patients recommended to undergo orthognathic surgery had more negative ANB angles (p<0.001) and smaller SNA angles (p<0.001) than patients not recommended for orthognathic surgery, demonstrating maxillary hypoplasia. Upon multivariate regression, patients with Veau III and IV clefts had an increased need for orthognathic surgery, p=0.047 and p=0.008, respectively.

CONCLUSIONS

Our findings suggest that higher cleft severity contributes to future orthognathic surgery. However, palatoplasty technique did not influence orthognathic surgery rates. Our results provide valuable data when surgeons are considering the impact of palatoplasty technique on sagittal growth restriction.

Nasal Airflow Dynamics following LeFort I Advancement in Cleft Nasal Deformities: A Retrospective Preliminary Study

Unilateral cleft lip and palate (UCLP) nasal deformity impacts airflow patterns and pressure distribution, leading to nasal breathing difficulties. This study aims to create an integrated approach using computer-aided design (CAD) and computational fluid dynamics (CFD) to simulate airway function and assess outcomes in nasal deformities associated with unilateral cleft lip and palate (UCLP) after LeFort I osteotomy advancement. Significant alterations were observed in nasal geometry, airflow velocity, pressure dynamics, volumetric flow rate, and nasal resistance postoperatively, indicating improved nasal airflow. The cross-sectional area increased by 26.6%, airflow rate by 6.53%, and nasal resistance decreased by 6.23%. The study offers quantitative insights into the functional impacts of such surgical interventions, contributing to a deeper understanding of UCLP nasal deformity treatment and providing objective metrics for assessing surgical outcome.

Correlation of Orthognathic Surgical Movements to Perception of Facial Appearance in Patients With Cleft Lip and Palate

STUDY DESIGN

Cephalometric scans were compared before and after surgery to assess the degree of correction. Correlations between skeletal movements and survey outcomes were determined using multivariate regression analysis.

OBJECTIVE

This study aims to identify relationships between subjective observer-reported improvements in esthetics and emotional appearance with specific surgical movements.

METHODS

Ten patients at a single tertiary institution (average age: 18.1 ± 0.8), 9 males and 1 female, underwent orthognathic repair and had comprehensive cephalometric records. Standardized anterior posterior and lateral pre and postoperative photographs of patients were included in a survey to clinicians to assess noncognitive domains on a Likert Scale (1-10). CLEFT-Q was administered to gauge patient satisfaction in categories of appearance, speech, and quality of life.

RESULTS

Per clinicians, multiple domains increased including facial attractiveness (4.1 ± 0.7 versus 7.3 ± 0.7, P < 0.001), friendliness (4.5 ± 0.4 versus 7.3 ± 0.5, P < 0.001), confidence (4.1 ± 0.4 versus 7.1 ± 0.4, P < 0.001), and recommendation for surgery decreased (8.9 ± 0.1 versus 3.6 ± 0.5, P < 0.001). Speech distress decreased with increased SNA and convexity, whereas Psychological and Social scores decreased with an increased ANB. Functional eating and drinking scores increased with maxillary depth.

CONCLUSIONS

Orthognathic surgery improves many noncognitive domains in patients with cleft lip and palate as assessed by both patients and clinicians on all aspects of facial attractiveness and perception. These findings demonstrate objective bases of skeletal adjustments for perceived improvements in facial appearance and emotion.

Sociodemographic Factors Predict Long-Term Attrition from Multidisciplinary Cleft Clinic

OBJECTIVE

Identify and describe factors associated with retention and attrition of patients during longitudinal follow-up at multidisciplinary cleft clinic.

DESIGN

Retrospective cohort study.

SETTING

Single, tertiary care center.

PATIENTS, PARTICIPANTS

Patients born between 1995 and 2007 with a diagnosis of cleft palate with or without cleft lip attending multidisciplinary cleft clinic.

INTERVENTIONS

None tested, observational study.

MAIN OUTCOME MEASURE(S)

Age at last clinical appointment with a multidisciplinary cleft team provider. Attrition was defined as absence of an outpatient appointment following 15 years of age.

RESULTS

Six hundred seventy-eight patients were included. The average age at last appointment across the entire cohort was 13.1 years (IQR 6.6-17.2). Patients who were Black (HR 1.60, 95% CI 1.10-2.32, p = 0.014) and other races (HR 1.90, 95% CI 1.22-2.98, p = 0.004) were more likely to be lost to follow-up compared to white patients. Publicly insured patients were more likely to experience attrition than those who were privately insured (HR 1.30, 95% CI 1.03-1.65, p = 0.030). Estimated income was not significantly associated with length of follow-up (p = 0.259). Those whose residence was in the fourth quartile of driving distance from our center experienced loss to follow-up significantly more than those who lived the closest (HR 2.04, 95% CI 1.50-2.78, p < 0.001).

CONCLUSIONS

There is a high degree of follow-up attrition among patients with cleft lip and palate. Race, insurance status, and driving distance to our center were associated with attrition in a large, retrospective cohort of patients who have reached the age of cleft clinic graduation.

Sagittal Growth Restriction of the Midface Following Isolated Cleft Lip Repair: A Systematic Review and Meta-Analysis

Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate repair, and is poorly understood. No study has examined the aggregate data on sagittal growth restriction of the midface following repair of the lip, but not palate, in these patients.

A systematic review of 3780 articles was performed. Twenty-four studies met inclusion criteria and 11 reported cephalometric measurements amenable to meta-analysis. Patients with Veau class I-III palatal clefts were included so long as they had undergone only lip repair. Groups were compared against both noncleft and unrepaired controls.

Cephalometrics were reported for 326 patients (31.3% female). Noncleft controls had an average SNA angle of 81.25° ± 3.12°. The only patients demonstrating hypoplastic SNA angles were those with unilateral CLP with isolated lip repair (77.4° ± 4.22°). Patients with repaired CL had SNA angles similar to noncleft controls (81.4° ± 4.02°). Patients with unrepaired CLP and CL tended toward more protruding maxillae, with SNA angles of 83.3° ± 4.04° and 87.9° ± 3.11°, respectively. Notably, when comparing SNA angles between groups, patients with CLP with isolated lip repair had significantly more hypoplastic angles compared to those with repaired CL (P < .0001). Patients with CLP with isolated lip repair were also more hypoplastic than noncleft controls (P < .0001). In contrast, there was no significant difference between the SNA of patients with repaired CL and controls (P = .648).

We found that cleft lip repair only appeared to contribute to MFH in the setting of concurrent cleft palate pathology, suggesting that scarring from lip repair itself is unlikely to be the predominant driver of MFH development. However, studies generally suffered from inadequate reporting of timing, technique, follow-up time, and cleft severity.

Electromyographic Evaluation of Masticatory Muscle Activity in Individuals with and without Cleft Lip/Palate: A Systematic Review and Meta-analysis

OBJECTIVE

This study aims to systematically review and meta-analyze the electromyographic activity of masticatory muscles in cleft palate and non-cleft patients, and identify influencing factors.

DESIGN

Systematic Review and Meta-analysis.

PATIENTS AND EXPOSURES

Patients with cleft lip/ palate.

COMPARISON

Patients without CL/P.

MAIN OUTCOME MEASURES

Electrical activity of masseter and temporalis muscles at rest and during peak activation.

RESULTS

After a comprehensive search in MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane's CENTRAL up to December 2022, without language or date restrictions. Eligible trials were selected based on the PECO question and assessed for bias using Cochrane's ROBINS-E tool. Eight clinical trials with 474 participants were included in the review. Then relevant data was extracted from included studies using customized forms. A random-effects meta-analysis was performed to combine the results of the studies, meta-analyses showed that CL/P patients have elevated electrical activity in the masseter (P = .01) and temporalis (P = <.01) muscles at rest compared to non-cleft control patients. During maximum bite force, cleft patients exhibited a statistically significant decrease in electrical activity in both the masseter (P = .03) and temporalis (P = <.01) muscles.

CONCLUSIONS

According to our meta-analysis, cleft patients exhibited increased resting muscle activity but decreased activity during maximum bite force, indicating reduced efficiency of masticatory muscles compared to non-cleft patients. These differences can be attributed to anatomical variations, compensatory mechanisms, and previous treatments.

Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature

OBJECTIVE

To review the evidence supporting the use of buccal fat pad (BFP) in primary and secondary cleft palate repair and its short- and long- term clinical outcomes.

DESIGN

Systematic review conducted by 2 independent reviewers following PRISMA guidelines.

SETTING: NONE PARTICIPANTS

Articles were identified from three databases (Pubmed/Medline, Embase and Web of Science). Search terms included "cleft palate", "palatoplasty", "palate repair", "buccal fat pad".

INTERVENTIONS

Use of BFP in primary and secondary cleft palatoplasty.

MAIN OUTCOME MEASURES

Primary outcomes were immediate postoperative complications, postoperative fistula, and maxillary growth. Secondary outcomes were palatal length, speech, and donor site morbidity.

RESULTS

Ninety-one reports were retrieved after excluding duplicates. Twenty-three studies were included (13 case series and 10 comparative studies). Overall level of evidence was low. Randomized and non-randomized studies had a high risk of bias. In primary palatoplasty, BFP was more frequently used filling lateral relaxing incisions(57.4%), or in the hard-soft palate junction and covering mucosal defects(30.1%). In these patients, post operative fistula incidence was 2.8%. Two studies found wider transverse maxillary dimensions after BFP use. No higher incidence of bleeding, infection, dehiscence, or flap necrosis was reported. In secondary palatoplasty, no recurrent fistulas were reported for patients undergoing BFP for fistula repair.

CONCLUSIONS

BFP appears to be associated with a favorable impact in fistula prevention and management, as well as in transverse maxillary growth. However, there is a high heterogeneity among studies, high risk of bias and overall low quality of evidence. More high-quality research with long-term follow-up is warranted.

The Accuracy of Jaws Repositioning in Bimaxillary Orthognathic Surgery in Patients with Cleft Lip and Palate Compared to Non-Syndromic Skeletal Class III Patients

Background: The present study aims to compare the accuracy of jaw repositioning in bimaxillary orthognathic surgery using digital surgical planning in cleft lip and palate patients and in non-syndromic skeletal class III patients in order to investigate if orthognathic surgery achieves different results in the first group of patients. Method: This study included 32 class III adult patients divided into 2 groups: cleft lip and palate (A, n = 16) and non-cleft (B, n = 16). For each patient, a 2D pre-surgical visual treatment objective was performed by the surgeon to predict hard tissue changes, and the surgical outcome was compared with that planned by using cephalometric measurement (ANB, SNA, SNB, Ar-Go-Me, S-Ar-Go). The statistical analysis showed equivalence between obtained and planned results for each measurement both in group A and in group B, but the difference between the planned and the obtained result was smaller in group B regarding ANB angle. Conclusions: Digital surgical planning ensures better predictability of the surgical results and higher accuracy of surgery in complex patients, such as those with cleft lip and palate.

Orthognathic Surgery Rate in Cleft Care

PURPOSE

To determine the true need for orthognathic surgery in patients with repaired cleft lip and/or palate (CL/P) at a high-volume craniofacial center.

METHODS

An institutional retrospective review of patients with CL/P born between 1975 and 2008 was performed. Patients with adequate documentation reflecting cleft care who were ≥ 18 years at the time of last craniofacial/dentistry follow-up were included. Patients with non-paramedian clefts or a comorbid craniofacial syndrome were excluded. Primary outcome variable was the total proportion of patients with CL/P who either underwent or were referred for orthognathic surgery Le Fort I (LF1) to correct midface hypoplasia. Secondary outcome variables were associations between cleft phenotype, midface hypoplasia severity, and number of cleft related surgeries with the eventual LF1 referral/recipiency.

RESULTS

One hundred seventy-seven patients with CL/P met inclusion criteria. A total of 90/177 (51%) patients underwent corrective LF1; however, 110/177 (62%) of patients were referred for surgery. Patients with secondary cleft palate involvement were referred for and underwent LF1 at significantly greater rates than those without secondary palate involvement (referred: 65% versus 13%, P = 0.001; underwent: 55% versus 0%, P < 0.001). Patients with bilateral cleft lip/palate were referred for and underwent LF1 at significantly higher rates than those with unilateral cleft lip/palate (referred: 71.0% versus 50.4%, P= 0.04; underwent: 84% versus 71%, P = 0.02). Number of secondary palate surgeries was positively correlated with increased LF1 referral (P = 0.02) but not LF1 recipiency (P = 0.15).

CONCLUSIONS

The incidence of orthognathic surgery redundant in patients with repaired CL/P was 51% at our institution, marginally above the higher end of previously reported rates. However, this number is an underrepresentation of the true requirement for LF1 as 62% of patients were referred for surgical intervention of midface hypoplasia. This distinction should be considered when counseling families.

Midface Growth Potential in Unoperated Clefts: A Systematic Review and Meta-Analysis

ABSTRACT

Competing hypotheses for the development of midface hypoplasia in patients with cleft lip and palate include both theories of an intrinsic restricted growth potential of the midface and extrinsic surgical disruption of maxillary growth centers and scar growth restriction secondary to palatoplasty. The following meta-analysis aims to better understand the intrinsic growth potential of the midface in a patient with cleft lip and palate unaffected by surgical correction. A systematic review of studies reporting cephalometric measurements in patients with unoperated and operated unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (ICP) abstracted SNA and ANB angles, age at cephalometric analysis, syndromic diagnosis, and patient demographics. Age and Region-matched controls without cleft palate were used for comparison. SNA angle for unoperated UCLP (84.5 ± 4.0°), BCLP (85.3 ± 2.8°), and ICP (79.2 ± 4.2°) were statistically different than controls (82.4 ± 3.5°), (all P ≤ 0.001). SNA angles for operated UCLP (76.2 ± 4.2°), BCLP (79.8 ± 3.6°), and ICP (79.0 ± 4.3°) groups were statistically smaller than controls (all P ≤ 0.001). SNA angle in unoperated ICP (n = 143) was equivalent to operated ICP patients (79.2 ± 4.2° versus 79.0 ± 4.3° P = 0.78). No unoperated group mean SNA met criteria for midface hypoplasia (SNA < 80). Unoperated UCLP/BLCP exhibit a more robust growth potential of the maxilla, whereas operated patients demonstrate stunted growth compared to normal phenotype. Unoperated ICP demonstrates restricted growth in both operated and unoperated patients. As such, patients with UCLP/BCLP differ from patients with ICP and the factors affecting midface growth may differ.Level of Evidence: IV.