Reviewing the orthognathic surgical care of the patient with cleft lip and palate: the single surgeon experience

Complications of orthognathic surgery in patients with cleft lip and palate: A systematic review

OBJECTIVE

Determine the main complications of orthognathic surgery in patients with cleft lip and palate.

METHODS

PubMed, LILACS, Cochrane, Embase, Scopus, and Google Scholar were systematically reviewed. Studies addressing the complications of orthognathic surgery in patients with cleft lip and palate were included. For the search, the strategy was used with the descriptors extracted from MeSH "Cleft Palate", "Orthognathic Surgery" and "Complications". The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the included studies. Patients of any sex, age, and ethnicity with cleft lip and palate submitted to orthognathic surgery were included in this systematic review. The study followed the PRISMA 2020 standards and was registered in PROSPERO with protocol CRD42020195927.

RESULTS

In the initial search, 1090 articles were found and after applying the inclusion and exclusion criteria, eleven studies were selected. The sample consisted of 629 patients who underwent Orthognathic Surgery, with an average age of 21.52 years. The majority of patients (390) presented unilateral transforamen proposals. In total, 150 complications were identified in the included studies, the most frequent being relapse of movement with 77 cases (51.3 %). Other reported, but less frequent, complications were gingival recession with root exposure, premaxillary mobility, intraoperative hemorrhage, fistulas and infection and velopharyngeal impairment. Most included studies did not have a control group, making meta-analysis unfeasible. Seven of the included studies presented a low risk of bias according to the NOS.

CONCLUSIONS

Orthognathic surgery in cleft patients is a safe procedure, however it presents particularities and more complications when compared to a non-cleft patient. In this study, the most common complication found was the relapse, and the surgeon must be aware of this complication and others, and try to minimize its negative effects on the patient. We strongly recommend further investigations with detailed methodologies, control groups, well-described criteria for reported complications, and comprehensive sample characteristics to provide higher-quality evidence.

Six-year post-surgical evaluation in the treatment protocols in the dental arches of children with oral cleft: longitudinal study

Oral cleft surgical repairs are performed using different techniques worldwide.

One-Jaw versus Two-Jaw Orthognathic Surgery for Patients with Cleft: A Comparative Study Using 3D Imaging Virtual Surgical Planning

Whether a one-jaw or two-jaw design is used in orthognathic surgery for patients with cleft remains varied and controversial. This study aimed to compare the two approaches using 3-dimensional imaging surgical simulation. This study was conducted on 41 consecutive patients with complete unilateral cleft lip and palate treated in the craniofacial center. All patients had original two-jaw virtual planning and orthognathic surgery. Simulation of one-jaw LeFort I surgery was performed using the same final dental occlusion on 3-dimensional images. Cephalometric data and asymmetry index were collected and compared among the designs. Average advancement of the maxilla was 7.46 mm in one-jaw and 4.80 mm in two-jaw design. SNA, SNB, and A-N perpendicular were significantly greater and close to normative data in the one-jaw design. ANB angles were similar in both designs. The anterior and posterior occlusal plane cants, the deviation of midline landmarks, and the asymmetry index were more improved in the two-jaw approach. It is concluded that the two-jaw cleft orthognathic surgery could significantly improve facial midline and symmetry compared with the one-jaw approach. However, the two-jaw surgery with mandibular setback produced less protrusive facial contour although a harmonious relationship between the maxilla and mandible was achieved.

The Likelihood of Orthognathic Surgery After Orofacial Cleft Repair

ABSTRACT

Midface hypoplasia is one of the most significant sequelae of cleft lip and/or palate surgery. A complete understanding of the rate of orthognathic surgery across varying cleft phenotypes is a powerful tool for educating patients and families as to the treatment course that the patient will incur during their lifetime. Understanding the average rates of orthognathic intervention also can act to develop metrics for outcome evaluation with different treatment protocols. Attempting to identify the average rates of orthognathic intervention, the authors conducted a systematic review and meta-analysis by combining studies from 1987 to 2016 describing the frequency of orthognathic intervention on the different cleft phenotypes as the primary outcome. Secondary outcomes included identification of surgical protocol, age of patient at orthognathic intervention, and the method by which patients were evaluated for orthognathic intervention. The rate of orthognathic surgery was 38.1% for bilateral cleft lip and palate (BCLP), 30.2% for unilateral cleft lip and palate (UCLP), 4.4% for isolated cleft palate (ICP), and 1.8% for patients with isolated cleft lip (ICL). 71% (n = 10) reported using lateral cephalograms for orthognathic surgery evaluation and only one of those studies reported specific objective cephalometric measurements for orthognathic intervention. Our findings demonstrated that BCLP possessed the highest rate of orthognathic intervention followed by UCLP, ICP, and ICL. ICP and ICL both possessed low rates of orthognathic intervention. By sharing our findings, the authors hope to provide a useful tool for informing patients' families as to their risk of needing orthognathic intervention.

The Need for Orthognathic Surgery in Nonsyndromic Patients with Repaired Isolated Cleft Palate

Objective

To determine the frequency of need for orthognathic surgery among nonsyndromic patients with isolated cleft palate repaired during infancy at The Hospital for Sick Children in Toronto, Canada.

Design

Retrospective cohort study.

Patients

Patients with nonsyndromic isolated cleft palate born between 1970 and 1997 with available records including a lateral cephalometric radiograph taken at 15 years of age.

Methods

Patients who had undergone or were being prepared for orthognathic surgery were automatically counted as requiring surgery. For the remaining patients, lateral cephalometric radiographs were traced and analyzed. Arbitrarily set cephalometric criteria were used to identify the “objective” need for orthognathic surgery.

Results

Of the 189 patients identified with nonsyndromic isolated cleft palate and for whom records were available, 25 (13.2%) were deemed to require orthognathic surgery. Of the surgical cohort, 92% required surgical correction for a Class III malocclusion. Similar percentages of males and females required orthognathic surgery. An apparently greater proportion of patients of Asian background (18.5%) than of white background (10.6%) required surgery, but this difference was not significant ( P = .205).

Conclusions

The current results suggest that approximately one in eight patients at our institution with nonsyndromic isolated cleft palate requires orthognathic surgery. There is a tendency for this to be higher in patients of Asian descent and lower in patients of white descent. Variability in extent, severity, and phenotype of the cleft, which may be attributed largely to genetics, may play an important role in dictating the need for orthognathic surgery.

Simultaneous options for cleft secondary deformities

INTRODUCTION

So much has been written by so many about secondary procedures in cleft surgery that testify not only the complexity and variable expression of cleft deformity itself but also the need to find methods of primary surgery that will reduce, if not avoid, adverse effects on all the structures and functions involved and affected. It must be the principal aim of cleft surgeon to restore the deformed and displaced regional anatomy to as close to normality as possible, whether or not true hypoplasia exists. The pathogenesis of secondary deformities is related to specific features as: the presence of scar tissues into the cleft basal bone area, that inhibits alveolar growth; scarring of palatal soft tissue, that inhibits growth and causes palatal orientation of dentoalveolar elements; and the exceeding lip tension, that may inhibits maxillary growth along dentoalveolar structures.

MATERIALS AND METHODS

From 2008 to 2011 at the Department of Cranio-Maxillo-Facial Surgery, Santo Spirito Hospital, Rome 25 patients (21 males and 4 females) who had undergone previous surgery for unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) were enrolled in our study. Diagnosis of deformity was made by means of a cephalometric and photographic analysis (Arnett), gipsometry and a radiological assessment (orthopantomography, lateral and frontal cephalometric X-rays). Moreover, every patient was studied with a temporomandibular joint (TMJ) tomography, TMJ magnetic resonance imaging (MRI) and a computerized gnatography to better evaluate potential TMJ dysfunctions. The surgical procedures adopted simultaneously were: Total or segmental maxillomandibular osteotomies, genioplasty, rhinoplasty, labioplasty, and application of facial prosthesis. Every patient received a postoperative questionnaire to evaluate his/her satisfaction with the surgery performed.

RESULTS

The surgical procedures adopted were Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO) in 16 patients (65%) and only Le Fort I osteotomy in 9 patients (35%). A relapse of malformation occurred in 4.5% of cases. Concerning the patient questionnaire, 96% of patients were satisfied with the jaw surgery and favorable for combined surgery, 88% were satisfied with lip-nose surgery, and finally 76% would advise to a friend.

CONCLUSIONS

Simultaneous correction of the deformities is indicated as to avoid several surgical distresses for the patient, to improve facial aesthetic and function in one surgical step, and to reduce risk of psychological consequences.