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

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.

Prognostic Factors for Orthognathic Surgery in Children With Cleft Lip and/or Palate: Dentition and Palatal Morphology

To determine dental and palatal morphology in children with cleft lip and/or palate (CL/P) and identify morphological prognostic factors for orthognathic surgery (OGS).

Retrospective cohort study.

Orthodontic department of a university dental hospital.

This study included 80 patients with bilateral and unilateral CL/P who had lateral cephalograms at the ages of 7 (T1), 15 (T2) years, and a dental plaster model at T1.

Plaster models at T1 were scanned with a three-dimensional (3D) scanner. Morphological features were extracted from 3D models with geometric morphometrics software as principal components (PCs). The combinations of the PCs and other predictive factors (ie, the No. of clefts in the lip and alveolus, the palatal repair method, sex, cephalometric variables at T1, and the No. of missing teeth) were examined by logistic regression to determine the predictability for OGS. The need for OGS and skeletal and dental discrepancies at T2 were examined as outcomes.

Shrinkage of the palate, including vertical shallowing and transverse narrowing of the posterior maxilla and cleft-side asymmetry of the anterior maxilla at T1, as well as the No. of clefts in the lip and alveolus, the palatal repair method, male sex, several cephalometric variables for the sagittal and vertical dimensions, and the No. of missing teeth, were found to be predictive factors for OGS.

Morphological prognostic factors for OGS in children with CL/P were determined.

Rhinoplasty and Le Fort I Maxillary Osteotomy in Cleft Patients

INTRODUCTION

Cleft patients often need orthognathic surgery to correct maxillary hypoplasia and rhinoplasty to correct nasal deformity. Rhinoplasty can be performed as a staged procedure after orthognathic surgery or simultaneously with maxillary osteotomy.

AIM

The authors evaluated need for and complications of staged and simultaneous rhinoplasties in patients with different cleft types undergoing maxillary osteotomy.

PATIENTS AND METHODS

This retrospective study examined 99 (54 females) consecutive nonsyndromic patients with cleft lip/palate [23 bilateral cleft lip and palate (BCLP), 51 unilateral cleft lip and palate (UCLP), and 25 cleft palate (CP)] with a mean age of 17.8 (range: 11.5-45.3) years who had undergone Le Fort I maxillary advancement or bimaxillary osteotomy at the Cleft Palate and Craniofacial Center, Helsinki University Hospital, Finland, between 2002 and 2016. Medical charts were accessed through the hospital's archives and database.

RESULTS

Of patients who underwent maxillary osteotomy, 45% (45/99) needed rhinoplasty (14 BCLP, 27 UCLP, and 4 CP). A significant difference (P<0.01) existed in the need for rhinoplasty between different cleft types, those with BCLP and UCLP needing the most operations (60% and 53%). In 20 patients (20%), rhinoplasty was performed simultaneously with maxillary osteotomy, and in 25 patients (25%) in a second operation after osteotomy. The overall complication rate was 14%. No difference existed in complication rate in patients with or without simultaneous rhinoplasty.

CONCLUSIONS

Of cleft patients who underwent maxillary osteotomy, 45% needed rhinoplasty. Patients with BCLP and UCLP needed rhinoplasty most often. Staged and simultaneous procedures were almost equally common with similar complication rates.

How differences in anatomy and physiology and other aetiology affect the way we label and describe speech in individuals with cleft lip and palate

BACKGROUND

Speech in individuals with cleft lip and/or palate (CLP) is a complex myriad of presenting symptoms. It is uniquely associated with the structural difference of velopharyngeal insufficiency (VPI), together with a wide and heterogeneous range of other aetiologies which often co-occur. The nature of the speech sound disorder (SSD) including VPI may also change over the course of an individual's care pathway. Differences in terminology and approaches to analysis are currently used, resulting in confusion internationally. Additionally, current diagnostic labels and classification systems in SSD do not capture the complexity and full nature of speech characteristics in CLP.

AIMS

This paper aims to explore the different aetiologies of cleft palate/VPI speech and to relate aetiology with speech characteristic(s). In so doing, it attempts to unravel the different terminology used in the field, describing commonalities and differences, and identifying overlaps with the speech summary patterns used in the United Kingdom and elsewhere. The paper also aims to explore the applicability of current diagnostic labels and classification systems in the non-cleft SSD literature and illustrate certain implications for speech intervention in CLP.

METHODS AND PROCEDURES

The different aetiologies were identified from the literature and mapped onto cleft palate/VPI speech characteristics. Different terminology and approaches to analysis are defined and overlaps described. The applicability of current classification systems in SSD is discussed including additional diagnostic labels proposed in the field.

OUTCOMES AND RESULTS

Aetiologies of cleft palate/VPI speech identified include developmental (cognitive-linguistic), middle ear disease and fluctuating hearing loss, altered oral structure, abnormal facial growth, VPI-structural (abnormal palate muscle) and VPI-iatrogenic (maxillary advancement surgery). There are four main terminologies used to describe cleft palate/VPI speech: active/passive and compensatory/obligatory, which overlap with the four categories used in the UK speech summary patterns: anterior oral cleft speech characteristics (CSCs), posterior oral CSCs, non-oral CSCs and passive CSCs, although not directly comparable. Current classification systems in non-cleft SSD do not sufficiently capture the full nature and complexity of cleft palate/VPI speech.

CONCLUSIONS AND IMPLICATIONS

Our attempt at identifying the heterogeneous range of aetiologies provides clinicians with a better understanding of cleft palate/VPI speech to inform the management pathway and the nature and type of speech intervention required. We hope that the unravelling of the different terminology in relation to the UK speech summary patterns, and those used elsewhere, reduces confusion and provides more clarity for clinicians in the field. Diagnostic labels and classification require international agreement.

WHAT THIS PAPER ADDS

What is already known on the subject Speech associated with cleft palate/velopharyngeal insufficiency (VPI) is a complex myriad of speech characteristics with a wide and heterogeneous range of aetiologies. Different terminology and speech summary patterns are used to describe the speech characteristics. The traditional classification of cleft palate/VPI speech is Articulation Disorder, although evidence is building for Phonological Disorder and contrastive approaches in cleft speech intervention. What this paper adds to existing knowledge This paper explores the range of aetiologies of cleft palate/VPI speech (e.g., altered oral structure, abnormal facial growth, abnormal palate muscle and iatrogenic aetiologies) and attempts to relate aetiology with speech characteristic(s). An attempt is made at unravelling the different terminology used in relation to a well-known and validated approach to analysis, used in the United Kingdom and elsewhere. Complexities of current diagnostic labels and classifications in Speech Sound Disorder to describe cleft palate/VPI speech are discussed. What are the potential or actual clinical implications of this work? There needs to be a common language for describing and summarising cleft palate/VPI speech. Speech summary patterns based on narrow phonetic transcription and correct identification of aetiology are essential for the accurate classification of the speech disorder and identification of speech intervention approaches. There is an urgent need for research to identify the most appropriate type of contrastive (phonological) approach in cleft lip and/or palate.

Isolated nonsyndromic cleft palate: multicenter epidemiological study in the Brazil

BACKGROUND

Nonsyndromic orofacial clefts (NSOC) are the craniofacial most common congenital malformations. There are evidences that the nonsyndromic cleft palate (NSCP) development differs from other NSOC. However, most of the publications treat NSCP without considering that information. Furthermore, few studies focus on NSCP. The aim of this study was to describe epidemiological findings of patients with isolated NSCP in Brazil.

METHODS

In this cross-sectional multicenter study, four reference Centers for treatment in three different Brazilian states was investigated. Data were obtained from clinical records of patients, between November 2021 and June 2022. Researched variables were sociodemographic, clinical characteristics and pregnancy and family history. Pearson's chi-square and ANOVA One-way tests were used for associations.

RESULTS

Majority were female (58.1%), white (60.7%) with incomplete NSCP (61.2%). There was an association between complete NSCP and a positive history of medical problems during pregnancy (p = 0.016; 27.9%; OR: 1.94; 1.12-3.35). Systemic alterations were perceived in 40.6% of the sample with odds ratio for development of the complete type (OR: 1.21; 0.74-1.97). Higher OR was visualized in medication use during pregnancy (OR: 1.35; 0.76-2.37) and positive family history of oral cleft (OR: 1.44; 0.80-2.55). Dental and surgical care was associated with higher age groups (p < 0.050).

CONCLUSIONS

NSCP was most prevalent in white skin color female. Complete NSCP is associated with medical problems during pregnancy. Medication use during pregnancy and positive family history of oral cleft increase the chance of developing complete NSCP.

Craniofacial Cephalometric Morphology in Caucasian Adult Patients with Cleft Palate Only (CPO)

Orofacial clefts are common birth defects that affect the morphology of the skull. Cleft palate only (CPO) has a different etiology than other types of clefts, and craniofacial morphology in CPO differs from that of UCLP and BCLP. The long-term effect of the cleft and its surgery is visible after growth cessation. However, few studies exist describing cephalometric craniofacial morphology in adults with CPO. The aim of the present study was to describe the cephalometric craniofacial morphology of adult patients with CPO compared to healthy patients. The study included analysis of cephalometric lateral headfilms of 28 adults with CPO and 28 healthy subjects. It was found that the angles of SNA, ANB, 1-:NB angle (°) and Wits appraisal were significantly smaller in CPO, whereas NL-NSL (°), 1+:NA angle (°) and 1+:NA (mm) had significantly higher values in CPO compared to the control group. It has been concluded that CPO in adult patients is characterized by a sagittal jaw discrepancy due to maxillary deficiency, with a tendency for compensatory inclination of the upper and lower incisors.

Early experience of wafer-free Le Fort I osteotomy with patient-specific implants in cleft lip and palate patients

PURPOSE

The use of virtual surgical planning and patient-specific saw and drill guides combined with customized osteosynthesis is becoming a gold standard in orthognathic surgery. The aim of this study is to report preliminary results of the use of virtual surgical planning and the wafer-free PSI technique in cleft patients.

MATERIALS AND METHODS

Patient-specific saw and drill guides combined with milled patient-specific 3D titanium alloy implants were used in reposition and fixation in Le Fort I osteotomy of 12 cleft patients. Surgical information was retrieved from hospital records. Pre- and post-operative lateral cephalograms were analyzed.

RESULTS

In 10 of 12 cases, the implants fitted as planned to predesigned drill holes and bone contours with high precision. In one patient, the mobilization of the maxilla was too demanding for virtually planned advancement, and the implants could not be used. In another patient, PSI fitting was impaired due to an insufficient mobilization of maxilla and tension on PSI fixation with screws. After the surgery, the mean advancement of the anterior maxilla (point A) of all patients was 5.8 mm horizontally (range 2.7-10.1) and -3.1 mm vertically (range -9.2 to 3.4). Skeletal relationships of the maxilla and mandible could be corrected successfully in all patients except for the one whose PSI could not be used.

CONCLUSIONS

Virtual surgical planning combined with PSI is a possible useful clinical adjunct for the correction of maxillary hypoplasia in cleft patients. Large maxillary advancements and scarring may be cause problems for desired advancement and for the use of implants.

Le Fort I Osteotomy in Cleft Patients: Maxillary Advancement and Articulation

BACKGROUND

Maxillary advancement may affect speech in cleft patients.

AIMS

To examine whether the amount of maxillary advancement and preoperativecephalometric skeletal and dentoalveolar relationships are associated with articulation errors of the Finnish alveolar consonants /s/, /l/, and /r/ in cleft patients.

MATERIALS AND METHODS

Fifty-seven nonsyndromic cleft patients who underwent Le Fort I or bimaxillary osteotomies were evaluated retrospectively. Pre- and post-operative lateral cephalometric radiographs and standardized speech video recordings were analyzed. The Aspin-Welch unequal variance t test, Student t test sign test, intraclass correlation and Kappa statistics were used in the statistical analyses.

RESULTS

The mean advancement of the maxilla (point A) was 4.65 mm horizontally (range -2.80 to 11.30) and -3.82 mm vertically (range -14.20 to 3.90). The overall articulation (especially the sounds /s/ and /l/) improved significantly postoperatively, but the amount of maxillary advancement did not affect the articulation. The preoperative mean percentages of /s/, /l/, and /r/ errors were 32%, 33%, 46% and the postoperative percentages 23%, 19%, 40%, respectively. Preoperative articulation errors of /s/ were related to palatal inclination of the upper incisors.

CONCLUSIONS

Orthognathic surgery may improve articulation errors. The amount of maxillary advancement is not related to the improvement.

Early Prediction of the Need for Orthognathic Surgery in Patients With Repaired Unilateral Cleft Lip and Palate Using Machine Learning and Longitudinal Lateral Cephalometric Analysis Data

ABSTRACT

The purpose of this study was to determine the cephalometric predictors of the future need for orthognathic surgery in patients with repaired unilateral cleft lip and palate (UCLP) using machine learning. This study included 56 Korean patients with UCLP, who were treated by a single surgeon and a single orthodontist with the same treatment protocol. Lateral cephalograms were obtained before the commencement of orthodontic/orthopedic treatment (T0; mean age, 6.3 years) and at at least of 15 years of age (T1; mean age, 16.7 years). 38 cephalometric variables were measured. At T1 stage, 3 cephalometric criteria (ANB ≤ -3°; Wits appraisal ≤ -5 mm; Harvold unit difference ≥34 mm for surgery group) were used to classify the subjects into the surgery group (n = 10, 17.9%) and non-surgery group (n = 46, 82.1%). Independent t-test was used for statistical analyses. The Boruta method and XGBoost algorithm were used to determine the cephalometric variables for the prediction model. At T0 stage, 2 variables exhibited a significant intergroup difference (ANB and facial convexity angle [FCA], all P < 0.05). However, 18 cephalometric variables at the T1 stage and 14 variables in the amount of change (ΔT1-T0) exhibited significant intergroup differences (all, more significant than P < 0.05). At T0 stage, the ANB, PP-FH, combination factor, and FCA were selected as predictive parameters with a cross-validation accuracy of 87.4%. It was possible to predict the future need for surgery to correct sagittal skeletal discrepancy in UCLP patients at the age of 6 years.

Cephalometric Predictors of Future need for Orthognathic Surgery in Korean Patients with Unilateral Cleft Lip and Palate Despite Long-term Use of Facemask with Miniplate

Objective

To investigate the cephalometric predictors of the future need for orthognathic surgery in Korean patients with unilateral cleft lip and palate (UCLP) despite long-term use of facemask with miniplate (FMMP).

Methods

The sample consisted of 53 UCLP patients treated by a single orthodontist using an identical protocol. Lateral cephalograms were taken before commencement of FMMP therapy (T0; mean age, 10.45 years), after FMMP therapy (T1; mean age, 14.72 years), and at follow-up (T2; mean age, 18.68 years). Twenty-eight cephalometric variables were measured. At T2 stage, the subjects were divided into FMMP-Nonsurgery (n = 33, 62.3%) and FMMP-Surgery (n = 20, 37.7%) groups according to cephalometric criteria (point A-nasion-point B [ANB] < –3°; Wits-appraisal < –5 mm; and Harvold unit difference [HUD] > 34 mm for FMMP-Surgery group). Statistical analyses including discrimination analysis were performed.

Results

In FMMP-Surgery group, the forward position of the mandible at T0 stage was maintained throughout the whole stages and Class III relationship worsened with significant growth of the mandibular body and ramus and counterclockwise rotation of the maxilla and mandible at the T1 and T2 stages. Six cephalometric variables at T0 stage including ANB, anteroposterior dysplasia indicator, Wits-appraisal, mandibular body length, HUD, and overjet were selected as effective predictors of the future need for surgical intervention to correct sagittal skeletal discrepancies.

Conclusions

Despite long-term use of FMMP therapy, 37.7% of UCLP patients became candidates for orthognathic surgery. Therefore, differential diagnosis is necessary to predict the future need for orthognathic surgery at early age.

Effect of maxillary advancement on speech and velopharyngeal function of patients with cleft palate: Systematic Review and Meta-Analysis

This systematic review (SR) aimed to evaluate speech and velopharyngeal function (VPF) changes of patients with cleft palate (CLP) after maxillary advancement (MA) surgery. A two-phase PROSPERO-registered SR (CRD42019141370) was conducted following the PRISMA statements. Search strategies were developed for main databases (PubMed, Scopus, Web of Science, COCHRANE, LILACS, and EBSCOhost) and Grey literature information sources. The GRADE tool was used to evaluate the quality of evidence. From a total of 908 articles, 10 (205 men and 147 women; mean age ranging from 18.0 to 25.7 years) were selected for meta-analysis. Moderate to high risk of bias (Rob) was observed. The most common methods for outcomes evaluation were the Nasometer (speech) and nasoendoscopy (VPF). Speech changed from normal to hypernasal, and VPF worsening were reported in most studies. Comparing maxillary advancement interventions (osteogenic distraction versus Le Fort I), no statistically significant differences were found regarding benefit on speech and VPF. In summary, the effect of MA on speech and VPF remains controversial in CLP patients. The RoB, inconsistencies, and imprecisions severely affected the overall quality of evidence. Further adequately delineated clinical studies are necessary to investigate the potential effect of MA interventions on speech and VPF in CLP patients.

Impact of surgical orthodontic treatment on quality of life in Chinese young adults with class III malocclusion: a longitudinal study

Background

The quality of life in Class III malocclusion patients are worse than those without the disorder and previous studies have shown that surgical orthodontic treatment has a different effect on these patients compared with mild or moderate malocclusion. This study aimed to investigate the changes in quality of life in patients with Class III malocclusion during surgical orthodontic treatment in Chinese young adults.

Methods

The 14-item Short Form Oral Health Impact Profile (OHIP-14), and the 22-item Orthognathic Quality of Life Questionnaire (OQLQ) were used to assess the effect of surgical orthodontic treatment on the quality of life in 21 patients with Class III malocclusion at pre-treatment (T₀), pre-surgical orthodontic treatment (6 to 8 months, T₁) and post-surgical orthodontic treatment (6 to 8 months after surgery, T₂), and 24 healthy individuals were included as controls. The comparisons in numerical variables between patients and controls were performed using Mann-Whitney U test. The scores of the two questionnaires between T₀, T₁, T₂ and controls (Tc) were compared using generalized estimating equation.

Results

According to OHIP-14 questionnaire, the mean scores in T₀ and T₁ were higher than those in T₂ and Tc (P < 0.001), and a significant decrease was observed after post-surgical orthodontic treatment (P < 0.001), which achieved a level similar to the control group (P > 0.05). As to OQLQ questionnaire, the mean scores of all domains showed a significant increase between T₀ and T₁ except for awareness of dentofacial aesthetics (P > 0.05) and social aspects of dentofacial deformity (P > 0.05), followed by a significant decrease between T₁ and T₂.

Conclusion

Surgical orthodontic treatment may improve quality of life in patients with Class III malocclusion, but pre-surgical orthodontic treatment may have an adverse effect on quality of life.

Cleft and Craniofacial Team Orthodontic Care in the United States: A Survey of the ACPA

Objective:

To better understand the capacity for orthodontic care, service features, and finances among members of the American Cleft Palate-Craniofacial Association (ACPA).

Design:

Cross-sectional survey.

Setting:

ACPA-approved multidisciplinary cleft teams.

Participants:

Cleft team coordinators.

Interventions:

Coordinators were asked to complete the survey working together with their orthodontists.

Main Outcome Measure:

Model for orthodontic care.

Results:

Coordinators from 82 out of 167 teams certified by ACPA completed the survey (response rate = 49.1%). Most orthodontists were private practice volunteers (48%) followed by university/hospital employed (22.8%). Care was often delivered in community private practice facilities (44.2%) or combination of university and private practice facilities (39.0%). Half of teams reported offering presurgical infant orthopedics (PSIO), with nasoalveolar molding being the most common. Cleft/craniofacial patients typically comprise 25% or less of the orthodontists’ practices. The presence of a university/hospital-based orthodontist was associated with higher rates of offering PSIO ( P < .001) and an increased percentage dedication of their practice to cleft/craniofacial care ( P < .001).

Conclusion:

Orthodontic models across ACPA-certified teams are highly varied. The employment of full-time craniofacial orthodontists is less common but is highly correlated with a practice with a high percentage of cleft care and the offering of advanced services such as PSIO. Future work should focus on how to effectively promote such roles for orthodontists to ensure high-level care for cleft/craniofacial patients requiring treatment from infancy through skeletal maturity.

Predicting need for orthognathic surgery in early permanent dentition patients with unilateral cleft lip and palate using receiver operating characteristic analysis

INTRODUCTION

The purpose of this study was to predict the need for orthognathic surgery in patients with unilateral cleft lip and palate (UCLP) in the early permanent dentition.

METHODS

In this retrospective cohort study, we included 61 patients with complete UCLP (36 male, 25 female; mean age, 18.47 years; range, 16.92-26.17 years). The subjects were grouped into an orthognathic surgery group and a nonsurgery group at the time of growth completion. Lateral cephalograms obtained at the age of 11 years were analyzed to compare the 2 groups. The receiver operating characteristic analysis was applied to predict the probability of the need for orthognathic surgery in early adulthood by using the measurements obtained at the age of 11 years.

RESULTS

SNB, ANB, SN, overbite, overjet, maxillary length, mandibular body length, and L1-MP were found to be significantly different between the 2 groups. For a person with a score of 2 in the 3-variable-based criteria, the sensitivity and specificity for determining the need for surgical treatment were 90.0% and 83.9%, respectively (ANB, ≤-0.45°; overjet, ≤-2.00 mm; maxillary length, ≤47.25 mm).

CONCLUSIONS

Three cephalometric variables, the minimum number of discriminators required to obtain the optimum discriminant effectiveness, predicted the future need for orthognathic surgery with an accuracy of 86.9% in patients with UCLP.