Clinical controversies in oral and maxillofacial surgery: Part one

Treatment of Maxillary Cleft Palate: Distraction Osteogenesis Versus Orthognathic Surgery—Part One: Maxillary Distraction

To present a technique of placing custom patient specific bone plates (PSI) in patients after large maxillary advancement by distraction.

Two cases are used illustrating plate design with a single plate or 2 plates when an anterior pedicle is required.

Both patients went on to heal after large maxillary advancements and continued orthodontic management shortly after the PSIs were placed.

. Virtual planning is the gold standard for planning a maxillary distraction. Placement of custom plates 1 month after distraction can shorten the period of consolidation, ensure stability, and improve the occlusal results.

To compare the treatment outcomes and effectiveness of Anterior Maxillary Distraction (AMD) with the LeFort I Osteotomy and Total Maxillary Distraction Osteogenesis (TMDO) to treat cleft maxillary hypoplasia.

(PROSPERO CRD42020223345) Thorough electronic search of seven databases, unpublished gray literature, and a hand search of the relevant studies reference lists was done. Studies assessing mid-facial skeletal, dentoalveolar, and soft-tissue outcomes of AMD in patients >8 years of age, hypoplastic cleft maxilla, and with either TMDO/LeFort 1/ both as control groups were included. Seven included articles were assessed for the study characteristics and qualitative synthesis. Three studies were analyzed quantitatively using the RevMan 5.4 software. The quality of studies was assessed using Cochrane ROB2 and the overall certainty of evidence using GRADE.

AMD was performed in 241 subjects, LeFort 1 in 145 subjects, and TMDO in 42 subjects. Maxillary advancement for AMD and LeFort 1 groups showed no statistically significant difference (Mean Difference, MD -0.64°) while TMDO showed statistically significant advancement than AMD (MD -1.44°). Statistically significant upward rotation of anterior maxilla was noted with AMD (MD -6.15 degrees) than Lefort 1. Upper incisor inclination improved in both AMD and TMDO groups (MD 1.5°). Improvement in the maxilla-mandibular relationship, convexity of face, lip and nose, and marked dentoalveolar changes in overjet and upper incisor position were noted in all the three groups. Discernible airway alterations were noted in LeFort 1 and TMDOs. Total relapse was the least with AMD.

Distraction osteogenesis exhibited better dento-skeletal outcomes and minor skeletal relapse than LeFort 1. TMDO is a preferred modality in treating severe maxillary hypoplasia associated with CLP than AMD. Further long-term prospective comparative studies are required, possibly involving the patient-centric merits.

Orthognathic surgery has become useful procedures for patients with cleft lip and palate (CLP) to improve the inharmonious relationship between the maxilla and mandible. The purpose of this study is to assess the postoperative stability and skeletal morphology following orthognathic surgeries for patients with skeletal class III deformity with CLP.

This study retrospectively evaluated the long-term stability of orthognathic surgery and the final profile of skeletal morphology in 30 patients using lateral cephalometric imaging. Sagittal split ramus osteotomy was performed for 10 patients (CLP-S), Le Fort I osteotomy was performed for 5 patients (CLP-L) and two-jaw surgery was performed for 15 patients (CLP-T). As a control, we included 5 patients treated by two-jaw surgery, 7 patients treated by SSRO without CLP and 20 CLP patients with orthodontic treatment alone.

In the CLP group at 2 years postoperatively, the mean relapse in SNA was 19.8% (CLP-T) and 18.1% (CLP-L), and the mean relapse in SNB was 17.6% (CLP-S) and 26.9% (CLP-T). No significant differences were observed in the relapse ratio of the same operation between with and without CLP. In comparison of surgical and non-operative patients with CLP, there were significant differences in preoperative skeletal factors, but the profiles were similar at the end of treatment.

Our orthognathic surgeries provided the same level of stability for patients with skeletal class III deformity with or without CLP, creating harmonious intermaxillary relationship.

Maxillary hypoplasia is a common outcome in patients with cleft lip and palate after surgical and orthodontic interventions, and maxillary distraction osteogenesis has become a useful procedure for patients with extensive maxillary deformities. The aim of this study was to evaluate long term (two years) stability after maxillary advancement of more than 10 mm by distraction osteogenesis in cleft patients using internal devices. We organised a retrospective study on 42 patients with cleft lip and palate using cephalometric analysis before and after maxillary distraction osteogenesis and evaluated them for 24 months. Postoperative measurements showed a marked advancement with an increase of 13.3 mm and 10.8° in the length of the maxilla (Co-A) and SNA, respectively, including a shift from Angle class III to class I in dental relations. Follow-up observations showed preservation of maxillary length with a relapse of only 6.0 % (mean (SD) 0.8 (0.7) mm) and 10% relapse in SNA angle (mean (SD)1.1 (1.4) °) one year postoperatively and a negligible regression at the two years’ follow up. This large-scale study shows stable results of skeletal advancement using distraction osteogenesis, indicating safe and reliable outcomes among patients with cleft lip and palate.

To evaluate the intra- and post-operative complications of tooth-borne anterior maxillary distraction in management of cleft maxillary hypoplasia over a 12-year period, and to establish whether the procedure involves a learning curve.

All patients with cleft maxillary hypoplasia satisfying the inclusion and exclusion criteria and undergoing anterior maxillary distraction with a tooth-borne palatal distractor between June 2007 to June 2018 were retrospectively studied by retrieving their individual medical records, which included radiographic (lateral cephalogram analysis at three different intervals) and speech assessment records. The presence of intra- and post-operative complications developing in this study period was noted. Furthermore, the frequency of intra- and post-operative complications occurring from years 2007–2018 were evaluated to study whether there was a decrease in the frequency of complications with increasing time. This was done to establish whether there was a learning curve associated with the surgical procedure. The results thus obtained were tabulated using SPSS 25.0 (SPSS Inc., Chicago, IL) and subjected to statistical analysis using the chi-squared test. A p value of less than 0.05 was considered statistically significant.

Out of the 458 patients included in the study, 78.82 % (n = 361) had no complications. In the remaining 97 patients, a total of 137 complications (46 intra-operative and 91 post-operative) were observed, making up for a complication rate of 21.17%. The intra-operative complications noted were appliance dislodgement (n = 19), palatal mucosal tears (n = 12), hemorrhage (n = 8), dental injuries (n = 6) and inadvertent fracture of the anterior segment (n = 1). The post-operative complications noted were anterior open bite (n = 24), gingival inflammation (n = 14), appliance dislodgement (n = 13), dental injuries (n = 10), relapse (n = 8), hemorrhage (n = 5), soft tissue infections (n = 4), palatal fistula (n = 3), speech impairment (n = 3), wound dehiscence not related to infection (n = 3), need for re-operation (n = 2), avascular necrosis of the anterior segment (n = 1) and maxillary sinusitis (n = 1). A statistically significant decrease (p < 0.001) in the frequency of complications with each passing year from 2007 to 2018 was observed. Most complications were seen to occur in the first 4 years (i.e. 2007–2010; a total of 74 complications in 54 patients), making up 11.79% of the complications. In the following 8 years (i.e. 2011–2018), 63 complications were noted in 43 patients, making up the remaining 9.38 % of the complications. These observations indicate that a learning curve was involved before carrying out the procedure without many complications.

Tooth-borne anterior maxillary distraction in managing cleft maxillary hypoplasia is associated with a wide range of complications: some avoidable and related to surgeon's experience; some related to the surgical procedure itself; and some unavoidable and related to the distractor appliance. Understanding potential complications allows the surgeon to ensure safe care through early intervention and to correctly inform the patient in the pre-operative discussion. The procedure involves a learning curve before it can be accomplished safely without many complications.