A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis

doi:10.1016/j.ijom.2005.06.008

International Journal of Oral and Maxillofacial Surgery

Volume 35, Issue 1, January 2006, Pages 14-24

https://doi.org/10.1016/j.ijom.2005.06.008 Get rights and content

Abstract

This meta-analysis aims to provide evidence-based data to assist surgeons to make an informed choice between distraction osteogenesis or conventional osteotomy for cleft lip and palate patients. A PUBMED search of the National Library of Medicine from 1966 to December 2003 was conducted. Keywords used in the search were ‘cleft’, ‘distraction’, ‘maxilla’, ‘maxillary’, ‘advancement’, ‘osteotomy’, and ‘orthognathic surgery’. This study concluded that distraction osteogenesis tends to be preferred to conventional osteotomy for younger CLP patients with more severe deformities. In such cases it was feasible to use distraction to correct moderate to large movement of the maxilla by either complete or incomplete Le Fort I osteotomy, and a concurrent mandibular osteotomy was less frequently required. Intra-operative and post-operative complications were uncommon with either technique, and some of the traditional ischemic complications related to conventional osteotomy were replaced by infection of the oral mucosa due to the prolonged retention of the distractors. There is still no conclusive data on any differences in surgical relapse, velopharyngeal function and speech between the two techniques. Both distraction osteogenesis and conventional osteotomy can deliver a marked improvement in facial aesthetics.

Section snippets

Materials and methods

Literature searches were performed for clinical trials of any form of cleft maxillary osteotomy and distraction by a PUBMED search of the contents of the National Library of Medicine from January1966 to December 2003. Keywords used in the search were ‘cleft’, ‘distraction’, ‘maxilla’, ‘maxillary’, ‘advancement’, ‘osteotomy’, and ‘orthognathic surgery’. The searches were confined to publications in English and Chinese. In all, 98 papers were identified and the full articles were retrieved from

Results

Of the 98 articles identified in the PUBMED search, 72 (73.46%) were related to cleft maxillary osteotomy1, 2, 4, 5, 6, 8, 9, 11, 12, 13, 14, 15, 19, 22, 24, 25, 26, 28, 29, 30, 31, 32, 33, 35, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 49, 50, 51, 52, 56, 58, 60, 61, 63, 64, 65, 66, 67, 69, 70, 71, 72, 74, 75, 76, 77, 78, 79, 80, 82, 84, 85, 86, 88, 89, 90, 97, 98, 99, 101, 103, 106, 107, and 26 (26.537%) to cleft maxillary distraction7, 10, 17, 18, 20, 21, 27, 34, 36, 37, 45, 53, 54, 55, 57, 59,

Discussion

Correcting the deformities of CLP patients with severe maxillary hypoplasia presents a definite challenge for oral and maxillofacial surgeons. Treatment planning and surgery are generally more complex for CLP patients than non-cleft patients because several phases of treatment are necessary and the required amount of maxillary advancement is generally larger in cleft deformities. The surgical difficulties of using conventional osteotomy to transpose the maxillary segments immediately in CLP

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Cited by (138)

Protocols in the management of cleft lip and palate: A systematic review
2023, Journal of Stomatology, Oral and Maxillofacial Surgery
Citation Excerpt :
In this review, one paper focused on conventional Le Fort I advancement compared with distraction osteogenesis, and DO was found to provide improved horizontal and vertical skeletal stability over time. In terms of speech, however, there was no difference suggesting that DO does not provide an extra advantage over Le fort in preventing Velopharyngeal insufficiency (VPI) for 6-10mm advancement [35]. Chua et al also analyzed the psychological impact of le fort1 and DO and found that both had a positive impact on patients and reduced distress up to two years post-procedure [36].
To identify clinical decisions on surgical as well as non-surgical modalities for the treatment of CLP patients based on randomized controlled trials (RCTs).
PubMed, Ebscohost, and Cochrane Library were searched and 20 articles based on RCTs conducted on cleft patient management were identified.
The topics explored were infant orthopedics, lip and palate repair, alveolar bone grafting, and management of cleft maxillary hypoplasia. Nasoalveolar molding (NAM) was found to have great benefits when carried out within one month of birth. Fisher and Mohler's lip repair technique and use of recombinant human bone morphogenetic protein-2 (rh-BMP2) for alveolar bone grafting showed promising results. rh-BMP2 for alveolar bone grafting appears to be a promising alternative to autografts.
Early commencement of NAM in neonatal life is of great benefit to cleft patients. There is a need for more multicentre collaborations, mainly to identify the ideal surgical technique to reduce the variability in treatment and to ensure that the patient receives appropriate evidence-based treatment.
Definitive Rhinoplasty and Orthognathic Surgery for Patients with Cleft Lip Palate
2023, Oral and Maxillofacial Surgery Clinics of North America
Effects of anterior maxillary distraction compared to LeFort-1 osteotomy and total maxillary distraction osteogenesis for treating hypoplastic maxilla in patients with cleft lip and palate- A systematic review and meta-analysis
2023, Journal of Stomatology, Oral and Maxillofacial Surgery
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.
Postoperative stability following orthognathic surgery and final skeletal morphology in class III patients with cleft lip and palate
2022, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
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.
Is Cleft Lip or Palate a Risk Factor for Perioperative Complications in Orthognathic Surgery?
2022, Journal of Oral and Maxillofacial Surgery
Perioperative outcomes following cleft orthognathic surgery are not well established. The purpose of this study was to compare the incidence of orthognathic specific complications (OSCs) in patients with and without cleft lip and/or palate.
The American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases were used to enroll patients undergoing orthognathic surgery. The primary predictor variable was a prior diagnosis of cleft lip and/or palate: cleft versus noncleft. The primary outcome variable was OSCs (yes/no) within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between cleft status and OSCs.
The study sample was composed of 1,149 subjects: 98 in the cleft group and 1,051 in the noncleft group. The incidence of OSCs was 6.1 and 4.7% for the cleft and noncleft groups, respectively (P = .461). After adjusting for age, cleft status, bone grafting, segmentation of the maxilla, and history of bleeding disorder, classification as American Society of Anesthesiologists (ASA) III (P = .002, odds ratio [OR] = 3.92, 95% confidence interval [CI] 1.63-9.40), ASA IV (P = .039, OR = 9.47, 95% CI 1.12-80.4), and isolated mandibular osteotomies (P = .006, OR = 3.23, 95% CI 1.40-7.48) were independent predictors of OSCs. Length of stay was 1.66 ± 1.14 days compared to 1.37 ± 3.74 days for the cleft and noncleft groups, respectively (P = .443).
There was no significant difference in the incidence of perioperative OSCs and length of hospital stay between cleft and noncleft patients. Cleft status was not an independent predictor of OSCs; instead, greater ASA classification and isolated mandibular osteotomies were the only predisposing factors. Patients with clefts undergoing orthognathic surgery do not have an increased risk of short-term OSCs within the limitations of this study.
Cleft Lip and Palate: Le Fort I Distraction Using an Internal Device
2021, Clinics in Plastic Surgery

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Invited Review PaperDistraction OsteogenesisA meta-analysis of cleft maxillary osteotomy and distraction osteogenesis

Abstract

Section snippets

Materials and methods

Results

Discussion

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

J Cranio Maxillofac Surg

Am J Orthod Dentofac Orthop

J Maxillofac Surg

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Cranio-Maxillofac Surg

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Path

J Cranio-Maxillofac Surg

J Cranio-Maxillofac Surg

Int J Oral Maxillofac Surg

J Craniomaxillofac Surg

J Cranio-Maxillofac Surg

J Oral Maxillofac Surg

J Maxillofac Surg

J Maxillofac Surg

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Maxillofac Surg

J Cranio-Maxillofac Surg

Int J Oral Maxillofac Surg

J Cranio-Maxillofac Surg

Soft tissue profile changes in patients with cleft lip and palate following maxillary osteotomies

Cleft Palate Craniofac J

Total maxillary advancement with and without bone grafting

J Oral Surg

Complications following orthognathic surgery that required early surgical intervention: fifteen years’ experience

Int J Adult Orthodon Orthognath Surg

Auditory tube function and audiogram changes following corrective orthognathic maxillary and mandibular surgery in cleft and non-cleft patients

Scand J Plast Reconstr Surg

Importance of soft tissue for skeletal stability in maxillary advancement in patients with cleft lip and palate

Cleft Palate Craniofac J

Skeletal relapse of maxillary osteotomies in unilateral cleft lip and palate patients

Int J Adult Orthodon Orthognath Surg

Treatment of maxillary arch collapse in an adult cleft palate patient: report of case

J Oral Surg

Segment distraction to reduce a wide alveolar cleft before alveolar bone grafting

Cleft Palate Craniofac J

Effects of maxillary advancement on the speech of a sub-mucous cleft patient

Cleft Palate J

Orthognathic surgical reconstruction of cleft palate deformities in adolescents

J Oral Surg

Craniofacial distraction with a modular internal distraction system: evolution of design and surgical techniques

Plast Reconstr Surg

Maxillary-midface distraction in children with cleft lip and palate: a preliminary report

Plast Reconstr Surg

Neuro-opthalmic complication after maxillary surgery

Bull Soc Belge Opthalmol

Management of alveolar clefts using dento-osseous transport distraction osteogenesis

Angle Orthod

Treatment of severe unilateral open bite and crossbite in cleft lip and palate patients

Euro J Orthod

Middle-third facial osteotomies: their use in the correction of congenital dentofacial and craniofacial deformities

J Oral Surg

An analysis of Le Fort I maxillary advancement in cleft lip and palate patients

Plast Reconstr Surg

Soft tissue response to orthognathic surgery in persons with unilateral cleft lip and palate

Cleft Palate Craniofac J

Mid-face osteotomy in the adolescent cleft palate patient

Aust Dent J

The lip profile after correction of retromaxillism in cleft and non-cleft patients

J Maxillofac Surg

Changes in speech following maxillary distraction osteogenesis

Cleft Palate Craniofac J

Invited Review Paper
Distraction Osteogenesis
A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis