Cleft Lip and Palate Midfacial Hypoplasia: Criteria to Choose the Treatment

Abstract

A series of skeletal and dentoalveolar/occlusal criteria were proposed for choosing the treatment modality for the management of midface hypoplasia in cleft lip/palate patients, focusing on functional improvement, aesthetics, and minimizing the risk of recurrence and secondary alterations. For which, 42 patients with nonsyndromic cleft lip/palate, all with previous primary lip/palate surgeries and without previous osteotomies, were analyzed. Orthognathic surgery (OS) (n ¼ 24) and maxillary distraction osteogenesis (n ¼ 18) with anterior segmental osteotomies (segmental distraction osteogenesis [SD]), alveolar transport disc (TD), and midface total distraction osteogenesis (TDO) by modified Le Fort III osteotomy was done.The average of maxillary advancement for OS was 5.58 AE 0.83 mm, for SD 9.4 AE 0.89 mm, for TD 8.00 AE 1.00 mm, and for TDO was 8.13 AE 1.55 mm.In the presence of infraorbital and/or zygomatic hypoplasia, TDO was performed using skeletal anchorage, with the requirement of occlusal stability in dental cast in occlusion. In short maxillary arch without dental cast feasibility in occlusion, hypodontia/agenesis or absence of premaxilla, TD and SD was performed. There was only 1 mm of recurrence in 1 patient of each group. Changes in speech were detected in 2 patients in the OS group (8.3%). Orthognathic surgery can be indicated for advancements 7 mm not requiring orbito-zygomatic advancement, whereas distraction osteogenesis can be indicated for advances >8 mm with or without the need for orbito-zygomatic advancement, in addition with other dentoalveolar factors and velopharyngeal function.

Optimizing Facial Esthetic Outcomes: Adding Distraction Osteogenesis to Your Classic Orthognathic Surgery Armamentarium

“…This alveolar "bone transport" has the potential to avoid the need for intraoral soft-tissue transfers for an "inner lining" and represents an alternative for the reconstruction of oral mucosa and gingiva by prefabricated osseo-mucosal-like tissue grafts. [23][24][25][26] At the occlusal level, distraction principles have been applied to orthodontic management. 27,28 Thus, the skeletal expansion has a direct effect on the overlying muscular and soft-tissue envelope.…”

“…Its increased complexity and technical difficulties have prevented its application in preimplant surgery, but it shows promise in native environment recovery in severe defect cases of patients with cleft lip and palate. This alveolar “bone transport” has the potential to avoid the need for intraoral soft-tissue transfers for an “inner lining” and represents an alternative for the reconstruction of oral mucosa and gingiva by prefabricated osseo-mucosal-like tissue grafts 23–26 . At the occlusal level, distraction principles have been applied to orthodontic management 27,28 …”

Malocclusions and oral disorders associated with cleft lip and palate; Prevention and treatment

“…However, in a more recent article published by Mundra Leela et al (2022), he concludes that alveolar bone grafting with pre-and postoperative orthodontics is currently the standard of care for the treatment of alveolar defects in patients with LPH. [26,27] In the study by Fariña et al (2021), the criteria for choosing the best treatment approach for cleft lip and palate midfacial hypoplasia are discussed, which may range from maxillary orthopedics and orthognathic surgery to reconstructive plastic surgery. After analysis of 42 patients, it is concluded that orthognathic surgery may be indicated for advancement ≤ 7 mm not requiring orbitozygomatic advancement, whereas distraction osteogenesis may be indicated for advancement > 8 mm with or without the need for orbitozygomatic advancement.…”

“…After analysis of 42 patients, it is concluded that orthognathic surgery may be indicated for advancement ≤ 7 mm not requiring orbitozygomatic advancement, whereas distraction osteogenesis may be indicated for advancement > 8 mm with or without the need for orbitozygomatic advancement. [28]…”

“…This is the optimal stage to guide occlusion and intercept malocclusions. [2,6,7,8] The objective of the present study was to review the literature in order to gather information on how cleft lip and palate are associated with the development of facial structures and occlusal alterations, and to establish possible solutions or treatments to benefit these patients.…”