Premaxillary Repositioning in the Severe Form of Bilateral Cleft Lip and Palate

Abstract

Severe forms of bilateral cleft lip and palate remain a challenging issue. Although nasoalveolar molding dramatically improves overall treatment success, the position of the premaxilla often remains dislocated. The authors attempted to relocate the malpositioned premaxilla into the correct position to obtain the correct three-dimensional (3D) maxillary arch structure and growth. Eight patients with severe bilateral cleft lip and palate were treated with premaxillary osteotomy for premaxilla repositioning. The position of the premaxilla was measured directly using cephalometry. Two raters including orthodontists evaluated the 3D (anteroposterior, transverse, and sagittal) outcomes. Regarding the long-term effects of premaxillary repositioning on midfacial growth, 3D computed tomography scan data were used, including the measurement of the SNA, SNB, and ANB angles according to the time period (T0: preoperative; T1: immediate postoperative; T2: long-term postoperative). All bilateral cleft lips and palates were satisfactorily repaired without any complications, including any premaxillary vascular compromise, nonunion, and occlusal instability. The average visual analog scale scores (0-5) of the anteroposterior, vertical, and transverse dimensions were 3.9, 3.7, and 3.2, respectively. Regarding the effect of premaxillary repositioning on midfacial hypoplasia, the change in the ANB between T1 and T2 was not significant, implying that premaxillary repositioning did not affect the long-term harmony between the maxilla and mandible (ANB of T2-T1: P = 0.1016) based on interim growth data at the time of follow-up and study completion. Premaxillary repositioning effectively corrected the malpositioned premaxilla and repaired the accompanying wide alveolar cleft, achieving successful restoration of maxillary arch coordination. In addition, premaxillary osteotomy after 8 years of age does not seem to cause significant maxillary retrusion.

Premaxillary osteotomy in children with bilateral cleft lip and palate: Skeletal and dental changes

“…Improvements in the position of the premaxilla provided better functioning and aesthetics to the patient, as the premaxilla becomes positioned normally, the superior incisors have better pro-inclination and intrusion, and the overbite is improved; overall, this facilitates later orthodontic movements. These results are similar to those reported by Kyung, et al (2016), who found that premaxillary repositioning effectively corrects a malpositioned premaxilla, achieving a successful restoration of maxillary arch coordination [17].…”

“…Premaxillary osteotomy is a potentially good solution for severe forms of BCLP [17], as it is not possible to correct BCLP with orthodontics in these severe cases. There are few studies that quantify which patients need osteotomy and which patients do not, as differences in treatment protocols make comparison dif icult.…”

“…There can also be associated dental anomalies, including alterations in the number of teeth (64.2%), with dental agenesis having the highest incidence (44.3%), with the upper lateral incisor (33.8%) the most frequently associated on the side of the cleft (74%). Additional defects include supernumerary (19.8%), ectopic, or microdontic teeth [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18].…”

Impact of Virtual Planning on Surgical Reposition of the Premaxilla Using an Endonasal Approach and Simultaneous Alveoloplasty

“…Thus, the premaxillary osteotomy is thought to be contraindicated in growing children. Despite the debate, recent publications agree that it could be accepted as a viable alternative for the repair of severe forms of bilateral alveolar cleft (El-Kassaby et al, 2013; Steinhäuser, 2014; Koh et al, 2016).…”

“…On the other hand, surgical repositioning is controversial, with different authors reporting the negative influence on the development of the midface. However, a recently published study has concluded that in children older than 8 years it does not seem to cause significant maxillary retrusion (Koh et al, 2016).…”