Sagittal Growth Restriction of the Midface Following Isolated Cleft Lip Repair: A Systematic Review and Meta-Analysis

Abstract

Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate repair, and is poorly understood. No study has examined the aggregate data on sagittal growth restriction of the midface following repair of the lip, but not palate, in these patients. A systematic review of 3780 articles was performed. Twenty-four studies met inclusion criteria and 11 reported cephalometric measurements amenable to meta-analysis. Patients with Veau class I-III palatal clefts were included so long as they had undergone only lip repair. Groups were compared against both noncleft and unrepaired controls. Cephalometrics were reported for 326 patients (31.3% female). Noncleft controls had an average SNA angle of 81.25° ± 3.12°. The only patients demonstrating hypoplastic SNA angles were those with unilateral CLP with isolated lip repair (77.4° ± 4.22°). Patients with repaired CL had SNA angles similar to noncleft controls (81.4° ± 4.02°). Patients with unrepaired CLP and CL tended toward more protruding maxillae, with SNA angles of 83.3° ± 4.04° and 87.9° ± 3.11°, respectively. Notably, when comparing SNA angles between groups, patients with CLP with isolated lip repair had significantly more hypoplastic angles compared to those with repaired CL ( P < .0001). Patients with CLP with isolated lip repair were also more hypoplastic than noncleft controls ( P < .0001). In contrast, there was no significant difference between the SNA of patients with repaired CL and controls ( P = .648). We found that cleft lip repair only appeared to contribute to MFH in the setting of concurrent cleft palate pathology, suggesting that scarring from lip repair itself is unlikely to be the predominant driver of MFH development. However, studies generally suffered from inadequate reporting of timing, technique, follow-up time, and cleft severity.

Evaluation of Orbitomalar Region Projection in Patients With Operated Cleft Lip and Palate (Cephalometric Study)

“…Although there are various publications about the orbital region in the literature, most of these studies evaluate soft tissue reference points (intercanthal, interocular distance, and lid fissure width) or orbital diameter in the transverse plane. 23 , 33 , 44 – 46 Suri et al 47 reported that in cases with unilateral CLP, the orbital rim in the sagittal plane showed similar projections to the control group in craniofacial CT analyses, and these findings were consistent with the results of the present study. Kane et al 48 conducted a 3D CT analysis of 28 cases with unilateral CLP and reported that serious asymmetries were observed in the orbital region compared to the normal side.…”

Tendon-associated gene expression precedes osteogenesis in mid-palatal suture establishment

“…Our data supports a close physical relationship between expanding palatine bone and the patent midline mesenchyme involving a neotendon-like structure, which may be a critical component for formation of a functional suture. It has been noted that even superficial disruption of the mid-palatal suture impedes midface expansion, and midface hypoplasia is still a potential outcome following CL/P repair (Celie et al, 2024; Freng, 1978; Fudalej et al, 2008; Li et al, 2015). The use of MSC-centered/derived therapies for bone regeneration and tendon healing, especially with adjunctive indiscriminate application of rhBmp2, should be revisited under the lens of our findings (Makar et al, 2021; Shen et al, 2022; Takagi & Urist, 1982).…”

What Are the Effects on Palate of Early Lip Surgery in Children With Cleft Lip and Palate? Cross-Sectional Evaluation From 5-Year-Old

“…19 Some studies stated that hypoplasia in growth is intrinsic to orofacial cleft, 20,21 whereas others argue that the sum of segmentation of maxilla, tissue hypoplasia and scar tension of lip repair surgeries causes growth modification. 22,23 However, a systematic review reinforced the evidence of the lip repair impact on maxillary growth, 19 because patients with unoperated cleft lip and palate showed potential growth, as compared with patients without cleft lip and palate. 24 The suggested hypothesis is that the intrinsec anatomy of the cleft and the absence of surgical repair contribute to the maximum potential of maxillary growth in individuals with nonoperated cleft lip and palate.…”

“…Notwithstanding, divergent justifications have been presented in the literature 19 . Some studies stated that hypoplasia in growth is intrinsic to orofacial cleft, 20,21 whereas others argue that the sum of segmentation of maxilla, tissue hypoplasia and scar tension of lip repair surgeries causes growth modification 22,23 . However, a systematic review reinforced the evidence of the lip repair impact on maxillary growth, 19 because patients with unoperated cleft lip and palate showed potential growth, as compared with patients without cleft lip and palate 24 .…”