Modified endonasal approach for premaxillary repositioning in the patient with bilateral cleft lip - a review of technique

Abstract

Objective In patients with bilateral cleft lip, the management of the cleft premaxilla can be challenging, because it remains mobile throughout childhood until stabilized with grafting. A small group of patients may have grossly malpositioned premaxillae that cannot be managed with traditional techniques. Concerns about compromised perfusion and scarring have led to attempts to reposition the premaxilla before alveolar grafting while preserving the gingival periosteum. Reported methods include utilizing a lip-split incision (Rahpeyma et al., 2016), conservative transoral approaches (Koh et al., 2016; Steinhauser, 2014), and endonasal approaches (Sierra et al., 2018; Martinez-Plaza, et al., 2018). At our institution, we use a staged approach, in which endonasal osteotomies via a Killian incision are performed to mobilize the cleft premaxilla, and then it is repositioned into a more anatomic position by using orthodontic splinting. Our primary outcome evaluated any adverse vascular compromise. Study Design This retrospective analysis catalogs 6 cases of endonasal premaxillary repositioning in patients with bilateral cleft palate since 1999. A chart review identified gender, age, vascular issues, infection, and overall progress for the management of the cleft. Indications for staged repositioning were severe vertical, horizontal, or rotation/torsion malalignments of the premaxilla. We report here our modified technique using an endonasal approach for repositioning an infra-positioned premaxilla. Results All cases reviewed had improved anatomic location without any vascular compromise. No infections were noted. The study included 4 females and 2 males (age range was 4–10 years). Four of these patients went on to have alveolar grafting, with 2 currently planned for eventual grafting. Three of the patients have had or are undergoing workup for orthognathic surgery, 1 did not need surgery, and 2 were lost to follow-up. Conclusions Endonasal osteotomy is a predictable way to reposition the bilateral cleft premaxilla while maintaining blood supply and preventing gingival scarring. This technique is minimally invasive and aids in anatomic repositioning for the orthodontic management of patients with complex bilateral cleft lip/palate. Further studies are needed to evaluate the stability of this procedure and considerations of simultaneous bone grafting.