Hypoplasia In Cleft Patients Research Articles

Early experience of wafer-free Le Fort I osteotomy with patient-specific implants in cleft lip and palate patients

The use of virtual surgical planning and patient-specific saw and drill guides combined with customized osteosynthesis is becoming a gold standard in orthognathic surgery. The aim of this study is to report preliminary results of the use of virtual surgical planning and the wafer-free PSI technique in cleft patients. Patient-specific saw and drill guides combined with milled patient-specific 3D titanium alloy implants were used in reposition and fixation in Le Fort I osteotomy of 12 cleft patients. Surgical information was retrieved from hospital records. Pre- and post-operative lateral cephalograms were analyzed. In 10 of 12 cases, the implants fitted as planned to predesigned drill holes and bone contours with high precision. In one patient, the mobilization of the maxilla was too demanding for virtually planned advancement, and the implants could not be used. In another patient, PSI fitting was impaired due to an insufficient mobilization of maxilla and tension on PSI fixation with screws. After the surgery, the mean advancement of the anterior maxilla (point A) of all patients was 5.8mm horizontally (range 2.7-10.1) and -3.1mm vertically (range -9.2 to 3.4). Skeletal relationships of the maxilla and mandible could be corrected successfully in all patients except for the one whose PSI could not be used. Virtual surgical planning combined with PSI is a possible useful clinical adjunct for the correction of maxillary hypoplasia in cleft patients. Large maxillary advancements and scarring may be cause problems for desired advancement and for the use of implants.

The Relationship Between Dental Agenesis and Maxillary Hypoplasia in Patients With Cleft Lip and Palate

Both dental agenesis and maxillary growth restriction are well-recognized sequelae in patients with unilateral cleft lip and palate, but their etiology remains controversial. The aim of this study was to evaluate the relationship between hypodontia and maxillary volume. A retrospective review of patients age 6 to 9 with Veau III (unilateral) cleft palate who underwent Cone Beam Computer Tomography in preparation for alveolar bone grafting at 2 major Children's Hospitals between 2010 and 2016 was conducted and serial panoramic radiographs were reviewed. Thirty-eight patients were identified that met inclusion criteria and had adequate imaging. Group 1 ("poor growers") consisted of the bottom 50% of Sella-Nasion-A point minus Sella-Nasion-B point (ANB) angles and Group 2 ("good growers") consisted of the top 50% of ANB angles. Group 1 had a significantly higher mean number of missing teeth (1.58 ± 0.28 missing teeth) compared to Group 2 (0.74 ± 0.23 missing teeth), and significantly lower maxillary volume (12.88 ± 0.61 cm3 versus 15.24 ± 0.88 cm3, respectively). The severity of maxillary hypoplasia in cleft patients increases with increased dental agenesis. These data indicate that intrinsic factors play a significant role in maxillary growth restriction in cleft patients, independent of the sequelae of surgical intervention.

Clinical efficacy of miniplates anchorage between the maxilla and the mandible for maxillary hypoplasia in cleft patients

Objective To investigate the effects of titanium miniplates used for anchorage between the maxilla and the mandible for maxilly hypoplasia in cleft patients. Methods Miniplates were inserted into the infrazygomatic crests and between the canine and lateral incisor in the mandible on both the right and left sides in 6 subjects (mean age, 11.3 years). Maxillomandibular elastics were attached between the upper and lower miniplates on each side. Cephalometric radiographs of each patient were evaluated at the beginning of treatment and at the end of active protraction treatment. Results A-point movement was increased mean 3.67 mm, SNA angle and ANB angle were increased by 2.75° and 3.1° respectively. Wit's appraisal was increased by 4.52 mm, and upper lip to E-plane was decreased mean 2.8 mm in a mean of 15 months and the significant difference was found (P<0.05). Miniplates stability was excellent in all patients throughout treatment. Conclusions Remarkable advancement in the middle face and consequent fullness in the soft-tissue profile can be achieved by using titanium miniplates protraction for maxilly hypoplasia in cleft patients in the late mixed-dentition and initial stage of permanent dentition period. Key words: Cleft lip; Cleft palate; Retrognathia; Traction; Titanium miniplate

Computer-Assisted Virtual Planning for Surgical Guide Manufacturing and Internal Distractor Adaptation in the Management of Midface Hypoplasia in Cleft Patients

We are reporting the treatment of severe maxillary hypoplasia in two patients with unilateral cleft lip and palate by using a specific approach combining the Le Fort I distraction osteogenesis technique coupled with computer-aided design/computer-aided manufacturing customized surgical guides and internal distractors based on virtual computational planning. This technology allows for the transfer of the virtual planned reconstruction to the operating room by using custom patient-specific implants, surgical splints, surgical cutting guides, and surgical guides to plate or distractor adaptation.

Use of repeat anterior maxillary distraction to correct residual midface hypoplasia in cleft patients.

ObjectivesThe study was designed to evaluate the efficacy of performing a second, repeat anterior maxillary distraction (AMD) to treat residual cleft maxillary hypoplasia.Materials and MethodsFive patients between the ages of 12 to 15 years with a history of AMD and with residual cleft maxillary hypoplasia were included in the study. Inclusion was irrespective of gender, type of cleft lip and palate, and the amount of advancement needed. Repeat AMD was executed in these patients 4 to 5 years after the primary AMD procedure to correct the cleft maxillary hypoplasia that had developed since the initial procedure. Orthopantomogram (OPG) and lateral cephalograms were taken for evaluation preoperatively, immediately after distraction, after consolidation, and one year postoperatively. The data obtained was tabulated and a Mann Whitney U-test was used for statistical comparisons.ResultsAt the time of presentation, a residual maxillary hypoplasia was observed with a well maintained distraction gap on the OPG which ruled out the occurrence of a relapse. Favorable movement of the segments without any resistance was seen in all patients. Mean maxillary advancement of 10.56 mm was achieved at repeat AMD. Statistically significant increases in midfacial length, SNA angle, and nasion perpendicular to point A distance was achieved (P=0.012, P=0.011, and P=0.012, respectively). Good profile was achieved for all patients. Minimal transient complications, for example anterior open bite and bleeding episodes, were managed.ConclusionAddressing the problem of cleft maxillary hypoplasia at an early age (12–15 years) is beneficial for the child. Residual hypoplasia may develop in some patients, which may require additional corrective procedures. The results of our study show that AMD can be repeated when residual deformity develops with the previous procedure having no negative impact on the results of the repeat procedure.

Techniques for the Treatment of Maxillary Hypoplasia in Cleft Patients: An Overview

Purpose of review Maxillary hypoplasia is often unavoidable sequelae in cleft lip and palate patients who had undergone timely surgical and orthodontic intervention. Since 1970s these deformities have been traditionally corrected by means of orthognathic surgery. Numerous published studies have tried different techniques to combat the same. The advantages and disadvantages of the various techniques are overviewed. Recent Findings Distraction osteogenesis is one of the recent major developments in the field of oral and maxillofacial surgery and provides promising outcome. Tooth borne device hyrax proved good skeletal stability of distracted anterior maxillary segment. Distraction forces when directly transferred to the bone resulted in significant dentoalveolar compensation. This modern technique has also been used to evaluate its immediate and long term impact on nasal index as well which showed significant increase. This technique overcomes significant disadvantages of relapse and velopharyngeal insufficiency and also helps to produce better normal facial esthetics and profiles and masticatory function. Summary The oral and maxillofacial surgeons have widely accepted the use of maxillary distraction osteogenesis as an attractive alternative to treat malocclusion in CLP patients and this has broadened the reconstructive spectrum. Recent advancements have led to a wider clinical application and improved acceptance.

Lateral incisor agenesis predicts maxillary hypoplasia and Le Fort I advancement surgery in cleft patients.

Severe maxillary hypoplasia in cleft patients is caused by a combination of pathogenic and iatrogenic factors. In this work, the authors investigated anatomical deficiencies in dentition for predicting Le Fort I maxillary advancement surgery for severe maxillary hypoplasia in cleft patients. Cleft lip-cleft palate and cleft palate patients older than 14 years of age were reviewed for demographics, dental anomalies, and Le Fort I advancement. Chi-square tests, t tests, and multivariate logistic regression analyses were performed to delineate the contribution of quantity and position of dental agenesis to maxillary advancement surgery. In the 114 patients reviewed (mean age, 19.2 years), 64.0 percent were male patients, 71.9 percent had dental agenesis, and 59.6 percent required Le Fort I advancement. In patients who did not exhibit dental agenesis, 18.8 percent required Le Fort I advancement compared with 74.4 percent of patients with dental agenesis (p < 0.0001). Le Fort I advancement surgery was increased to 76.3 percent when dental agenesis was at the lateral incisor position (p < 0.0001) and 86.4 percent when patients were missing two or more teeth (p < 0.0001). Both sella-to-nasion-to-A point angle (p = 0.003) and A point-to-nasion-to-B point angle (p = 0.04) measurements were decreased in patients missing dentition at the lateral incisor position. Adjusting for multiple missing teeth and orthodontic compensations, multivariate logistic regression analyses demonstrated that lateral incisor agenesis is an independent predictor for Le Fort I advancement surgery (OR, 4.4; 95 percent CI, 1.42 to 13.64; p = 0.01). Lateral incisor agenesis correlated to maxillary hypoplasia and independently predicted the need for Le Fort I advancement in cleft patients, potentially as an anatomical readout of intrinsic growth deficiency. Risk, III.

Lateral Incisor Agenesis Predicts Maxillary Hypoplasia and Le Fort I Advancement Surgery in Cleft Patients

PURPOSE: Maxillary dental agenesis in cleft patients frequently correlates to orthognathic surgery at skeletal maturity due to both intrinsic growth deficiencies and iatrogenic compensatory maneuvers. In this work, we investigate anatomic deficiencies in dentition in predicting Le Fort I advancement and maxillary hypoplasia in cleft patients. METHODS: 114 cleft lip/palate and cleft palate patients older than 14 years of age were reviewed for demographics, dental anomalies, and Le Fort I advancement at the UCLA Craniofacial Clinic between 2008-2013. Chi square tests, t tests, and multivariate logistic regression analyses were performed to delineate the contribution of quantity and position of dental agenesis to maxillary advancement surgery. RESULTS: 114 patients were reviewed (mean age 18.9 years, range 14-23). In this cohort, 64.0% were male, 71.9% had some form of dental agenesis, and 59.6% required Le Fort I advancement. The types of clefts were isolated cleft palate (10.5%), unilateral cleft lip and palate (66.7%), and bilateral cleft lip and palate (22.8%). The type and laterality of clefts did not demonstrate any statistically significant correlation to Le Fort I advancement. In patients who did not exhibit dental agenesis, 18.8% required Le Fort I advancement versus 74.4% of patients with dental agenesis (p<0.0001). Requirement for Le Fort I advancement surgery was increased to 76.3% when dental agenesis was specifically at the lateral incisor position (p<0.0001) and 86.4% when patients were missing two or more teeth (p<0.0001). Using standard cephalometric measurements, both SNA and ANB were decreased in patients missing dentition at the lateral incisor position (p=0.003, p=0.04). Adjusting for multiple missing teeth and canine substitution, multivariate logistic regression analyses demonstrated that lateral incisor agenesis is an independent predictor for Le Fort I advancement surgery (OR 4.4, CI 1.42-13.64, p=0.01). CONCLUSIONS: Lateral incisor agenesis correlated to maxillary hypoplasia and independently predicted the need for Le Fort I advancement in cleft patients, potentially as an anatomic readout of intrinsic growth deficiency. We suggest its utility as part of a treatment algorithm for cleft patients.

Early rigid fixation decreases consolidation period of rigid external distraction for maxillary hypoplasia in cleft patients without jeopardizing surgical outcome

Early rigid fixation decreases consolidation period of rigid external distraction for maxillary hypoplasia in cleft patients without jeopardizing surgical outcome

Residents' journal review

Residents' journal review

Letters From Our Readers

Letters From Our Readers

New treatment modality for maxillary hypoplasia in cleft patients

To present cleft patients treated with protraction facemask and miniplate anchorage (FM/MP) in order to demonstrate the effects of FM/MP on maxillary hypoplasia. The cases consisted of cleft palate only (12 year 1 month old girl, treatment duration = 16 months), unilateral cleft lip and alveolus (12 year 1 month old boy, treatment duration = 24 months), and unilateral cleft lip and palate (7 year 2 month old boy, treatment duration = 13 months). Curvilinear type surgical miniplates (Martin, Tuttlinger, Germany) were placed into the zygomatic buttress areas of the maxilla. After 4 weeks, mobility of the miniplates was checked, and the orthopedic force (500 g per side, 30 degrees downward and forward from the occlusal plane) was applied 12 to 14 hours per day. In all cases, there was significant forward displacement of the point A. Side effects such as labial tipping of the upper incisors, extrusion of the upper molars, clockwise rotations of the mandibular plane, and bite opening, were considered minimal relative to that usually observed with conventional protraction facemask with tooth-borne anchorage. FM/MP can be an effective alternative treatment modality for maxillary hypoplasia with minimal unwanted side effects in cleft patients.