Frequency of Le Fort I osteotomy after repaired cleft lip and palate or cleft palate.

OBJECTIVE: Diminished maxillary growth is a consequence of labiopalatal repair, and many patients with cleft lip and palate require Le Fort I advancement. The goal of this study was to determine the frequency of maxillary hypoplasia as measured by need for Le Fort I. SUBJECTS: Retrospective cohort study of males born before 1987 and females before 1989. Records of 173 patients with cleft lip and palate and 34 with cleft palate were reviewed. METHODS: Documented age, gender, cleft type, and need for Le Fort I. Pearson chi-square and Fischer's exact analyses were performed to evaluate the frequency of Le Fort I. RESULTS: Of 217 patients with cleft lip and palate or cleft palate, 40 were syndromic; of the remaining 177 patients, 69 had cleft lip, 78 had cleft lip and palate, and 30 had cleft palate. Thirty-seven of 177 patients (20.9%) required Le Fort I, subcategorized by cleft type: 0/69 for cleft lip, 37/78 for cleft lip and palate, and 0/35 for cleft palate (p<.0001). Of the 37/78 (47.4%) cleft lip and palate patients, the frequency of Le Fort I correlated with severity: 5/22 unilateral incomplete cleft lip and palate; 16/33 unilateral complete cleft lip and palate; 1/2 bilateral incomplete cleft lip and palate; 2/4 bilateral asymmetric complete/incomplete cleft lip and palate; 13/17 bilateral complete cleft lip and palate (p<.05). CONCLUSION: Overall frequency of Le Fort I was 20.9% in patients with cleft lip and palate and cleft palate. Of those with cleft lip and palate, 47.7% required maxillary advancement, but none with isolated cleft lip or cleft palate required correction. Frequency of Le Fort I osteotomy correlated with the spectrum of severity of labiopalatal clefting.     

Relapse rate after surgical treatment of maxillary hypoplasia in non-growing cleft patients: a systematic review and meta-analysis

Maxillary hypoplasia in cleft lip and palate is a complex deformity. Despite surgical improvements, postoperative relapse persists. This systematic review was performed to determine the mean horizontal relapse rates for the surgical techniques used to treat maxillary hypoplasia: Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis. This study followed the PRISMA statement. The PubMed, Embase, Science Direct, and Web of Science databases were searched through to June 2018. Studies on non-growing cleft lip and palate patients who had undergone one of the three surgical procedures and who had postoperative horizontal maxillary changes assessed at >6 months post-surgery were included. Stata SE was used to estimate pooled means, heterogeneity, and publication bias. The search strategy identified 326 citations, from which 24 studies were selected. Relapse rates following Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis were 20%, 12%, and 12%, respectively. Relapse rates with and without bone grafting were 19% and 66%, respectively. The relapse rate following distraction osteogenesis with internal distraction was lower than that with external distraction. Study limitations were heterogeneity, which was above moderate, the low number of high-quality studies, and unidirectional assessment of postoperative maxillary movement.     

Stability after Le Fort I osteotomy in cleft lip and palate patients

Le Fort I osteotomies were performed in 20 patients with cleft lip and palate as a one-segment movement, and the fragments were fixed with miniplates without bone grafting. Tracings of preoperative and serial postoperative lateral cephalograms were used to determine changes in maxillary position. The posterior nasal spine, not subjected to extensive changes during surgical procedures and remodeling, was found to be the most reliable landmark for measuring maxillary advancement and stability. The mean maxillary advancement was 5.96 mm. Analysis did not reveal significant changes in linear and angular measurements from immediately postoperative to 6 months postoperative. A modest maxillary advancement by Le Fort I osteotomy, along with alleviation of palatal scar tissue tension and miniplate fixation, is a stable surgical method in patients with cleft lip and palate.     

Two-point nasomaxillary fixation of the Le Fort I osteotomy: assessment of stability at one year postoperative

The purpose was to assess maxillary position among patients undergoing Le Fort I maxillary advancement with internal fixation placed only at the nasomaxillary buttresses. This was a retrospective study of patients undergoing a Le Fort I osteotomy for maxillary advancement, with internal fixation placed only at the nasomaxillary buttresses. Demographic and cephalometric measures were recorded. The outcome of interest was the change in maxillary position between immediately postoperative (T1), 6 weeks postoperative (T2), and 1 year postoperative (T3). Fifty-eight patients were included as study subjects (32 male, 26 female; mean age 18.4 ± 1.8 years). Twenty-five subjects (43.1%) had a diagnosis of cleft lip and palate. Forty-three subjects (74.1%) had bimaxillary surgery, 16 (27.6%) had bone grafts, and 18 (31.0%) had segmental maxillary osteotomies. At T3, there were no subjects with non-union, malunion, malocclusion, or relapse requiring repeat surgery. Mean linear changes between T1 and T3 were ≤1 mm. Mean angular changes between T1 and T3 were <1°. There was no significant difference in stability in multi-segment maxillary osteotomies (P =  0.22) or with bone grafting (P =  0.31). In conclusion, anterior fixation alone in the Le Fort I osteotomy results in a stable maxillary position at 1 year postoperative.     

Le Fort I osteotomy in cleft patients: Maxillary advancement and velopharyngeal function

BackgroundMaxillary advancement may affect speech in cleft patients.AimsTo evaluate whether the amount of maxillary advancement in Le Fort I osteotomy affects velopharyngeal function (VPF) in cleft patients.MethodsNinety-three non-syndromic cleft patients (51 females, 42 males) were evaluated retrospectively. All patients had undergone a Le Fort I or bimaxillary (n = 24) osteotomy at Helsinki Cleft Palate and Craniofacial Center.Preoperative and postoperative lateral cephalometric radiographs were digitized to measure the amount of maxillary advancement. Pre- and postoperative speech was assessed perceptually and instrumentally by experienced speech therapists. Student's t-test and Mann–Whitney's U-test were used in the statistical analyses. Kappa statistics were calculated to assess reliability.ResultsThe mean advancement of A point was 4.0 mm horizontally (range: −2.8–11.3) and 3.9 mm vertically (range −14.2–3.9). Although there was a negative change in VPF, the amount of maxillary horizontal or vertical movement did not significantly influence the VPF. There was no difference between the patients with maxillary and bimaxillary osteotomy.ConclusionsThe amount of maxillary advancement does not affect the velopharyngeal function in cleft patients.     

Long-term results in maxillary deficiency using intraoral devices

Cleft lip and palate patients often present maxillary retrusion and class III malocclusion after cleft repair. Maxillary distraction is a technique that can provide simultaneous skeletal advancement and expansion of soft tissue. Twelve patients with cleft maxillary deficiency due to cleft lip and palate were treated by Le Fort I osteotomy and two intraoral distraction devices that were activated after 4 days of latency period, 1mm per day on both sides. Long-term clinical and cephalometric evaluation of one and two years demonstrate stable results concerning the skeletal, dental and soft tissue relations. In this paper we discuss the advantages of distraction osteogenesis as a method for treatment of maxillary deficiency in cleft patients in terms of stability and relapse. The indications for maxillary distraction: (1) Moderate and severe retrusion that needs large advancement as in cleft lip and palate patients. (2) Forward and downward lengthening of the maxilla with no need for intermediate bone graft. (3) Growing patients. In conclusion, maxillary distraction in moderate or severe retrusion, as in cleft patients offers marked maxillary advancement with long-term stability.     

Postoperative stability following maxillary downward movement with Le Fort I inclined osteotomy at the lateral nasal cavity wall

Downward movement of the maxilla is regarded as one of the less stable long-term orthognathic surgical procedures. To increase postoperative stability with direct bone contact, the conventional Le Fort I osteotomy was modified with an inclined osteotomy at the lateral nasal cavity wall. The aim of this study was to evaluate the postoperative stability of the new method for Le Fort I inclined osteotomy for downward maxillary movement.The study included 27 patients with anterior vertical deficiency of the maxilla who underwent Le Fort I inclined osteotomy for downward maxillary movement. Patients were classified into two groups according to the amount of downward movement. The amounts of relapse (cephalometric changes) of the two groups were compared and statistically analyzed.The mean amount of relapse was about 1 mm. The tendency of relapse was not increased by a large initial downward movement with Le Fort I inclined osteotomy. Le Fort I inclined osteotomy was used safely for downward movement in order to increase bone height at the piriform aperture area and resulted in direct bone contact, suggesting it is a useful technique for maintaining postoperative stability. A further study with a larger number of patients is necessary.     

Skeletal stability of Le Fort I osteotomy in patients with isolated cleft palate and bilateral cleft lip and palate

The skeletal stability of Le Fort I osteotomy was evaluated retrospectively in 14 patients with isolated cleft palate (CP, mean age 27.2 years) and 11 patients with bilateral cleft lip and palate (BCLP, mean age 23.7 years). The osteotomy was fixed with titanium plates and the osteotomy gap was grafted with autologous bone. Neither intermaxillary fixation nor occlusal splints were used postoperatively. Skeletal stability was analysed both horizontally and vertically by cephalograms taken shortly before operation, immediately afterwards, and at six months and at one year postoperatively. In the CP group the mean maxillary horizontal advancement (point A) was 4.7 mm (range 0.3-7.8) and the mean vertical lengthening 3.6 mm (range 0.7-6.1). One year postoperatively the mean relapse was 8.5% (0.4 mm) horizontally and 16.7% (0.6 mm) vertically. In the BCLP group the mean horizontal advancement was 5.3 mm (range 0.2-10.7) and the mean vertical lengthening 7.3 mm (range 0.6-11.8). The mean postoperative relapse was 9.4% (0.5 mm) horizontally and 17.8% (1.3 mm) vertically. The skeletal stability and relapse were similar in both cleft types although BCLP patients had more residual cleft problems and their mean surgical advancement was greater. There was great individual variation.     

Vector alignment in maxillary distraction osteogenesis

Maxillary distraction osteogenesis is an alternative treatment of cleft patients with severe maxillary hypoplasia. The aim of this paper is to present the combined surgical/orthodontic treatment of a cleft lip and palate patient and to evaluate the maxillary distraction procedure and the distraction vector in high Le Fort I osteotomy.     

Importance of soft tissue for skeletal stability in maxillary advancement in patients with cleft lip and palate.

OBJECTIVE: Assessment of stability of the advanced maxilla after two-jaw surgery and Le Fort I osteotomy in patients with cleft palate based on soft tissue planning. SUBJECTS: Between 1995 and 1998, 15 patients with cleft lip and palate deformities underwent advancement of a retruded maxilla, without insertion of additional bone grafts. Eleven patients had bimaxillary osteotomies and four patients only a Le Fort I osteotomy. Relapse of the maxilla in horizontal and vertical dimensions was evaluated by cephalometric analysis after a clinical follow-up of at least 2 years. RESULTS: In the bimaxillary osteotomies, horizontal advancement was an average 4 mm at point A. After 2 years, there was an additional advancement of point A of an average of 0.7 mm. In the mandible, a relapse of 0.8 mm was seen after an average setback of 3.9 mm. In the four patients with Le Fort I osteotomy, point A was advanced by 3.8 mm and the relapse after 2 years was 0.9 mm. Vertical elongation at point A resulted in relapse in both groups. Impaction of the maxilla led to further impaction as well. CONCLUSION: Cephalometric soft tissue analysis demonstrates the need for a two-jaw surgery, not only in severe maxillary hypoplasia. Alteration of soft tissue to functional harmony and three-dimensional correction of the maxillomandibular complex are easier to perform in a two-jaw procedure. It results in a more stable horizontal skeletal position of the maxilla.     

Maxillary distraction resulting in facial advancement at Le Fort III level in cleft lip and palate patients: a report of two cases

An 18-year-old female and a 14-year-old male who had previously received surgery for primary repair of a nonsyndromic cleft lip and palate (including alveolar defect bone grafting) unintentionally developed facial advancement at the Le Fort III level after surgical correction of their maxillary hypoplasia. The Le Fort I osteotomy, originally performed for their maxillary dentoalveolar hypoplasia, was an incomplete osteotomy. It was performed without down-fracture, leaving the pterygomaxillary and septal junctions intact. The gradual advancement of the maxilla during distraction osteogenesis was planned to correct the hypoplastic maxilla, and also prevent subsequent hypernasality; however, during the distraction procedure by means of a rigid external device both patients developed an unintentional facial advancement at the Le Fort III level.     

Factors related to relapse after Le Fort I maxillary advancement osteotomy in patients with cleft lip and palate.

OBJECTIVE: To identify factors associated with relapse after maxillary advancement in cleft lip and palate patient. SUBJECTS: Seventy-one cleft lip and palate patients underwent Le Fort I maxillary advancement osteotomy between 1988 and 1998, and 58 patients (42 unilateral cleft and 16 bilateral cleft) with complete data were investigated for relapse by clinical and cephalometric analysis. The clinical follow-up period ranged from 1.5 to 8.5 years (mean 2.5 years). RESULTS: Horizontal advancement averaged 6.9 mm. There was a significant correlation between surgical movement and postoperative relapse in both the horizontal and vertical planes. In vertical repositioning, 15 patients had maxillary intrusion and 31 had inferior repositioning. There was a significant difference between the intrusion group and the inferior repositioning group. There was a significant correlation between surgical and postoperative rotation regardless of the direction. Other factors were evaluated by the horizontal relapse rate. Type of cleft and the rate of relapse were statistically associated. A relapse was more likely to occur in patients with bilateral cleft. There were no significant associations with the rate of relapse in type of operations or previous alveolar bone grafting. There was no significant correlation between the rate of relapse and the number of missing anterior teeth, postoperative overbite and overjet, and age at operation. Four of 71 patients experienced major relapse, and 3 of them underwent jaw surgery again. CONCLUSIONS: Based on clinical and cephalometric analysis, two-jaw surgery should be performed in cases of severe maxillary hypoplasia, and overcorrection may be useful in inferior repositioning or surgical rotation. Special attention should be paid to the patient with bilateral cleft, multiple missing teeth, or shallow postoperative overbite.     

Cranial nerve injury after Le Fort I osteotomy

A Le Fort I osteotomy is widely used to correct dentofacial deformity because it is a safe and reliable surgical method. Although rare, various complications have been reported in relation to pterygomaxillary separation. Cranial nerve damage is one of the serious complications that can occur after Le Fort I osteotomy. In this report, a 19-year-old man with unilateral cleft lip and palate underwent surgery to correct maxillary hypoplasia, asymmetry and mandibular prognathism. After the Le Fort I maxillary osteotomy, the patient showed multiple cranial nerve damage; an impairment of outward movement of the eye (abducens nerve), decreased vision (optic nerve), and paraesthesia of the frontal and upper cheek area (ophthalmic and maxillary nerve). The damage to the cranial nerve was related to an unexpected sphenoid bone fracture and subsequent trauma in the cavernous sinus during the pterygomaxillary osteotomy.     

计算机辅助牵引成骨术的模拟和初步评价

目的 介绍并应用计算机辅助正颌外科模拟系统（CASSOS 2001）模拟，预测上颌骨牵引成骨术，评价治疗前后的软，硬组织变化。方法 1例男性，14岁唇腭裂术后上颌严重发育不足患者，应用CASSOS 2001系统作术前头影测量分析，手术和牵引方向模拟，牵引后面型预测,实际牵引成骨治疗后的头影测量分析等，手术模拟中分别进行了Le Fort I型截骨术和Le Fort Ⅱ型截骨术的模拟。对多项头影测量作了比较。结果 牵引前后数据比较显示，面中部凹隐畸形获得了显著改善；手术模拟与实际术后结果比较显示，上颌骨Le Fort I型截骨后牵引成骨术所获得的面型改善可以达到正颌外科Le Frot Ⅱ型截骨前移后的效果。结论 上颌牵引成骨对于严重的上颌骨局部畸形，尤其是唇腭裂术后上颌骨严重发育不足，是一种极其有效的治疗方法：CASSOS 2001系统不仅为正颌外科手术，也为牵引成骨治疗提供了一种对医生和患者都有极大帮助的模拟和预测方法。     

Stability of maxillary surgical movement in unilateral cleft lip and palate with preceding alveolar bone grafting.

OBJECTIVE: To evaluate the long-term three-dimensional stability of Le Fort I maxillary osteotomy in patients with unilateral cleft lip and palate (CLP) who had preceding alveolar bone grafting. DESIGN: Analysis of prospectively collected data. Setting: University teaching hospital and postgraduate training center. SUBJECTS: Thirty consecutive patients with unilateral cleft lip and palate, who underwent the procedure between 1990 and 1999, satisfied the inclusion criteria and had complete records. There were 9 males and 21 females, with an age range of 14 to 28 years (mean, 18 years), and follow-up range of 12 to 66 months (mean, 62 months). METHODS: Cephalometric and study cast analyses using pre- and postoperative records (3, 6, 12, 24, and 36 months). Evaluation of surgical movement and postsurgical change at all above time intervals was carried out to determine stability of surgical maxillary movement in the horizontal and vertical planes and to identify rotational and transverse relapse. RESULTS: Total relapse of surgical movement was 31% in the horizontal plane and 52% in the vertical plane, as well as 30% rotational. Relapse correlated with extent of surgical movement, and most relapse occurred in the first 6 months after surgery. No significant transverse relapse was documented. CONCLUSION: Alveolar bone grafting prior to osteotomy stabilizes the transverse dimension of the dental arch, but does not improve horizontal, vertical, or rotational relapse, which remains significant. Correlation of relapse with extent of surgical movement does suggest that planned over-correction is a reasonable option.     

Surgical orthodontic treatment for a patient with unilateral cleft lip and palate and temporomandibular disorder

The patient was a 12-year-old female who presented with unilateral cleft lip and palate, facial asymmetry, mandibular protrusion, resorption of condyle heads, and transverse maxillary deficiency. At the age of 13 years 10 months, maxillary expansion and autogenous bone graft were performed to improve the maxillary collapsed arch. Aged 14 years 10 months, she described symptoms of temporomandibular joint pain and dysfunction. Segmental Le Fort I osteotomy and intraoral vertical ramus osteotomy (IVRO) were performed at the age of 15 years 11 months. Segmental Le Fort I osteotomy resulted in improved sagittal and transverse discrepancy of the maxilla. After IVRO, facial symmetry, a good facial profile, and disappearance of TMD symptoms were achieved. The occlusion and esthetics were stable after 5 years of retention.     

Skeletal relapse of maxillary osteotomies in unilateral cleft lip and palate patients

The outcomes of a consecutive series of 10 adults who had unilateral cleft lip and palate and who had undergone Le Fort I advancement fixed with miniplates were investigated. The amount and timing of horizontal and vertical relapse, the correlation between advancement and relapse, and the effectiveness of various methods of internal fixation were analyzed with respect to the authors' clinical experience and the data from the international literature. Tracings of the preoperative and serial postoperative lateral cephalograms--taken immediately and during the 1 1/2 to 2 postoperative years--were analyzed to calculate horizontal and vertical maxillary change. We found that the use of rigid fixation is associated with a significantly more stable postoperative result, as described by other authors. Our study suggests that this useful technique does not eliminate but reduces and controls the problem of relapse in a series of unilateral cleft lip and palate adult patients undergoing Le Fort I osteotomy.     

Traumatic arteriovenous malformation following maxillary Le Fort I osteotomy.

OBJECTIVE: Complications following maxillary Le Fort I osteotomy are rare. The authors present the rare complication of an arteriovenous malformation following such a procedure in a 25-year-old woman with a cleft lip and palate that was treated successfully with radiologically guided embolization.     

唇腭裂术后牙颌面畸形的正颌外科治疗

作者对10例唇腭裂术后继发上颌骨发育障碍的成年患者行正颌外科治疗，并提出一种改良的Le Fort Ⅰ型分块截骨前移术。即在不影响腭咽闭合功能和不产生口鼻瘘的条件下前移上颌，通过术前、术后的正颌外科电脑模拟系境预测，牙髓活力的测定、腭咽闭合功能评价，面貌外形的对比，作者认为采用该术式是可行的，术后可获得功能与形态兼顾的满意效果。     

Cephalometric pharyngeal changes after Le Fort I osteotomy in patients with unilateral cleft lip and palate

Pharyngeal changes after Le Fort I osteotomy were evaluated cephalometrically in 37 patients (27 M, 10 F; mean age 23.8 years) with unilateral cleft lip and palate (UCLP). Seven patients had previously undergone velopharyngeal (VPP) flap surgery to improve speech. One year postoperatively the patients without previous VPP showed a significant change (55%-85% of the surgical change) in the upper and lower sagittal depth of the nasopharyngeal airway, but not in the depth of oropharyngeal airway, length of soft palate, or position of hyoid bone. No significant changes were observed between 6 months and 1 year postoperatively. Mean surgical horizontal advancement was 4.7 mm and the mean vertical lengthening 4.7 mm anteriorly and 1 mm posteriorly. There was a correlation between the amount of horizontal advancement and the amount of change in the nasopharyngeal airway. The patients with previous VPP showed significant postoperative change (85% of the surgical change) only in the lower nasopharyngeal airway, although their surgical advancement was similar to that without previous VPP. Patients with previous VPP showed significantly smaller depths of upper nasopharyngeal airway postoperatively than the patients without previous VPP. Five patients (13%) needed VPP after the osteotomy. There was no difference in the nasopharyngeal airway in the patients with VPP after the osteotomy when compared to those without, but they seemed to have shortest maxillary lengths and largest mean surgical changes vertically both anteriorly (5.5 mm) and posteriorly (2.3 mm). Moderate maxillary advancement in UCLP patients results in significant changes in the nasopharyngeal airway.