Orthognathic Cleft—SurgicalOrthodontic.pdf

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Orthognathic Cleft—Surgical/OrthodonticTreatmentDaniel Levy-Bercowski, Eladio DeLeon Jr, John W. Stockstill, and Jack C. Yu

In some cases early intervention and multiphase orthodontic treatment are

insufficient to correct the skeletal and soft-tissue disharmonies present in

cleft lip and palate patients. Commonly, midface deficiency with skeletal and

dental Class III malocclusion is present in combination with other dental

anomalies. In cleft lip and palate patients, orthognathic surgery may involve

maxillary advancement with a LeFort surgical procedure, maxillary distrac-

tion osteogenesis, and mandibular setback in combination with maxillary

advancement, and, on rare occasions, isolated mandibular setback. The

selection of the optimal treatment for a specific patient depends on the

patient’s age, amount of needed advancement, severity of the maxilloman-

dibular discrepancy, impact of the surgery on the speech, relapse/stability

relationship, esthetic outcome, and the consideration of the possible compli-

cations. The need for multidisciplinary treatment planning and sequentially

staged treatment is essential for successful patient outcomes. The purpose of

this article is to outline multidisciplinary strategies in cleft lip and palate patient

care. (Semin Orthod 2011;17:197-206.) © 2011 Elsevier Inc. All rights reserved.

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C left lip and palate (CLP) patients presentwith a multitude of functional and estheti-

ally challenging conditions. Quite often, success-ul treatment outcomes are dependent uponroper timing of treatment as well as appropriateequencing. For example, midface deficiency withskeletal Class III malocclusion is a common find-

ng in patients with CLP. Early intervention andultiple phases of treatment permit many patients

o be treated with acceptable results without theeed for orthognathic surgery. However, patientsith severe skeletal disharmony will require surgi-al correction following cessation of growth. Sur-

Assistant Professor, Department of Orthodontics and Craniofa-cial Center, Georgia Health Science University, Augusta, GA; Gold-stein Chair of Orthodontics and Post-graduate Program Director,Georgia Health Science University, Augusta, GA; Associate Profes-sor, Department of Orthodontics, Georgia Health Science University,Augusta, GA; Professor of Surgery, Georgia Health Science Univer-sity, Augusta, GA.

Address correspondence to Daniel Levy-Bercowski, DDS, MSD,1430 John Wesley Gilbert Drive, School of Dentistry, Department ofOrthodontics, Craniofacial Center, Georgia Health Science Univer-sity, Augusta, GA 30912. E-mail: [email protected]

© 2011 Elsevier Inc. All rights reserved.1073-8746/11/1703-0$30.00/0

Seminars in Orthodontics, Vol 17, No

ical correction usually requires an isolated LeFortadvancement osteotomy to correct maxillary hy-oplasia. Occasionally, the midface and the max-

llomandibular discrepancy require other optionsuch as bimaxillary surgery or distraction of theidface. Therefore, individualized evaluation and

reatment planning is recommended.Ideally, the orthognathic surgical treatment

lan is finalized once growth is completed. Theurgical repositioning of the jaws attempts toptimize the maxillomandibular relationship, oc-lusion, and facial esthetics. Orthodontic prepara-ion of the CLP patient, including dental and skel-tal findings, records, and the different types ofurgical procedures to correct the residual skele-al discrepancies, will be described in this article.pecific attention is given to proper treatmentequencing and the incorporation of the strate-ically planned modalities.

Skeletal and Dental Findings in Patientswith Cleft Lip and Palate

In patients with CLP, the maxilla is hypoplasticin varying degrees because of (1) the original

1973 (September), 2011: pp 197-206

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198 Levy-Bercowski et al

pharyngeal tissues, and (2) as a result of lip andpalate repairs during infancy.1-3 The maxillarykeletal growth deficiency is 3-dimensional, re-ulting in a shortening of the maxillary lengthnd a decrease in transverse and vertical dimen-ions.4-7 In unilateral clefts, the sagittal maxillaryeficiency is evident at a very early age and isrogressive over time, whereas in bilateral clefts,

his deficiency appears later because of the ini-ial prominent premaxilla (Fig 1).8,9

With regard to dental development, there aremany abnormalities that can be found in chil-dren with CLP. These embryonic failures in-clude supernumerary or missing teeth, hypoplas-tic or dysmorphic teeth, and impacted, rotated,

Figure 1. Maxillary hypoplasia. (A) Cephalometricview generated from CBCT image showing the skele-tal Class III relationship. (B) Intraoral view showing

or ectopically erupted teeth.6,10 Lateral incisorsre absent in 10%-20% of primary dentition inLP patients and 3%-50% of patients in theermanent dentition. If the permanent maxil-

ary lateral tooth is present, it may erupt into theleft defect with little or no periodontal support.

Tooth size deficiencies (microdontia) and de-ayed maxillary dental development on the ipsi-ateral side of the cleft have been reported.11

Canine impaction occurs more frequently in patientswith unilateral CLP than in the noncleft population.The incidence of dental caries and gingivitis are alsogreater in children with clefts.12-14

Malocclusion is commonly observed in pa-tients with CLP. Various dental and skeletalproblems include posterior crossbite (singletooth or quadrant), maxillary incisor rotation,retroclined or lingually positioned incisors, andexcessive spacing for the lateral incisor in thecleft region. Midline deviations and arch asym-metries are also common in these patients.6 Allof the listed conditions mandate multidisci-plinary care as part of the global CLP treatment.Again, the timing and sequencing of care arecritical for a successful outcome.

Orthodontic Treatment BeforeOrthognathic Surgery

The orthodontic treatment for the CLP patientmay be performed during 4 specific dental de-velopmental periods: the neonatal or presurgicalorthopedics period, primary dentition, mixed den-tition, and permanent dentition.6,10,15 For exam-

le, the goals of the presurgical orthopedic treat-ent during the neonatal period are to align

nd approximate the hard and soft tissues of theleft segments to resemble the normal neonatalorphology. One of the treatment modalities

uring this period is the nasoalveolar moldingechnique for unilateral and bilateral CLP pa-ients.16-18

During the primary dentition period, correc-tion of dental irregularities can be made, partic-ularly problems such as the eruption of an inci-sor or supernumerary tooth at or near the cleftpalate region. The treatment of the CLP patientin the primary dentition is focused upon maxil-lary expansion, in order to eliminate any func-tional shift. Similarly, speech aids and obturatorsmay also be used at this time to lessen the effects

199Orthognathic Cleft—Surgical/Orthodontic Treatment

Figure 2. Different orthopedic and orthodontic expansion systems used to correct transverse discrepancy of themaxilla. (A) Bonded fan expander, (B) full-coverage bonded expander, (C) quad-helix, (D) banded fan

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200 Levy-Bercowski et al

Transverse correction of the maxilla in theform of maxillary expansion is performed dur-ing the mixed and early permanent dentitions.Expansion appliances may be either banded orbonded and include the quad helix, Hyrax, fanexpander, and self-ligation brackets using verylight forces (Fig 2). In addition, correction ofdental crowding, rotations, and anterior cross-bite can be treated during the initial treatmentperiod. Caution is advised during these proce-dures regarding root approximation to bone aswell as to adjacent teeth to avoid root damage.Finally, maxillary protraction is ideally per-formed at this developmental stage to improvethe maxillary skeletal relationship in the sagittaldimension (Fig 3). Any orthodontic treatment atthe mixed dentition is completed as part of theinterdisciplinary treatment plan created in con-junction with the surgeons before any proposedsecondary bone graft (Fig 4).19

As the patient transitions into the permanentdentition phase and completes the adolescentgrowth, more attention is given to the orthodon-tic correction of skeletal and dental discrepan-cies.10,19 When skeletal growth is completed andpotential growth modification has been ex-cluded as a possible treatment option, definitiveorthodontic treatment is initiated. For severesagittal jaw discrepancies, orthodontic prepara-

Figure 3. Maxillary protraction therapy to improvedimension. (A) Petit facemask, (B) pretreatment C

tion for orthognathic surgery is the treatment ofchoice.20 Again, proper timing of any surgicalprocedure is critical to obtain a successful out-come.

The aim of the orthognathic surgery is torestore normal jaw function and improve facialesthetics. In cleft cases, the maxilla provides apoor foundation for the lip and the nose. Con-sequently, deformities in this region cannot berepaired correctly without reconstructive sur-gery of the maxillary deformity.21 The timing ofthe surgery is critical and is usually not indicateduntil active facial growth is completed exceptwhen psychosocial implications are involved. Tomore accurately determine skeletal maturity andfacial growth completion in patients relative tothe ideal timing for surgery, several radiographicanalyses may be used, including hand-wrist eval-uation22 and cervical vertebral maturation anal-ysis.23,24 The most accurate maturation analysis,

owever, is the serial cephalometric superimpo-ition.25

The orthognathic surgery for the CLP patientis planned (1) after eruption of the permanentdentition, (2) once the maxillary and mandibu-lar arches are orthodontically coordinated, and(3) at completion of the maxillofacial growth.26

The anterior dental decompensation usually isnot a major goal, and extraction of teeth is

skeletal relationship of the maxilla in the sagittalIII malocclusion, and (C) transverse and sagittal

thelass

erapy.

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201Orthognathic Cleft—Surgical/Orthodontic Treatment

almost never required except for extraction ofover-retained primary teeth or supernumeraryteeth. In cleft patients, the upper lip usuallyprevents extreme proclination of the upper in-cisors that often occurs in skeletal Class III non-cleft patients. In the absence of adequate sagittalmaxillary growth, “normal” mandibular growthcan produce a significant disharmony. In addi-tion, in the presence of any maxillary verticaldeficiency, the mandible rotates anteriorly andsuperiorly with a resultant increase in maxillo-

Figure 4. Orthodontic treatment in combinationith secondary bone grafting. (A) Before secondaryone grafting and labial-alveolar fistula, (B) afterone grafting, with fistula closed, moving the lateral

ncisor to the arch, and (C) with incisor align-ent.

mandibular discrepancies.25

Orthognathic Surgery in Cleft Lip andPalate Patients

Presurgical Orthodontic Records

The orthodontic records allow the interdisci-plinary team to formulate a final surgical planand to fabricate surgical splints that will helpdefine the postsurgical result. Comprehensiverecords include panoramic radiographs, lateralcephalometric radiographs, and limited field orfull field of view cone beam computed tomogra-phy (CBCT) as indicated. Anteroposterior radio-graphs as well as periapical and occlusal radio-graphs are taken as needed. These radiographsallow for visualization of the cleft area as well asthe osteotomy site, providing the clinicians withhelpful information needed in planning themodel surgery. Additional records include acomprehensive clinical facial evaluation, ex-traoral and intraoral photographs, and dentalcasts of the maxillary and mandibular dentition(Fig 5). The pretreatment dental casts aremounted on a semiadjustable articulator by theuse of a facebow transfer and centric relation jawregistration. The facebow relates the upper arch tothe condylar axis and centric relation registrationis used to relate the lower cast to the upper castindependent of tooth contact (Fig 6).19

When the mounted casts, the cephalometricanalysis, and the information gathered from theclinical evaluation are used, the interdisciplinaryteam is able to determine a terminal jaw positionand the surgeon can then duplicate the surgicalmovements in the model surgery, maximizingfunctional and esthetic balance.19

The CLP patient presents with complex orth-odontic problems involving the dentition, skele-tal structures, and facial soft tissue. Becausethese problems present as morphologic and po-sitional abnormalities in 3-dimensional space,accurate radiographic imaging is essential. Thelimited focus field CBCT technology provides anexcellent radiographic resource in the diagnosisand eventual treatment of CLP patients. Limitedfocus field CBCT will provide accurate 3-dimen-sional information upon which to make diagnos-tic and treatment planning decisions in additionto the possibility of creating a computer gener-ated three-dimensional model of the existingdefect (Fig 7). Often, CBCT imaging precludes

, cep

202 Levy-Bercowski et al

techniques because of its versatility and accuratereplication of anatomical structures.

LeFort I Osteotomy

CLP patients who present with severe maxillaryhypoplasia will benefit from LeFort I advance-ment surgery when this osteotomy is performedduring their postadolescent years. After interdis-ciplinary treatment planning and completion ofthe orthodontic presurgical preparation, com-prehensive presurgical records are gathered toformulate the final surgical plan and to fabricatesurgical splints that will define the postsurgicalresult. A critical part of these records are thedental casts that have been mounted as previ-ously described, and the bite registration takento relate the skeletal characteristics of the pa-tient to their dental make-up.

An occlusal splint is fabricated preoperativelyto guide the surgical positioning. The patient istaken to the operating room after detailed plan-ning and preparations are complete. Once thepatient is under general anesthesia with nasal

Figure 5. Diagnostic records in a patient with unilateand extraoral photographs, study models, panoramic

intubation, a vertical reference distance between

the medial corner of the eye (medial canthus)and the maxillary dental midline at the level ofthe arch wire is measured and recorded. Thisreference is important for the vertical position-ing of the maxilla. If lengthening of the maxillais anticipated, the final vertical measurementshould reflect that increase in length. However,if the treatment plan calls for impaction, thenthe final vertical measurement should reflect theappropriate amount of vertical decrease whencompared with the original reference measure-ment. Next, a horizontal measurement is takenfrom the maxillary interincisal point to the anti-tragal notch on both sides, allowing for the tri-angulation to verify the horizontal position ofthe maxilla. For example, if the treatment plancalls for 9-mm advancement at the incisor level,then the final horizontal measurement shouldbe 9 mm more than the initial reading. Thesurgical splint is then inserted upon the upperdentition to confirm proper fit. The splint isthen removed and inserted on the mandibulardentition to ensure that the inferior surface will

eft lip and palate on the left side, including intraoralhalometric, occlusal, and periapical radiographs.

ral cl

index into the lower teeth. If necessary, occlusal

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203Orthognathic Cleft—Surgical/Orthodontic Treatment

equilibration of the splint may be performed tomore closely duplicate the preoperative modelsurgery.27

After the splint is adequately adapted to themaxillary and mandibular dentition, the maxil-lary oral mucosa is infiltrated with 0.25% bupiv-acaine with 1:200,000 epinephrine to aid in he-mostasis and analgesia. A circumvestibular incisionis made from the maxillary first molar to first mo-lar. A periosteal elevator is then used to raise afull-thickness mucoperiosteal flap, and it should

Figure 6. Dental cast mounted on a semiadjustablerticulator: (A) maxillary cast mounted to the articu-ator with facebow transfer and mandibular cast

ounted to maxillary with centric relation registra-ion, (B) model surgery of LeFort I procedure.

be pointed out that dissection may be more diffi-

cult in cleft patients because of scarring from pre-vious bone grafts. In keeping with presurgicalguidelines established during model surgery, sur-gical incision lines are marked above or cepahlic tothe apices of the maxillary teeth. The osteotomy isstarted just inferior to the zygomatic buttress usinga reciprocating saw from lateral to medial, goingbelow the inferior turbinates under copious salineirrigation.27

After the posterior buccal osteotomy and sep-aration of the lateral nasal walls and beforedown-fracture of the maxilla, the anesthesiolo-gist should maintain moderate hypotension inthe patient to decrease potential hemorrhage.After mobility of the maxilla is achieved, thesplint is wired to the maxilla by the use of 28-Gstainless-steel wires, and the patient is placedinto maxillomandibular fixation (MMF). Thisoften requires substantial forward tractions torender the anterior repositioning of the maxilla.The mandible is now rotated gently with lightdigital pressure until bone contacts in theplanned maxillary position. This maneuver en-sures that the condyles are in the seated posi-tion.

Excessive posterior force on the mandible toachieve MMF will more likely result in the recur-rence of the Class III occlusion during the post-operative period. Specifically and ideally, thecorrect physiological position of the condyles isin the most superoanterior position of the gle-noid fossa and on the posterior aspect of thearticular eminence with the temporomandibulardisk interposed. Anterior-posterior, vertical, andhorizontal dimensions of the surgical movementof the maxilla are then measured to determinewhether the desired amount of surgical move-ment has been achieved. If these measurementsare acceptable to the surgeon, the maxilla isfixed using 1.5 mm or 2.0 mm miniplates andscrews. Typically 4 plates and 16 screws are em-ployed. MMF is released after fixation is com-plete and the mandible is passively rotated toverify occlusion. Finally, elastics are placed in aClass III vector, which has the lower elastic at-tachment (bracket hook) more anterior to assistin the surgical movement (Fig 8).27

In patients who have not had alveolar cleftbone grafting, a 2- or 3-piece maxillary osteot-omy surgery must be considered. The normalcircumvestibular incision is not used because of

s, Atl

204 Levy-Bercowski et al

eral cleft palate, the premaxillary oral mucosamust be kept intact, otherwise avascular necrosisof the premaxilla may ensue. This ischemia ofthe premaxillary segment in bilateral clefts canbe avoided by prior alveolar bone grafting. Ifalveolar bone grafts have not been done beforethe LeFort I osteotomy procedure, then tunnel-ing incisions or limited horizontal incisions areused to access the lateral segments, keeping theoral mucosa over the central premaxillary seg-ment intact. Bone grafting between the lateralsegments is usually necessary for stability of theincised premaxillary segment which has beenstabilized by the surgical splint.27

Mandibular Osteotomies

Occasionally, cleft patients may also have an iso-lated mandibular prognathism. These condi-

Figure 7. Limited focus field CBCT images: 3D diagnodeformity in a patient with unilateral cleft lip and psystem; PracticeWorks, Inc and Kodak Dental System

tions warrant mandibular osteotomy with set-

back. There are 3 common types of surgeryinvolving the mandible in these patients: thebilateral sagittal split ramus osteotomy (BSSRO),intraoral vertical ramus osteotomy, and the an-terior horizontal osteotomy of the mandible.The BSSRO and intraoral vertical ramus osteot-omy can correct occlusion, but the anterior hor-izontal osteotomy of the mandible can only im-prove facial profile, with BSSRO as the mostcommon procedure.28

More commonly, cleft patients have a nega-tive overjet �10 mm and a significant horizontalmaxillomandibular discrepancy. Bimaxillary sur-gery is indicated in these cases. Bimaxillary, ortwo-jaw, surgery will reduce the distance re-quired in both the maxillary and the mandibularmovements needed to correct these severe skel-etal problems. One requirement when this type

imaging of the cleft region showing the nasal-alveolaron the left side (Kodak 9000 3D extraoral imaging

anta, GA).

sticalate

of surgery is being performed is that intermedi-

orthodontic preparation, and (C) after surgery.

205Orthognathic Cleft—Surgical/Orthodontic Treatment

ate and final surgical splints be fabricated beforethe surgery and be inserted at the time of sur-gery. Specifically, intermediate splints give therelation of the new maxillary position to theexisting mandible, while final splints relate thefinal mandibular position to the fixed final max-illary position.19

Complications

Complications from orthognathic surgery incleft patients range from malocclusion, inferioralveolar nerve damage, inadequate or incom-plete splits in the BSSRO, postoperative bleed-ing from the pterygoid plexus in LeFort I osteot-omies, velopharyngeal incompetence after LeFortI advancement, and postsurgical relapse. Less fre-quently occurring injuries include surgical mal-union and infection. Rarely, negative sequelae mayinclude ocular injuries, including blindness,stroke, and death from the LeFort I osteotomy.These adverse events are more likely if the lat-eral nasal walls before down-fracture were notcompletely cut resulting in abnormal crack andcrack propagations.19,28

Conclusions

Orthodontic treatment is essential for all CLPcases, and the decision to proceed in a surgicalor nonsurgical manner is critical to the overallsuccessful outcome for the patient. Because oneobjective of presurgical orthodontics is the de-compensation of the existing malocclusion, it isimperative that a detailed and sequentially timedtreatment plan be developed before any actualtreatment is rendered. Furthermore, and given thelong-term need for orthodontic intervention inCLP, proper treatment planning must be staged totemporally assign the appropriate treatment asneeded. Orthognathic surgery may involve maxil-lary advancement, maxillary distraction osteogen-esis, mandibular setback in combination withmaxillary advancement, and, on rare occasions,isolated mandibular setback. The selection of theoptimal treatment for a specific patient dependsupon several physiological and functional param-eters including the amount of advancementneeded, severity of the maxillomandibular discrep-ancy, the impact of the surgery on speech, re-lapse/stability relationships, esthetic outcome, and

Figure 8. LeFort I Surgery in a skeletal and dentalClass III cleft patient. (A) Pretreatment, (B) after

the consideration of the possible complications.

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Currently, innovations in distraction osteogenesishave decreased conventional osteotomies as thesole treatment for correction of maxillary andmandibular discrepancies. However, conventionalosteotomies still play an important role in thetreatment of the very complex and multiphasicCLP patient.

AcknowledgmentsThe authors extend their sincere gratitude to Kyle Hunt,DDS and Martin Salgueiro, DDS for their contribution withthe manuscript.

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