Premaxillary osteotomy in children with bilateral cleft lip and palate: Skeletal and dental changes

Abstract

Purpose: To evaluate changes in children with bilateral cleft lip and palate (BCLP) who premaxillary osteotomy and secondary alveolar bone grafting as compared to children with BCLP who are not indicated for surgery, and to determine variables that diff erentiate patients who do or do not require osteotomy. Material and methods: Twenty-four children with BCLP were included in the study: 12 who underwent osteotomy (intervention group) and 12 who had no surgery (control group). Radiographic and model values of the intervention group were compared before (T1) and after (T2) premaxillary osteotomy, and measurements were compared with those from the control group at T1. Results: Convexity, ANB (point A-nasion-point B), and maxillary depth was more diminished at T2 in children in the intervention group. Point A, anterior nasal spine, and pogonion were retroposed after surgery, and the anterior spine was higher. At T2, the upper incisors were proinclinated and intruded, and overbite was improved. Models revealed increased intermolar intercanine width as well as intrusion of upper incisor after surgery. Premaxilla and upper molars were more extruded, had a higher total maxillary height and increased extrusion of upper incisor in children who underwent osteotomy. Conclusion: After surgery, children who undergo surgery have a premaxilla that is more normalized and more level with the occlusal plane, as well as improved dental inclination. Variables that diff erentiate children who require osteotomy from those who do not include more extrusion and protrusion of the premaxilla, and a greater extrusion of the upper incisors. Premaxillary osteotomy in children with bilateral cleft lip and palate: Skeletal and dental changes

Evaluation of Radiographic Outcomes of Alveolar Graft Associated with Premaxillary Osteotomy Performed with rhBMP-2

“…9,14,33 This concern increases in bilateral alveolar grafts associated with premaxillary osteotomy due to greater complexity, tissue manipulation and risk of premaxillary devitalization. 6,8,12,14 Accordingly, the present study evaluated AG + PO radiographic outcomes based on previously validated rating scales in order to prove that rhBMP-2 and iliac crest bone have similar success rates, both with better outcomes when surgeries are performed before canine eruption on the cleft side.…”

“…On the other hand, AG + PO is still a controversial procedure, 12 usually indicated only for severe abnormalities that cannot be treated orthodontically. 4,7,8 Hence, this study was useful to show that rhBMP-2 is a viable alternative material also to perform AG + PO.…”

“…However, the protocol is not effective for vertical excesses greater than 7-8 mm. 4,7,8 Bilateral alveolar bone grafting presents considerable challenges: severe bone and soft tissue deficiency, a protruded and often displaced premaxilla, premaxillary mobility, and a high prevalence of oronasal fistulae after primary surgeries. 9 Studies have shown that better outcomes are achieved when alveolar grafts are performed before eruption of the maxillary canines at the cleft site.…”

“…This would have the advantage of aligning and leveling maxillary segments and the arguable advantage of facilitating closure of oronasal fistulae. 5,8,12 More accurate nasal closures performed during AG + PO have been reported, although fistulae after AG + PO may be associated with both difficult closure of the various layers during surgery 6,13 and with compromised blood supply. 8,12,14 In addition, a study demonstrated a 90% reduction in the risk of fistula symptoms after performing alveolar bone grafting alone.…”

“…5,8,12 More accurate nasal closures performed during AG + PO have been reported, although fistulae after AG + PO may be associated with both difficult closure of the various layers during surgery 6,13 and with compromised blood supply. 8,12,14 In addition, a study demonstrated a 90% reduction in the risk of fistula symptoms after performing alveolar bone grafting alone. This reduction was not influenced by the type of cleft and timing of surgery.…”