Orthognathic Surgery in the Young Cleft Patient: Preliminary Study on Subsequent Facial Growth

transcript

Oral Maxillofac Surg6:2524-2536, 2008

Orthognathic Surgery in the Young CleftPatient: Preliminary Study on

Subsequent Facial GrowthLarry M. Wolford, DMD,* Daniel Serra Cassano, DDS,†

David A. Cottrell, DMD,‡ Mohamed El Deeb, DDS, MS,§

Spiro C. Karras, DDS,� and Joao Roberto Goncalves, DDS, PhD¶

Purpose: This study evaluated the long-term effects of orthognathic surgery on subsequent growth ofthe maxillomandibular complex in the young cleft patient.

Patients and Methods: We evaluated 12 young cleft patients (9 male and 3 female patients), with amean age of 12 years 6 months (range, 9 years 8 months to 15 years 4 months), who underwent Le FortI osteotomies, with maxillary advancement, expansion, and/or downgrafting, by use of autogenous boneor hydroxyapatite grafts, when indicated, for maxillary stabilization. Five patients had concomitantosteotomies of the mandibular ramus. All patients had presurgical and postsurgical orthodontic treatmentto control the occlusion. Radiographs taken at initial evaluation (T1) and presurgery (T2) were comparedto establish the facial growth vector before surgery, whereas radiographs taken immediately postsurgery(T3) and at longest follow-up (T4) were used to determine postsurgical growth. Each patient’s lateralcephalograms were traced, and 16 landmarks were identified and used to compute 11 measurementsdescribing presurgical and postsurgical growth.

Results: Before surgery, all patients had relatively normal growth. After surgery, cephalograms showedstatistically significant growth changes from T3 to T4, with the maxillary depth decreasing by �3.3° �1.8°, Sella-nasion-point A by �3.3° � 1.8°, and point A-nasion-point B by �3.6° � 2.8°. The angulationof the maxillary incisors increased by 9.2° � 11.7°. Of 12 patients, 11 showed disproportionatepostsurgical jaw growth. Maxillary growth occurred predominantly in a vertical vector with no antero-posterior growth, even though most patients had shown anteroposterior growth before surgery. Thedistance increased in the linear measurement from nasion to gnathion by 10.3 � 7.9 mm. Four of 5patients operated on during the mixed dentition phase had teeth that erupted through the cleft area. Avariable impairment of postoperative growth was seen with the 2 types of grafting material used. Nosignificant difference was noted in the effect on growth in patients with unilateral clefts versus thosewith bilateral clefts. The presence of a pharyngeal flap was noted to adversely affect growth, whereas

*Clinical Professor, Department of Oral and Maxillofacial Sur-

ery, Texas A&M University Health Science Center Baylor Col-

ege of Dentistry, and Private Practice, Baylor University Medical

enter, Dallas, TX.

†Formerly, Fellow, Department of Oral and Maxillofacial Surgery,

exas A&M University Health Science Center Baylor College of

entistry and Baylor University Medical Center, Dallas, TX; Cur-

ently, Assistant Professor of Orthodontics, Pediatric Dentistry De-

artment, Araraquara Dental School, São Paulo State University,

raraquara, São Paulo, Brazil.

‡Formerly, Fellow, Oral and Maxillofacial Surgery, Texas A&M

niversity Health Science Center Baylor College of Dentistry and

aylor University Medical Center, Dallas, TX; Currently, Professor

nd Chairman of Oral and Maxillofacial Surgery, Boston University

oldman School of Graduate Dentistry, Boston, MA.

§Formerly, Professor, Division of Oral and Maxillofacial Surgery,

chool of Dentistry, University of Minnesota, Minneapolis, MN;

�Formerly, Fellow, Oral and Maxillofacial Surgery, Texas A&M Uni-

versity Health Science Center Baylor College of Dentistry and Baylor

University Medical Center, Dallas, TX; Currently, Private Practice,

Chicago, IL.

¶Formerly, Fellow, Department of Oral and Maxillofacial Sur-

gery, Texas A&M University Health Science Center Baylor College

of Dentistry and Baylor University Medical Center, Dallas, TX;

Currently, Assistant Professor of Orthodontics, Pediatric Dentistry

Department, Araraquara Dental School, São Paulo State University,

Araraquara, São Paulo, Brazil.

Address correspondence and reprint requests to Dr Wolford:

3409 Worth St, Suite 400, Dallas, TX 75246; e-mail: lwolford@

swbell.net

0278-2391/08/6612-0016$34.00/0

doi:10.1016/j.joms.2008.06.104

urrently, Private Practice, Minneapolis, MN.

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WOLFORD ET AL 2525

simultaneous mandibular surgery did not. After surgery, 11 of 12 patients tended toward a Class IIIend-on occlusal relation.

Conclusions: Orthognathic surgery may be performed on growing cleft patients when mandated bypsychological and/or functional concerns. The surgeon must be cognizant of the adverse postsurgicalgrowth outcomes when performing orthognathic surgery on growing cleft patients with the possibilityfor further surgery requirements. Performing maxillary osteotomies on cleft patients would be morepredictable after completion of facial growth.© 2008 American Association of Oral and Maxillofacial Surgeons

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cleft lip/palate deformity occurs in approximately 1n every 700 live births in the United States.1 Inhildren born with cleft lip and/or palate, significantisturbances of the growth of the jaws, malocclu-ions, and discrepancies in maxillomandibular skele-al alignment will frequently develop as a result ofurgical repairs of the cleft lip and palate or otheractors and may require correction with orthodonticsnd orthognathic surgery.1-4 The surgical proceduresommonly performed during childhood are cleft lipepair, cleft palate repair, alveolar cleft repair, andharyngeal flap.1 The lip and palatal repairs are pref-rably repaired in infancy to facilitate eating, ensureaximum speech and language development, andinimize problems with self-esteem.5 The alveolar

left repair and pharyngeal flap are usually done latern the first decade.

The growth potential in unoperated children withleft lip and/or palate is relatively normal. Multiplerimary and secondary surgical reconstructive proce-ures often result in inhibited maxillary growth.2,3

he maxilla can become underdeveloped, affectinghe alveolus, dentition, and associated soft-tissuetructures.1 However, in adolescents and adults whoave previously undergone cleft lip and palate repair,nterior and posterior crossbites; midface hypoplasia;nteroposterior (AP), vertical, and transverse maxil-ary deficiency; residual lip and nasal deformities; andpeech problems commonly develop.1 Studies haveeen done regarding the skeletal morphology duringuberty in cleft and non-cleft patients. Verticalrowth impairment of the maxilla is found in patientsith cleft lip/palate. The maxilla shows a significant

lockwise rotation, increase in the anterior height ofhe mandible, and decrease in the posterior height ofhe maxilla.6

Normal facial growth is invaluable in properly man-ging growing patients with maxillary deformities.round 12 years of age, most transverse maxillaryrowth is complete. AP growth of the maxilla is basi-ally complete by about the age of 15 years in femaleatients and 17 or 18 years in male patients.7 Normalertical maxillary growth, however, continues intodulthood.8 Approximately 98% of facial growth is

y age 17 to 18 years.9 Maxillary Le Fort I osteotomy,ometimes combined with mandibular surgery, is thetandard procedure for re-establishing facial balancend dental occlusion in cleft patients.5 Studies haveeen done regarding the earliest age that would allowhe decision as to whether later orthognathic surgeryhould be included in the treatment plan. Scheuer etl10 noted that unfavorable facial growth in cleft pa-ients may occur during puberty and recommendedurgical and orthodontic treatment after the comple-ion of growth. Veleminska et al11 developed an equa-ion that provides early detection for young cleft pa-ients at risk of growth during the treatment. The bestquation predicts the intermaxillary relations at 15ears of age with high reliability.There is extensive literature on the effects and

tability of orthognathic surgical correction of maxil-ary deformities in young non-cleft patients.8 Epker etl12 noted that after superior repositioning of theaxilla, maxillary growth did continue but predomi-antly in a vertical direction. Vig and Turvey13 foundontinuation of vertical maxillary growth but little AProwth. Mogavero et al14 reported that superior repo-itioning of the maxilla (correction for vertical maxil-ary hyperplasia) resulted in cessation of AP growthut continuation of vertical growth at the same rate asefore surgery and maintenance of harmoniousrowth with the mandible. Studies in adolescent mon-eys are in general agreement with the previouslyentioned findings.15,16 Wolford et al8,9 reported that

he Le Fort I osteotomy, when used to correct verticalaxillary hyperplasia, eliminates further AP growth of

he maxilla but with continued vertical maxillaryrowth at the same presurgical rate, creating a post-urgical vector of facial growth in a downward andackward direction.There are many reports in the literature on stability

f orthognathic surgical correction of maxillary defor-ities in adult cleft patients. Posnick and Tompson17

ound that 97% of patients maintained a positive over-et, 89% maintained a positive overbite, and 5%hifted to a neutral overbite. However, some studieshowed a significant relapse of Le Fort I osteotomiesn horizontal and vertical planes.18-22 Bertolini et al5

ound that the use of rigid fixation is more stable

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2526 ORTHOGNATHIC SURGERY IN YOUNG CLEFT PATIENT

ostoperatively and does not eliminate the relapseut reduces it. Heliovaara et al23 noted that the skel-tal relapse of Le Fort I osteotomy was similar inatients with cleft palate and in those with cleft lipnd palate.

Surgical management of the growing patient re-ains controversial, and there are no substantive data

n the literature in reference to growth of the maxillafter orthognathic surgery in the growing cleft pa-ient.24 Freihofer25 indicated that he observed defi-ient growth of the maxilla in these patients, but nopecific quantification of the results was presented.

olford and Stevao1 reported that orthognathic sur-ery can have a significant untoward effect on facialrowth and development in patients with cleft lip/alate and considered end-stage reconstruction afterompletion of most of their facial growth, which issually age 15 years for female patients and 17 to 18ears for male patients. Wolford et al26 previouslyndicated unfavorable growth of the maxilla after

axillary osteotomies in growing cleft patients. Ifurgery is done before completion of facial growth,he subsequent adverse effect on maxillary growthnd continued growth of the mandible will result inecurrence of the facial deformity and malocclu-ion.5,8,9,26

This retrospective study was undertaken to evalu-te the long-term effects of orthognathic surgery onubsequent growth of the maxillomandibular com-lex in the young cleft patient. Although distractionechniques are an alternative approach to treatinghese patients, this article will address only the surgi-al orthognathic approach to treating this patientopulation.

atients and Methods

PATIENTS

This study evaluated records of 12 young cleft pa-ients (9 male and 3 female patients) who underwentrthognathic surgery. Six patients had bilateral clefts,nd 6 had unilateral clefts. Patients were selectedccording to the following criteria: 1) young growingleft patients, 2) treatment with Le Fort I osteotomy,nd 3) all surgical procedures performed by 1 surgeonL.M.W.). Patients were rejected based on the follow-ng criteria: 1) previous bony surgical intervention inhe craniofacial area, 2) less than 18 months of follow-p, 3) presence of a craniofacial syndrome, and) inadequate or poor-quality records (radiographs).The mean patient age at surgery was 12 years 6onths (range, 9 years 8 months to 15 years 4onths). Initial records (T1) were taken at a mean of

8 months (range, 3 years 4 months to 11 months)

days (range, 1 to 10 days) before surgery (T2) and atmean of 6 days (range, 3 to 12 days) after surgery

T3); the long-term follow-up records (T4) were takent a mean of 3 years 8 months (range, 1 year 8 monthso 7 years) after surgery.

ORTHODONTICS

All patients had presurgical orthodontic treatment.ome had long-term postsurgical orthodontic careith use of interarch elastics with a Class III vector in

n attempt to control the occlusion.

OCCLUSION

Each patient’s occlusion was evaluated to deter-ine the presurgical, immediate postsurgical, and

ong-term occlusal results. The occlusion was evalu-ted based on Angle’s classification of first molar andanine relations. Interarch transverse relations werelso monitored to detect the development of cross-ite. Of the 12 patients, 5 were in the mixed dentitionhase at the time of surgery and were evaluatedlinically and radiographically to determine whetherreviously unerupted permanent teeth erupted intohe cleft region area after orthognathic surgery andone grafting of the alveolar clefts.

SURGICAL TECHNIQUES

Maxillary osteotomies were performed at the Leort I level by use of either the traditional design asescribed by Epker and Wolford27 or the maxillarytep osteotomy modification as described by Bennettnd Wolford.28 In all cases the maxillary tuberositiesere separated from the pterygoid plates, and the

artilaginous nasal septum and vomer were separatedrom the maxilla. In those patients in the mixed den-ition phase, precautions were taken to perform thesteotomies at a higher level than usual, just belowhe infraorbital nerve, to avoid the apices of the une-upted developing teeth and thus prevent injury tohem.

Five patients had a skeletal Class I or Class II end-oncclusion and were treated with Le Fort I osteotomieserformed primarily for superior repositioning and/oraxillary expansion. The remaining 7 patients under-ent maxillary advancements of 4 to 8 mm, expan-

ion, and/or downgrafting. Five patients in the mixedentition phase had their maxillas stabilized withhreaded Steinmann pins,28 and in 2 of 5 patients,upport with interosseous wires and infraorbital sus-ension wires was also used. Bone plates were used

n 7 patients who were not in the mixed dentitionhase. Of the 12 patients, 5 had concomitant osteot-mies of the mandibular ramus.29

Oronasal fistulas in the alveolar cleft areas werelosed during the same surgical procedure with local

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y use of autogenous bone from the iliac crest.27 Fourf the 7 patients who were not in the mixed dentitionhase received autogenous bone grafts for maxillarytabilization, and 3 received grafts of porous blockydroxyapatite (PBHA) (Interpore International, Ir-ine, CA).19,30-39

One unilateral cleft patient had an existing superi-rly based posterior pharyngeal flap. It was length-ned by performing an incision at its base at theosterior pharyngeal wall, down to the prevertebral

ascia. Vertical incisions were then made at the lateralspects of the flap, ascending through the lateral oro-asal portals. The entire pharyngeal base of the flapas then undermined, allowing enough relaxation for

he maxilla to be advanced without tension from theharyngeal flap.

CEPHALOMETRIC EVALUATION

Radiographs T1 and T2 were compared to establishhe facial growth vector before surgery, T2 and T3ere used to determine the direction and extent of

urgical change, and T3 and T4 were analyzed toetermine postsurgical growth.

CEPHALOMETRIC MEASUREMENTS

Standardized lateral cephalometric radiographsQuint Sectograph; American Dental, Hawthorne,A) were traced by a single investigator (L.M.W.). A

otal of 16 landmarks were identified (Fig 1). Theseandmarks were used to compute 1 linear and 10ngular measurements (Figs 2, 3) describing maxil-omandibular relations. Sella-nasion (SN) minus 7°

as used as the horizontal reference plane (HRP).

STATISTICAL METHODS

After collection of all data for statistical analysis,test was performed to evaluate postsurgical stabil-

ty and growth (T4-T3). A significance level of P lesshan .05 was applied.

esults

PRESURGICAL GROWTH (T2-T1)

Five patients who had a Class I skeletal and occlusalelation or a Class II end-on occlusion at the initialvaluation showed relatively harmonious growth be-ween the maxilla and mandible and a relativelyormal vector of facial growth before surgery (FigsA, 5A, 6A). Six patients had a tendency toward alass III skeletal and occlusal relation but maintained

his relation without change. Just 1 patient had arogressively worsening Class III skeletal relation,ue to maxillary hypoplasia and bilateral condylar

SURGICAL CHANGES (T3-T2)

Five patients in the mixed dentition phase hadaxillary expansion and/or superior repositioning

nd were stabilized with threaded Steinmann pins andires.28 Seven patients had maxillary advancements,

anging from 4 to 8 mm; expansion; and/or down-rafting and were stabilized with rigid fixation via 4one plates. Five patients had mandibular ramus os-eotomies including sagittal split13 for mandibular ad-ancements (3 patients), setback (1 patient), and bi-ateral inverted-L osteotomies for mandibular setback1 patient).

POSTSURGICAL STABILITY (T4-T3)

Cephalograms showed a statistically significantostsurgical change with maxillary depth (MxD) (ie,ngle of A point [A]–nasion [N] to HRP), decreasing in1 of 12 patients by a mean of �3.3° � 1.8° (range,6° to 0°) (Tables 1, 2). In 7 of 12 patients who

nderwent maxillary advancement, the mean postsur-ical AP maxillary growth for MxD was �3.9° (range,

IGURE 1. Landmarks used for cephalometric assessment. HRP isonstructed at 7° to the SN plane. N, nasion; S, Sella turcica; Ba,asion; Pt, pterygoid point; A, A point; UMT, upper molar mesialusp tip; LMT, lower molar distal cusp tip; UIE, upper incisor edge;IA, upper incisor apex; LIE, lower incisor edge; LIA, lower incisorpex; B, B point; Pog, pogonion; Gn, gnathion; Me, menton; Go,onion.

olford et al. Orthognathic Surgery in Young Cleft Patient. J Oralaxillofac Surg 2008.

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6° to �2°). In 5 patients who did not have a max-llary advancement, the mean change for MxD was

2.8° (range, �6° to 0°). In 4 patients who receivedutogenous bone grafts from the iliac crest to stabilizehe maxilla, MxD decreased by �4.2° (range, �6° to3°), and in 3 patients who received PBHA grafts,xD decreased by �3.3° (range, �4° to �2°). In 1atient who underwent orthognathic surgery with anxisting pharyngeal flap, the MxD decreased to areater extent compared with patients without flaps.The angle of N-A to N-B point (B) line (ANB) de-

reased by �3.6 (range, �8° to 2°) and showed sta-istically significant horizontal relapse at A point. Ver-ically, the maxilla showed significant growth thatas seen by increased length at N-gnathion (Gn) of

0.3 mm (range, 1 to 25 mm) (Figs 4B, 5B, 6B). Upperncisor angulation (angle of upper incisor to N-A lineUI/NA]) increased by 9.2° (range, �19° to 27°) be-ause of the counterclockwise rotation of upper inci-or and decrease in the angle of N-A to N-S line (SNA).n the patients who underwent maxillary advance-

IGURE 2. Distances and planes used to define linear and angulareasurements. N-Gn, distance from nasion to gnathion; SNA,ngle of N-A to N-S line; SN/Pog, angle of N-S to N-Pog line; FA,acial axis (angle of basion-nasion to pterygoid point–gnathionine).

ent, the mean value for UI/NA was 10.7° (range, 5°WM

o 23°), and the patients who did not have maxillarydvancement showed a mean of 5.8° (range, 2° to7°). In those receiving bone grafts the angle UI/NA

ncreased by a mean of 9.3° (range 5° to 16°), whereashose patients grafted with PBHA had a mean UI/NAncrease of 12° (range, 3° to 23°). In 1 patient whonderwent orthognathic surgery with an existing pha-yngeal flap, the angulation of the maxillary incisorsecreased compared with patients without flaps.The mandible had no horizontal changes at B point

nd pogonion. Mandibular depth (MdD) (ie, the anglef B point-N to HRP) and the angle of pogonion (Pog)o SN remained stable at long-term follow-up. Verti-ally, the maxillomandibular complex showed signif-cant vertical growth that was seen by increasedength at N-Gn of 10.3 mm (range, 1 to 25 mm). In 1atient who underwent orthognathic surgery with anxisting pharyngeal flap, the angulation of the man-ibular incisors decreased compared with patientsithout flaps.No significant difference was apparent in postsur-

ical growth of unilateral versus bilateral cleft pa-ients. There also appeared to be no significant effect

IGURE 3. Distances and planes used to define additional angulareasurements. OPA, angle of occlusion plane to HRP; MP, angle ofandibular plane to HRP; ANB, angle of N-A to N-B line; LI/NB,ngle of lower incisor to N-B line.

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n maxillary growth and development when mandib-lar osteotomies were performed simultaneously.

OCCLUSAL RELATIONS AND ERUPTION OF TEETH(T4-T3)

Of the 12 patients in the study, 11 tended towardhe development of a Class III end-on occlusal rela-ion, and in 1 a super Class III relation developedecause of untreated bilateral condylar hyperplasia.n several patients who underwent surgical maxillaryxpansion, posterior crossbites tended to develop.All 5 patients who underwent surgery in the mixed

entition phase were treated with alveolar cleft bonerafting as part of their operation. Four patientshowed eruption of the maxillary canines through therafted alveolar clefts. In 1 patient, with a unilateralleft, the canine tooth remained unerupted within theleft area at long-term follow-up.

Clinical CaseA young male patient, aged 11 years 7 months,

IGURE 4. A, The superimposed presurgical tracings show 3 yeanilateral cleft lip and palate, as well as a skeletal Class II relation.urgery to 4 years 6 months after surgery, after multiple maxillaryownward and backward growth vector of the maxillomandibular

olford et al. Orthognathic Surgery in Young Cleft Patient. J Or

resented with a repaired unilateral left cleft lip and m

alate, in the mixed dentition phase, and a Class IIkeletal and occlusal dentofacial deformity (Figs 7A,B,A-D, 9A). After orthodontic preparation, surgery waserformed in one operation including 1) multipleaxillary osteotomies for superior repositioning and

xpansion (Fig 9B), 2) closure of oronasal fistula inhe cleft alveolus, and 3) bone graft of the alveolarleft from iliac crest. The patient was evaluated 4onths after surgery, showing good facial balance

nd occlusion (Figs 7C,D, 8E-H). The permanentuspid eventually erupted through the grafted alve-lar cleft area. At 5 years after surgery (age 16 yearsmonths), the patient presented with a skeletal

nd occlusal Class III relation, anterior and bilateralosterior crossbites, slight anterior open bite, max-

llary hypoplasia, and poor facial balance (Figs 7E,F,I-K). The lateral cephalogram shows the Class IIIkeletal and occlusal relation, deficient verticalrowth of the maxilla, and orthodontic preparationor a reoperation to advance and downgraft the

onths of relatively normal growth of a young boy with a repairedsuperimposition of cephalometric tracings from immediately aftermies, alveolar bone grafting, and a chin augmentation, shows aex.

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Growth studies from the University of MichiganArbor, MI)7 show that from the age of 9 yearshrough the age of 16 years, MxD changes less than 1°or both male patients and female patients. Likewise,dD remains within 1° with normal growth. Thecclusal plane normally decreases in angulation, fromge 9 years to 16 years by approximately 5° in maleatients and female patients. Lisson et al6 investigatedertical skeletal morphology of 23 cleft patients (12nilateral and 11 bilateral) and 20 non-cleft patients atge 10 and 15 years. It was concluded that a verticalrowth impairment of the maxilla was found in pa-ients with cleft lip and palate. The maxilla of cleftatients showed a significant clockwise rotation, andhe posterior height of the maxilla was significantlyhorter. An increase in the anterior height of theandible was found in the cleft patients. In this study

he presurgical growth in the 5 patients with presur-ical skeletal Class I or II relations showed harmoni-us growth between the maxilla and mandible, main-aining a normal MxD and normal vector of facial

IGURE 5. A, The superimposed presurgical tracings show 2 yeanilateral cleft lip and palate, as well as a skeletal Class II relationonths after surgery, after multiple maxillary osteotomies and alveond-on Class III incisor and skeletal relation.

rowth before surgery. Six patients had a tendency t

oward a Class III skeletal relation, and just 1 patientad a progressively worsening Class III skeletal rela-ion, due to maxillary hypoplasia and bilateral condy-ar hyperplasia with a horizontal growth vector.

In previous postsurgical growth studies in non-cleftases for surgical correction of vertical maxillary ex-ess, a significant deficiency was seen in AP maxillaryrowth.13,14 Growing patients with vertical maxillaryxcess continue to have excessive vertical growth ofhe dentoalveolar process after surgery, during therowth phase, equal in magnitude to the presurgicalate of growth.7,8,11-15 In patients with repaired clefts,owever, postsurgical maxillary growth is signifi-antly altered.1,5,24,25 Maxillary growth may be ad-ersely affected by 5 factors: 1) separation of the nasaleptum and vomer from the maxilla, 2) scar tissuerom previous surgical procedures, 3) orthodonticechanics (ie, Class III elastics), 4) vascular compro-ise, and 5) bone grafting to the maxillary alveolar

left.Cleft palate patients are known to relapse more (up

o 68%) than non-cleft patients after surgical correc-

onths of relatively normal growth of a young boy with a repairedperimposed tracings from immediately after surgery to 5 years 5e grafting, show a downward and posterior growth vector and an

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ate significant overcorrection to compensate for thiselapse tendency.5 Hochban et al21 investigated 31on-growing patients (14 unilateral cleft patients and7 non-cleft patients) who underwent maxillary ad-ancement by Le Fort I osteotomy. There was a sig-ificantly higher relapse tendency after maxillary ad-ancement in patients with clefts (20% to 25%orizontal relapse) compared with the non-cleftroup (10% relapse). Mehra et al19 investigated 74dult patients (41 women and 33 men) who under-ent Le Fort I maxillary advancement and sagittal

plit mandibular ramus osteotomies. The sample wasivided into 2 groups: group 1 comprised 17 cleftatients (mean follow-up, 37.9 months) and group 2omprised 57 non-cleft patients (mean follow-up,8.8 months). The mean horizontal relapse of A pointas about 17% in group 1 and 9% in group 2. Theean vertical relapse of the upper incisor was abouttimes greater in group 1 (29%) than in group 2

9.5%).This study evaluated the records of 12 young cleft

IGURE 6. A, The superimposed presurgical tracings show 11 moleft lip and palate, as well as a skeletal Class I relation. B, Superfter surgery, after maxillary osteotomies, alveolar bone grafting, adownward and posterior rotation of the maxillomandibular com

atients who underwent orthognathic surgery. The 5 m

atients in the mixed dentition phase had maxillaryxpansion and/or superior repositioning; 7 patientsad maxillary advancements (ranging from 4 to 8m), expansion, and/or downgrafting; and 5 patientsad mandibular ramus osteotomies including sagittalplit for mandibular advancements (3 patients), set-ack (1 patient), and bilateral inverted-L osteotomiesor mandibular setback (1 patient).

The mean postsurgical change in MxD was �3.3°range, �6° to 0°). However, critical observationhows that the maxilla remained in essentially theame AP position. The nasofrontal region, however,ontinued to grow forward at a normal rate, thusreating a decreased MxD and relative AP maxillaryypoplasia. Hochban et al21 reported that 14 unilat-ral cleft patients who underwent maxillary advance-ent by Le Fort I osteotomy had decreases in the

ngle SNA (�1.3°) and MxD (�1.6°) 1 year afterurgery.

Of our 12 patients, 7 underwent maxillary advance-ent of 4 to 8 mm, and the mean postsurgical AP

relatively normal growth of a young girl with a repaired bilaterald tracings from immediately after surgery and 5 years 11 monthsandibular advancement, show a significant change in growth with

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axillary growth measured by MxD was �3.9°

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range, �6° to �2°). The mean postsurgical MxDhange in the 5 patients who did not have a maxillarydvancement was �2.8° (range, �6° to 0°). Thislightly lesser decrease in MxD in this latter groupay reflect a difference in growth potential between

he 2 maxillary types and/or some AP surgical relapsen the group that underwent maxillary advancement.o significant difference was apparent in postsurgicalrowth of unilateral versus bilateral cleft patients. Theame result was shown by Heliovaara et al.23 Several

Table 1. POSTSURGICAL CHANGES

Mean SD Minimum

ngle (°)MxD 87.42 4.46 80MdD 83.58 2.54 80FA 85.08 3.18 80OPA 10.42 5.81 2MP 32.33 5.00 25UI/NA 15.17 8.32 8LI/NB 17.75 7.92 5ANB 3.83 4.32 �3SNA 80.33 5.66 73SN/Pog 75.67 3.77 69

ength (mm)N-Gn 118.08 8.21 110

bbreviations: FA, facial axis (angle of basion-nasion to pterP, angle of mandibular plane to HRP; LI/NB, angle of lowf N-A to N-S line; SN/Pog, angle of N-S to N-Pog line; N-Gn

Table 2. POSTSURGICAL STABILITY (T4 � T3)

T4 � T3

Mean P Value SD Minimum Maximum

ngle (°)MxD �3.33 �.01 1.78 �6 0MdD 0.92 2.43 �4 4FA 0.17 3.64 �6 5OPA 0.08 2.02 �3 4MP �0.25 3.02 �4 4UI/NA 9.25 �.05 11.74 �19 27LI/NB 3.25 5.69 �3 15ANB �3.58 �.01 2.81 �8 2SNA �3.33 �.01 1.78 �6 0SN/Pog 0.92 2.43 �4 4

ength (mm)N-Gn 10.33 �.01 7.88 1 25

bbreviations: FA, facial axis (angle of basion-nasion toterigoid point-gnathion line); OPA, angle of occlusionlane to HRP; MP, angle of mandibular plane to HRP; LI/NB,ngle of lower incisor to N-B line; ANB, angle of N-A to N-Bine; SNA, angle of N-A to N-S line; SN/Pog, angle of N-S to-Pog line; N-Gn, distance from nasion to gnathion.

molford et al. Orthognathic Surgery in Young Cleft Patient. J Oralaxillofac Surg 2008.

uthors have described horizontal relapse of the max-lla after Le Fort I osteotomy. Heliovaara et al reportedhat the mean horizontal relapse of A point in adultleft patients who underwent Le Fort I osteotomy was.5% (cleft palate group) and 9.4% (bilateral cleft lipnd palate group) relative to the amount of advance-ent. Thongdee and Samman18 reported a mean hor-

zontal maxillary relapse of 31% of the surgical move-ent in 30 cleft patients (9 male and 21 femaleatients; mean age, 18 years [range, 14 to 28 years]).osnick and Dagys22 reported a mean horizontal max-

llary relapse of 23.2% of the surgical movement in 35left patients (mean age 18 years old). Landes andallon20 reported a mean horizontal maxillary relapse

n 22 cleft patients who underwent Le Fort I osteot-my and mandibular osteotomy (11 of the 22 pa-ients) of 30% (titanium miniplate osteofixation) and4% (resorbable miniplate).Four patients received autogenous bone grafts from

he iliac crest, and 3 received PBHA grafts to stabilizehe maxilla. Postsurgical changes in horizontal growthMxD) for those receiving bone grafts averaged �4.2°range, �6° to �3°), and for those who receivedBHA, the mean was �3.3° (range, �4° to �2°). Thisnding seems to show, in this small patient sample,lightly greater deficiency of growth in the bone graftroup. Several authors have described the use ofBHA grafting during orthognathic surgery. Mehra etl19 reported that maxillary advancement with Le Fortosteotomies using rigid fixation and interpositionalBHA grafting during bimaxillary surgery is a stablerocedure with good predictability in cleft and non-cleftatients, regardless of the direction of vertical maxillary

um Mean SD Minimum Maximum

4 84.08 4.50 76 897 84.5 3.06 81 910 85.25 4.14 77 927 10.5 6.27 2 202 32.08 5.95 23 423 24.42 9.07 12 411 21 8.90 0 320 0.25 5.63 �11 70 77 5.77 70 881 76.58 3.92 71 83

5 128.42 8.06 116 143

oint-gnathion line); OPA, angle of occlusion plane to HRP;isor to N-B line; ANB, angle of N-A to N-B line; SNA, anglence from nasion to gnathion.

illofac Surg 2008.

9891433198

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ovement. When one is using PBHA as a bone graft

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WOLFORD ET AL 2533

ubstitute in orthognathic surgery, it is important to useone plates (rigid fixation) to provide stress shielding ofhe material and minimize micromovement during thenitial healing phase.35,36 Cottrell and Wolford36 pre-ented 5-year follow-up data on 245 consecutive pa-ients with 289 PBHA implants placed in the maxillain direct communication with the maxillary sinus)nd found that the lateral maxilla wall grafting had a5.7% long-term success rate.Maxillary growth occurred predominantly in a ver-

ical vector with virtually no AP growth, even thoughost patients had shown AP growth before surgery. A

ess severe deficiency of maxillary growth was seen inhe female patients in this study and may be indicativef them being closer to the end of their pubertalrowth at the time of surgery than were the maleatients. The wide range shows significant variability,ost likely attributable to the effect of vertical max-

llary growth and subsequent downward and back-ard rotation of the mandible, and may not be reflec-

ive of true mandibular growth. Of the 12 patients, 10howed this downward and backward rotation of theaxillomandibular complex. This postsurgical growth

IGURE 7. A, B, A young male patient, aged 11 years 7 monthslass II skeletal dentofacial deformity. C, D, The patient is seen 4f the alveolar cleft with iliac crest. E, F, The patient is seen 5 yealass III skeletal dentofacial deformity.

howed a significant untoward effect of the Le Fort I v

steotomy and alveolar cleft bone grafting on postsurgi-al maxillary growth. Several authors have describedertical relapse of the maxilla after Le Fort I osteotomy.eliovaara et al23 reported a mean vertical relapse ofpoint in adult cleft patients who underwent Le Fortosteotomy of 16.7% (cleft palate group) and 17.8%

bilateral cleft lip and palate group). Thongdee andamman18 reported a mean postsurgical vertical re-apse of 52% relative to the surgical movement in 30left patients (9 male and 21 female patients; meange, 18 years [range, 14 to 28 years]). Posnick andagys22 reported a mean postsurgical vertical re-

apse of 19% relative to the surgical movement in 35left patients (mean age, 18 years). Landes andallon20 reported a mean postsurgical vertical re-

apse in 22 cleft patients who underwent Le Fort Isteotomy and mandibular osteotomy (11 of the 22atients) of 39% (titanium miniplate osteofixation)nd 30% (resorbable miniplate).

The mean change in the angulation of the maxillaryncisors, relative to NA, was 9.2° (range, �19° to 27°).his showed that, in 11 cases, the maxillary incisorsnderwent an increase in angulation, and this wide

n with unilateral cleft defect, in the mixed dentition phase, and aafter surgery, after multiple maxillary osteotomies and bone graftsurgery showing a poor facial balance, maxilla hypoplasia, and

illofac Surg 2008.

, is seemonthsrs after

ariation can again be attributed to the variability of

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he downward and posterior rotation of the mandibles a result of vertical maxillary growth.

The increase in angulation of the maxillary incisorsn the group that underwent maxillary advancementveraged 10.7° (range, 5° to 23°). Patients who didot have maxillary advancement showed a mean in-rease in angulation of the incisors of 5.8° (range, 2°o 17°). The greater increase in maxillary incisor an-ulation in those patients who required maxillarydvancement may reflect a greater deficiency in ver-ical and AP maxillary growth potential in these pa-ients, or it may indicate some AP surgical relapse ofhe maxilla, with an increase in the resultant dentalompensations.Postsurgical changes in the upper incisor angula-

ion in 4 patients who received bone grafts averaged.3° (range, 5° to 16°) and in the 3 patients whoeceived PBHA, the mean was 12° (range, 3° to 23°).his seems to show, in this small patient sample, alight increase in the maxillary incisor angulationhen PBHA was used.There also appears to be no significant effect onaxillary growth and development when mandibular

urgery is performed simultaneously. Posnick andagys22 reported that no significant difference was

een in horizontal and vertical relapse between pa-ients who had maxillary surgery alone (n � 24) and

IGURE 8. A-D, The presurgical occlusion shows an anterior ovcclusion remained stable 4 months after surgery with permanent terafting of the alveolar cleft. I-K, At 5 years postsurgery the occlusis well as anterior and bilateral posterior crossbites.

hose who had surgery on both jaws (n � 11). i

Just 1 patient in this study had orthognathic surgeryith a pre-existing pharyngeal flap. The pharyngealap was undermined, allowing the maxilla to be ad-anced without placing tension on the flap. Cephalo-etric analysis at longest follow-up showed a greater

ecrease in MxD and significantly increased verticalacial growth in this patient compared with the 11atients without flaps. A pharyngeal flap can exert aethering effect on the maxilla, causing a significant,dditional restriction in AP maxillary growth and anncrease in the magnitude of the vertical growth vec-or. Pharyngeal flaps can also present an obstacleuring attempts to mobilize the maxilla in the Le Fortosteotomy.40 Upon healing, the tethering effect of

he flap will again be present. Such tension coupledith possible postoperative obstruction of the nasal

irway may result in mouth breathing that may alsoontribute to the excessive vertical maxillary growtheen in these young patients. Posnick and Dagys22

eported that no significant difference was seen inon-growing patients who had pharyngoplasty sur-ery (n � 13) at the time of Le Fort I osteotomy.In this study 5 patients showed normal Class I or II

keletal growth during the presurgical phase, but 4anifested disproportionate postsurgical growth,ith Class III skeletal and occlusal relations develop-

Class II occlusal relation, and mixed dentition phase. E-H, Thepted into the cleft region area after orthognathic surgery and boneed toward the development of a Class III end-on occlusal relation

illofac Surg 2008.

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WOLFORD ET AL 2535

In conclusion, orthognathic surgery may be per-ormed on growing cleft patients when mandated bysychological and/or functional concerns. Carefulase selection is imperative, and the surgeon must beognizant of the following postsurgical outcomeshen performing orthognathic surgery on growing

left patients:

1) Expect absence of maxillary AP growth aftersurgery. Postsurgical maxillary growth becomespredominantly vertical.

2) Patients with proportionate presurgical growthwill exhibit disproportionate postsurgicalgrowth, with Class III skeletal and occlusalrelations developing as a result of adverseaffects on maxillary growth.

3) Delay orthognathic surgery until growth is com-

IGURE 9. A, The presurgical lateral cephalometric radiograph shase. B, The immediate postsurgical lateral cephalometric radiog

nterosseous wires and infraorbital suspension wires after multiple, The lateral cephalometric radiograph obtained 6 years after su

he maxilla, and orthodontic preparation for a new orthognathic s

plete. Facial growth is usually 98% complete by

age 15 years in female patients and by age 17 to18 years in male patients.

Delaying surgery until growth is complete can re-ult in worsening of the facial deformity, creatingajor functional, esthetic, and psychosocial problems

t an important stage in human psychosocial develop-ent. If such problems are severe, surgery can be

one at an earlier age with the understanding that itay need to be repeated after growth is complete.istraction procedures may be an alternative to therthognathic surgery approach, but post-treatment dis-roportionate growth factors may be exhibited as well.

eferences1. Wolford LM, Stevao EL: Correction of jaw deformities in pa-

n anterior overbite, Class II occlusal relation, and mixed dentitionows the maxilla stabilized with threaded Steinmann pins and withry osteotomies and bone graft of the alveolar cleft with iliac crest.hows the Class III occlusion, anterior open bite, vertical growth of

illofac Surg 2008.

hows araph shmaxillargery surgery.

tients with cleft lip and palate. Proc (Bayl Univ Med Cent)15:250, 2002

2. Normando AD, da Silva Filho OG, Capelozza Filho L: Influenceof surgery on maxillary growth in cleft lip and/or palate. JCraniomaxillofac Surg 20:111, 1992

3. Ross RB: Treatment variables affecting facial growth in com-plete unilateral cleft lip and palate. Part 1: Treatment affectinggrowth. Cleft Palate J 24:5, 1987

4. Horswell BB, Levant BA: Craniofacial growth in unilateral cleftlip and palate: Skeletal growth from eight to eighteen years.Cleft Palate J 25:114, 1988

5. Bertolini F, De Riu G, Zorzan G, et al: Skeletal relapse ofmaxillary osteotomies in unilateral cleft lip and palate patients.Int J Adult Orthognath Surg 15:30, 2000

6. Lisson JA, Hanke I, Trankmann J: Changes of vertical skeletalmorphology in patients with complete unilateral and bilateralcleft lip and palate. Cleft Palate Craniofac J 42:490, 2005

7. Riolo ML, Moyers RE, McNamara JA Jr, et al: An Atlas ofCraniofacial Growth. Ann Arbor, MI, Center for Human Growthand Development, University of Michigan, 1974

8. Wolford LM, Karras SC, Mehra P: Considerations for orthog-nathic surgery during growth, part 2: Maxillary deformities.Am J Orthod Dentofac Orthop 119:102, 2001

9. Wolford LM, Karras SC, Mehra P: Considerations for orthog-nathic surgery during growth, part 1: Mandibular deformities.Am J Orthod Dentofac Orthop 119:95, 2001

0. Scheuer HA, Holtje WJ, Hasund A, et al: Prognosis of facialgrowth in patients with unilateral complete clefts of the lip,alveolus and palate. J Craniomaxillofac Surg 29:198, 2001

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2. Epker BN, Schendel SA, Washburn M: Effects of early surgicalsuperior repositioning of the maxilla on subsequent growth:III. Biomechanical considerations, in McNamara JA, Carlson DS,Ribbens KA (eds). Monograph No. 12, Craniofacial GrowthSeries. Ann Arbor, MI, Center for Human Growth and Devel-opment, University of Michigan, 1982, pp 231-250

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4. Mogavero FJ, Buschang PH, Wolford LM: The effects of orthog-nathic surgery of growth of the maxilla in patients with verticalmaxillary excess, in Bell WH: Modern Practice in Orthognathicand Reconstructive Surgery. Philadelphia, PA, Saunders, 1991,pp 1932-1955

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6. Shapiro PA, Kokich VG, Hohl TH: The effects of early Le FortI osteotomies on craniofacial growth of juvenile Macaca nem-estrina monkeys. Am J Orthod 79:492, 1981

7. Posnick JC, Tompson B: Cleft-orthognathic surgery: Complica-tions and long-term results. Plast Reconstr Surg 96:255, 1995

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9. Mehra P, Wolford LM, Hopkin J, et al: Stability of maxillaryadvancement using rigid fixation and porous-block hydroxyap-atite grafting: Cleft palate versus non-cleft patients. Int J AdultOrthod and Orthognath Surg 16:193, 2001

0. Landes CA, Ballon A: Five-year experience comparing resorb-able to titanium miniplate osteosynthesis in cleft lip and palate

1. Hochban W, Ganss C, Austermann KH: Long-term results aftermaxillary advancement in patients with clefts. Cleft PalateCraniofac J 30:237, 1993

2. Posnick JC, Dagys AP: Skeletal stability and relapse patternsafter Le Fort I maxillary osteotomy fixed with miniplates: Theunilateral cleft lip and palate deformity. Plast Reconstr Surg94:924, 1994

3. Heliovaara A, Ranta R, Hukki J, et al: Skeletal stability of Le FortI osteotomy in patients with isolated cleft palate and bilateralcleft lip and palate. Int J Oral Maxillofac Surg 31:358, 2002

4. Eskenazi LB, Schendel SA: An analysis of Le Fort I maxillaryadvancement in cleft lip and palate patients. Plast ReconstrSurg 90:779, 1992

5. Freihofer HP Jr: Results of osteotomies of the facial skeleton inadolescence. J Maxillofac Surg 5:267, 1977

6. Wolford LM, Cooper RL, El Deeb M: Orthognathic surgery onthe young cleft patient and the effect on growth [abstract].Presented at the American Cleft Palate Association AnnualMeeting, St Louis, MO, May 1990

7. Epker BN, Wolford LM: Dentofacial Deformities: Surgical Orth-odontic Correction. St Louis, MO, Mosby, 1980

8. Bennett MA, Wolford LM: The maxillary step osteotomy mod-ification and Steinmann pin stabilization. J Oral Maxillofac Surg43:307, 1985

9. Wolford LM, Bennett MA, Rafferty CG: Modification of themandibular ramus sagittal split osteotomy. Oral Surg Oral MedOral Pathol 64:146, 1987

0. Holmes RE, Wardrop RW, Wolford LM: Hydroxyapatite as abone graft substitute orthognathic surgery. J Oral MaxillofacSurg 46:661, 1988

1. Moenning JE, Wolford LM: Coralline porous hydroxyapatiteas a bone graft substitute in orthognathic surgery: 24-Monthfollow-up results. Int J Adult Orthod Orthognath Surg 4:105,1989

2. Mehra P, Castro V, Freitas RZ, et al: Stability of the LeFort Iosteotomy for maxillary advancement using rigid fixation andporous block hydroxyapatite grafting. Oral Surg Oral Med OralPath Oral Radiol Endod 94:18, 2002

3. Wolford LM, Freitas RZ: Porous block hydroxyapatite as a bonegraft substitute in the correction of jaw and craniofacial defor-mities. Proc (Bayl Univ Med Cent) 12:243, 1999

4. Ayers RA, Wolford LM, Bateman TA, et al: Quantification ofbone ingrowth into porous block hydroxyapatite in humans.J Biomed Mater Res 47:54, 1999

5. Ayers RA, Simske SJ, Nunes CR, et al: Long-term bone ingrowthand residual microhardness of porous block hydroxyapatiteimplants in humans. J Oral Maxillofac Surg 56:1297, 1998

6. Cottrell DA, Wolford LM: Long-term evaluation of the use ofcoralline hydroxyapatite in orthognathic surgery. J Oral Maxil-lofac Surg 56:935, 1998

7. Nunes CR, Simske SJ, Sachdeva R, et al: Long-term ingrowthand apposition of porous hydroxylapatite implants. J BiomedMater Res 36:560, 1997

8. Wardrop RW, Wolford LM: Maxillary stability following down-graft and/or advancement procedures with stabilization usingrigid fixation and porous block hydroxyapatite implants. J OralMaxillofac Surg 47:336, 1989

9. Wolford LM, Wardrop RW, Hartog JM: Coralline porous hy-droxyapatite as a bone graft substitute in orthognathic surgery.J Oral Maxillofac Surg 45:1034, 1987

0. Posnick JC, Ewing MP: Skeletal stability after Le Fort I maxillaryadvancement in patients with cleft lip and palate. Plast Recon-

Orthognathic Surgery in the Young Cleft Patient: Preliminary Study on Subsequent Facial Growth

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