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Patterns and Outcomes of Maxillary Distraction in Patients with Cleft Lip and Palate
Steven Du
*, Benjamin Massenburg, Dominic Romeo, Meagan Wu, Jinggang Ng, Hyun-Duc Nah, Joseph A. Napoli, Jesse A. Taylor, Scott Bartlett, Jordan W. Swanson
Division of Plastic, Reconstructive, and Oral Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA
Background: Several studies suggest high relapse rates after larger orthognathic maxillary advancements in patients with cleft lip and palate (CLP), yet this is common practice in many craniofacial centers. We studied patterns and outcomes of maxillary distraction osteogenesis (MaxDO), with a primary endpoint of malocclusion requiring secondary orthognathic surgery (OS).
Methods: We retrospectively reviewed all patients with diagnosis of CLP who underwent MaxDO from 2007 to 2022. 26 CLP patients who underwent MaxDO for midface hypoplasia and Angle Class III malocclusion between ages 9.0-19.2 years were included. Using patient factors, cephalometric analysis, and surgical history, we determined predictors for long-term occlusal normalization and risk factors for relapse and additional OS. Chi-square tests were used for binomial variables and multivariate logistic regression was performed.
Results: Patients with genetic syndromes (66.7% versus 40.0%, p=0.250), prior oronasal fistula repairs (61.5% versus 30.8%, p=0.116), ANB angle below -5 degrees (64.3% versus 20.0%, p=0.089), and those who were not overcorrected (55.6% versus 25.0%, p=0.149) had higher rates of secondary OS. In females, MaxDO achieved stable occlusion without additional surgery in 83.3% of those who had surgery after the age of 13.5 years, compared to 20.0% in those under 13.5 years old (Figure 1, p=0.036). In males, MaxDO achieved stable occlusion in 50.0% after the age of 17 years, compared to 0% below 17 years old (Figure 1, p=0.018). On multivariate logistic analysis, age at time of MaxDO was associated with long-term normalization of occlusion (p=0.045).
Conclusion: Le Fort I distraction osteogenesis effectively achieves maxillary advancements <12mm in patients with CLP. In young children, maxillary advancement with distraction osteogenesis may normalize severe malocclusion through secondary school ages as a bridge to definitive OS. In most females over 13.5 and half of males over 17, strategic MaxDO achieves stable normalization of occlusion without need for further orthognathic surgery.
Figure 1. Percentage of patients in each group ending up in Class III malocclusion, Class I malocclusion after orthognathic surgery, or Class I malocclusion after distraction only.
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