Abstract Objectives: 1. To compare the surgical treatment methods of ...

Abstract
Objectives:
1. To compare the surgical treatment methods of conventional osteotomy and
distraction osteogenesis on cleft lip and palate deformities by a comprehensive
review of the literatures.
2. To compare the clinical morbidities and surgical relapse of maxillary Le Fort I
advancement in cleft lip and palate patients (CLP) by either distraction osteogenesis
with internal distractor or conventional osteotomy with mini-plate fixation through a
randomized clinical trial
Materials and Methods:
Part I: A Meta-analysis of Cleft Maxillary Osteotomy and Distraction Osteogenesis
A meta-analysis of the literature was conducted on distraction osteogenesis and
conventional osteotomy in cleft lip and palate patients by a comprehensive
computerized PUBMED search of the National Library of Medicine from January
1966 to December 2003. Keywords used in the search were cleft, distraction,
maxilla, maxillary, advancement, osteotomy, and orthognathic surgery.
The
surgical planning, surgical movement, amount of movement, type of fixation, bone
grafting & site of harvest, distraction rate, rhythm, latency and consolidation, postoperative
care, complications, follow-up period, relapse, speech, velopharyngeal,
auditory function and soft tissue changes were analyzed.

Part II: Cleft Maxillary Distraction versus Orthognathic Surgery: Clinical Morbidities
and Surgical Relapse
29 CLP patients with diagnosis of moderate maxillary hypoplasia underwent Le Fort
I osteotomy requiring an advancement of 4-10 mm were randomized to either for
distraction or immediate maxillary transposition.
In the distraction group, active
distraction was commenced at day - 3 after distractor insertion at a rate of 1mm per
day until achieving a class I incisor relationship. The distractors were removed
around the third post-operative month. In the osteotomy group, the cleft maxilla was
mobilized to the pre-planned class I occlusion during the operation and then fixed by
4 titanium mini-plates and screws.
The clinical morbidities were recorded by standardized questionnaires during
operation and post-operatively at 2 and 8 weeks, 3, 6 and 12 months. Skeletal and
dental relapse were assessed by using lateral cephalographs taken pre-operatively
and post-operatively at the same interval. Serial comparisons of dental and skeletal
cephalometric landmarks were used for the determination of surgical relapse.
Result:
Part I: This search revealed 98 articles. 72 articles were related to cleft maxillary
osteotomy and 26 were related to cleft maxillary distraction. This review revealed
that 1418 cleft patients underwent maxillary osteotomy and 276 patients underwent
distraction osteogenesis. The surgical planning of the two groups studied was
similar. The reported surgical movement in the distraction group was mainly in the
anterior-posterior as well as some also in the transverse plane. In the osteotomy
group, it was only in antero-posterior and vertical planes. The amount of

advancement achieved in both groups was quite similar. However, the maximum
amount of movement reported for distraction was larger.
Part II:
In the distraction group, two patients developed mucosal infection around the
distractors and one has occlusal relapse, whereas in the osteotomy group, one
patient encountered haemorrhage from transection of the descending palatine
vessels during maxillary mobilization, one patient had exposure of plate leading to
sinusitis and one patient developed occlusal relapse. For the skeletal relapse of the
osteotomy group, a vertical relapse of A-point in upward direction was noted
between the 2 nd - 8 th week and 8 th -12 th week post-operatively of 6% and 33%,
respectively. In contrast, the A-point moved further downward by 15% and 10% at
the same interval in the distraction group. In the horizontal relapse of A and P-points,
a backward surgical relapse of 21% and 13% was found, whereas in the distraction
group, both points moved further forward for 25% and 15% during the 8 th – 12 th
weeks post-operatively. The results were statistically significant between the two
groups.
Conclusion:
Part I:
The literature review revealed that patients who had distraction osteogenesis were
younger than those who had orthognathic surgery. The amount of advancement
was significantly greater in distraction as compared to that of the conventional
osteotomy. There is however lack of good data on long term results and relapse on
distraction osteogenesis when compared with conventional osteotomy in CLP

deformities.
The effect of Le Fort I maxillary osteotomy and distraction
osteogenesis on velopharyngeal function remains a controversial issue. Both
distraction osteogenesis and conventional osteotomy can induce significant soft
tissue changes affecting the facial aesthetics.
Part II:
This study highlights that intra-operative and post-operative complications may
develop in either distraction by internal maxillary distractor or the conventional
osteotomy in CLP patients. Clinical occlusal relapse may develop during the early
post-operative period in the transposed maxilla with either distraction or conventional
osteotomy. Conventional osteotomy by immediate maxillary transposition produces
more skeletal relapse in both vertical and horizontal plane than the cleft distraction,
particularly in the early post-operative 3 months.