The aim of this study was to investigate the influence of the pharyngeal flap procedure on the frequency of Le Fort I osteotomies in full-grown nonsyndromic cleft patients. A retrospective review of 508 full-grown cleft patients born between 1 January 1983 and 31 December 1992 was performed. Following data analysis, 140 males older than 18 years and 111 females over the age of 16 years were included. 69 of the 251 included cleft patients required pharyngeal flap surgery (27.5%). Revision flap surgery was performed in 17.4% of the cases. A significantly lower age at time of the initial pharyngeal flap procedure was found in patients requiring revision surgery (5.6 years versus 6.8 years). The frequency of Le Fort I osteotomies was significantly higher in the patients with a pharyngeal flap (19%) compared to those without (8%) ( p < 0.05). The results of this study point towards the pharyngeal flap procedure being one of the possible limiting factors for maxillary antero-posterior growth in cleft patients.
The aim of cleft treatment is to obtain the best possible functional and aesthetic result when facial growth is completed; but the optimal timing and approach for the surgical management continues to be a source of controversy. Therefore, factors influencing the outcome need to be studied.
In general, the presence of maxillary hypoplasia in repaired cleft patients is a well-recognized phenomenon. Most authors advocate the theory that iatrogenic factors, especially primary lip and palate repair, cause the main restriction of maxillary growth.
The Le Fort I advancement osteotomy (LFI) is the standard surgical procedure to treat Angle Class III relationships due to maxillary retrusion. The incidence of maxillary hypoplasia is often translated into the number of LFI osteotomies performed. The frequency of LFI varies from 0.0 to 69.6%. The influence of primary lip or palate repair on maxillary growth has been the subject of many reports, but the influence of pharyngeal flap surgery (PFS) is seldom discussed and the results are contradictory. This is remarkable, since 20–38% of cleft palate patients require this procedure.
Oberoi et al. delineated factors possibly contributing to maxillary hypoplasia, one of them being PFS. In a group of 16 unilateral cleft lip and palate patients without maxillary hypoplasia only one patient had undergone (secondary) PFS surgery (6.25%), whereas in the group with maxillary hypoplasia 4 of 16 patients had PFS before during palate repair and 4 had PFS as a secondary (after palate repair) procedure (50%); these results were not supported by statistical investigations.
Although some small differences in growth pattern were seen in previous studies on the effect of pharyngeal flaps on maxillary growth, no conclusive evidence was provided.
The sparse number of reports considering the influence of PFS on maxillary growth combined with the small number of patients studied and the short follow up period, show more studies are required. This report attempts to address the possible effect of the commonly performed PFS on subsequent maxillary growth in cleft patients. Additional risk factors for PFS and LFI, including cleft subtype, gender and number of previous surgical procedures, will be evaluated.
Materials and methods
508 consecutive cleft patients born between 1 January 1983 and 31 December 1990 (male) and 31 December 1992 (female) and treated at the authors’ institution were evaluated retrospectively. The indication for a LFI was assessed when facial skeletal growth had been completed. Since this is on average 2 years earlier in females (at the age of 16 years) than in males (at the age of 18 years) the included birth dates of patients differed between genders.
Inclusion criteria were lip and/or alveolar process and/or palate and/or submucous non-syndromal cleft patients, with maturity of the facial skeleton. The treatment was according to the institution protocol as shown in Table 1 . Exclusion criteria were cleft patients with other congenital deformities, patients who died before reaching the age of 16 years (females)/18 years (males), midfacial clefts, previous radio- or chemotherapy, incomplete documentation and exceptions to the protocol.
|3–5 months||Lip repair (according to the Millard technique)|
|9–11 months||Closure of the soft palate cleft in case of cleft lip, alveolus and palate (CLAP), closure of the soft and hard palate cleft in case of cleft palate (CP) (according to the Wardill-Kilner, Von Langenbeck, Perko or Kriens technique)|
|8–13 years||Alveolar bone grafting and closure of the hard palate in case of cleft lip, alveolus and palate (CLAP)|
|16–18 years||If necessary: orthognathic surgery after completion of facial skeletal development and secondary nose and/or lip corrections|