Page 526 - Read Online

Page 12 of 15 Corthouts et al. Plast Aesthet Res 2020;7:46 I http://dx.doi.org/10.20517/2347-9264.2020.97

important objective is to reduce the number of operations as they are considered to be stressful for the
family and to make it more difficult to cope successfully. Likewise, the number of surgeries has an impact
on the psychological well-being of the patient. There does not seem to be any consensus on the best
time to perform palate closure, where every timing has its own advantages and disadvantages [7,20] . Some
studies [15,19,21,22] assumed that the early surgical repair of the cleft palate is responsible for the impaired
maxillary growth and concluded that it was better to delay surgical palate repair. During the maxillary
growth spurt an important proportion of the final length of the maxilla is gained. It is possible that the
benefit of delayed hard palate on maxillofacial growth closure can only be achieved by closing when the
[19]
[16]
greatest proportion of the final maxillary length is already achieved . However, Zheng et al. claim that
isolated surgery has minor effects on growth disturbances and conclude that early palatal closure should
therefore be performed because it will not negatively affect maxillofacial growth. Furthermore, early
primary repair operations facilitate ease of feeding and good speech development, and there is a strong
desire from the patient’s parents themselves to have the cleft closed as early as possible [7,22,23] . Nevertheless,
the growth spurt of these children should be awaited before conclusive results are formed concerning the
measured cephalometric values regarding sagittal growth of the skeleton, since the results in patients in
mixed dentition show a lot of variability. Regarding this concept, researchers should be aware of the fact
[24]
that the end of growth in cleft children is later than in healthy noncleft children .
Whereas most studies agree that palatal closure is the most detrimental factor for the evolution of maxillary
growth, other studies are convinced that lip repair is the most important factor in the restraint of maxillary
growth in patients with UCLP [10,25] . There is however agreement that pressure from a tense upper lip causes
[26]
retro inclined upper incisors, a retruded maxilla and obtuse nasolabial angle . This usually results in an
[2]
anterior cross bite . It is crucial to stretch the importance of an optimal result of lip closure. Lip, nose and
chin are the key regions in a patient’s face and they have the most significant impact on facial aesthetics,
[27]
self-esteem and self-image. Thus lip, nose and columella are most frequently surgically revised in UCLP
patients.

There is still a lot of discussion about which technique and timing is most beneficial for alveolar closure.
Alveoloplasty is performed to stabilize the maxillary arch, facilitate the eruption of the canine (and the
lateral incisor), raise the alar base of the nose and to reconstruct the residual nasoalveolar fistula . Overall,
[28]
[2]
3 used techniques can be distinguished : gingivoperiosteoplasty, primary bone grafting and secondary
bone grafting. Although gingivoperiosteoplasty has the big advantage that it requires fewer surgeries, it
[29]
seemed to have an inhibitory effect on maxillary growth . Primary bone grafting led to inconsistent
alveolar ossification and was suspected to interfere with anterior maxillary growth . Patients treated
[14]
with secondary bone grafting seemed to have better maxillary growth and appeared to be needing less
[18]
[29]
orthognathic surgery . Brudnicki et al. discovered that maxillary length increased when alveolar bone
grafting was performed at a later age, specifically when performed beyond the age of eight years old. This
would suggest that the timing of bone grafting is critical to maxillofacial growth.
Unanimity with regard to a superior treatment protocol in terms of closure of the lip, closure of the palate
and closure of the alveolar cleft, was not reached in this systematic review. The reasons for conflicting
results from the selected studies include the great variance in treatment protocols, as shown by the varied
timing of surgical repair and different surgical techniques [Table 2]. This systematic review also had some
methodological deficiencies [Table 1] and limitations. First, 4 studies [6,9,12,18] did not compare operated
UCLP patients with a noncleft control group. Consequently, it is not clear how the measured cephalometric
outcomes are related to a healthy, normal population. Second, some studies were well designed and well-
executed but had small sample sizes. Seven [6,11-16] of the 11 included articles had samples less than 100
patients. This could imply that the statistical power of these studies was too low to detect differences. Third,
[10]
one study examined the cephalometric values for males and females separately and this might have