Clinical Paper
Cleft Lip and Palate
Avascular necrosis in cleft maxillary repositioning: a review of cases and introduction of the ‘delayed maxillary flap’

https://doi.org/10.1016/j.ijom.2020.05.003Get rights and content

Abstract

There is a low incidence of serious complications with the Le Fort I maxillary osteotomy, but avascular necrosis is a serious problem that occurs at a higher frequency in the cleft population compared to non-cleft patients. In this retrospective study, cleft patients who had exhibited any manifestation of avascular necrosis of the maxilla following a Le Fort I advancement were identified. Five patients were found to have had vascular compromise, ranging from loss of gingival tissue to necrosis of bone and loss of teeth. In each case, possible risk factors were assessed, and secondary revision palatal surgery prior to maxillary advancement, particularly closure of oronasal fistulae with transpositional flaps, was noted to be present. Drawing on this finding and a review of the literature, clinical recommendations are made for minimizing the risk of this major complication. The use of the ‘delayed maxillary flap’ technique is introduced and described as a potentially beneficial procedure for cleft patients with a high risk of vascular compromise.

Section snippets

Patients and methods

Records of all cleft lip and palate patients who underwent a Le Fort I maxillary repositioning were retrieved from the database of the Section of Oral and Maxillofacial Surgery, Royal Children’s Hospital of Melbourne, and interrogated for any events of vascular compromise.

From a sample of 207 patients, five were noted to have suffered varying manifestations of avascular necrosis and all had at least 3 years of postoperative follow-up. All patients underwent standard primary lip and palate

Results

There were three patients with unilateral cleft lip and palate and two patients with bilateral cleft lip and palate who manifested a degree of avascular necrosis. At the time of the complication, the age range was 18–23 years, and all patients were male. All patients had a maxillary advancement (Le Fort I down-fracture osteotomies), two of which involved concurrent segmental expansion (Table 1). Four of the patients had residual palatal fistulae following their primary surgery that were closed

Discussion

Avascular necrosis has also been referred to as aseptic necrosis, although the former terminology is preferred in this clinical setting. This complication is a rare and potentially devastating outcome from maxillary surgery and is seen more frequently in the cleft population, but may also occur in patients with systemic diseases. Reported cases secondary to systemic diseases include a case report of non-surgical avascular necrosis of the midface following an episode of disseminated

Introduction of the ‘delayed maxillary flap’ technique

As many cleft patients have a significant transverse maxillary deficiency, a surgically-assisted rapid maxillary expansion is often indicated. This procedure will often reduce the need for segmental expansion during a maxillary advancement. It has been observed that patients who have undergone an earlier surgically-assisted maxillary expansion, have noticeably better perfusion of the down-fractured segment during the subsequent definitive orthognathic procedure with or without segmentalization.

Funding

No funding source.

Competing interests

None to declare.

Ethical approval

Approved with individual patient consents.

Patient consent

Written consent was obtained from all patients/guardians of patients to use images and records for publication.

References (25)

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