Duration of presurgical orthodontic treatment in individuals with nonsyndromic oral clefts undergoing orthognathic surgery

Arturo Medrano Gutierrez; Gisele da Silva Dalben; Renato Yassutaka Faria Yaedú

doi:10.4103/jclpca.jclpca_26_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 9 | Issue : 1 | Page : 24-29

Duration of presurgical orthodontic treatment in individuals with nonsyndromic oral clefts undergoing orthognathic surgery

Arturo Medrano Gutierrez¹, Gisele da Silva Dalben¹, Renato Yassutaka Faria Yaedú²
¹ Department of Pediatric and Community Dentistry, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, São Paulo, Brazil
² Department of Pediatric and Community Dentistry, Hospital for Rehabilitation of Craniofacial Anomalies; Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil

Date of Submission	30-Jun-2021
Date of Acceptance	09-Sep-2021
Date of Web Publication	01-Jan-2022

Correspondence Address:
Prof. Gisele da Silva Dalben
Rua Silvio Marchione 3-20, Vila Universitária, 17012-900 Bauru, São Paulo
Brazil

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jclpca.jclpca_26_21

Abstract

Introduction: Evaluating the length of orthodontic-surgical treatment is a key factor to properly inform and guide the patient about the duration of treatment and consequently achieve agreement and adherence to treatment, as well as for health-care institutions that sponsor this type of treatment. Objective: The aim of the present study was to investigate the duration of orthodontic treatment before orthognathic surgery, in patients with nonsyndromic oral clefts, as well as the number of consultations required for that purpose. Materials and Methods: This was an observational, retrospective, descriptive study conducted on data obtained from the patients' medical records. The study analyzed 485 medical records and, after applying the inclusion criteria, the sample included 227 medical records. All data were tabulated in an Excel spreadsheet for calculation of means and standard deviations (SDs), for the time period analyzed. Results: The time for orthodontic preparation was 8.2 years with a range of attendance from 1 to 130 visits and a mean of 37 visits (SD ± 24). Conclusion: The results suggest that there is a longer time than reported in the literature for orthodontic preparation for orthognathic surgery, which could contribute to the increase in total time for orthodontic-surgical treatment.

Keywords: Cleft lip, cleft palate, orthodontics, orthognathic surgery

How to cite this article:
Gutierrez AM, da Silva Dalben G, Yaedú RY. Duration of presurgical orthodontic treatment in individuals with nonsyndromic oral clefts undergoing orthognathic surgery. J Cleft Lip Palate Craniofac Anomal 2022;9:24-9

How to cite this URL:
Gutierrez AM, da Silva Dalben G, Yaedú RY. Duration of presurgical orthodontic treatment in individuals with nonsyndromic oral clefts undergoing orthognathic surgery. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2023 Mar 31];9:24-9. Available from: https://www.jclpca.org/text.asp?2022/9/1/24/333642

Introduction

Orofacial clefts present a multifactorial etiology and require a dynamic and extensive rehabilitation involving a multidisciplinary team interacting from the 1^st month of life to adulthood. Patients with nonsyndromic clefts present a predominantly Class III skeletal facial pattern with maxillary hypodevelopment due to the cleft as well as genetic aspects, cleft width, combined with the iatrogenic effects of primary reparative surgeries. Patients with oral clefts are often submitted to a long and extended rehabilitation treatment. Orthognathic surgery and orthodontic treatment are fundamental parts in this type of treatment.^[1] Evaluating the treatment time before orthognathic surgery is fundamental to know the total orthodontic-surgical treatment time, as well as to understand and evaluate its influence on the burden of care and total time required for the global rehabilitative treatment.

Regarding the treatment times in patients without clefts and without alterations, it has been observed that the primary responsibility in relation to the preparation time, sequence, and timing of surgery belongs to the orthodontist, yet there is still a need to better understand the clinical characteristics that determine if a patient is ready for surgery.^[2]

One of the first studies to mention the time of presurgical orthodontic treatment presented a mean presurgical orthodontic treatment time of 14.3 months. This study evaluated a sample of 312 individuals divided into three groups: treated by experienced professionals from a college (mean time of preparation 11 months), treated by orthodontic residents (mean time of preparation 15 months), and treated in private orthodontic practice (mean time of preparation 17 months).^[3] Subsequently, another study from England presented a mean time of 15.4 months for presurgical treatment, and the authors found an increase of 4.4 months in cases with the need of tooth extractions.^[4] Five years later, another study from North America evaluated the type of malocclusion, suggesting a mean time of 17 months; and the variable operator was significantly affected.^[5] A study from Finland evaluated a sample of 37 individuals and the meantime of orthodontic preparation was 17.5 months; the authors included the variable type of movement and suggested that extractions increased the treatment time.^[6]

In Spain, the reported preparation time was 24 months.^[7] A study from Sweden has shown a preparation time of 19.2 months, and the only statistically significant variable was the operator.^[8] More recently, the meantime of orthodontic preparation in a study from Eastern England was 23 months; the variables that affected the duration of treatment were the diagnosis of relationship between incisors and bone bases, change of operator, total number of visits, accomplishment of extractions, and unit or location of the operator.^[9] These data refer to samples of patients without clefts; thus, they are only reference values [Table 1].

Table 1: Papers investigating the treatment time before orthognathic surgery and the total orthodontic-surgical treatment time in patients without clefts

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Individuals with cleft lip and palate usually have Angle Class III malocclusion. In adulthood, when the maxillomandibular discrepancy is excessive, orthognathic surgery is indicated to correct these functional and esthetic problems. However, these individuals have structural differences that require a strategic approach compared to individuals without cleft. In general, orthodontic preparation for surgery in individuals with clefts takes longer than in patients without clefts.^[10] In this sense, the Eurocleft study evaluated the number of consultations and the duration of orthodontic treatment in 5 groups of patients treated in different European centers, in which the duration of orthodontic treatment varied between 3.3 and 8.5 years, with 49 and 94 consultations. When preventive orthopedics was performed, the duration ranged from 0 to 15 months of treatment with 0–17 visits and 0–146 days of hospital stay.^[11] This study concluded that it is not possible to correlate the quantity or burden of care with the quality of results.^[12] More recently, another study published in Brazil, by a team from a large center, evaluated the burden of care in a sample of patients with unilateral cleft lip and palate, in which the Goslon occlusal index was evaluated. Among their results, they concluded that patients with severe malocclusion experienced a greater burden of care than patients with less severe initial malocclusion. This study found a mean orthodontic treatment time of 11.68 years, with a mean of 61.8 consultations for total orthodontic treatment, in a sample of 100 patients, among which only 30 were submitted orthognathic surgery.^[13] Both studies applied the GOSLON Yardstick for patients with unilateral cleft lip and palate.

In general, studies assessing the time of orthodontic-surgical treatment or, more specifically, the treatment time before orthognathic surgery present a large number of variables. These variables are not standardized across studies and are related to others by statistical tests that are often inconclusive, thus leading to confounding outcomes. This is particularly true considering the myriad of variables that affect individuals with clefts submitted to orthodontic-surgical treatment. Therefore, the aim of the present study was to investigate, by a descriptive study with objective evaluation of few variables, the duration of orthodontic treatment before orthognathic surgery, in patients with nonsyndromic oral clefts, as well as the number of consultations required for that purpose.

Materials and Methods

This was an observational, retrospective, descriptive study conducted on data obtained from the patients' medical records. This study was approved by the Institutional Review Board of a reference center in the rehabilitation of craniofacial anomalies.

The inclusion criteria were the medical records of all individuals with nonsyndromic oral clefts submitted to orthognathic surgery between 2013 and 2018 operated by a single surgeon from a tertiary craniofacial center, with finalized orthodontic preparation for orthognathic surgery and records containing all data of interest. The exclusion criteria were syndromic oral clefts, patients who had not completed orthodontic preparation for orthognathic surgery and lack of thorough records for the collection of data.

The study analyzed 485 medical records and, after applying the inclusion and exclusion criteria, the sample included 227 medical records. Subsequently, the following dates were collected from the medical records:

Onset of presurgical orthodontic treatment: The first consultation immediately after performing the alveolar bone graft (ABG) or, if the ABG was not performed, the study considered the date for onset of treatment as the decision to finalize the case with orthodontic-surgical treatment, after 9 years of age
Treatment definition (definition of approach): Referring to the first date in which the professional recorded that “the case should be conducted for orthognathic surgery” (orthodontic-surgical treatment)
Completion of orthodontic preparation for orthognathic surgery: This considered the date of last consultation before surgery
Number of consultations: Referring to the number of consultations that the patient needed during orthodontic treatment before orthognathic surgery, following the aforementioned standards to identify these two stages (initial and final). It should be mentioned that some patients attended orthodontic consultations both in the tertiary craniofacial center and in other services in their cities of origin, yet we were only able to achieve data on consultations performed in the craniofacial center, where this study was conducted.

The treatment time was calculated from the time interval between the dates of onset and completion of presurgical orthodontic treatment, for the patients who presented these data, with a final sample of 277 patients. All data were tabulated in an Excel spreadsheet for calculation of means and standard deviations, for the time period analyzed.

Results

The present sample was composed of 148 patients (46.57%) living outside the state of São Paulo and 129 (46.57%) living in the state of São Paulo (where the study was conducted). Concerning the type of cleft, 39 patients (14%) had clefts not affecting the alveolar ridge and 238 patients (86%) had clefts with alveolar ridge involvement. Patients in the present sample initiate the presurgical orthodontic treatment at the mean age of 16.57 (±5.86) years and finalized orthodontic preparation for orthognathic surgery at the mean age of 24.79 (±5.37) years.

In response to the primary outcome, a mean time of orthodontic preparation for orthognathic surgery of 8.20 years with standard deviation (SD) of 3.68 was observed from the onset to completion of presurgical orthodontic treatment, excluding the time elapsed until accomplishment of surgery. This considered as onset the first consultation immediately after ABG or, if it had not been performed, the date of treatment definition after 9 years of age.

In general, the number of consultations for all patients in this sample (without any type of distribution) was a mean of 37 consultations with a standard deviation of ± 24 due to great heterogeneity in the values found. The maximum value was 130 consultations, and the lowest value was only one consultation.

Discussion

Considerations about the onset of presurgical orthodontic treatment

Following a chronological order right after ABG (when needed) and later the definition of surgical treatment, the patients started presurgical orthodontic treatment with a mean of 16.57 (SD: 5.86) years. This is an optimal age to start orthodontic preparation for orthognathic surgery, since after the secondary ABG, the difficulties with orthodontic planning due to discontinuity of the alveolar ridge are overcome^[1] and considering that orthodontic preparation for orthognathic surgery in patients without clefts varies between 1 and 2 years, these patients should reach 18–19 years of age prepared for orthognathic surgery. However, due to the age shown at the completion of preparation, with a mean of 27.79 and SD of 5.37 years, it was evident that there is still a long time between the onset and completion of orthodontic preparation for orthognathic surgery.

Studies with samples of patients have adopted different criteria to define the date of treatment onset, such as the date of placement of the first appliance,^[9] the age at the placement of separating rings,^[6] and also, the date when the first active orthodontic component was placed.^[5] As this is a sample of patients with clefts, it is necessary to characterize the moment of initiation of treatment considering the ABG (when needed), or, when the ABG is no necessary, we can characterize the surgical treatment definition after 9 years of age. In other words, the first date in which the professional recorded that “the case should be conducted for orthognathic surgery” (orthodontic-surgical treatment), after 9-year old.

Considerations about the date of placement of fixed appliances

There is inconsistency in determining the event that represents the onset of orthodontic preparation for orthognathic surgery. This is evident when analyzing the methodology of studies conducted in the United Kingdom, where the onset of treatment is considered in the placement of the first appliance,^[5],[9] while in Sweden, the onset is marked by the placement of separation elastic bands^[8] and another study that did not clearly define this date, suggesting that it was considered “usually upon placement of separation rings.”^[6] Therefore, in the present study, the date of placement of fixed appliance was a highly conflicting date, due to the large number of appliances worn by these patients. Certainly, this precludes a correct standardization of methodology and simultaneously confounds and mixes stages. Thus, what appears to be a “post-graft” stage can disguise a stage before orthognathic surgery. All aforementioned studies reveal data from samples of patients without clefts, in which there were no reports of surgical approaches with doubtful or borderline planning/prognosis, possibly because they are retrospective studies on convenience samples in which all participants had already undergone orthognathic surgery. Therefore, in the assessment of patients with clefts, it must be understood that in these patients, there are several placements of fixed and removable appliances, which can confound variables and generate methodological biases.

Considerations about the date of finalization of presurgical orthodontic treatment

The patients completed orthodontic preparation for orthognathic surgery with a mean age of 24.79 (SD: 5.37) years. Following the initially proposed methodology, the completion of treatment is the date referring to the last consultation before orthognathic surgery. In the study by Luther et al.,^[5] the date of preparation completion was the date of final planning when the impressions and radiographs were obtained. According to Jeremiah et al.,^[9] it was the date when “the patient was considered ready for surgery;” finally, in Sweden, this date was considered following the last orthodontic adjustment before surgery.^[8] In disagreement from our methodology, for this variable, a previous study considered treatment completion as the date of surgery.^[6]

Considerations about the time of orthodontic treatment before orthognathic surgery

The answer to the primary outcome in this study is that the time of orthodontic preparation in patients with nonsyndromic oral clefts (n = 277) is 8.20 (SD: 3.68) years (disregarding the date of surgery), considering only the onset and completion dates of preparation for orthognathic surgery, with a mean value of 37 consultations (without any type of distribution) and SD 24. In this case, even though the SD is still lower than the mean, it is high in relation to the other mean values found in this study, again indicating that data for this variable were very different or varied. For this variable, the maximum value found was 130 consultations, and the lowest value found was only one consultation.

To describe the onset of preparation in the present sample, the methodology considered the first consultation after ABG as treatment onset, considering the need to standardize this variable. When ABG was not performed, the definition of planning was considered. In this sense, it is important to state that, when evaluating the date when surgery was requested on the patient's form, it can be suggested that this date is the onset of preparation for orthognathic surgery. Conversely, it could also be suggested that this would be the completion of preparation, depending on the moment when surgery was requested, and there is no norm or standard to define this request within the patients' records. In the average, 2.63 (SD: 1.83) years passed between the date when surgery was requested and later performed. Since this is a date with higher degree of subjectivity and no references were found addressing this variable, it is unfeasible to compare these data with other studies, thus the discussion on the “surgery request” is limited.

To describe the completion of preparation, it is necessary to consider that it ends when the patient is ready to undergo orthognathic surgery^[9] or at the time of the last adjustment of fixed appliances before surgery.^[8] Alternatively, if it was not possible to record any of the previous dates, it is possible to consider the date of surgery as the moment of completion.^[6] Thus, it is clear that this date is not always homogeneous for all samples in the literature. In the present study, which considers the last consultation before surgery as the completion of preparation, it is necessary to state that, from this last consultation before orthognathic surgery until the actual performance of surgery, there was a waiting time of 0.35 (SD: 0.07) years or 4.2 months.

Two studies on patients with unilateral cleft lip and palate can better contextualize this result. The Eurocleft reported a total orthodontic treatment time with a mean duration between 3.3 and 8.5 years, with a mean between 49 and 96 consultations.^[11] Conversely, a more recent study from the same institution where the present study was conducted published a mean time of 11.7 years with a mean of 61.8 consultations for total orthodontic treatment, yet in their sample of 100 patients, only 30 underwent orthognathic surgery,^[13] and thus, these results can be a reference to the values found in the present study.

For example, regarding this study by Alberconi et al. 2018,^[13] the fact that isolated orthodontic treatment took longer and the number of consultations was also higher for patients treated at the same center as our study agrees with the literature, since in general, the presurgical treatment constitutes 70% or more of the treatment time, being the more intense and time-consuming stage of orthodontic-surgical treatment.^[4]

If these results were more time-consuming and with a greater number of consultations, there might be a worrisome discrepancy indicating that the time of preparation for orthognathic surgery would be longer than the total time of orthodontic treatment (always considering that, since the type and size of the sample are different, it is not possible to make analyses or inferences, rather only suggestions of data that may be consistently pertinent). These studies in patients with clefts are directed only to unilateral cleft lip and palate, assessing the total orthodontic treatment time, which does not allow comparison with the present results, yet they can certainly help to contextualize a scenario where the treatment time may be long, especially observing data from patients without clefts.

The literature clearly demonstrates that the orthodontic treatment time for orthognathic surgery presents much lower values for patients without clefts, even considering the study conducted in Spain that presented the longest values of treatment time, namely 2 years (24 months) for presurgical treatment and 3 years (36 months) for total treatment.^[7] In this sense and also in relation to studies that evaluated the time of orthodontic-surgical treatment, Proffit and Miguel suggested that there are two fundamental reasons prolonging the duration of orthodontic-surgical treatment as a whole: the first is an attempt to perform isolated compensatory treatment, and the second is the delay while awaiting for completion of growth.^[3]

Conclusion

The treatment time evidenced by the present study suggests that the presurgical orthodontic treatment may be taking longer than expected, especially considering as parameter data related to the time of orthodontic-surgical treatment of patients without clefts. This delay may be influenced by a previous attempt to perform isolated compensatory treatment and the delay to wait for the completion of growth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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