Ortopedia prequirúrgica en el tratamiento de pacientes con fisura labio y paladar / Presurgical orthopedics in the treatment of patients with cleft lip and palate

RESUMEN: Introducción: Dentro del tratamiento estándar de los pacientes con fisura labio-máxilo-palatinas se encuentra la ortopedia prequirúrgica. Esta se realiza con el objetivo de modular la posición, alineación y estabilización de los segmentos maxilares previo a la primera cirugía. Pese a que es ampliamente utilizada, su efectividad es controversial. Métodos: Se realizó una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Se extrajeron los datos desde las revisiones identificadas, se analizaron los datos de los estudios primarios, posteriormente se realizó un metaanálisis y se preparó una tabla de resumen de los resultados utilizando el método GRADE. Resultados y Conclusiones: Se identificaron 14 revisiones sistemáticas que en conjunto incluyeron 57 estudios primarios, de los cuales, cinco corresponden a ensayos clínicos aleatorizados. Concluimos que no es posible establecer con claridad si la ortopedia prequirúrgica mejora o perjudica la morfología maxilar, debido a que la certeza de la evidencia ha sido evaluada como muy baja. Por su parte, la ortopedia prequirúrgica podría resultar en poca o nula diferencia en el crecimiento y desarrollo facial, las alteraciones oclusales, la satisfacción parental, la alimentación, el habla y la apariencia facial y nasolabial, pero la certeza de la evidencia es baja.

ABSTRACT: Introduction: Within the standard treatment of patients with labio-maxillo-palatal cleft is presurgical orthopedics. This procedure seeks to modulate the position, alignment and stabilization of the maxillary segments prior to the first surgery. Although it is widely used, its effectiveness is currently controversial. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified 14 systematic reviews that included 57 primary studies, five of which correspond to randomized trials. We conclude that it is uncertain whether presurgical orthopedics improves or deteriorates maxillary morphology, because the certainty of the evidence has been very low. On the other hand, presurgical orthopedics may make little or no difference to facial growth and development, occlusal alterations, parental satisfaction, feeding, speech, and facial and nasolabial appearance, but the certainty of the evidence is low.

Effect of Presurgical Orthopedics and Lip Adhesion on Maxillary Alveolar Arch in Complete Unilateral Cleft of Primary and Secondary Palate

The ultimate goal of the treatment of cleft lip and palate is the obliteration of the entire cleft early without disturbing facial bone growth. Presurgical orthopedics attempts to correct the characteristic skeletal deformities that occur in cleft lip and palate, and lip adhesion reduces the tension of the definite lip repair and allows gentle molding until the solidification of the arch occurs. Additionally lip adhesion gives a psychologic benefit to the patient's parents because of the improvement in appearance. The authors performed presurgical orthopedics and lip adhesion for 26 cases of complete unilateral cleft of primary and secondary palate between 1997 and 2001. Postoperatively, the patients are evaluated by the analysis using preoperative and postoperative dental casts. Dental cast analyses evaluate width, length, height of maxillary alveolar cleft, alveolar gap, palatal gap, and angle of arch. Results include improvement of alignment of maxillary alveolar arch and reducement of cleft gap. Also, this study of serial dental cast is the objective method to explain the corrective effect on maxillary alveolar arch in cleft lip and palate. In conclusion, presurgical orthodontics and lip adhesion achieve the main goal of moving the palate into a normal position and stabilizing the arch with a bony bridge that attracts teeth. It avoids the difficult anterior fistulae and presents a more symmetrical platform upon which the lip can be united and the nose can be corrected early. Additionally, there is a psychologic benefit to the patient's parents because of the improvement in appearance