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A Novel Vector Control Device in Horizontal Bone Transport
... The prosthodontic evaluation and treatment usually occur in the last phase, when surgical and orthodontic treatment have been completed (Esper et al., 2009;Abreu et al., 2015). Different options are possible in patients with large defects or missing premaxilla, including fixed restorations (Bidra, 2012;Erverdi et al., 2013;Balkaya et al., 2014;Levy-Bercowski et al., 2019), hybrid prostheses, overdenture prostheses, and dental implants (Weischer et al., 1997;Acharya and Brecht, 2014). The objective of this clinical case report is to describe the interdisciplinary management of a young adult patient with CBCLP with missing premaxilla, and his prosthodontic rehabilitation using a fixed dental prosthesis to camouflage the bony defect and restore the facial and dental aesthetics. ...
The smile is an important part of the individual’s facial expression, it allows the communication of emotions and ideas. However, its aesthetics can be severely compromised in patients with cleft lip and palate due to multiple missing, malformed and malposed teeth, abnormal soft tissue morphology, upper lip scar tissue, and altered anatomy in the lower third of the face. This clinical case reports the interdisciplinary treatment approach of a young male patient with complete bilateral cleft lip and palate and missing premaxilla. Prosthodontic rehabilitation included a zirconia-based fixed dental prosthesis, with pink porcelain to camouflage the bony defect and restore the facial and dental aesthetics. Maxillary second premolars received lithium disilicate crowns to obtain a more harmonious smile line and adequate occlusion. A resin-bonded fixed partial denture restored a missing mandibular central incisor. Tooth proportions, gingival contours and facial ratios routinely used in noncleft patients, were used to achieve a consonant smile. The final restorations satisfied the patient’s expectations, restored an aesthetically pleasant smile, and provided an adequate occlusion.
... Our studies show that the AWDA is a successful appliance in cases of DO. [8,9] The only disadvantage can be the unaesthetic appearance of the appliance because of the metal casts, but veneer facets can overcome this limitation. Moreover, we clinically observed that it is well tolerated by the patients; they did not complain about esthetics during the 6-7 months' time with the appliance. ...
Cleft lip and palate (CLP) is defined as a congenital deformity caused by failed fusion of medial and lateral palatine processes during 4-12 th weeks of embryogenesis, resulting in an open communication between oral and nasal cavities. In CLP patients, maxillary hypoplasia, velopharyngeal insufficiency, and alveolar clefts are the major issues that have to be taken care of after labiopalatal reconstruction. Rather than several consecutive operations, such as bone-grafting and orthognathic surgery, alveolar distraction can be a better treatment option in many cases. Archwise Distraction Appliance (AWDA) is a rigid, tooth-borne, custom-made appliance that is developed to control the distraction vector with double archwire system. Our experiences show that the AWDA is a successful appliance in cases of distraction osteogenesis. Moreover, alveolar distraction has significant advantages over conventional treatment modalities for CLP patients.
... 23 To prevent these side effects, expansion appliances, buccally extending metal bars, palatal arch bars, temporary anchorage devices, intraoral elastics, and specially designed archwise appliances can be used, or a 2-step distraction appliance addressing different vectoral problems can be applied. 20,21,[23][24][25][26][27] However, some of these can be complicated procedures. Because the methods attempting to create an arch curvature during bone transport are relatively novel techniques, there are no randomized clinical trials showing their effectiveness on forming a curve, and the results are mainly based on case reports. ...
The comprehensive treatment of a patient with cleft lip and palate requires an interdisciplinary approach for functional and esthetic outcomes. A 20-year-old woman with bilateral cleft lip and palate had a chief complaint of unesthetic appearance of her teeth and the presence of oronasal fistulae. Her clinical and radiographic evaluation showed a dolichofacial growth pattern, a Class II skeletal relationship with retroclined maxillary central incisors, 5 mm of negative overjet, maxillary constriction, maxillary and mandibular crowding, congenitally missing maxillary right incisors and left lateral incisor, and a transposed maxillary left canine. Her treatment plan included the extraction of 3 premolars, maxillary expansion, segmental maxillary osteotomy, repair of the oronasal fistulae, rhinoplasty, periodontal surgery, and prosthodontic rehabilitation. To obtain a better occlusion and reduce the dimensions of the fistulae, orthognathic surgery comprising linear and rotational movements of the maxillary segments (premaxilla, right and left maxillary alveolar segments) in all 3 axes was planned by performing 3-dimensional virtual surgery on 3-dimensional computerized tomography. At the end of the interdisciplinary treatment, a functional occlusion, a harmonious profile, and patient satisfaction were achieved. Posttreatment records after 1 year showed stable results.
... Out of many available treatment methods, we chose distraction osteo- genesis. The results of this case report are comparable with those of investigations focused mainly on maxillary segmental distraction ( Liou et al., 2000;Guerrero, 2002;Erverdi et al., 2012a;Erverdi et al., 2012b). The method used a tooth- borne distractor and required an osteotomy surgery only, which is an advantage compared with distractions made with the Liou distractor. ...
This article describes a new method that enables vector control during alveolar distraction osteogenesis in the treatment of a cleft palate patient. The patient presented with unilateral complete cleft lip and palate, and the alveolar part of the defect was covered by a mobile buccal flap. The distraction was performed by sliding the surgically released tooth segment with the help of an intraoral distractor over 1.5-mm stainless steel archwires held by metal crowns. This vector-controlled method enabled new bone and attached gingiva formation in harmony with the proper alveolar shape.
Distraction osteogenesis is a commonly used process in the treatment of patients with craniofacial disorders, especially in those with cleft lip and palate (CLP) having severe maxillary deficiency. This chapter discusses the use of alveolar distraction osteogenesis in the treatment of CLP with large defects. Major goals in the treatment of CLP include achieving labial, palatal, and velopharyngeal closure; a balanced profile; a harmonious facial appearance; and a good occlusion. One of the most critical aspects in the preparation of the dental arch for alveolar distraction osteogenesis is creating enough space to facilitate interdental vertical osteotomies. Compared to tooth‐borne appliances, bone‐anchored systems can present challenges in positioning the distraction device with the correct force vector. Bone‐anchored distraction appliances are often preferred over tooth‐borne systems when segmental anterior maxillary distraction is required and may also be used as an alternative to tooth‐borne appliances in alveolar transport distraction.
Cleft lip and palate treatment is a long journey for the patient, family, and also the team that is involved in the treatment that starts from the first day of birth and continues till the late adolescence. The first shock the parents live the first day they meet their baby turns to questions and worries. In this moment, health-care professionals should have the ability to calm down the parents, assure them their baby is a great gift as any other baby is, and direct them to an adequate cleft team to be sure that they will have the right journey map for the future.
The main aim in the treatment of cleft lip and palate cases is to achieve labial, palatal, velopharyngeal closure, a balanced profile, harmonic facial appearance, and a good occlusion (Eppley and Sadove 2000; Phua and de Chalain 2008; Cheung and Chua 2006; Jackson et al. 2004; Williams et al. 2001). Most of the time, these goals are accomplished in the early ages. However, in 20–25% of the patients (Kumar et al. 2006), dentofacial skeletal deformities, and in 4–45% (Phua and de Chalain 2008) of the patients, oronasal fistula occurrence, which require secondary surgical corrections can be seen. In this subgroup, if there is oronasal fistula, the main needs can be listed as surgical interventions for complete soft tissue coverage and secondary alveolar bone grafting. Also, surgeries that involve both jaws (either orthognathic surgery or distraction osteogenesis) may be necessary too. In severe cases with wide oronasal fistula, the usual approach is covering the gap with buccal, labial mucosal flaps or tongue flaps (Nakakita and Utsugi 1990; Argamaso 1990; Diah et al. 2007). However, tongue flaps may not always be very successful. Some complications, such as flap failure, bleeding, swelling, pain, infection, hematoma, contour deformities, temporary loss of tongue sensation, gustatory changes, requirement for a two-stage or three-stage procedures, and in rare cases, partial or total necrosis of flap can be observed (Elyassi et al. 2011).
Interdental distraction osteogenesis has been introduced as a successful treatment protocol for repairing large clefts. In this article, a new method for reconstruction of the premaxilla in 2 bilateral cleft lip and palate patients is introduced. The aim was to distract the lateral segments through the curve of the dental arch, achieve complete closure of the gaps, and use the premaxilla as a bone graft. Patient 1 (20-year-old female) had double jaw surgery before but presented residual alveolar cleft and small premaxilla. Patient 2 (21-year-old male) had anterior and posterior crossbite and caries of teeth on premaxilla. Following the preliminary fixed orthodontic treatment in both patients, archwise distraction protocol was performed. The distraction duration and the achieved amount of new bone per side were 4 weeks/22 mm and 5 weeks/25 mm in Patients 1 and 2, respectively. At the end of a 2-month retention period, docking side surgery was performed and premaxilla was used as the bone graft. The protocol was very effective for not only closure of the large cleft defects but also the reconstruction of the premaxilla. Anteroposterior relationship and the patients' profiles were considerably and positively affected.
Alveolar transport distraction osteogenesis (ATDO) is an alternative treatment method to vertical alveolar distraction osteogenesis in cases of large bony defects, especially when the bone is limited in size. ATDO was performed in 10 patients with 12 defects. The mean age of the patients was 39.1 years. The average bone length gain was 18.2 mm. Implants were inserted following a 3-month consolidation period. Three patients needed additional bone grafting for horizontal widening. Final prosthetic rehabilitation was performed at least 3 months following implant insertion. The mean follow-up period was 63 months and the survival rate of the 25 implants placed was 92%. All failures (n = 2) occurred during the early healing period. Although the results are not totally predictable, it can be concluded that ATDO can be effective in the reconstruction of the alveolar crest prior to implant placement. © 2018 International Association of Oral and Maxillofacial Surgeons
Stable occlusion and a pleasing esthetic appearance are often difficult to achieve in patients with congenital defects and severe midfacial deficiencies. Conventional therapy, such as orthodontic treatment followed by orthognathic surgery, is often not sufficient to fully correct the dental and esthetic problems. An interdisciplinary approach for these patients should include prosthodontic treatment that will assist in establishing a harmonious occlusion and improve facial appearance. This clinical report describes the interdisciplinary approach for a young patient with a history of bilateral cleft lip and palate, spina bifida, hydrocephalus, and ventriculoperitoneal shunt. The patient was treated with conventional orthodontic treatment and orthognathic surgery that failed to fully correct the malocclusion. A removable overlay prosthesis made of crystallized acetyl resin was used to reestablish esthetics and create a stable occlusion.
This case report presents an early clinical evaluation of a patient with bilateral cleft lip and palate (CLP) treated with ArchWise Distraction Osteogenesis Technique and Appliance. A 16-year-old patient with a bilateral CLP had a chief complaint of missing upper anterior teeth and poor aesthetics. The patient had class III skeletal and dental relationships, maxillary hypoplasia, maxillary posterior arch constriction, premaxillary deficiency, multiple missing teeth due to an alveolar cleft, and a concave profile. Treatment plan consisted of maxillary expansion with quad helix appliance, leveling and aligning of the arches with fixed orthodontic appliances, and archwise distraction osteogenesis. Osteotomies were performed to mobilize the posterior segments. Activation of the distractors was continued until the lateral segments had contacted each other, and then sagittal distraction was performed in order to correct the sagittal discrepancy. Patient was referred to the oral surgeon and prosthodontist for the final restorations. A very large gap was successfully repaired using this protocol while maintaining the ideal arch form and generating new bone behind the distracted segments.
The aim of this study was to describe the treatment of class II malocclusion by sagittal advancement of the alveolar bone in the symphyseal area using an intraoral archwise distractor device and to determine the effects of this method on the dentoalveolar complex. Fifteen patients (10 female, five male) aged 16–20 years with a class II division 2 malocclusion, characterized by mandibular dentoalveolar retrusion and a prominent chin, underwent archwise alveolar distraction in the anterior mandible. Lateral cephalometric radiographs were obtained before distraction (T0), after 6 weeks of consolidation (T1), and after debonding (T2). Linear and angular skeletal, dental, and soft tissue measurements were performed. Forty-seven parameters were measured for each of the 15 subjects on pre- and postoperative lateral cephalometric radiographs (T0, T1, and T2). The distraction protocol was successful in all patients. Skeletally, the mandible showed a clockwise rotation. B-point moved forward significantly (P < 0.05). Overjet decreased significantly (P < 0.001). The total profile angle was unaffected, and the improvement in the submental fold was highly significant (P < 0.001). The intraoral archwise distraction force that is applied through brackets and archwires is sufficiently effective for alveolar advancement. This procedure is simple and effective in the treatment of specific adult patients with a class II division 2 malocclusion, characterized by a prominent chin and severe mandibular dentoalveolar retrusion.
Cleft lip and palate treatment is a long journey for the patient, family, and also the team that is involved in the treatment that starts from the first day of birth and continues till the late adolescence. The first shock the parents live the first day they meet their baby turns to questions and worries. In this moment, health-care professionals should have the ability to calm down the parents, assure them their baby is a great gift as any other baby is, and direct them to an adequate cleft team to be sure that they will have the right journey map for the future.
The main aim in the treatment of cleft lip and palate cases is to achieve labial, palatal, velopharyngeal closure, a balanced profile, harmonic facial appearance, and a good occlusion (Eppley and Sadove 2000; Phua and de Chalain 2008; Cheung and Chua 2006; Jackson et al. 2004; Williams et al. 2001). Most of the time, these goals are accomplished in the early ages. However, in 20–25 % of the patients (Kumar et al. 2006), dentofacial skeletal deformities, and in 4–45 % (Phua and de Chalain 2008) of the patients, oronasal fistula occurrence, which require secondary surgical corrections can be seen. In this subgroup, if there is oronasal fistula, the main needs can be listed as surgical interventions for complete soft tissue coverage and secondary alveolar bone grafting. Also, surgeries that involve both jaws (either orthognathic surgery or distraction osteogenesis) may be necessary too. In severe cases with wide oronasal fistula, the usual approach is covering the gap with buccal, labial mucosal flaps or tongue flaps (Nakakita and Utsugi 1990; Argamaso 1990; Diah et al. 2007). However, tongue flaps may not always be very successful. Some complications, such as flap failure, bleeding, swelling, pain, infection, hematoma, contour deformities, temporary loss of tongue sensation, gustatory changes, requirement for a two-stage or three-stage procedures, and in rare cases, partial or total necrosis of flap can be observed (Elyassi et al. 2011).
Because of the high failure rates, large alveolar cleft defects cannot be successfully closed with bone grafting. Vega introduced the use of the hyrax screw for the closure of such defects by distraction osteogenesis. However, his technique was more invasive with a difficult adaptation of the appliance at the surgical table. To overcome these limitations, a completely tooth-borne trifocal distraction appliance was devised and placed after osteotomy in a 22-year-old repaired group 3 cleft patient who had a 15-mm alveolar defect on the right side. The tooth-borne trifocal distraction appliance was successful in the controlled closure of a large alveolar cleft with minimal invasiveness and low costs making this procedure feasible for a greater number of patients.
Conventional orthognathic surgery and orthodontic techniques occasionally fail to completely correct the occlusal relationship and esthetic deficits of patients with cleft lip and palate and severe midface deficiency. Prosthodontic rehabilitation is often required to establish adequate occlusion and provide a more proportional facial appearance. This clinical report describes the interdisciplinary management of an adult with complete bilateral cleft lip and palate who was treated with distraction osteogenesis using a rigid external distraction device for maxillary advancement and his prosthodontic rehabilitation with a dual path removable partial overdenture to develop definitive facial and dental esthetic form.
Distraction osteogenesis technique has been successfully applied in the craniofacial area for long time, and it is being applied increasingly more in cleft lip and palate patients also. Especially in large cleft palate cases, bone grafting or surgical procedures such as distraction osteogenesis can be applied in order to ensure a smooth alveolar arc. In this literature review, alveolar (segmental) distraction osteogenesis applications in patients with cleft lip and palate, indications of the technique, advantages and disadvantages, application methods and types of appliances used for this purpose have been evaluated. As conclusion, especially with the application of alveolar (segmental) distraction osteogenesis, successful outcome can be achieved in cleft lip and palate patients with velopharyngeal insufficiency, maxillary hypoplasia and maxillary crowding, and this technique may be an alternative to conventional osteotomies and extraoral distractions.
Conventional orthognathic surgery and orthodontic techniques occasionally fail to completely correct the occlusal relationship and esthetic deficits of patients with cleft lip and palate and severe midface deficiency. Prosthodontic rehabilitation is often required to establish adequate occlusion and provide a more proportional facial appearance. This clinical report describes the interdisciplinary management of an adult with complete bilateral cleft lip and palate who was treated with distraction osteogenesis using a rigid external distraction device for maxillary advancement and his prosthodontic rehabilitation with a dual path removable partial overdenture to develop definitive facial and dental esthetic form.
Copyright © 2015 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.
Rigid external distraction is a highly effective technique for correction of maxillary hypoplasia in patients with orofacial clefts. The clinical results after correction of sagittal maxillary deformities in both the adult and pediatric age groups have been stable. The purpose of this retrospective longitudinal cephalometric study was to review the long-term stability of the repositioned maxilla in cleft patients who underwent maxillary advancement with rigid external distraction. Between April 1, 1995, and April 1, 1999, 17 consecutive patients with cleft maxillary hypoplasia underwent maxillary advancement using rigid external distraction. There were 13 male patients and four female patients, with ages ranging from 5.2 to 23.6 years (mean, 12.6 years). After a modified complete high Le Fort I osteotomy and a latency period of 3 to 5 days, patients underwent maxillary advancement with rigid external distraction until proper facial convexity and dental overjet and overbite were obtained. After active distraction, a 3- to 4-week period of rigid retention was undertaken; this was followed by removable elastic retention for 6 to 8 weeks using, during sleep time, an orthodontic protraction face mask. Cephalometric radiographs were obtained preoperatively, after distraction, at 1 year after distraction, and 2 or more years after distraction. The mean follow-up was 3.3 years (minimum, 2.1 years; maximum, 5.3 years). The following measurements were obtained in each cephalogram: three linear horizontal and two linear vertical maxillary measurements, two angular craniomaxillary measurements, and one craniomandibular measurement. Differences between the preoperative and postoperative cephalometric values were analyzed by paired t tests (p < 0.05). The cephalometric analysis demonstrated postoperatively significant advancement of the maxilla. In addition, the mandibular plane angle opened 1.2 degrees after surgery. After the 1- to 3-year follow-up period, the maxilla was stable in the sagittal plane. Minimal anteroposterior growth was observed in the maxilla compared with that exhibited in the anterior cranial base. However, there was significant vertical maxillary growth over the 3-year observation period. The mandibular plane angle tended to decrease during the follow-up period. The cephalometric data from this study support the clinical impression of maxillary stability after maxillary advancement with rigid external distraction in cleft patients. This effective and stable technique is now considered for all pediatric patients with severe cleft maxillary hypoplasia and for adolescent and adult patients with moderate to severe deformities.
Bone grafting is a successful protocol for cleft repair but it is very challenging to close large gaps using local gingival tissue. In the last decade, interdental distraction osteogenesis has been introduced as a successful treatment protocol for repairing such large clefts. In this article a new method for closing the alveolar cleft is introduced and one case is presented. A tooth supported distractor which was specially designed to be inserted on to the main arch wire was used for the distraction. The aim was to distract the tooth segments through the curve of the dental arch and achieve complete closure of the gaps. The distractor introduced had several advantages: it is simple to apply, activate and remove; there is no need for a second operation; it is an outpatient procedure. In the case reported, a very large gap was successfully closed using this protocol whilst maintaining the ideal arch form and generating new bone behind the distracted segments.
Infrabony defects in the alveolus pose a substantial treatment complication for restorative dentists. The properties of regenerate bone produced by dentoalveolar distraction, with and without a latency period, remain largely unknown.
Six male foxhound dogs between 1 and 2 years of age underwent osteotomies around the mandibular second premolar to create a dentoalveolar segment that was distracted (1 mm/day for 10 days) through a large periodontal defect created in the third premolar area. A split-mouth design was used, with 1 randomly selected side starting distraction immediately, and the other side starting distraction after a 5-day latency period. The nonlatency and latency sides had 7 and 6 weeks of consolidation, respectively. Microcomputed tomography scans (taken at 15 and 60 μm) were used to evaluate bone quality and quantity of the regenerate bone, as well as the maturational differences in the regenerate.
The transport segments were distracted 7 to 8 mm over 10 days. The majority (>75%) of the specimens showed complete or almost complete vertical and buccolingual bone fill. Except for trabecular separation, there were no significant differences between the latency and nonlatency sides in the quantity or quality of bone produced. Although relative bone volume tended to increase between the mesial and distal aspects of the regenerate, there were no significant differences in material properties in the regenerate. The control bone was denser and greater in quantity than the regenerate bone.
Except for slight differences in maturation, latency had little or no effect on the regenerate bone produced. Dentoalveolar distraction immediately after alveolar bone surgery appears to produce bone of adequate quantity and quality for dental implant restorations.
Alveolar clefts are commonly closed by a bone grafting procedure. In cases of wide clefts the deficiency of soft tissue in the cleft area may lead to wound dehiscence and loss of the bony graft. Segmental maxillary bony transfer has been mentioned to be useful in such cases. Standard distraction devices allow unidirectional movement of the transported segment. Ideally the distraction should strictly follow the dental arch. The aim of this study was to analyze distraction devices that were adapted to the individual clinical situation of the patients. The goal was to achieve a distraction strictly parallel to the dental arch.
Six children with unilateral clefts of lip, palate, and alveolus between 12 and 13 years of age were included in the study. The width of the cleft was between 7 and 19 mm. Dental cast models were used to manufacture individual distraction devices that should allow a segmental bony transport strictly parallel to the dental arch. Segmental osteotomy was performed under general anesthesia. Distraction was started 5 days after surgery. All distracters were tooth fixed but supported by palatal inserted orthodontic miniscrews.
In all patients, a closure of the alveolar cleft was achieved. Two patients required additional bone grafting after the distraction procedure. The distraction was strictly parallel to the dental arch in all cases. In 1 case a slight cranial displacement of the transported maxillary segment could be noticed, leading to minor modifications of the following distractors.
Distraction osteogenesis is a proper method to close wide alveolar clefts. Linear segmental transport is required in the posterior part of the dental arch, whereas in the frontal part the bony transport should run strictly parallel to the dental arch. An exact guided segmental transport may reduce the postoperative orthodontic complexity.
To evaluate the feasibility of anterior maxillary segmental distraction (AMSD) to correct maxillary hypoplasia and severe dental crowding in cleft lip and palate (CLP) patients, 7 patients (average age 16.4 years) with maxillary hypoplasia, shortened maxillary dental arch length and severe anterior dental crowding secondary to CLP were selected for this study. After anterior maxillary segmental osteotomy, 3 patients were treated using bilateral internal distraction devices, and 4 patients were treated using rigid external distraction devices. Photographs and radiographs were taken to review the improvement in facial profile and occlusion after distraction. An average 10.25 mm anterior maxillary advancement was obtained in all patients after 10-23 days of distraction and 9-16 weeks of consolidation. The sella-nasion-point A (SNA) angle increased from 69.5 degrees to 79.6 degrees. Midface convexity was greatly improved and velopharyngeal competence was preserved. The maxillary dental arch length was greatly increased by 10.1 mm (P<0.01). Dental crowding and malocclusion were corrected by orthodontic treatment. These results show that AMSD can effectively correct the hypoplastic maxilla and severe dental crowding associated with CLP by increasing the midface convexity and dental arch length while preserving velopharyngeal function, and dental crowding can be corrected without requiring tooth extraction.
We assessed the long-term skeletal stability of the repositioned maxilla, midface in patients who underwent maxillary advancement using distraction osteogenesis (DO).
The study included 19 nongrowing patients with maxillary hypoplasia with a Class III relationship, a normally developed mandible, and follow-up after DO exceeding 2 years. Eleven men and 8 women participated, with a mean age at treatment of 20.7 years (range 15.4-33.4 years). Twelve patients had midfacial hypoplasia associated with a cleft lip and palate (CLP), and 7 patients had developed noncleft-related hypoplasia. The surgical treatment included our modified Le Fort I osteotomy in combination with intraoral (5 cases) or extraoral (14 cases) distraction devices. Distraction was started after a latency period of 5 to 7 days and continued until the proper convexity was obtained. After active distraction, a 3- to 4-week period of retention was allowed, followed by rigid internal fixation (IF) with or without distractor removal. Lateral cephalometric films before midfacial distraction (T0), after IF with or without distractor removal (T1), 6 months after T1 (T2), and 2 or more years (mean 2.8 years) after T1 (T3) were analyzed. The maxillary A-point in the Frankfort horizontal reference plane was used to assess the skeletal changes in the maxillary position (x, y) at each time point (T1-T3). In addition, we analyzed the differences in the devices and techniques.
Midfacial DO was successful in all cases, resulting in a mean change obtained at point A of 10.3 mm (8.4 mm horizontally, 4.7 mm inferiorly). Point A underwent a moderate amount of skeletal relapse at T2 [0.4 mm (5%) horizontally and 0.6 mm (13%) superiorly], with a mean of 8% (0.6 mm) horizontally and 19% (1.0 mm) superiorly over the mean 2.8-year (2.0-4.8 years) follow-up. After long-term follow-up, the maxillary advancement with DO was stable in both CLP and non-CLP patients with maxillary hypoplasia. In addition, our original technique using a rigid external device provided the most reliable results in terms of skeletal stability.
This retrospective study showed that DO of the maxilla gives a very stable midface, offering a promising treatment alternative for patients with maxillary hypoplasia.
The closure of a wide alveolar cleft and fistula in cleft patients and the reconstruction of a maxillary dentoalveolar defect in traumatic patients are challenging for both orthodontists and surgeons. This is due to the difficulty in achieving complete closure by using local attached gingiva and the great volume of bone required for the graft. In this article, the authors propose using interdental distraction osteogenesis to create a segment of new alveolar bone and attached gingiva for the complete approximation of a wide alveolar cleft/fistula and the reconstruction of a maxillary dentoalveolar defect. They performed this procedure on one patient with a traumatic maxillary dentoalveolar defect and 10 patients with unilateral or bilateral cleft lips and palates who had varied dentoalveolar clefts/fistulas. Interdental and maxillary osteotomies were performed on one side of the dental arch by the cleft or defect. After a latency period of 3 days, the osteotomized distal segment of the dental arch was then distracted and transported toward the cleft or defect by using a toothborne intraoral distraction device. The alveoli and gingivae on both ends of the cleft or defect were approximated after distraction osteogenesis. The need for extensive alveolar bone grafting was eliminated. A segment of new edentulous alveolus and attached gingiva was created interdentally at a site distant to the cleft or defect. In the cleft patients, teeth were moved orthodontically into the regenerate (newly formed alveolar bone) dental crowding 1 week after distraction. The orthodontic tooth movement was rapidly completed in 3 months, and the edentulous space was eliminated. Interdental distraction osteogenesis minimizes an alveolar cleft/fistula and helps reconstruct a maxillary dentoalveolar defect by approximating the native alveoli and gingivae; it also creates new alveolar bone and gingiva for rapid orthodontic tooth movement.
To describe the morphological changes of nasopharyngeal components after maxillary distraction and clarify whether the morphological characteristics are related to velopharyngeal function (VPF).
Perceptual judgments of hypernasality and nasendoscopy were performed before and after treatment. Lateral cephalograms were obtained to describe the morphological changes.
Department of Oral and Maxillofacial Surgery, Miyazaki Medical College, Miyazaki, Japan.
Nine patients with repaired cleft palate in the mixed dentition stage underwent maxillary distraction using a face mask and an intraoral fixed appliance system.
The severity of hypernasality, velopharyngeal insufficiency, and measurements such as pharyngeal depth, velar length, and the rotation of the palatal plane were evaluated.
Increase in pharyngeal depth was not always proportional to the amount of advancement. It depended on the posture of the posterior pharyngeal wall and the rotation of palatal plane.
Cephalometric measurements of the nasopharynx before and after surgery confirmed subsequent changes in VPF. These were suggested to be useful in predicting future VPF. When performing maxillary distraction in patients with cleft palate in the mixed dentition stage, and when velopharyngeal closure is found to occur by velar contact against the hypertrophied adenoid, patients should be counseled about risks of subsequent deterioration in their speech before surgery.
The simultaneous use of cleft reduction and maxillary advancement by distraction osteogenesis has not been applied routinely because of the difficulty in three-dimensional control and stabilization of the transported segments. This report describes a new approach of simultaneous bilateral alveolar cleft reduction and maxillary advancement by distraction osteogenesis combined with autogenous bone grafting. A custom-made Twin-Track device was used to allow bilateral alveolar cleft closure combined with simultaneous maxillary advancement, using distraction osteogenesis and a rigid external distraction system in a bilateral cleft lip and palate patient. After a maxillary Le Fort I osteotomy, autogenous iliac bone graft was placed in the cleft spaces before suturing. A latency period of six days was observed before activation. The rate of activation was one mm/d for the maxillary advancement and 0.5 mm/d for the segmental transport. Accordingly, the concave facial appearance was improved with acceptable occlusion, and complete bilateral cleft closure was attained. No adjustments were necessary to the vector of the transported segments during the activation and no complications were observed. The proposed Twin-Track device, based on the concept of track-guided bone transport, permitted three-dimensional control over the distraction processes allowing simultaneous cleft closure, maxillary distraction, and autogenous bone grafting. The combined simultaneous approach is extremely advantageous in correcting severe deformities, reducing the number of surgical interventions and, consequently, the total treatment time.
To review the impact of maxillary advancement by orthognathic surgery and distraction osteogenesis on speech and velopharyngeal status based on the literature of the past 30+ years, to review the methods employed in previous studies to explain discrepancies in results, and to make recommendations for future studies.
Thirty-nine published articles on the effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status were identified and were systematically analyzed. A total of 747 cases of cleft and noncleft patients were selected, including craniofacial deformities and syndromes mainly involving maxillary hypoplasia.
Findings varied. Many studies found that surgery had no impact on speech and velopharyngeal status. Some reported worsening only in patients with preexisting velopharyngeal impairment or those with borderline velopharyngeal function before surgery. There was no clear difference in outcome between distraction and conventional osteotomy, although there have been few systematic comparisons. There was great variation among reviewed studies in the number of subjects, speech sample, number and type of listeners, speech outcome measures, and timing of postoperative assessment. Few studies employed reliability measures.
None of the 39 reviewed studies compared conventional osteotomy and distraction by including both groups in a single study. Randomized controlled trials with adequate number of subjects and follow-up duration are needed.
The advantages of this technique over the traditional alveolar reconstruction are as follows: no need for bone grafts, which involve a donor site, minimal surgical time, no hospitalization, progressive improvement with excellent psychological adaptation, bone height and width that are similar to the neighboring alveolus with excellent possibilities for dental implants, and a natural reconstruction that aids the orthodontist with final tooth movement. Finally, the morbidity is minimal. The disadvantages are few; long treatment requires patient cooperation and close follow-up. Implant placement ideally should happen 6 to 8 months after the initial surgery. A crestal incision is made to expose the newly developed alveolar bone, and a fixture of adequate size and length is inserted. If further bone augmentation is needed on the buccal side of the alveolus, the bone collected from the suction tramp may be mixed with alloplastic materials and layered over. A collagen membrane also may be used. The alternatives of taking grafts from the chin or tuberosity also may be considered. There is still the chance to augment the soft tissues at the uncovering stage by various surgical techniques to obtain an ideal alveolar ridge.
Orthognathic surgery alters or even worsens symptoms of velopharyngeal insufficiency in cleft patients. The goal of this study was to evaluate how advancing the maxilla would affect the speech and articulation disorders of these patients.
This was a retrospective study in which we compiled and evaluated the speech scores of 54 cleft lip and palate patients who underwent maxillary advancement between 1981 and 2001. Although 34 individuals underwent an isolated Le Fort I advancement, 20 patients had a combined Le Fort I advancement/mandibular setback operation. The following variables were recorded from both preoperative and postoperative speech evaluations: presence of a pharyngeal flap at the time of surgery, oronasal fistulas, nasality, 7 different articulation errors, velopharyngeal function assessment, and overall speech score. Preoperative and postoperative changes in the data were analyzed using the McNemar test and paired t test.
A decrease in competent velopharyngeal function mechanisms was noted postoperatively (42% to 18%), increased borderline incompetence (9% to 22%), and complete velopharyngeal insufficiency (13% to 20%). Speech scores deteriorated significantly (P <.05), whereas articulation defects insignificantly (P =.146) improved after surgery (84% to 73%), with those related to the anterior dentition (P =.064) showing the greatest change (64% to 47%). The frequency of hyponasality decreased after surgery. The number of cases of mild to moderate hypernasality increased.
This study confirms previous findings that patients with clefts of the lip and palate or palate alone are predisposed to velopharyngeal function alteration after maxillary advancement, particularly with borderline function preoperatively. However, the results show that surgical correction of skeletal relationships and occlusion may translate into improvements in certain aspects of speech disorders.