Management of severe cleft maxillary deficiency with distraction osteogenesis: Procedure and results

doi:10.1016/S0889-5406(99)70310-0

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 115, Issue 1, January 1999, Pages 1-12

https://doi.org/10.1016/S0889-5406(99)70310-0 Get rights and content

Abstract

Distraction osteogenesis has become an important technique to treat craniofacial skeletal dysplasia. In this study, the technique of maxillary distraction with a rigid external distraction device is presented. Cephalometric results in the first 14 consecutive patients are analyzed. The study sample consisted of 14 patients with various cleft types and maxillary hypoplasia treated with the rigid external distraction technique. Analysis of the predistraction and postdistraction cephalometric radiographs revealed significant skeletal maxillary advancement. All patients had correction of the maxillary hypoplasia with positive skeletal convexity and dental overjet after maxillary distraction. The morbidity for the procedure was minimal. Surgical and orthodontic procedures are thoroughly described. (Am J Orthod Dentofacial Orthop 1999;115:1-12)

Section snippets

Patient Selection and Evaluation

Patients were selected based on cause and severity of the maxillary hypoplasia. Presurgical records were obtained including a comprehensive speech evaluation by the speech and language pathologist. The cephalometric radiographs are obtained at the completion of distraction and at yearly intervals to monitor outcome. Time was spent with the patient and the patient’s family, explaining in detail the distraction process with photographs and video imaging, as well as discussion with other patients

CEPHALOMETRIC EVALUATION

The preoperative and postretention lateral cephalometric radiographs were used for analysis. The postretention radiographs were obtained 3 to 4 months after distraction. The radiographs were traced, and 13 anatomic landmarks were recorded (Fig 7).

. Anatomic landmarks: sella (S), center of sella turcica; nasion (N), most anterior point of nasal frontal suture; anterior nasal spine (ANS), most anterior point of the spine; A point (A), most anterior limit of the maxillary alveolar bone at the level

RESULTS

All of the surgery and RED device placement in this series was performed by a single surgeon (JWP). Perioperative antibiotics were routinely used. All patients began routine oral hygiene and an unrestricted soft diet 24 hours postoperatively. No intermaxillary fixation nor bone grafts were used.

There was no surgical morbidity in any of the 14 patients in this series. There were no problems with bleeding or infection. None of the patients required a blood transfusion; there were no problems of

DISCUSSION

It has been estimated that 25% to 60% of all patients born with complete unilateral cleft lip and palate will require maxillary advancement to correct the maxillary hypoplasia and improve aesthetic facial proportions.11, 12 Patients with severe cleft maxillary deficiency are difficult to treat with standard surgical/orthodontic approaches. These patients have maxillary hypoplasia (vertical, horizontal, and transverse dimensions) and often thin or structurally weak bone. The hypoplasia in cleft

CONCLUSIONS

Maxillary distraction osteogenesis after complete osteotomy with the RED technique is a highly effective treatment modality to manage cleft-related maxillary hypoplasia. The technique allows for vector control of the osteotomized maxilla throughout the distraction process. It has been used, with minimal morbidity, in children as young as 5 years of age, adolescents, and adults. In all patients treated with RED the initial negative skeletal convexity and dental overjet were satisfactorily

Acknowledgements

We thank Dr. Eric Jein-Wein Liou for computer and statistical assistance.

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Cleft and Craniofacial Surgery
2023, Journal of Oral and Maxillofacial Surgery
Virtual planning and CAD/CAM-assisted distraction for maxillary hypoplasia in cleft lip and palate patients: Accuracy evaluation and clinical outcome
2021, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Traditional Le Fort I osteotomy may correct the majority of cases (Meazzini et al., 2015; Iannetti et al., 2004); however, in the presence of severe maxillary hypoplasia requiring larger advancements, scarring from previous surgeries can limit the stretching of soft tissue and hinder mobilization of the maxilla, resulting in an insufficient forward repositioning of the maxilla and a high relapse rate (Stoelinga et al., 1987; Posnick et al., 1994; Cheung et al., 2006; Iannetti et al., 2004; Saltaji et al., 2012; Thongdee et al., 2005; Kanno et al., 2008; Jiang et al., 2020). In severe CLP midface hypoplasia, use of DO allows progressive bone elongation, with concomitant expansion of the soft tissue envelope, mitigating the retractile forces of the scar tissues, allowing larger movements and reducing the risk of relapse (Cohen et al., 1995; Molina et al., 1998; Figueroa et al., 1999, 2004; Swennen et al., 1999; Rachmiel et al., 2005; Cheung et al., 2006; Scolozzi, 2008; Jiang et al., 2020; Richardson et al., 2020). Both external rigid distractors and internal miniaturized distractors have been used.
The aim of this prospective study was to report the experience with a specific guided distraction protocol for the treatment of CLP patients with severe midface hypoplasia.
From January 2016 to April 2019, six consecutive, non-growing, CLP patients with maxillary hypoplasia underwent a specific distraction protocol based on the use of VSP, CAD/CAM-generated surgical splints, cutting guides, prebent internal maxillary distractors, early removal of distractors, and acute callus manipulation and fixation.
STL files for VSP, using multislice CT scans taken preoperatively (T0) and 3 months after distractor removal (T1) were superimposed using the free software 3D Slicer and Geomagic Wrap to evaluate the accuracy of maxillary repositioning and assess 3D bone changes. Clinical outcome was evaluated at the 1-year follow-up (T2).
The patients and surgeon were satisfied with the occlusal and aesthetic outcomes. A maximum difference of 2 mm between the VSP and the actual surgical outcome was chosen as the success criterion for accuracy. The average linear difference for selected points was <2 mm in four patients and >2 mm in two patients. The average distance of the postoperative maxilla from the VSP model was 2.28 mm (median 1.85), while the average forward movement of the maxilla was 10.18 mm
The protocol used is effective and accurate in the correction of severe maxillary hypoplasia in CLP patients. Early removal of the distractor and stabilization with plates reduces patient discomfort and does not jeopardize stability. This protocol should be reserved for complex cases due to the costs of the procedure, which are not negligible.
Cleft Lip and Palate: Le Fort I Distraction Using an Internal Device
2021, Clinics in Plastic Surgery
A retrospective analysis of complications associated with tooth-borne anterior maxillary distraction for managing cleft maxillary hypoplasia: A 12-year experience
2020, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
This correlation indicated that a learning curve was involved and that, with increasing surgical experience, the procedure could be accomplished with a significantly decreased number of complications. Approximately 25%–47% of CLP patients presenting with maxillary hypoplasia require a surgical intervention (maxillary advancement in the form of conventional orthognathic surgery, total maxillary DO, or AMD) for achieving desirable aesthetic and functional results (Richardson et al., 2016b; Scolozzi, 2008; Polley and Figueroa, 1999; Good et al., 2007). AMD using a tooth-borne palatal distractor is a novel technique that is been increasingly used for correcting mild to moderate degrees of cleft maxillary hypoplasia, and it offers a number of advantages over conventional orthognathic surgery in terms of stable long-term results and improved if not unhampered speech outcomes (Richardson et al., 2016a, 2016b).
To evaluate the intra- and post-operative complications of tooth-borne anterior maxillary distraction in management of cleft maxillary hypoplasia over a 12-year period, and to establish whether the procedure involves a learning curve.
All patients with cleft maxillary hypoplasia satisfying the inclusion and exclusion criteria and undergoing anterior maxillary distraction with a tooth-borne palatal distractor between June 2007 to June 2018 were retrospectively studied by retrieving their individual medical records, which included radiographic (lateral cephalogram analysis at three different intervals) and speech assessment records. The presence of intra- and post-operative complications developing in this study period was noted. Furthermore, the frequency of intra- and post-operative complications occurring from years 2007–2018 were evaluated to study whether there was a decrease in the frequency of complications with increasing time. This was done to establish whether there was a learning curve associated with the surgical procedure. The results thus obtained were tabulated using SPSS 25.0 (SPSS Inc., Chicago, IL) and subjected to statistical analysis using the chi-squared test. A p value of less than 0.05 was considered statistically significant.
Out of the 458 patients included in the study, 78.82 % (n = 361) had no complications. In the remaining 97 patients, a total of 137 complications (46 intra-operative and 91 post-operative) were observed, making up for a complication rate of 21.17%. The intra-operative complications noted were appliance dislodgement (n = 19), palatal mucosal tears (n = 12), hemorrhage (n = 8), dental injuries (n = 6) and inadvertent fracture of the anterior segment (n = 1). The post-operative complications noted were anterior open bite (n = 24), gingival inflammation (n = 14), appliance dislodgement (n = 13), dental injuries (n = 10), relapse (n = 8), hemorrhage (n = 5), soft tissue infections (n = 4), palatal fistula (n = 3), speech impairment (n = 3), wound dehiscence not related to infection (n = 3), need for re-operation (n = 2), avascular necrosis of the anterior segment (n = 1) and maxillary sinusitis (n = 1). A statistically significant decrease (p < 0.001) in the frequency of complications with each passing year from 2007 to 2018 was observed. Most complications were seen to occur in the first 4 years (i.e. 2007–2010; a total of 74 complications in 54 patients), making up 11.79% of the complications. In the following 8 years (i.e. 2011–2018), 63 complications were noted in 43 patients, making up the remaining 9.38 % of the complications. These observations indicate that a learning curve was involved before carrying out the procedure without many complications.
Tooth-borne anterior maxillary distraction in managing cleft maxillary hypoplasia is associated with a wide range of complications: some avoidable and related to surgeon's experience; some related to the surgical procedure itself; and some unavoidable and related to the distractor appliance. Understanding potential complications allows the surgeon to ensure safe care through early intervention and to correctly inform the patient in the pre-operative discussion. The procedure involves a learning curve before it can be accomplished safely without many complications.
Cleft and Craniofacial Surgery
2017, Journal of Oral and Maxillofacial Surgery
Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?
2023, Cleft Palate Craniofacial Journal

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Management of severe cleft maxillary deficiency with distraction osteogenesis: Procedure and results☆,☆☆

Abstract

Section snippets

Patient Selection and Evaluation

CEPHALOMETRIC EVALUATION

RESULTS

DISCUSSION

CONCLUSIONS

Acknowledgements

Br J Plast Surg

Am J Orthod Dentofacial Orthoped

J Oral Maxfac Surg

J Oral Maxfac Surg

Am J Orthod

Br J Oral Maxillofac Surg

Am J Orthod Dentofacial Orthop

J Craniomax Surg

Lengthening the human mandible by gradual distraction

Plast Reconstr Surg

Monobloc craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: a preliminary report

J Craniofac Surg

Maxillary-midface distraction in children with cleft lip and palate: a preliminary report

Plast Reconstr Surg

Management of severe maxillary deficiency in childhood and adolescence through distraction osteogenesis with an external adjustable rigid distraction device

J Craniofac Surg

Principles of biomechanics

Treatment variables affecting facial growth in complete unilateral cleft lip and palate: 7, an overview of treatment and facial growth

Cleft Palate J

The need for orthognathic surgery in patients born with complete cleft palate or complete unilateral cleft lip and palate

Oral Surg Oral Diag

Long-term results after maxillary advancement in patients with cleft

Cleft Palate Craniofac J

Skeletal stability and relapse patterns after LeFort I maxillary osteotomy fixed with miniplates: the unilateral cleft lip and palate deformity

Plast Reconstr Surg