Treatment of severe maxillary hypoplasia with oligodontia and complete bilateral cleft lip and palate by maxillary anterior segmental distraction osteogenesis

Effective maxillary advance treatment is difficult to achieve without impairing velopharyngeal function in patients with severe maxillary deficiency. We describe successful orthodontic treatment using maxillary anterior segmental distraction osteogenesis (MASDO) in a patient with cleft lip and palate. A 20-year-old woman with bilateral cleft lip and palate, multiple congenitally missing teeth, reduced maxilla, concave soft-tissue profile, and skeletal Class III jaw relationship was treated with a combination of orthodontic treatment and MASDO. After treatment, the anterior maxilla was displaced forward with new bone formation induced in the distraction gap for insertion of dental implants. Maxillary hypoplasia was successfully treated while preserving the velopharyngeal function with MASDO. We suggest that MASDO is useful for patients with severe maxillary hypoplasia.     

Maxillary distraction osteogenesis to treat maxillary hypoplasia: comparison of an internal and an external system.

BACKGROUND: Distraction osteogenesis (DO) has become a mainstream surgical technique for patients with jaw deformities. In cases of maxillary hypoplasia, DO with a rigid external distraction (RED) system has been used for maxillary advancement; however, DO with internal devices is currently popular. MATERIALS: This article describes DO with an internal device and a RED system in 2 patients with maxillary hypoplasia with oligodontia. The first patient, a young girl, had a concave profile due to maxillary hypoplasia and 9 congenitally missing permanent teeth. At age 11 years 11 months, she received DO with an internal device. The second patient, a boy aged 11 years 7 months, was treated with DO with a RED system. RESULTS: In the girl, the maxilla was advanced 5.0 mm without any dentoalveolar compensation. In the boy, the maxilla was advanced 7.0 mm, but undesirable mesial movement of posterior teeth was observed. CONCLUSIONS: DO with internal devices is simpler and more useful than the RED system for maxillary hypoplasia with oligodontia.     

上颌前牵引联合快速扩弓矫治儿童骨性Ⅲ类错前后软硬组织变化

目的:探讨上颌前牵引联合快速扩弓对儿童骨性Ⅲ类错的矫治效果。方法:对28例儿童骨性Ⅲ类错病人(7～10岁)进行上颌前牵引治疗,在前牵引前快速扩弓1周。分别在治疗开始(T0)和结束(T1)时拍摄头颅定位侧位片,进行定点测量分析。结果:①硬组织变化:ANB角增加5.37°(P<0.05),Wit’s值增加5.74 mm(P<0.05),Ptm-A增加2.49 mm(P<0.05),Yaxis增加1.82°(P<0.05);SNB角减小0.75°(P>0.05),Go-Me、Co-Gn分别增加0.64 mm、2.21 mm,但P>0.05,SN-PP减小0.61°(P>0.05),PP-MP增加5.54°(P<0.05),下面高、下面高/全面高分别增加3.98(P<0.05)、1.61(P>0.05);U1-NA角增加3.10°(P<0.05),L1-NB角减小1.23°(P<0.05),Ms6-PP距增加1.13 mm(P<0.05);②软组织测量项目变化:面型角增大5.98°,颏唇角减小2.45°、H角增大5.2°,上唇-E线距增大1.42 mm,下唇-E线距减小1.18 mm(P<0.05)。结论:前牵引联合快速扩弓矫治儿童骨性Ⅲ类错,可产生显著治疗效果,能促进上颌骨的生长,使面型改善,但下颌出现顺时针旋转,高角病人慎用。     

改良LeFort工骨切开和正畸前方牵引矫正骨性上颌后缩一例报告

目的　探讨外科手术和正畸前方牵引治疗骨性上颌后缩的可行性。方法　一例 16岁女性骨性上颌后缩患者 ,前牙反。经术前正畸后 ,先行改良LeFortⅠ骨切开术 颏成形术 ,但不前移上颌骨 ,而是通过面具进行前方牵引。结果　骨性上颌后缩得到明显改善 ,反解除 ,SNA由 77.35°矫治到80 .2 5°。结论　改良LeFortⅠ骨切开术结合正畸前方牵引是治疗生长发育停止后骨性上颌后缩的的一个有效手段。     

Long-term stability of LeFort III distraction osteogenesis with a rigid external distraction device in a patient with Crouzon syndrome

A 6-year-old boy, diagnosed with Crouzon syndrome, had moderate exorbitism, a concave profile, an anterior crossbite of -4.0 mm, and a skeletal Class III jaw-base relationship caused by midfacial hypoplasia. At age 8 years 9 months, a LeFort III osteotomy was performed, and distraction osteogenesis was immediately started with the rigid external distractor system. The midface was advanced approximately 10.0 mm for 6 days, including overcorrection. After the distraction, a reverse headgear was used for 6 years to prevent relapse and to accelerate expected growth. At age 16 years 5 months, after extraction of the maxillary first premolars and mandibular third molars, 0.022-in preadjusted edgewise brackets were placed to treat the edge-to-edge incisor relationship and minor crowding. After 13 months of treatment, the facial profile was significantly improved, and an acceptable occlusion was achieved. During the 9-year observation period after the distraction, acceptable facial growth occurred, and no relapse of the maxillary advancement was observed. However, syndrome-specific growth and methodologically induced relapse should be considered when planning a LeFort III distraction in children for the treatment of Crouzon syndrome.     

Dual segmental distraction osteogenesis of the midface in a patient with Apert syndrome.

OBJECTIVE: To present orthodontic treatment combined with dual segmental distraction osteogenesis in a patient with Apert syndrome. PATIENT: A 15-year-old boy exhibited severe midfacial hypoplasia with retruded and hypoplastic maxilla and anterior open bite. The patient was treated with a rigid external distraction II system for distraction osteogenesis, a preadjusted edgewise appliance, and a modified maxillary protraction headgear. The concave profile with midfacial hypoplasia was improved. A tight occlusal relationship between maxillary and mandibular teeth was achieved. Postoperative treatment results have been stable for 1 year.     

Rigid external distraction using skeletal anchorage to cleft maxilla united with alveolar bone grafting.

OBJECTIVE: Documentation of the application of maxillary distraction osteogenesis using rigid external distraction (RED) with skeletal anchorage combined with predistraction alveolar bone grafting (ABG) in cleft maxilla. DESIGN: Case report. PATIENT: A patient with numerous congenital missing teeth and severe maxillary deficiency related to complete bilateral cleft lip and palate with large alveolar bone defect. INTERVENTION: The patient received preoperative orthodontic treatment, predistraction ABG, and maxillary distraction osteogenesis using RED with skeletal anchorage. RESULTS: Predistraction ABG completely united the cleft maxilla. The united maxilla was successfully advanced by the RED system with skeletal anchorage, despite unsound dentition with numerous congenital missing teeth. CONCLUSION: The present study demonstrates that the combination of predistraction ABG and RED system with skeletal anchorage is effective for the treatment of severe maxillary deficiency related to complete bilateral cleft lip and palate with large bone defect and numerous congenital missing teeth.     

唇腭裂继发上颌骨发育不足牵引成骨后颌骨变化

目的　比较唇腭裂术后继发上颌骨发育不足患者颅外支架式牵引成骨术 (RigidExternalDistraction ,RED)前后上下颌骨前后向和垂直向位置及牙颌关系变化 ,评价RED治疗上颌发育不足效果。方法　唇腭裂术后继发上颌骨发育不足患者 2 2名 ,其中男性 1 4名 ,女性 8名 ,平均年龄为 1 5 3岁。所有患者在改良高位LeFortⅠ型截骨术基础上行颅外支架式上颌骨牵引成骨术。测量RED前后头颅定位侧位片上下颌骨位置及牙颌关系各项指标 ,用配对t检验比较RED术前术后变化。　结果　RED前后SNA角、NA与FH夹角、Ptm至S距离、Ptm至A距离、上中切牙至腭平面距离、上颌第一磨牙至腭平面距离、SNB角、面角、颌凸角、下颌平面角、ANB角、Y轴角、NA与AMe比、覆牙合和覆盖变化具高度显著性差异。　结论　RED用于唇腭裂术后继发上颌骨发育不足患者 ,可有效地延长上颌骨长度和高度并使之前移 ;下颌骨则顺时针旋转 ,上下颌骨间位置和比例更为协调 ,下颌骨的生长发育方向更趋于正常     

Facemask therapy with rigid anchorage in a patient with maxillary hypoplasia and severe oligodontia.

In this report, we describe the treatment of a 10-year-old girl with a Class III skeletal relationship with maxillary hypoplasia and severe oligodontia. The maxillary arch was in a complete crossbite relationship with the mandibular arch. The treatment plan called for displacing the maxillary complex anteriorly with a facemask. Because of the lack of available teeth, a rigid anchorage implant was used in combination with the remaining teeth to provide anchorage. A titanium lag screw was placed in the maxillary alveolus. Three weeks later, 800 g of orthodontic force was applied. A significant anterior displacement of the nasomaxillary complex was achieved with the facemask. At the end of treatment, a temporary removable partial denture was placed.     

唇腭裂术后上颌骨发育不良骨牵引矫治的临床研究

目的:探讨口内入路牵引成骨技术在唇腭裂术后继发上颌骨发育不良患者成年之前矫治中的作用。方法:对12例9～12岁唇腭裂术后继发上颌骨明显发育不良者,采用高位LeFortI型截骨术,将上颌骨完全断离,安装口内牵引器,按一定的速度和频率牵引上颌骨向前,对术前、术后头颅定位X线侧位片进行颅颌面软硬组织的测量分析,数据以SPSS10.0统计软件包进行t检验。结果:本组病例上颌骨牵引前移明显,SNA角增加7°～11°,软组织鼻尖点、鼻底点及上唇最突点明显前移,面部外形得到明显改善,上下前牙获得正常覆牙合、覆盖关系。随访3～36个月,咬合关系保持稳定。结论:骨牵引成骨技术可以很好地用于矫治唇腭裂术后继发上颌骨发育不良,早期解除上颌骨畸形,使面部软组织得到适应性改变,面型更为协调,避免或减轻口颌系统继发畸形和功能障碍,不失为唇腭裂术后继发上颌骨发育不良的有效治疗方法。     

Maxillary distraction osteogenesis in cleft lip and palate patients with skeletal anchorage.

OBJECTIVE: Maxillary distraction osteogenesis with the rigid external distraction (RED) system has been used to treat cleft lip and palate (CLP) patients with severe maxillary hypoplasia. We introduce maxillary distraction osteogenesis for CLP patients with skeletal anchorage adapted on a stereolithographic model. PATIENTS: Six maxillary deficiency CLP patients treated according to our CLP treatment protocol had undergone maxillary distraction osteogenesis. METHOD: In all patients, computed tomography (CT) images were recorded preoperatively, and the data were transferred to a workstation. Three-dimensional skeletal structures were reconstructed with CT data sets, and a stereolithographic model was produced. On the stereolithographic model, miniplates were adapted to the surface of maxilla beside aperture piriforms. The operation performed involved a high Le Fort I osteotomy with pterygomaxillary disjunction. Miniplates were fixed to the maxillary segment with three or four screws and used for anchorage of the RED system. Retraction of the maxillary segment was initiated after 1 week. RESULTS: The accuracy of the stereolithographic models was enough to adapt the miniplates so that there was no need to readjust the plates during surgery. Postoperative cephalometric analysis showed that the direction of the retraction was almost parallel to the palatal plane, and dental compensation did not occur. CONCLUSIONS: We performed maxillary distraction osteogenesis with skeletal anchorage adapted on the stereolithographic models. Excellent esthetic outcome and skeletal advancement were achieved without dentoalveolar compensations.     

Maxillary distraction resulting in facial advancement at Le Fort III level in cleft lip and palate patients: a report of two cases

An 18-year-old female and a 14-year-old male who had previously received surgery for primary repair of a nonsyndromic cleft lip and palate (including alveolar defect bone grafting) unintentionally developed facial advancement at the Le Fort III level after surgical correction of their maxillary hypoplasia. The Le Fort I osteotomy, originally performed for their maxillary dentoalveolar hypoplasia, was an incomplete osteotomy. It was performed without down-fracture, leaving the pterygomaxillary and septal junctions intact. The gradual advancement of the maxilla during distraction osteogenesis was planned to correct the hypoplastic maxilla, and also prevent subsequent hypernasality; however, during the distraction procedure by means of a rigid external device both patients developed an unintentional facial advancement at the Le Fort III level.     

Maxillary advancement using distraction osteogenesis with intraoral device

This article describes the surgical orthodontic treatment of maxillary hypoplasia in a patient with cleft lip and palate using maxillary distraction osteogenesis with internal maxillary distractors. Maxillary advancement was performed to correct the retrusive maxillary facial profile and Class III malocclusion. Rotational movement of the distraction segment was made to correct the upper dental midline. Although maxillary advancement was insufficient because of unexpected breakage of the intraoral distractor after completion of the distraction, skeletal traction with a face mask compensated for the shortage. Successful esthetic improvement and posttreatment occlusal stability were achieved with no discernible relapse after 2 years of retention.     

Relapse rate after surgical treatment of maxillary hypoplasia in non-growing cleft patients: a systematic review and meta-analysis

Maxillary hypoplasia in cleft lip and palate is a complex deformity. Despite surgical improvements, postoperative relapse persists. This systematic review was performed to determine the mean horizontal relapse rates for the surgical techniques used to treat maxillary hypoplasia: Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis. This study followed the PRISMA statement. The PubMed, Embase, Science Direct, and Web of Science databases were searched through to June 2018. Studies on non-growing cleft lip and palate patients who had undergone one of the three surgical procedures and who had postoperative horizontal maxillary changes assessed at >6 months post-surgery were included. Stata SE was used to estimate pooled means, heterogeneity, and publication bias. The search strategy identified 326 citations, from which 24 studies were selected. Relapse rates following Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis were 20%, 12%, and 12%, respectively. Relapse rates with and without bone grafting were 19% and 66%, respectively. The relapse rate following distraction osteogenesis with internal distraction was lower than that with external distraction. Study limitations were heterogeneity, which was above moderate, the low number of high-quality studies, and unidirectional assessment of postoperative maxillary movement.     

Skeletal stability in patients with clefts after large maxillary advancements using intraoral distraction

Maxillary hypoplasia is a common outcome in patients with cleft lip and palate after surgical and orthodontic interventions, and maxillary distraction osteogenesis has become a useful procedure for patients with extensive maxillary deformities. The aim of this study was to evaluate long term (two years) stability after maxillary advancement of more than 10 mm by distraction osteogenesis in cleft patients using internal devices. We organised a retrospective study on 42 patients with cleft lip and palate using cephalometric analysis before and after maxillary distraction osteogenesis and evaluated them for 24 months. Postoperative measurements showed a marked advancement with an increase of 13.3 mm and 10.8° in the length of the maxilla (Co-A) and SNA, respectively, including a shift from Angle class III to class I in dental relations. Follow-up observations showed preservation of maxillary length with a relapse of only 6.0 % (mean (SD) 0.8 (0.7) mm) and 10% relapse in SNA angle (mean (SD)1.1 (1.4) °) one year postoperatively and a negligible regression at the two years’ follow up. This large-scale study shows stable results of skeletal advancement using distraction osteogenesis, indicating safe and reliable outcomes among patients with cleft lip and palate.     

Advancement of the anterior maxilla by distraction (case report).

INTRODUCTION: Several techniques of distraction osteogenesis have been applied for the correction of compromised midface in patients with clefts of the lip, alveolus and palate. PURPOSE: This article presents a technique of callus distraction applied in a specific case of hypoplasia of a cleft maxilla with the sagittal advancement of the maxilla thus not affecting velopharyngeal function. CONCLUSION: The decision to apply distraction osteogenesis for advancement of the anterior maxillary segment in cleft patients offers many advantages.     

Maxillary expansion and protraction in correction of midface retrusion in a complete unilateral cleft lip and palate patient

A 7-year-old girl with a cleft lip and palate had a midface retrusion due to growth inhibition of the maxillary complex. She presented for correction of a severe total crossbite with a Class III skeletal pattern. Initially, maxillary expansion was provided to widen the maxilla and then maxillary protraction headgear was worn to improve the sagittal skeletal relation. Fixed orthodontic appliances were placed to align the dentition and Class III elastics were used to establish intercuspation and stability. The maxillary expansion and protraction usually provide effective improvement in skeletal Class III patients with repaired cleft lip and palate patients. The success of the orthopedic procedure essentially depends on the individual growth of the maxilla and the mandible. This case report shows the significant growth of the mandible after maxillary expansion and protraction in late adolescence.     

Correction of a severe Class III malocclusion.

The success of early orthopedic treatment in patients with Class III anomalies depends on facial skeletal development and type of treatment. This case report describes the treatment of a 12.6-year-old girl who had a severe Class III malocclusion with a 6-mm anterior crossbite, a deep overbite, a narrow maxilla, and unerupted maxillary canines. The treatment plan included rapid palatal expansion to expand the maxilla, reverse headgear to correct the maxillary retrognathia, a removable anterior inclined bite plane to correct the anterior crossbite and the deep overbite, and fixed edgewise appliances to align the teeth. One canine was brought into alignment, but the other was placed in occlusion in its transposed position. Ideal overjet and overbite relationships were established, and the final esthetic result was pleasing.     

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

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)     

两种外置式牵引治疗严重上颌发育不全

目的：探讨两种外置式牵引治疗严重上颌发育不全的效果。方法：使用自行设计制作的颌骨牵引装置，在全麻下行LeFortⅡ型截骨，将牵引钩置入鼻底或梨状孔侧缘，从鼻孔引出，对8例严重上颌发育不全成年患者前牵引治疗，其中3例采用面弓弹性前牵引，5例采用坚固外固定支架牵引，治疗前后拍摄定位头颅侧位片测量分析。结果：采用坚固外固定支架前牵引治疗的5例患者按术前设计的要求顺利完成牵引成骨，患者咬合关系和软组织侧貌改变明显，上颌平均前移11．6mm。面弓弹性前牵引的3例患者中，1例达到预期效果，2例弹性牵引后效果不明显改为坚固外固定支架前牵引后达到效果，其中1例由于额部因长期压迫出现局部缺血改换为坚固外固定支架。结论：RED是治疗严重上颌后缩畸形的有效方法，对唇腭裂严重上颌发育不全患者慎用面弓弹性牵拉。