-
Distraction osteogenesis is rapidly becom-ing an alternative
technique to treat craniofacial dys-plasias. It was initially used
successfully to treat unilat-eral or bilateral mandibular
dysplasias.1 The applica-tion to other regions of the craniofacial
skeleton arecurrently being explored, and animal and clinical
trialshave been conducted.2-8 The purpose of this report is
topresent our technique for maxillary distraction osteo-genesis in
cleft patients with severe maxillary deficien-cy, with the use of a
rigid external distraction (RED)device (Fig 1), to describe the
orthodontic appliancerequired to deliver the traction force through
the denti-tion to the maxillary bone, and to present the
clinicaland cephalometric results in our initial series of 14
con-secutive patients.
MATERIAL AND METHODSPatient Selection and Evaluation
Patients were selected based on cause and severity ofthe
maxillary hypoplasia. Presurgical records wereobtained including a
comprehensive speech evaluationby the speech and language
pathologist. The cephalo-metric radiographs are obtained at the
completion of dis-traction and at yearly intervals to monitor
outcome.Time was spent with the patient and the patients
family,explaining in detail the distraction process with pho-
tographs and video imaging, as well as discussion withother
patients and their families who have undergonethe procedure. The
patient and parents were thoroughlyfamiliarized with the mechanics
of the distraction appa-ratus and distraction protocol before the
procedure.
Intraoral SplintIn order to apply traction to the maxilla
through the
dentition, a rigid intraoral splint needs to be
fabricated.Orthodontic bands with 0.050 inch headgear tubes
arefitted either on the second primary molars (childrenunder 6
years) or first permanent molars and an algi-nate or compound
impression is taken of the maxillaryarch. The impression is poured
with dental stone. Thesplint is made on the working model, with
0.045 or0.050 stainless steel rigid orthodontic wire. If thepatient
does not have orthodontic brackets, the labialand palatal wires are
bent in close contact with most ofthe maxillary teeth. If the
patient has orthodonticbrackets, the labial wire has to be bent
outward andgingivally to clear the existing appliances. If needed,
atranspalatal bar can be added to increase rigidity. Con-necting
wires between the labial and palatal archesthrough the embrasures
between the lateral and canineteeth bilaterally or in any other
area where the wire canbe passed without interfering with the
occlusion mayalso be incorporated (Fig 2).
The basic design of the splint has been successful-ly used in
patients undergoing protractive face masktherapy. The rigid splint
is then tried in the patient,assuring adequate fit, and two
markings are done onthe labial wire just medial to both
commissures. Thesplint is removed from the patients mouth and
twostraight pieces of 0.050 or 0.060 inch rigid stainless
1
ORIGINAL ARTICLE
Management of severe cleft maxillary deficiency with
distractionosteogenesis: Procedure and results
Alvaro A. Figueroa, DDS, MS,a and John W. Polley, MDbChicago,
Ill.
Distraction osteogenesis has become an important technique to
treat craniofacial skeletal dysplasia. In thisstudy, 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 14patients
with various cleft types and maxillary hypoplasia treated with the
rigid external distractiontechnique. Analysis of the predistraction
and postdistraction cephalometric radiographs revealed
significantskeletal maxillary advancement. All patients had
correction of the maxillary hypoplasia with positive
skeletalconvexity and dental overjet after maxillary distraction.
The morbidity for the procedure was minimal.Surgical and
orthodontic procedures are thoroughly described. (Am J Orthod
Dentofacial Orthop1999;115:1-12)
From the Craniofacial Center and Department of
Orthodontics,University of Illinois at Chicago.aAssociate
Professor, Department of Orthodontics.bDirector, Craniofacial
Center; Associate Professor, Department of Surgery.Reprint requests
to: Alvaro A. Figueroa, DDS, MS, Craniofacial Center, Uni-versity
of Illinois at Chicago, 811 S. Paulina St., Rm. 161 COD M/C
588,Chicago, IL 60612; E-mail, [email protected] 1999 by the
American Association of Orthodontists.0889-5406/99/$8.00 + 0
8/1/91527
-
2 Figueroa and Polley American Journal of Orthodontics and
Dentofacial OrthopedicsJanuary 1999
steel orthodontic wire are soldered perpendicular to thelabial
wire. These vertical wires have a short end towardsthe vestibule
that eventually will be used as intraoralhooks. The long end of the
vertical wire is marked whilethe device is in the mouth to bend the
external tractionhooks (Fig 2). The wire is bent under, over and
anteriorto the lip. The ends of the wire are bent in a circle
to
eliminate sharp ends and to have a rigid eyelet fromwhere to
apply the traction. This traction eyelet is posi-tioned at the
level of the floor of the nose or at any otherdesired level to
control rotational movements of themaxilla (Fig 2). The purpose of
this external hook is toavoid any irritation to the lip while
applying traction andalso to control the direction of the traction
forces, rela-tive to the approximate center of resistance of the
max-illa.9,10 The completed splint is cemented in the
clinicalsetting and at the time of surgery, circumdental wires
arepassed through most of the maxillary teeth to increaserigidity
and stability (Fig 3).
In certain instances, it becomes necessary to do anintraoral
splint to an abnormal arch form, knowing thatafter distraction, the
patient will undergo further ortho-dontic treatment or surgical
orthodontic expansion ofthe arch. If it is determined that the arch
will be expand-ed surgically at the time of the required osteotomy
fordistraction, the cast has to be cut, aligned, and the splintmade
to the newly desired maxillary arch form.
It is preferable to do arch expansion proceduresbefore or after
maxillary distraction to avoid movingthe maxillary bone
simultaneously in several directionswhere vector control can become
more difficult. If theclinician desires to expand simultaneously
with anteri-or distraction, an expansion screw can be
incorporatedinto the splint, which has to be split into two
segments,but the rigidity of the device may be compromised.
The intraoral splint can also be made with a com-mercially
available orthodontic headgear facebow witha long external outer
bow and an inner bow withoutloops. The inner bow is bent to the
desired arch form,and the loose ends are passed through the
headgeartubes for future soldering. The outer bow is bent down-ward
and anteriorly, in order to clear the upper lip. Theadvantage of
using a face bow is that the wires for thetraction hooks (outer
bow) are strong and rigid and thetraction hooks are already
soldered (Fig 4). It is diffi-cult to use the face bow in maxillary
arches with poorarch form or in young children because it is
difficult toadapt the inner bow to the teeth, making
circumdentalwiring difficult.
In younger patients in which cooperation might be afactor, the
splint can be cemented after the patient isanesthetized and before
surgical preparation in the oper-ating room. In cases in which a
splint has been made to asurgically created arch form, the splint
has to be cement-ed after the maxillary osteotomy is completed and
thesegments have been mobilized. This procedure can bedifficult, as
the segments are mobile and maintaining adry field can be
difficult. Adequate assistance from thesurgeon and assisting
personnel are required to hold thesegments in place and maintain a
dry field.
Fig 1. A, Disassembled RED device with activating andassembling
screwdrivers. B, Patient undergoing RED.Note anterior adjustable
outrigger system connectedwith surgical wires to the hooks from the
intraoral appli-ance. C, Close-up view of the distraction screws
linkedto the intraoral splint through the external traction
hookswith surgical wires.
-
American Journal of Orthodontics and Dentofacial Orthopedics
Figueroa and Polley 3Volume 115, Number 1
Surgery and Rigid External Distraction DevicePlacement
The indications, details of surgery, and placementof the
cranially fixed rigid external distraction (RED)device have been
previously reported.8 A complete LeFort I osteotomy is performed,
including pterygomax-
illary and septal dysjunction, with mobilization. Metal-lic
markers are placed above and below the osteotomyand in the anterior
aspect of the maxilla for follow-up,and the soft tissue incision is
closed. In young children,a modified high LeFort I osteotomy, with
minimaldownfracturing, is required to avoid disturbing devel-
Fig 2. A, Intraoral appliance in working model. Note
transpalatal bar as well as interdental bars to increase rigidity.
B,Vertical wires soldered perpendicular to labial aspect of
intraoral splint. Upper portion of wire to be used as
intraoralhooks and lower extensions to be used for external
traction hooks. C, Facial photograph of patient with cheek
mark-ings identifying approximate center of rotation of maxilla to
be used as guidelines to bend external traction hooks. D,External
traction hooks with eyelets for connecting wire to RED device. Note
position of eyelets at the level of the floorof the nose and above
approximate center of resistance of maxilla. External traction
hooks have been bent to com-fortably clear upper lip.
-
4 Figueroa and Polley American Journal of Orthodontics and
Dentofacial OrthopedicsJanuary 1999
oping tooth buds (Fig 5). Every effort is made at thetime of
surgery to make an osteotomy cut that willdirect the maxillary
segment with the appropriate hori-zontal and vertical vectors to
prevent the creation of ananterior open bite or elongation of the
lower face. Inyounger patients, the presence of tooth buds may
notallow placement of the osteotomy in the desired direc-tion,
making the placement of the traction hooksextremely important to
control maxillary vertical andhorizontal movements. Once the
maxillary osteotomy
is completed, the halo portion of the RED device isadjusted for
the width of the neurocranium and is rigid-ly fixed around the head
with two or three scalp screwson each side. The vertical bar of the
RED is in the cen-ter, sufficiently anterior and also parallel to
the facialplane. Initially the vertical facial bar is removed as
thetraction forces are not applied until 3 to 5 days aftersurgery,
facilitating postoperative management andfeeding.
Distraction ProtocolA sample of 14 patients with various cleft
types
(Table I) underwent distraction with the RED device(Fig 1). The
vertical bar was connected to the halo andthe horizontal bar with
the distraction screws and wasplaced at the appropriate vertical
level based on thevector needed to obtain the desired maxillary
move-ment 4 days (with children) or 5 days (with teenagersand
adults) after surgery. The force vector is deter-mined by clinical
evaluation and through cephalomet-ric prediction tracings (Fig 2).
A 25 gauge surgical wirewas used to connect the traction hook to
the tractionscrews (Fig 1).
Distraction was performed at home by turning theactivating screw
at a rate of 1 mm per day (2 turns).
Fig 3. Intraoral appliance used to deliver distractionforce to
the maxilla. Note circumdental wiring.
Fig 4. A, Intraoral splint made with an orthodontic headgear
face bow with long external outer bow. B, Complet-ed intraoral
appliance made from a head gear face bow.The outer bow has been
bent to form the traction hooks.Note small soldered hooks (arrow)
to be used during thefacial mask retention phase after
distraction.
Fig 5. Intraoperative view of a modified high LeFort Iosteotomy
in 6-year-old patient. Note proximity of theosteotomy to the
infraorbital nerve (arrow). Three metal-lic bone markers were
utilized for postoperative follow-up. Traction hook in the
foreground.
Table I. Diagnosis and sex distribution of the sampleDiagnosis N
Male Female
UCL/P 7 5 2BCL/P 5 4 1Facial cleft and BCL/P 2 1 1Total 14 10
4
-
American Journal of Orthodontics and Dentofacial Orthopedics
Figueroa and Polley 5Volume 115, Number 1
The patients were followed weekly to assess bone con-solidation
and to make adjustments in the vertical posi-tion of the horizontal
traction bar and screws, to main-tain control over the maxillary
position.
Once the appropriate amount of distraction wasachieved, the RED
system was left in place for 2 to 3weeks to permit bone
consolidation. The RED devicewas removed in the clinic. After the
RED device was
Fig 7. Anatomic landmarks: sella (S), center of sella turci-ca;
nasion (N), most anterior point of nasal frontal suture;anterior
nasal spine (ANS), most anterior point of thespine; A point (A),
most anterior limit of the maxillary alve-olar bone at the level of
the incisor root apex; posteriornasal spine (PNS), intersection
between the nasal floorand the posterior contour of the maxilla;
apex of maxillaryincisor root (U1A), uppermost point of the incisor
root; tipof maxillary incisor crown (U1T), maxillary incisor
edge;tip of mandibular incisor (L1T), mandibular incisor edge;apex
of mandibular incisor root (L1A), lowermost point ofthe mandibular
incisor root; B point (B), most anterior limitof the mandibular
alveolar bone at the level of the incisorroot apex; pogonion (PG),
most anterior limit of themandibular symphysis; menton (ME), most
anterior pointof the mandibular symphysis; gonion (GO), the point
atthe greater convexity of the mandibular gonial region.Reference
planes: sella-nasion plane (SN); palatal plane(PPL), line through
ANS and PNS; maxillary incisor axis(U1), line passing through U1A
and U1T); mandibularplane (Mand Pl), tangent to the lower border of
themandible through ME and GO.
Fig 6. Six-year-old female with left unilateral cleft lip
andpalate and maxillary hypoplasia treated with
maxillarydistraction with RED. Predistraction (A) and
postdistrac-tion (B) photographs. Note improvement in facial
con-vexity, cheek projection, and balance of face. C,
Patientunderwent 6 to 8 weeks of retention with a removableface
mask with elastic traction.
A
-
6 Figueroa and Polley American Journal of Orthodontics and
Dentofacial OrthopedicsJanuary 1999
removed, the labial hooks were cut. Positive tractionwas
continued by means of elastic traction through anorthodontic face
mask, using the intraoral hooks (Fig6). For this purpose, one or
two 6 oz elastics were usedon each side. The retention period after
active distrac-tion was between 6 and 8 weeks. Although not done
inthis series of patients, if orthodontic appliances are inplace,
interarch elastics can be used to further improveocclusal
relations.
CEPHALOMETRIC EVALUATIONThe preoperative and postretention
lateral cephalo-
metric radiographs were used for analysis. The postre-tention
radiographs were obtained 3 to 4 months afterdistraction. The
radiographs were traced, and 13anatomic landmarks were recorded
(Fig 7). All tracingswere done by a single investigator (AAF).
Availabilityof serial radiographs in all patients permitted
landmarkverification. All x-rays were corrected to 0%
magnifi-cation. We looked at the recorded anatomic landmarksand
calculated 14 measurements, 7 angular and 7 linear(4 horizontal and
3 vertical). For the linear measure-ments, an x-y coordinate system
with the S-N plane as
the horizontal was used. Linear horizontal changeswere measured
relative to a line perpendicular to the S-N plane, passing through
sella, and vertical changeswere measured perpendicular to the S-N
plane. Thepreoperative and postoperative cephalometric valueswere
statistically analyzed by means of a paired t test.
RESULTSAll of the surgery and RED device placement in
this series was performed by a single surgeon
(JWP).Perioperative antibiotics were routinely used. Allpatients
began routine oral hygiene and an unrestrictedsoft diet 24 hours
postoperatively. No intermaxillaryfixation nor bone grafts were
used.
There was no surgical morbidity in any of the 14patients in this
series. There were no problems withbleeding or infection. None of
the patients required ablood transfusion; there were no problems of
dentalinjury, avascular necrosis, or gingival injury. Therewere no
complications with wearing the externaldevice, including pain,
discomfort, or loosening duringthe distraction process. The
intraoral splint remainedintact in all patients through the active
and retentionphases. None of the families had difficulty
followingthe distraction instructions.
The predistraction and postdistraction angular andlinear
cephalometric measurements are given in TablesII and III. The
average predistraction SNA angle was77.6 and the postdistraction
SNA angle was 85.3, foran average increase of 7.7. The average
predistractionANB was -1.2 and postdistraction was 7.3, with
anincrease of 8.6. The skeletal angle of convexityincreased
postdistraction by 17.2. All of these threemeasurements were
statistically significant. The hori-zontal ANS change between
predistraction and post-
Fig 8. Predistraction (solid line) and postdistraction (bro-ken
line) average cephalometric tracings for all patients.Note
maxillary advancement with correction of negativeoverjet and
improvement of skeletal convexity, upper lipand nose advancement,
and minimal changes inmandibular position.
Fig 9. Predistraction (solid line) and postdistraction (bro-ken
line) average tracings of the maxilla for all patients.Note minimal
changes in incisor position relative to themaxillary palatal
plane.
-
American Journal of Orthodontics and Dentofacial Orthopedics
Figueroa and Polley 7Volume 115, Number 1
distraction cephalometric radiographs was 7.1 mm, andthe average
horizontal advancement of the A point afterdistraction was 8.3 mm.
The horizontal advancement atthe upper incisal edge averaged 11.6
mm, and allpatients had a positive correction of their overjet
withan average 12.7 mm change. All of the linear horizon-tal
changes were significant (P < .001) between predis-traction and
postdistraction measurements. The desiredtreatment goals were
obtained in all patients. The ver-tical changes in the position of
ANS, A point, andupper incisor edge were small and not
significant.None of the patients resulted with an open bite.
Themandibular plane angle changed 2.2. The averageskeletal changes
after RED are shown in Fig 8.
The predistraction and postdistraction dental changesare also
given in Tables II and III and Fig 9. The changein the angle of the
upper incisor edge to the palatal planeaveraged -1.2 for all
patients, and it was not statistical-ly significant. None of the
patients in this series resultedwith interdental spaces created
posterior to the most dis-tal point of anchorage of the intraoral
splint.
DISCUSSIONIt has been estimated that 25% to 60% of all
patients born with complete unilateral cleft lip andpalate will
require maxillary advancement to correctthe maxillary hypoplasia
and improve aesthetic facialproportions.11,12 Patients with severe
cleft maxillarydeficiency are difficult to treat with standard
surgi-cal/orthodontic approaches. These patients have maxil-lary
hypoplasia (vertical, horizontal, and transversedimensions) and
often thin or structurally weak bone.The hypoplasia in cleft
patients is also compounded byresidual palatal and alveolar
fistulas, absent and aber-rant dentition, pharyngeal flaps, and
scarring of thepalatal and pharyngeal soft tissues.
The physical deformities associated with maxillaryhypoplasia
contribute to multiple functional deficien-cies. These include
severe malocclusions that result in
compromised mastication and speech and nasal pha-ryngeal airway
patency. The severe concave facial pro-file has negative
psychosocial ramifications. Currentprotocols for the treatment of
maxillary hypoplasia incleft patients rely on a
surgical/orthodontic approach,including a LeFort I maxillary
advancement with con-comitant fistula closure, and maxillary and
alveolarbone grafting. This surgery includes rigid internal
fix-ation hardware for stabilization of the repositionedmaxilla in
the postoperative period.
The long-term results of cleft patients with maxil-lary
deficiency treated in such fashion have beenreported and allude to
increased relapse tendency(greater than 20%) after maxillary
advancement.13-16All of the patients in our series, if they had
undergonecorrection of the deformity with a standard orthognath-ic
approach, would have also required mandibular set-back surgery
because of the severity of the maxillaryhypoplasia. The main
disadvantage to this two-jawapproach for cleft patients is that the
majority of themhave a mandible that is normal in both size and
posi-tion or even small and retrognathic,17-24 Setback of
themandible in an effort to reduce the amount of
maxillaryadvancement compromises final lower facial form
andesthetics. Expansion of the soft tissue facial maskyields the
most pleasing long-term aesthetic facial bal-ance and harmony. This
concept is extremely importantin cleft patients.25
The concept of gradually advancing the maxillaafter LeFort I
corticotomy was originally presented byMolina and
Ortiz-Monasterio.26 In their technique, anorthodontic face mask
with elastics was used to deliv-er the traction force to the
maxilla. This technique hasseveral shortcomings, such as not
delivering controlledforces, pressure sores on the chin and
forehead, com-pliance, and most importantly the inability to
advancethe maxilla sufficiently to correct severe cleft
maxillaryhypoplasia. We have used this face mask approachafter
complete maxillary osteotomy with disappointing
Table II. Angular changes after RED (n = 14)Measurements
Postdistraction
(degrees) Predistraction (4 months) Difference Significance
SNA 77.6 5.6 85.3 5.6 7.7 2.9 **SNB 78.8 4.0 77.9 4.1 0.8 1.8
NSANB 1.2 3.5 7.3 3.0 8.6 3.6 **Convexity 3.5 7.5 13.7 6.0 17.2 7.3
**
(NAPg)Mand Pl/SN 39.2 6.7 41.4 5.9 2.2 2.4 *
angleU1 -PPL 100. 7 15.7 98.8 14.4 1.2 11.3 NS
angle
*P < .01, **P < .001.
Table III. Horizontal (x) and vertical (y) linear changesafter
RED (n = 14)
Landmark-axis Change (mm)
ANS-x 7.1 + 3.9**ANS-y 0.4 + 3.0A Point-x 8.3 + 3.3**A Point-y
1.3 + 3.4U1-x 11.6 + 4.6**Ul-y 1.8 + 3.5Overjet 12.7 3.0**
**P < .001.
-
8 Figueroa and Polley American Journal of Orthodontics and
Dentofacial OrthopedicsJanuary 1999
results.27 The patients were undercorrected with resid-ual
anterior crossbites. This limited maxillary skeletalresponse has
also been observed by others.28-30 Theseunfavorable experiences
prompted us to modify thetechnique and use a RED device.
RED uses a skeletally (cranial) fixed distractiondevice that
allows for predictable control over the dis-traction process. The
RED device is adjustable, offeringthe ability to change the
vertical and horizontal vector ofdistraction, at any time, without
discomfort to thepatient during the distraction process. The
differencebetween the two systems is evidenced by the
greatermaxillary advancement obtained in those patients
whounderwent RED, compared with those reported inpatients who
underwent face mask distraction.27-30
In the past, it has been virtually impossible usingmaxillary
advancement alone to treat patients withsevere maxillary
deficiency. With the use of RED, aseverely hypoplastic maxilla can
be repositioned andmaintained to the desired horizontal and
vertical posi-tion without the use of bone grafting and fixation
hard-ware (Fig 10). Contrary to the use of protraction
facemask,31,32 with or without osteotomy, maxillaryadvancement with
distraction using the RED systemcan be done with minimal
alterations on mandibularposition (Fig 8).
Maxillary advancement at the LeFort I level withthe RED device
allows for complete versatility in boththe amount and direction of
the distraction process.This control on maxillary movement is
feasible
Fig 10. Profile photographs and cephalometric radiographs of a
10-year-old patient with bilateral cleft lip and palateand severe
maxillary hypoplasia before (A and B) and after (C and D)
distraction. Note dramatic improvement in facial,skeletal, and
dental relations after a 16 mm total maxillary advancement with
correction of anterior crossbite. (Printedwith permission, J
Craniofacial Surg 1997;8:181-5.
A
B
C
D
-
American Journal of Orthodontics and Dentofacial Orthopedics
Figueroa and Polley 9Volume 115, Number 1
because of the design of the RED device system. Theexternal
distraction system allows complete verticaladjustability of the
distraction screws mounted on thehorizontal bar. The design of the
intraoral splint, withplacement of the external traction hooks
located at thelevel or above the palatal plane, assures the
clinicianthat the vector of the distraction force can be
controlledrelative to the position of the center of mass of the
max-illa. It is believed that the center of resistance, of thenot
osteotomized maxillary bone, is located approxi-mately at the apex
of the maxillary premolars in the lat-eral view.9,10 With the RED
system, one can controland change as needed, the force vector that
passesthrough (straight advancement) or above (downwardadvancement)
the center of resistance of the maxilla(Figs 1 and 2). This is one
of the main advantages ofRED over internal devices that inherently
have limitedvector control.
Before bending the traction hooks, the clinician can
transfer the approximate center of resistance of themaxilla from
the cephalometric radiographs and fromthe clinical examination to
the face of the patient. Theskin is marked, corresponding to the
center of resis-tance, and the external traction hooks are bent to
thedesired position (Fig 2). After connecting the distrac-tion
screw with the traction hook, the clinician canevaluate the
direction of the distraction force and canadjust it, relative to
the center of mass or resistance ofthe maxilla (Fig 1).
Because the intraoral splint is made rigid enough,preventing
permanent deformation of the tractionhooks, the use of casted full
coverage rigid splints isnot necessary. The slight flexibility
present in the trac-tion hooks allows for energy storage that may
result incontinuous force to the maxilla between activations.This
continuous tension is believed to be conducive toosteogenesis,33,34
a favorable event during the distrac-tion process. Our current
experience indicates that the
Fig 11. Preoperative (A and B) facial profile view and intraoral
view of a 512 year old boy with right unilateral cleft lipand
palate and bilateral crossbites. Facial and intraoral views 3
months after distraction (C and D). Note improvementin facial
convexity and lip and nose relations, as well as correction of the
crossbites. The intraoral splint is still securedwith circumdental
wires and is being used for the retention period after
distraction.
-
10 Figueroa and Polley American Journal of Orthodontics and
Dentofacial OrthopedicsJanuary 1999
use of a commercially available face bow facilitates
thefabrication of the intraoral splint. The outer face bowwire has
significant diameter to allow for the necessaryrigidity. The amount
of necessary soldering is also min-imized as the outer bows are
used as the traction hooks.Care must be taken to bend the traction
hook while theouter bow arms are long; working with short
segmentsof wire of heavy diameters is difficult. The commer-cially
available face bow is indicated for those patientswith a dental
alveolar arch of sufficient size and formto facilitate contouring
the inner bow. If the dental alve-olar arch is irregular or too
small, it will be difficult toobtain close adaptation to the teeth,
which makesplacement of the required circumdental wires a
difficultand unstable process. For small or irregular arches,
we
prefer to bend our own splint with appropriate gaugewire. The
advantages of the described intraoral splintare various and include
the following: It is custom designed, which is imperative,
especially in
patients with clefts that present with severe dental
malpo-sitions and collapsed cleft arch segments.
The device is inexpensive and easily constructed by
theorthodontist.
It is hygienic, comfortable, and nontraumatic. It does not
interfere with speech and eating. Simultaneous orthodontic
movement, such as correction of
dental rotations, as well as expansion, can be performed. The
active and retention intraoral devices are the same. The vectors of
distraction can be changed at any time dur-
ing the distraction process without discomfort to thepatient,
thus allowing for force vector changes as needed.
Fig 12. Preoperative facial profile view and intraoral view in a
12-year-old female with right cleft lip and palate with max-illary
hypoplasia, anterior crossbite, and open bite (A and B).
Postoperative views (C and D) after maxillary distractionwith RED
demonstrating improvement in facial convexity, fullness of the
infraorbital region, and improved lip and noserelations. The
intraoral view demonstrates correction of anterior crossbite and
open bite. Degree of maxillary advance-ment is shown by the
position of the second maxillary premolar in full Class II relation
after distraction (arrows).
-
American Journal of Orthodontics and Dentofacial Orthopedics
Figueroa and Polley 11Volume 115, Number 1
The use of the cranium as an anchorage base for thestabilization
after maxillofacial surgery is not a newconcept.35 Not even the
youngest patients had com-plaints or problems with wearing the
device throughoutthe distraction process. No special scalp pin care
is re-quired and the use of ointments and creams at the scalppin
interface is discouraged. The patients simply sham-poo and wash
their hair with the device in place. TheRED device is removed in
the clinic after the rigid reten-tion phase usually without the use
of local anesthesia.
Contemporary surgical/orthodontic approaches forthe treatment of
maxillary deficiency in cleft patients isusually dependent on the
patient having reached skele-tal maturity before the reconstructive
surgery can beperformed. The RED technique for maxillary
distrac-tion osteogenesis eliminates the negative technical
fac-tors associated with traditional orthognathic surgery
inpatients in transitional dental development. An osteoto-my with
complete mobilization is required with norepositioning or placement
of bone grafts. Rigid inter-nal fixation hardware is not used,
eliminating the riskof dental injury during plate stabilization;
thus thistechnique can be used throughout childhood. The
onlylimitations in the application of this technique forpatients
with severe skeletal hypoplasia include ade-quate dentition
(primary or permanent) for fixation ofthe intraoral splint and
patient tolerance to the externaldistraction device. Because the
RED system uses den-tal support, the presence of a healthy
dentition isrequired. Skeletal anchorage for maxillary
tractionhooks or osseointegrated implants may need to be
con-sidered for patients with inadequate dentition. Rigidexternal
distraction has allowed us to effectively treatpatients with severe
maxillary skeletal hypoplasia fromthe age of 5 years and up (Figs
11 and 12). No longeris it necessary to wait years for the patient
to reachmaturity before their severe maxillary facial deformityis
corrected with the associated functional, esthetic,and psychosocial
benefits.
All patients treated with RED are cautioned that apercentage
will require a final finishing LeFort pro-cedure at skeletal
maturity. It is anticipated that thisprocedure will not require a
major movement, thusenhancing stability. This technique provides an
excel-lent modality for correcting severe maxillary deficien-cy in
patients with facial clefting and other anomalieswith structurally
thin bone in the maxilla (ectodermaldysplasia, Johansson Blizzard
syndrome, etc.).
Modifications of this technique are undergoingclinical trials to
advance not only the maxilla at theLeFort I level but also
advancement at the LeFort II, III,monoblock, and fronto-orbital
levels. This articlereports our preliminary experience with this
technique.
We will prospectively follow these patients to evaluatethe
stability of maxillary distraction, and its effects onfacial,
dental, and velopharyngeal development.
CONCLUSIONSMaxillary distraction osteogenesis after complete
osteotomy with the RED technique is a highly effectivetreatment
modality to manage cleft-related maxillaryhypoplasia. The technique
allows for vector control ofthe osteotomized maxilla throughout the
distractionprocess. It has been used, with minimal morbidity,
inchildren as young as 5 years of age, adolescents, andadults. In
all patients treated with RED the initial neg-ative skeletal
convexity and dental overjet were satis-factorily corrected with
the associated favorable softtissue changes.
We thank Dr. Eric Jein-Wein Liou for computer andstatistical
assistance.
REFERENCES
1. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH.
Lengthening the humanmandible by gradual distraction. Plast
Reconstr Surg 1992;89:1-8.
2. Rachmiel A, Pottaric Z, Jackson IT, Sugihara T, Clayman L,
Tops JS, et al. Midfaceadvancement by gradual distraction. Br J
Plast Surg 1993;46:201-7.
3. Altuna G, Walker DA, Freeman E. Surgically assisted rapid
orthodontic lengthening ofthe maxilla in primates: a pilot study.
Am J Orthod Dentofacial Orthoped 1995;107:531-6.
4. Block MS, Cervini D, Chang A, Gottsegen GB. Anterior
maxillary advancement usingtooth-supported distraction
osteogenesis. J Oral Maxfac Surg 1995;53:561-5.
5. Polley JW, Figueroa AA, Charbel FB, Berkowitz R, Reisberg D,
Cohen M. Monobloccraniomaxillofacial distraction osteogenesis in a
newborn with severe craniofacialsynostosis: a preliminary report. J
Craniofac Surg 1995;6:421-3.
6. Chin M, Toth BA. Distraction osteogenesis in maxillofacial
surgery using internaldevices: review of 5 cases. J Oral Maxfac
Surg 1996;54:45-53.
7. Cohen SR, Burstein FD, Stewart MB, Rathburn MA.
Maxillary-midface distraction inchildren with cleft lip and palate:
a preliminary report. Plast Reconstr Surg1997;99:1421-6.
8. Polley JW, Figueroa AA. Management of severe maxillary
deficiency in childhoodand adolescence through distraction
osteogenesis with an external adjustable rigid dis-traction device.
J Craniofac Surg 1997;8:181-5.
9. Nanda R. Biomechanical and clinical considerations of a
modified protraction head-gear. Am J Orthod 1980;76:125-39.
10. Nanda R, Kuhlberg A. Principles of biomechanics. In: Nanda
R, editor. Biomechan-ics in Clinical Orthodontics. Philadelphia:
W.B. Saunders Co; 1997. p. 1-22.
11. Ross RB. Treatment variables affecting facial growth in
complete unilateral cleft lip andpalate: 7, an overview of
treatment and facial growth. Cleft Palate J 1987;24:71-7.
12. Panula K, Lorius BBJ, Pospisil OA. The need for orthognathic
surgery in patients bornwith complete cleft palate or complete
unilateral cleft lip and palate. Oral Surg OralDiag
1993;4:23-8.
13. Hochban W, Gans C, Austermann KH. Long-term results after
maxillary advancementin patients with cleft. Cleft Palate Craniofac
J 1993;30:237-43.
14. Cheung LK, Sammam N, Hiu E, Tiderman H. The 3-dimensional
stability of maxil-lary osteotomies in cleft patients with residual
alveolar clefts. Br J Oral MaxillofacSurg 1994;32:6-12.
15. Posnick JC, Dagys AP. Skeletal stability and relapse
patterns after LeFort I maxillaryosteotomy fixed with miniplates:
the unilateral cleft lip and palate deformity. PlastReconstr Surg
1994;94:924-32.
16. Erbe N, Stoelinga P, JW, Leenen RJ. Long-term results of
segmental repositioning ofthe maxilla in cleft palate patients
without previously grafted alveolo-palatal clefts.
JCraniomaxillofac Surg 1996;24:109-17.
17. Aduss H. Craniofacial growth in complete unilateral cleft
lip and palate. Angle Ortho1971;41:202-13.
18. Bishara SE, Krause CJ, Olin WH, Weston D, Tan Ness J,
Felling C. Facial and dentalrelationships of individuals with
unoperated clefts of the lip and/or palate. Cleft PalateJ
1976;13:238-52.
19. Smahel Z, Brejcha M. Differences in craniofacial morphology
between complete andincomplete unilateral cleft lip and palate in
adults. Cleft Palate J 1983;20:113-27.
20. Bishara SE, Jakobsen JR, Krause JC, Sosa-Martinez R.
Cephalometric comparisonsof individuals from India and Mexico with
unoperated cleft lip and palate. Cleft PalateJ 1986;23:116-25.
-
12 Figueroa and Polley American Journal of Orthodontics and
Dentofacial OrthopedicsJanuary 1999
21. Ross RB. Treatment variables affecting facial growth in
complete unilateral cleft lipand palate. Part I, treatment
affecting growth. Cleft Palate J 1987;24:5-23.
22. Semb G. A study of facial growth in patients with unilateral
cleft lip and palate treat-ed by the OSLO CLP team. Cleft Palate
Craniofac J 1991;28:1-21.
23. Smahel Z, Brejcha M, Mullerova Z. Craniofacial morphology in
unilateral cleft lip andpalate in adults. Chir Plast
1991;33:224-41.
24. da Silva Filho OJ, Normando AD, Capelozza Filho L.
Mandibular growth in patientswith cleft lip and/or cleft palate:
the influence of cleft type. Am J Orthod DentofacialOrthop
1993;104:269-75.
25. Rosen R. Facial skeletal expansion: treatment strategies and
rational. Plast ReconstrSurg 1992;89:798-808.
26. Molina F, Ortiz-Monasterio F. Maxillary distraction: three
years of clinical experience.In: Proceedings of the 65th Annual
Meeting of the American Society of Plastic andReconstructive
Surgeons. Plastic Surgical Forum 1996; XVIIII:54.
27. Polley JW, Figueroa AA. Rigid external distraction (RED):
its application in cleftmaxillary deformities. Plast Reconstr Surg
1998;102;1360-72.
28. Rachmiel A, Laufer D, Aizenbud D. Surgical assisted
orthopedic protraction of themaxilla in cleft palate patients by
distraction osteogenesis. Am Cleft Palate-Craniofa-cial Association
54th Annual Meeting, New Orleans, La., April 1997. Abstract
198.
29. Diner PA, Martinez H, Carbadar Y, Dumit A, Levaillant JM,
Ducou Le Pointe H, et al.
Experience with distraction in maxillary deficiency at Trousseau
Hospital. Interna-tional Congress on Cranial and Facial Bone
Distraction Processes. Paris, France. June1997. Abstract 60.
30. Hung KF, Lin WY, Huang CS, Chen KT, Lo LJ. The maxillary
movement distraction:preliminary results. International Congress on
Cranial and Facial Bone DistractionProcesses. Paris, France. June
1997. Abstract 55.
31. Chong YH, Ive JC, rtun J. Changes following the use of
protraction headgear forearly correction of Class III malocclusion.
Angle Orthod 1996;66:351-62.
32. da Silva Filho OG, Magro AC, Capelozza Filho L. Early
treatment of Class III mal-occlusion with rapid maxillary expansion
and maxillary protraction. Am J OrthodDentofacial Orthop
1998;113:196-203.
33. Chierici G. Experiments on the influence of oriented stress
on bone formation replac-ing bone grafts. Cleft Palate J
1977;14:114-23.
34. Ilizarov GA. The tension-stress effects on the genesis and
growth of tissues: Part I, theinfluence of stability of fixation
and soft tissue preservation. Clinical Orthopedic andRelated
Research. 1989;238:249-81.
35. Stoelinga PJ, vd Vijver HR, Leenen RJ, Blijdorp PA,
Schoenaers JHA. The preventionof relapse after maxillary
osteotomies in cleft palate patients. J Craniomax
Surg1987;15:326-31.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERSBound volumes of the
American Journal of Orthodontics and Dentofacial Orthopedics
are available to subscribers (only) for the 1999 issues from the
Publisher, at a cost of $96.00($115.56 Canada and $108.00
international) for Vol. 115 (January-June) and Vol. 116
(July-December). Shipping charges are included. Each bound volume
contains a subject and authorindex and all advertising is removed.
Copies are shipped within 60 days after publication ofthe last
issue of the volume. The binding is durable buckram with the
journal name, volumenumber, and year stamped in gold on the spine.
Payment must accompany all orders. ContactMosby, Inc., Subscription
Services, 11830 Westline Industrial Drive, St. Louis, MO
63146-3318, USA; telephone (314)453-4351 or (800)325-4177.
Subscriptions must be in force to qualify. Bound volumes are not
available in placeof a regular Journal subscription.