Distraction osteogenesis in CLP

DISTRACTION OSTEOGENESIS AND

ORTHOGNATHIC SURGERY FOR A PATIENT WITH UNILATERAL CLEFT

LIP AND PALATE

DR.SABA BASITMCPS RESIDENTORTHODONTICS

AFID

Case ReportBy: Ji Hyun Kim and CoworkersFrom: AJO-DO March 2015

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DISTRACTION OSTEOGENESIS

Medscape

“A process in which increased amount of both bone and soft

tissue are created as a result of the gradual

displacement of surgically created bony fractures.”

“A process used in orthopedic surgery and oral and maxillofacial

surgery to repair skeletal deformities

and in reconstructive surgery.”Also called

‘callus distraction’ ‘callotasis’

‘Osteodistraction’

DO

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“Distraction osteogenesis is a way to make a longer bone out of a

shorter one.”

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DIAGNOSIS AND ETIOLOGY

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DEMOGRAPHIC DETAILS 22yrs old female Korean woman

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PRESENTING COMPLAINS

Depressed upper lip Protruded lower jaw Midline deviation

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History

Born with a complete unilateral CLP Received a cheilorrhaphy and a palatorrhaphy

when she was 10 years old No history of orofacial congenital anomalies or

deformities in her family No other relevant medical history

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Extraoral Features Midface deficiency Increased mandibular body length Lower facial height comparatively longer than midfacial

height The length of the mental region was much greater than that of the upper lip

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PRETREATMENT PHOTOGRAPHS

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Intraoral Features Angle class III molar Anterior crossbite Maxillary jaw deviated to the right Missing maxillary second premolars Palatally ectopic maxillary right first premolar Maxillary dental midline deviated by 3mm Peg laterals

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Cast..

Reverse overjet

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Panoramic Radiographs

Original cleft defect in the maxillary left lateral incisor area

Potentially impacted 3rd molars Multiple restorations

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Cephalometric Analysis

Skeletal class III relationship with a retrognathic maxilla.

Hyperdivergent skeletal pattern. Retrusive upper lip shows high value of z-angle Bimax retroclinations

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Treatment objectives

The midface anteroposterior deficiency

The maxillary Jaw deviation to the right

The skeletal class III relationshipand improve the facial profile

The class III molar relationship and the anterior crossbite

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TO

CO

RR

ECT

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Treatment Options:1. Orthodontic and Surgical treatment (Maxillary advancement with posterior impaction and mandibular setback)

2. Orthodontic with Distraction Osteogenesis and Orthognathic Surgery.

(The maxillary advancement with DO followed by orthognathic surgery to posteriorly impact the maxilla and set back the mandible.)

Considering the severity of the skeletal discrepancy,the second option was chosen as a potentially more

stabletreatment method. The RED device was planned to

be used to accomplish the maxillary DO.

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Why Distraction Osteogenesis?

Disadvantages of Orthognathic Surgery in severe maxillary deficiency

•Relapse rates of 25% to 40%•Instability•Limited amount of advancement•Highly invasive surgical technique

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TREATMENT PROCEDURE

Distraction Osteogenesis

Predistractio

n phase

Distraction and

consolidatio

n phase

Post distraction phase

Preoperative Orthodontics Orthognathic Surgery

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PREDISTRACTION PHASE

Intraoral appliance fabricated Orthodontic bands Vertical wires with hooks soldered perpendicular to the labial

wire Two additional short vertical wires with hooks were also

soldered to the labial wire at the position of the canines.

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DISTRACTION AND CONSOLIDATION PHASE

Complete maxillary osteotomy A RED system with 3 screws on each side of cranium. The extraoral hooks were tied to the vertical pin of the RED device. Latency period of 8 days Distraction at the rate of 0.5 mm twice per day for 10 days Intraoral device maintained till 8 weeks

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POST DISTRACTION PHASE

The extra-oral portion was cut Facemask for an additional 2 months to minimize

relapse Force approximately 340 g (12 oz) with 2 heavy elastics

5/16 inc per side.

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AFTER DO Preadjusted fixed appliances Preoperative orthodontics #14 was extracted. Aligning and leveling Decompensation

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ORTHOGNATHIC SURGERY Lefort I Osteotomy

1. 5 mm of advancement,2. 3 mm of posterior impaction,3. Horizontal rotation for midline correction

Mandible set back 6mm bilateral sagittal split ramus osteotomy

Genioplasty

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RETENTION AND STABILITY Appliances were removed Lingual fixed retainers Mandibular right second molar was splinted

with adjacent tooth Removable wraparound retainers

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TREATMENT RESULTS

The total maxillary advancement with DO was 10 mm

Since 2-jaw surgery with mandibular setback was planned from the beginning, no further maxillary advancement through DO was performed.

Total 7 mm of maxillary advancement

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Post treatment extra- oral photographs

The posttreatment extraoral photographs showed a balanced profile.

The intraoral photographs demonstrated good alignment with acceptable overjet and overbite.

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Midline discrepancy was corrected. The molar relationship on the right side, class III. The molar relationship on the left side, class I.

The final cephalometric analysis: Improved profile Reduced mandibular body length Long mental region reduced Maxillary incisors remained retroclined Improved madibular incisor incliniation

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Total treatment time 36 months 2-year posttreatment photographs

and the cephalometric analysis showed good stability.

Pt. was satisfied

DISCUSSION

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Patient’s strong concern1. Midline coincidence2. Improvement of lateral facial profile

She decided to have: 2-jaw surgery Of 10 mm, the true amount of distraction achieved was 7 mm. The 10-mm distraction with the RED device used in this patient was insufficient.

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Problems That Made The 2-jaw Surgery Inevitable Severe retrusion of the maxilla Dental midline deviation of 3 mm Lack of maxillary incisal exposure and upper lip

support Depression of the nasolabial folds

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RED

RED appliance allows 3-plane guidance. Considering the occlusal plane angle and the

maxillary incisal exposure ,it is intended to induce the force vector of the DO to be forward and downward by adjusting the length of the vertical hook.

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RED The distraction vector can be controlled by both

the external device and the intraoral device of the RED system

In this patient, the amount of advancementneeded was more than 10 mm; therefore, orthognathic

surgery alone was considered insufficient and unstable.

10mm

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Retention after DO:

Suggested retention period for DO 6 to 8 weeks. Red device 8 weeks of consolidation and 8

weeks of retention with the facemask to prevent relapse as much as possible.

The 2.4 mm of relapse occurred during the preoperative orthodontic treatment

1. There was no supplementary appliance for retention

2. Soft tissue factors and muscle stretch

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Other Considerations

Patient had secondary caries on all 4 maxillary molars.

To strengthen the anchorage, banding of all 4 molars was planned.

For a patient with multiple missing teeth or not enough bone in the cranial vault, mini implants or plates could be considered for the skeletal anchorage.

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Literature review (RELAPSE)

Louis et al says that relapse rate of OGS increases as the amount of maxillary advancement increase.

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Literature Review: According to some studies, the maximum maxillary advancement

achieved by conventional OGS techniques varies, ranging from 5mm - 10mm,depending upon scar contracture.

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LITERATURE REVIEW (Relapse)

In our patient, 2.4 mm of relapse, which is about 34% of the total amount of advancement, occurred during the preoperative orthodontic treatment

According to Hochban et al, Cheung et al, Erbe et al reported that relapse rate after maxillary advancement of 7.8mm,3.3mm and 4.6mm was 25%,27% and 40% respectively.

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Recommendation

Overcorrection during DO is suggested

Cho and Kyung et al. recommended overcorrection is of 20% to 30% to minimize relapse.

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Conclusion

DO is an efficient treatment modality in severe cleft-related maxillary hypoplasia.

It promotes correction of bone and soft tissues simultaneously.

Reduces the amount of maxillary movement during the surgery.

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Critical Appraisal TITLE Distraction osteogenesis and orthographic surgery

for a patient with unilateral cleft lip and palate

STUDY DESIGN Case report STATISTICS USED Not Applicable DATA ANALYSIS Not Applicable LEVEL OF EVIDENCE 5 CONCLUSION DO is an efficient treatment modality in

cleft-related maxillary hypoplasia. LIMITATIONS Single case

RCT’s are not thereExperimental study

INFERENCE Such type of studies are already being conducted in our setup, they need to be continued.

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