Khe Hở Môi Và Vòm Miệng: Chẩn Đoán Và Quản Lý Điều Trị (Cleft Lip and Palate)

493
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
2–8
4–9
0–7
0–1
Fig. 21.22 Case BM-BK 36. Incomplete bilateral cleft
lip and palate. 0–7: Untreated palatal arch. 2–8: The pro-
truding premaxilla was treated with POPLA. 4–9: Class
III malocclusion with an anterior open bite. 14–6: Missing
right and left lateral incisors with closure of their spaces.
Anterior–posterior arch length is shortened. Even after
use of a protraction facial mask, extensive orthodontics
was still necessary to attempt to correct the amateur cross-
bite. Comments: Facial pro fi le evaluation shows a protru-
sive lower lip with a severe mandibular incisor inclination.
The lower fi rst bicuspids were extracted in order to retract
the lower anterior teeth. The upper incisors will only be
slightly advanced
Fig. 21.21 (continued)

494
S. Berkowitz and M. Mejia
Fig. 21.23 ( a – p ) Case CS (AY-45) CUCLP. Latham–
Millard PSOT. This case also demonstrates the loss of the
lateral incisor space with slight midfacial retrusion at
9 years. ( a ) Newborn 3 months. ( b ) Intraoral view at
3 months. ( c ) 411/42 months after palatal manipulation;
periosteoplasty and lip adhesion. ( d ) Looking at the perios-
teoplasty, palate cleft is open. ( e ) 911/42 months, after
rotation advancement lip surgery. ( f ) 1 year and 3 months.
Cleft palate closed via modi fi ed van Langenbeck proce-
dure. ( g ) 2 years and 1 month. ( h ) 3 years and 8 months. ( i )
5 years and 8 months(j) Intraoral photograph with teeth in
an anterior tip-to-tip relationship. (k, l) l 7 years and
8 months; frontal and lateral photographs
a
b
c
d
e
f
g
j
k
l
h
i

495
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
o
p
q
m
n
( m , n ) 9 years, 10 months.
Comment: The facial aesthetics are most pleasing even
with the teeth in a tip-to-tip relationship. It still remains to
be seen whether the profile will become more recessive
after the pubertal growth spurt. ( o , p ) Final facial photo-
graphs at 18 years. ( q ) Final occlusion at 18 years old
showing good overbite and overjet. The upper left lateral
incisor was replaced with PONTIC attached to a bridge.
Comments: The results turned out well due to a vertical
facial growth pattern
Fig. 21.23 (continued)

496
S. Berkowitz and M. Mejia
Fig. 21.24 Case CS (AY-45). Serial
casts CUCLP. 0–3: newborn. 1–9:
After palatal segments were brought
together with PSOT. Teeth are slightly
in an open bite and in a tip-to-tip
relationship. The right lateral incisor
space is closed. Ages 3–9, 4–6, 5–9,
and 6–3 show the same occlusion
relationship. Serial casts CUCLP
0–3
1–9
3–9
4–6
5–9
6–3
7–7
9–10
8
At 7–7, 8, and 9–10: The permanent central incisors are erupting in good overjet–overbite relationship;
however, the closure of the right lateral incisor space is due to the maxillary incisors being displaced to the left. Serial casts CUCLP
Fig. 21.24 (continued)

497
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
10–9
12–0
13–0
16–0
18–0
10–9 to 13–0 Slight anterior
crossbite. A protraction facial mask is to be used to
advance the right central incisor. The left incisors are
rotated and impacted. The lateral incisor is missing.
13 years: The left central incisor and upper first bicuspids
were extracted. 16 years: A maxillary retainer with a false
tooth was used. 18 years: A fixed bridge with replace-
ment tooth was placed
Fig. 21.24 (continued)

498
S. Berkowitz and M. Mejia
3 years
a
b
6 years
3 years 11 months
12 years
N
A
BaH
Basion-horizontal
C.S. Case# AY-45
Gn
Gn
3–11
5–10 6–9
7–8
9–3
Ba
Ar
S
3 years
12 years
7 years 10 months
Fig. 21.25 ( a , b ) Case CS (AY-45). ( a ) Cephalometric
tracings. Lateral cephalometric tracings show the midface
is becoming more recessive relative to the anterior cranial
base and mandible. ( b ) Superimposed polygons using
Basion horizontal procedure. The above fi nding is veri fi ed
in this series of superimposed polygons. Although slight
forward growth of the midface is evident between 3–11
and 7–8, no further growth is seen between 7–8 and
9–3 years of age

499
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
Fig. 21.26 ( a – w ) Case AS (AY-46). CBCLP with
Millard–Latham PSOT. Retarded midfacial growth in the
mixed dentition. ( a , b ) Newborn. ( c ) Latham’s pinned
appliance in place. ( d ) At 6 months. Premaxilla is aligned
within the arch. ( e ) At 6 months. ( f – h ) 6 years and
6 months. Frontal and lateral face. ( i ) Small columella
with depressed nasal tip. CBCLP with Millard–Latham
PSOT. ( j ) Good arch alignment. Small palatal fi stula. ( k )
Good occlusion
a
b
c
d
e
f
g
h
i
j
k
l

500
S. Berkowitz and M. Mejia
s
t
v
w
u
( l – n ) 9 years. Raised nasal tip.
( o – r ) Facial and dental occlusion. The left deciduous lat-
eral incisor is in crossbite. Retarded midfacial growth in
the mixed dentition. CBCLP with Millard–Latham PSOT.
( s – u ) Final facial photographs. ( v , w ) Final occlusion(j)
Good arch alignment. Small palatal fistula. (k) Good
occlusion. (l–n) 9 years. Raised nasal tip. (o–r) Facial and
dental occlusion. The left deciduous lateral incisor is in
crossbite. Retarded midfacial growth in the mixed denti-
tion. CBCLP with Millard–Latham PSOT(s–u) Final facial
photographs. (v, w) Final occlusion
Fig. 21.26 (continued)
m
n
o
p
q
r

501
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
1–2
2–9
3–4
7–7
9–10
8
10–9
Fig. 21.27 Case AS (AY-46). CBCLP with Millard–Latham PSOT

502
S. Berkowitz and M. Mejia
A.S. Case# AY-46
3 years
12 years
a
6 years
18 years
3 years
18 years
9 years 11 months
Fig. 21.28 ( a ) Case AS (AY-46). CBCLP with Millard–
Latham PSOT. Serial lateral cephalometric tracings and b
serial superimposed polygons (Basion horizontal method)
show retarded midfacial growth. Fortunately, the vertical
mandibular growth pattern complements a reduced midfa-
cial growth, preventing the creation of an anterior cross-
bite. Comments: Protraction orthopedic forces will be
initiated when more permanent teeth have erupted.
10–9: Upper left lateral incisor is
missing. The left maxillary central incisor is impacted.
18–0: Final occlusion. Treatment plan: (1) Extract upper
left lateral incisor and bring in blocked out impacted
central incisor. (2) Bring upper right and left cuspids into
lateral incisor position. (3) Reshape upper right cuspid.
(4) Two-unit bridge to replace upper left lateral incisor
12–0
13–0
18–0
Fig. 21.27 (continued)

503
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
21.4
Conservative Non-POPLA
CUCLP and CBCLP Cases
In non-POPLA CBCLP cases, the protruding
premaxilla’s overjet is gradually reduced so
that it can be easily aligned within the alveolar
arch by 7–8 years of age. In some patients, this
may spontaneously occur after only 2–3 months
of simple palatal expansion. However, depend-
ing on the facial growth pattern, some maxil-
lary dental overjet with a convex facial pro fi le
may still remain into the mixed dentition stage.
In our study, only two cases with a severely
protruding premaxilla at birth developed a
retrusive Class III malocclusion requiring sur-
gical maxillary LeFort I advancement. This
need was mainly due to reduced maxillary
growth coupled with a forward-growing man-
dible. The use of a protraction facial mask in
both cases was unsuccessful in correcting the
midfacial recessiveness.
With non-POPLA treatments, successful sec-
ondary alveolar bone grafts occurred in 70 % of
the cases. In most of these cases, the impacted
lateral incisor erupted into its normal position
within the alveolus, or, if absent, the space was
left open for a replacement tooth. If one or both
lateral palatal segments are in a Class II relation-
ship and one or both lateral incisors are absent,
the cuspid(s) can be substituted for the missing
lateral incisor(s). In these patients, the maxillary
and mandibular anterior arch forms are congru-
ent at the completion of orthodontic treatment.
Anterior arch congruency cannot exist in POPLA
cases without extensive orthodontics/surgery.
Flattening of the facial pro fi le, thereby con-
tributing to improved facial aesthetics, occurs
gradually as the upper and lower portions of the
face grow forward while the midface’s forward
growth is restrained by the forces created by the
united lip. Most signi fi cantly, after 2 years of age,
3D measurements show that the premaxilla is in
the same ideal position within the maxillary arch,
its forward growth having been retarded by the
intact lip musculature forces.
Poor facial growth occurs either when the
mandible’s growth is vertically directed and/or
the midface fails to grow in concert with the man-
dible. Any of these variables can occur in either
non-POPLA- or POPLA-treated cases which are
not under the surgeon’s control and are unpre-
dictable at birth.
The growth analysis of these CBCLP cases
demonstrates that increases in A–P maxillary
arch length, between the incisal papilla and the
fi rst permanent molars, are dependent on the
functional integrity of the PVS. Once PVS func-
tion is diminished by excessive forces, growth
recovery will not return.
Establishing lip muscle continuity soon after
birth causes slow molding of both the overex-
panded lateral palatal and premaxillary segments
S
N
Ar
Ba
A
BaH
Go
Gn
3–11
5–10 6–9
7–8 0–3
b

( b ) CBCLP with Millard–Latham
PSOT. This case demonstrates why it was possible to
establish good facial aesthetics and occlusion without the
need to advance the midface or retract the mandible.
Although a slight facial concavity exists, it was still aes-
thetically acceptable
Fig. 21.28 (continued)

504
S. Berkowitz and M. Mejia
leading to the narrowing of the anterior and pos-
terior palatal cleft spaces. In non-POPLA
CBCLP, the posterior-directed pressure of the
elastic strip appears to be within physiological
limits, and in most cases, reduced pressure per-
mits additional PVS growth. This is seen in the
graphic analysis of both superimposed serial
lateral cephaloradiographs and from electroni-
cally produced 3D tracings of palatal dental
casts (Figs. 21.30 and 21.31 ).
In non-POPLA CBCLP cases, the A–P palatal
dimension is greater between birth and 6 years,
while with POPLA CBCLP treatment, once the
premaxilla is set back, there is no further change
in the anteroposterior fi rst molar to incisor
dimension due to pressure-caused hemorrhage at
the premaxillary vomerine suture leading to
fi brosis and then synostosis. Most of the alveolar
cleft spaces are obliterated with new bone uniting
the repositioned palatal segments.
POPLA
non-POPLA
3 years old
70
a
b
*
*
60
50
40
30
20
10
0
70
60
50
40
30
20
10
0
6 years old 9 years old 12 years old
POPLA
3 years old 6 years old 9 years old 12 years old
non-POPLA
POPLA
non-POPLA
3 years old
70
80
*
*
60
50
40
30
20
10
0
60
*
*
50
40
30
20
10
0
6 years old 9 years old 12 years old
POPLA
3 years old 6 years old 9 years old 12 years old
non-POPLA
Fig. 21.29 ( a ) The charts report the percentage of chil-
dren with unilateral cleft lip and palate receiving presurgi-
cal or nonpresurgical orthopedics, by crossbite. At every
age level, a greater percentage of youngsters treated with
presurgical orthopedics developed crossbites than did
those treated with nonpresurgical orthopedics (presurgical
orthopedics, nonpresurgical orthopedics). This difference
existed for both the anterior crossbite (above) and the buc-
cal crossbite (below). Asterisk: Some of the worst cross-
bite cases in the presurgical orthopedics group were
treated by Berkowitz starting at about 9 years of age,
thereby reducing the frequency of crossbite in this group
beginning at this age level. ( b ) The charts report the per-
cent of children with bilateral cleft lip and palate receiving
presurgical orthopedics or nonpresurgical orthopedics, by
crossbite. At every age level, a greater percentage of
youngsters treated with presurgical orthopedics developed
crossbites than did those treated with nonpresurgical
orthopedics (presurgical orthopedics; nonpresurgical
orthopedics). This difference existed for both the anterior
crossbite (above) and the buccal crossbite (below).
Asterisk : Some of the worst crossbite cases in the presur-
gical orthopedics group were treated by Berkowitz start-
ing at about 9 years of age, thereby reducing the frequency
of crossbite in this group beginning at this age level

505
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
In the non-POPLA CUCLP cases studied, only
16 % (8 of 51) are in anterior crossbite at 3 years
of age, a condition that is easily correctable by
advancing the premaxillary portion of the non-
cleft larger segment. 60 % of the POPLA cases
are anterior crossbites at 3 years (Fig. 21.29a ).
Buccal crossbites in both non-POPLA and
POPLA treatment series were easily corrected
since the type of palatal surgery performed
between 18 and 36 months did not inhibit palatal
expansion. Only 3 of 51 cases (6 %) had a
complete buccal crossbite at 3 years of age
(Table 21.1 , Fig. 21.29a ). The relative increase
in percentage of buccal crossbites in POPLA
cases at 3 years is signi fi cant (60 % at 3 years),
because it necessitated more crossbite corrective
procedures at 5–6 years of age (Table 21.2 ,
Fig. 21.29a ).
21.5
Variations in Palatal
Osteogenic De fi ciency
and Its In fl uences on Surgical
Treatment
The location of palatal bone de fi ciency is highly
variable and can exist to various degrees. In
CBCLP, the extent of osteogenic de fi ciency in the
anterior part of the palate can vary in size and
shape. In a few of these instances, the palatal cleft
space is usually present immediately posterior to
the premaxilla, even when the incisors are in good
or poor overbite/overjet relationship. In conserva-
tively treated cases, if this large cleft space is
present with the incisors in good overbite/overjet,
further surgical treatment needs to be evaluated in
the mixed dentition or at early adolescence. When
there is insuf fi cient mucoperiosteal tissue to sur-
gically close this palatal cleft space, successful
secondary alveolar bone grafting will not be pos-
sible. In these instances, the only solution is for
the posterior palatal segments to be advanced to
reduce the cleft space to usable dimensions and
immediately followed by secondary alveolar bone
grafts (Posnick and Ewing 1990 ) . In our study,
this surgery was necessary in only two of 20 non-
POPLA cases; both cases were successfully
treated by Wolfe using the Posnick procedure.
Should this same form of skeletal palatal
de fi ciency exist in POPLA-treated cases, the pre-
maxilla would be severely retruded so much so
that one or both lateral incisor cleft spaces would
be closed and ultimately bridged by bone, thus
preventing the orthodontic– orthopedic correc-
tion of the anterior crossbite. The lack of sub-
sequent anterior maxillary and mandibular arch
congruency would prevent the achievement of a
good dental overbite/overjet relationship, even
after midfacial surgical advancement.
21.6
Correction of Midfacial
De fi ciencies in Conservatively
Treated Non-POPLA Cases
A slight anterior crossbite can be easily corrected
orthodontically by using the maxillary protrac-
tion mechanics of a facial mask, with or without
the extraction of one mandibular central incisor.
In the non-POPLA CBCLP cases, it was neces-
sary to surgically advance a retrusive midface in
only two patients Figs. 21.30 , 21.31 , and 21.32 .
A well-developed, relatively protrusive mandible
existed in only one of these children. Fortunately,
Table 21.2 Obtained signi fi cant chi-square values ( p < 0.05) in tests of differences in number of patients having cross-
bites between presurgical and nonpresurgical orthopedics treatments
Approximate age of participant
3 years
6 years
9 years
12 years
Total sample
Unilateral cleft
Anterior crossbite
16.8
30.0
10.2
18
77.5
Buccal crossbite
30.9
6.5
6.5
4.8
42.8
Bilateral cleft
Anterior crossbite
10.3
11.5
24.5
8.5
35.5
Buccal crossbite
49
49
6.5
35
173

506
S. Berkowitz and M. Mejia
S.A.
D.K.
AY-46
7–0
6–5
0–1
0–1
V.L.
13–0
16–3
B.G.
0–0–23
0–1
8–8
19–0
9–0
17–0
AH-62
AI-53
AI-31
Fig. 21.30 Superimposed palatal cast tracings of the
hard palate of four patients were acquired using a 3D
electromechanical digitizer. In each tracing, the
alveolar ridge is the lateral border. The tracings are
superimposed horizontally at the rugae and registered
vertically
J.D.
AE-23
7–1
17–4
R.F.
J.K.
0–1
8–6
16–4
6–2
15–3
AF-64
AJ-7
Fig. 21.31 Superimposed palatal cast tracings of the
hard palate of three patients were acquired using a 3D
electromechanical digitizer. In each tracing, the
alveolar ridge is the lateral border. The tracings are
superimposed horizontally at the rugae and registered
vertically

507
21 A Comparison of the Effects of the Latham–Millard POPLA Procedure
no long-term speech changes resulted after max-
illary advancement in these two instances. Lateral
cephalometrics showed good velar length and
elevation within a pharyngeal space of average
depth. Intraoral examination showed good lateral
pharyngeal wall movements as well.
21.7
Similar Presurgical
Orthopedics as It Was Utilized
in the Past: It Failed Then as It
Does Now
During the 1920s and 1930s, the cleft surgeon’s
treatment philosophy exempli fi ed by Brophy
( 1923 ) was to repair the cleft defect by establishing
“normal” anatomical palatal form soon after birth,
through the use of external and internal palatal
compression techniques. The fi rst priority then was
to improve facial aesthetics, followed in turn by
good dental function and speech. Unfortunately,
the Brophy procedure led to extensive midfacial
deformity and was eventually discontinued.
Due to the bene fi t of long-term facial and
palatal growth records, many if not most sur-
geons and speech–language pathologists have
recognized the extent to which time, or more
precisely growth, serves as their ally or enemy.
However, some surgeons are still endeavoring to
devise a procedure that can be used during the
fi rst 2 years for all CBCLP and CUCLP cases,
hopeful that good facial growth will follow.
In recent years, serial documentation of the
natural evolution of postnatal facial and palatal
development of children with complete bilateral
and unilateral cleft lip and palate has yielded
important objective data – data that help explain
the dynamics of facial skeleton and palate growth
under the in fl uence of various surgical proce-
dures. This knowledge has greatly improved the
ability of surgeons and orthodontists to develop
physiologically based concepts that lead to suc-
cessful long-term treatment outcomes.
This study supports Gillie’s (Millard,
personal communication ) belief that time is
both the surgeon’s ally and most trenchant
critic. It further supports the thesis that no sin-
gle surgical procedure performed at birth is
suitable for all cleft types and faces since there
is great variation in palatal osteogenesis and in
facial growth patterns. Staged treatment based
on the individual patient’s facial assets and
de fi cits must be the controlling factor in design-
ing therapy.
C.M.
AC-66
6–5
16–3
0–23
10 weeks
2–5
4–9
12–0
6–1
W.M.
N.D.
BP-18
AD-81
Fig. 21.32 Superimposed palatal cast tracings of the
hard palate of three patients were acquired using a 3D
electromechanical digitizer. In each tracing, the
alveolar ridge is the lateral border. The tracings are
superimposed horizontally at the rugae and registered
vertically

508
S. Berkowitz and M. Mejia
References
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Part X
Midfacial Orthodontic/Orthopedic
and/or Surgical Changes

511
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_22, © Springer-Verlag Berlin Heidelberg 2013
22
22.1
Protraction of the Maxilla
Using Orthopedics
Children with complete unilateral and bilateral cleft
of the lip and palate are usually at risk for poor
facial growth. They are prone to developing midfa-
cial retrusion related to maxillary hypoplasia or
growth retardation secondary to excessive palatal
scarring. Usually, this results in an anterior dental
crossbite or severely rotated maxillary incisors
which may occlude in a tip-to-tip relationship with
the mandibular incisors. Depending on the age of
the patient and the extent of midfacial maldevelop-
ment, some of these early problems can be cor-
rected using midfacial orthopedic protraction forces
which increase growth at the circumaxillary sutures
as they are repositioned anteriorly (Fig. 22.1 ).
When all else fails, midfacial surgery is available.
Some of the earlier work in this fi eld, which
encouraged a rethinking of the use of orthopedic
forces for the correction of midfacial retrusion,
includes Hass ( 1970 ) , Delaire ( 1971 ) , Delaire
et al. ( 1972, 1973, 1976, 1978 ) , Irie and Nakamura
Protraction Facial Mask
Samuel Berkowitz
S. Berkowitz , DDS, M.S., FICD
Adjunct Professor, Department of Orthodontics ,
College of Dentistry, University of Illinois ,
Chicago , IL , USA
Clinical Professor of Surgery and Pediatrics (Ret),
Director of Research (Ret),
South Florida Cleft Palate Clinic,
University of Miami School of Medicine ,
Miami , FL , USA
Consultant (Ret), Craniofacial Anomalies Program ,
Miami Children’s Hospital , Miami , FL , USA
e-mail: sberk3140@aol.com
a
b
Fig. 22.1 ( a , b ) Protraction of the maxillary complex
using orthopedic forces. The maxilla articulates with
nine bones: two of the cranium, the frontal and ethmoid,
and seven of the face, viz., the nasal zygomatic, lacri-
mal, inferior and nasal concha, palatine, vomer, and its
fellow of the opposite side. Sometimes it articulates
with the orbital surface and sometimes with the lateral
pterygoid plate of the sphenoid. Illustration showing
how protraction forces applied to the maxilla depends
on the disarticulation and growth at all the dependent
sutures (Courtesy of E. Genevoc)

512
S. Berkowitz
( 1974 ) , Ranta ( 1988 ) , Subtelny ( 1980 ) , Friede
and Lennartsson ( 1981 ) , Sarnas and Rune ( 1987 ) ,
Berkowitz ( 1982 ) , Tindlund ( 1989 ) , Nanda
( 1978 ) , and Molstad and Dahl ( 1987 ) . More
recently, this area has been in fl uenced by the
work of Tindlund et al. (Irie and Nakamura 1974 ;
Ranta 1988 ; Subtelny 1980 ; Delaire et al. 1978 ;
Friede and Lennartsson 1981 ; Sarnas and Rune
1987 ; Berkowitz 1982 ; Tindlund 1989 ; Tindlund
and Rygh 1993 ; Nanda 1978 ; Molstad and Dahl
1987 ) and Buschang et al. ( 1994 ) .
Earlier attempts by Kettle and Burnapp ( 1955 )
in which anteriorly directed extraoral forces were
derived from chin caps were relatively unsuc-
cessful. Facial mask therapy seems to offer better
control and a wider range of force application.
In many cases, in the mixed dentition, palatal
expansion using fi xed orthodontic appliances was
applied simultaneously with protraction to correct
a bilateral crossbite and create a more favorable
condition for midfacial growth and development.
Prior to the use of orthopedic forces, many stan-
dard orthodontic treatments designed to move the
dentition to correct a class III malocclusion due to
midfacial retrusion in the absence of mandibular
prognathism failed. Orthodontic forces applied to the
teeth by class III elastics would not displace the max-
illa; at best, they would fl are the maxillary incisors
without creating an adequate incisor overbite and
axial inclination. This treatment was found to be
unsatisfactory and soon fell out of favor.
Since 1975, Berkowitz has been using a
modi fi ed protraction facial mask originally pop-
ularized by Delaire et al. ( 1972 ) (Figs. 22.2 ,
22.3 , and 22.4 ). It has been very successful in
controlling the direction of protruding forces
Fig. 22.2 ( a ) Frontal and ( b ) lateral views of a Delaire-
style protraction facial mask. Padded chin and forehead
rests distribute reaction forces of 350–400 g per side
equally to both areas. Elastics are attached to hooks placed
on the arch wire between the cuspids and lateral incisor.
( c ) Intraoral view of edgewise rectangular arch with hooks
for protraction elastics. ( d – f ) Delaire-style protraction
facial mask used with a fi xed labial-palatal wire frame-
work. Elastic forces of 350–400 g per side can still be
used with this intraoral framework

513
22 Protraction Facial Mask
without causing severe sore spots on the chin or
forehead. He has found that protraction forces do
not modify the direction of mandibular growth
as Delaire et al. ( 1972 ) claimed, but by increas-
ing midfacial height, the mandible is reposi-
tioned downward and backward with growth to
make the patient’s maxillary retrusion appear
less evident.
Protraction forces (350–450 g per side) must
be intermittent (the mask is worn only for 11 h
per day) and directed downward and forward
from a hook located mesial to the maxillary cus-
pids. Pulling downward from the molars should
be avoided because it will tilt the palatal plane
downward in the back by extruding the molars
and thus opening the bite. When the midfacial
height is de fi cient, protraction forces need to be
modi fi ed to increase vertical as well as anterior
growth. This is done by using more vertically
directed elastic forces.
Fig. 22.3 ( a – x ) Case BB (WW-62). Maxillary protraction
in a UCLP. ( a ) Complete unilateral cleft lip and palate.
( b , c ) Lip and nose after surgery. ( d ) Cuspid crossbite of
the lateral cleft segment at 5 years of age due to mesioan-
gular rotation of the palatal segment. ( e ) Buccal occlusion
after expansion using a quad helix expander. ( f , g ) 6 years
of age. Note relapse of cuspid crossbite due to failure of
using a palatal arch retainer. ( h ) Palatal view showing
good arch form
a
c
f
g
h
d
e
b

514
S. Berkowitz
i
l
j
k
m
n
o
p
Fig. 22.3 (continued) ( i , j ) Facial photographs at 8 years.
( k ) Orthodontic alignment of incisors prior to secondary
alveolar bone graft. ( l ) Protraction facial mask with elastics.
( m , n ) class III elastics used to maintain tension at circumax-
illary suture during the time not wearing protraction forces.
( o ) Occlusion after orthopedic–orthodontic forces. Lateral
incisor space regained. ( p ) Removal retainer with lateral
incisor pontic

515
22 Protraction Facial Mask
Berkowitz has found 350–450 g of force per
side to be adequate in most instances, but there
are rare instances when the elastic force needs to
be reduced to prevent sore spots at the chin point.
Friede and Lennartsson ( 1981 ) have used pro-
traction forces between 150 and 500 g per side.
Ire and Nakamura ( 1974 ) have used 400 g per
side, Roberts and Subtelny ( 1988 ) 670 g, Sarnas
and Rune ( 1987 ) 300–800 g, and Tindlund et al.
( 1993a, b ) 350 g per side. Unfortunately, when
q
s
v
x
w
u
t
r
Fig. 22.3 (continued) ( q , r ) Fixed bridge at 18 years of
age replacing missing lateral incisor and stabilizing max-
illary arch form. ( s – u ) 17 years prior to nose–lip revision.
( v – x ) Facial photos at 19 years, showing good facial sym-
metry after revision

516
S. Berkowitz
performed in the mixed dentition, treatment time
may extend into years because of the need to
keep pace with mandibular growth. If this is the
case, treatment should be divided into intermit-
tent periods not to exceed 6 months at a time with
a break for 1 month between periods. Following
this formula, the patient will usually remain
cooperative.
Although Berkowitz has been successful in
using strong elastic forces with labile-lingual
appliances during the deciduous dentition, he
recommends starting treatment at 7–8 years of age
when all of the maxillary incisors can be bracketed
and a rectangular edgewise arch with lingual root
torque used as Subtelny ( 1980 ) suggested. The
torqued rectangular arch will carry the incisor
roots forward, moving skeletal landmark point
“A” anteriorly, which prevents stripping of the
alveolar crest with subsequent incisor fl aring. The
arch wire needs to be tied back so that it does not
slide anteriorly, tipping the incisor, rather than
moving the entire maxilla forward orthopedically.
Tindlund et al. ( 1993a, b ) conclude that early
transverse expansion of the maxilla together with
protraction orthodontic treatment is an effective
method for normalizing maxillomandibular
Case# BB. WW-62
a
b
4–11
15–0
16–4
18–0
N
A(α)
FH′
Po
Ar
S
Ba
16–4
18–0
Go
4–11
15–0
Fig. 22.4 Case BB (WW-62) ( a ) Lateral cephalometric
tracings and superimposed polygons (Basion horizontal
method) for case BB (WW-62) show an excellent facial
growth pattern. ( b ) The midfacial growth increment
between 15 and 16–4, when the protraction facial mask
was used, increased midfacial protrusion to a greater
degree than that which would have occurred normally

517
22 Protraction Facial Mask
discrepancies in cleft lip and palate patients. The
average age at the start of treatment was 6 years,
12 months, and the average duration of treatment
was 13 months. Signi fi cant changes were achieved
due to anterior movement of the upper jaw and a
more posterior positioning of the lower jaw result-
ing from clockwise mandibular rotation.
Berkowitz also found that the combined use of
palatal expansion and protraction forces before
the pubertal growth spurts to be a more ef fi cient
means of gaining orthopedic advancement than
the use of protraction forces alone. He speculates
that the expansion forces possibly disarticulate
the circumaxillary sutures, thus allowing the
maxillary complex to be carried downward and
forward more easily.
Delaire et al. ( 1976 ) and Subtelny ( 1980 ) have
stated that orthopedic forces applied to the entire
maxillary complex are more likely to be effective
in younger children.
Berkowitz’s clinical experience supports the
recommendation by Abyholm et al. ( 1981 ) and
Bergland et al. ( 1986 ) (1) that a rigid fi xation of
the advanced maxilla should be maintained for at
least 3 months after bone grafting, and (2) the use
of protraction forces. This is necessary to help
reduce the tendency to relapse created by the sur-
rounding soft tissue of the lip, muscles, and skin.
Many patients with a complete bilateral cleft
lip and palate have a protruding premaxilla until
10 years of age or older, but after the postnatal man-
dibular growth spurt, the maxillary incisor teeth
may be in crossbite. Protraction orthopedic forces
with anterior crisscross elastics upright and reposi-
tion the premaxilla forward, perhaps by inducing
bone growth at the premaxillary-vomerine suture.
Fixed retention is always necessary to control the
improved incisal overbite–overjet relationship
at least until secondary alveolar bone grafting is
done.
References
Abyholm FE, Bergland O, Semb G (1981) Secondary
bone grafting of alveolar clefts: a surgical/orthodontic
treatment enabling a non-prosthodontic rehabilitation
in cleft lip and palate patients. Scand J Reconstr Surg
15:127
Bergland O, Semb G, Abydholm F, Borchgrevink H,
Eskeland G (1986) Secondary bone grafting and orth-
odontic treatment on patients with bilateral complete
clefts of the lip and palate. Ann Plast Surg 17:460–471
Berkowitz S (1982) Some questions, a few answers in max-
illa-mandibular surgery. Clin Plast Surg 9:603–633
Buschang PH, Porter C, Genecov E, Genecov D (1994)
Face mask therapy of preadolescents with unilateral
cleft lip and palate. Angle Orthod 64:145–150
Delaire J (1971) Considerations sur la croissance faciale
(en particulier du maxillaire superieur): deductions
therapeutiques. Rev Stomatol 72:57–76
Delaire J, Verdon P, Lumineau J-P, Chierga-Negrea A,
Talmant J, Boisson M (1972) Quelques resultats de
tractions extra-orales a appui fronto-mentonnier dans le
traitement orthopedique des malformations maxillo-
mandibulaires de classe III et des sequelles osseuses des
fentes labio-maxillaires. Rev Stomatol 73:633–642
Delaire J, Verdon P, Kenesi MC (1973) Extraorale Zugkraften
mit
Stirn-Kinn-Abstutzung
zur
Behandlung
der
Oberkieferdeformierungen als Folge von Lippen-Kiefer-
Gaumenspalten. Fortschr Kieferorthop 34:225–237
Delaire J, Verdon P, Flour J (1976) Ziele und Ergebnisse
extraoraler Zuge in postero-anteriorer Richtung in
Anwendung einer orthopädischen Maske bei der
Behandlung von Fallen der Klasse III. Fortschr
Kieferorthop 37:247–262
Delaire J, Verdon P, Flour J (1978) Moglichkeiten und
Grenzen extraoraler Krafte in postero-anteriorer
Richtung unter Verwendung der orthopädischen
Maske. Fortschr Kieferorthop 39:27–40
Friede H, Lennartsson B (1981) Forward traction of the max-
illa in cleft lip and palate patients. Eur J Orthod 3:21–39
Haas AJ (1970) Palatal expansion: just the beginning of
dentofacial orthopedics. Am J Orthod 57:219–255
Irie M, Nakamura S (1974) Orthopedic approach to severe
skeletal class III malocclusion. Am J Orthod 67:375–377
Kettle MA, Burnapp DR (1955) Occipito-mental anchor-
age in the orthodontic treatment of dental deformities
due to cleft lip and palate. Br Dent J 989:12–14
Molstad K, Dahl E (1987) Face mask therapy in children
with cleft lip and palate. Eur J Orthod 9:3212–3215
Nanda R (1978) Differential response of midfacial sutures
and bones to anteriorly directed extraoral forces in
monkeys. J Dent Res 57:362
Ranta R (1988) Protraction of cleft maxilla. Eur J Orthod
10:215–222
Roberts CA, Subtelny JD (1988) Use of the face mask in
the treatment of maxillary skeletal retrusion. Am
J Orthod Dentofacial Orthop 93:388–394
Sarnas K-V, Rune B (1987) Extraoral traction to the max-
illa with face mask: a follow-up of 17 consecutively
treated patients with and without cleft lip and palate.
Cleft Palate J 24:95–103
Subtelny JD (1980) Oral respiration: facial maldevelop-
ment and corrective dentofacial orthopedics. Angle
Orthod 50:147–164
Tindlund RS (1989) Orthopaedic protraction of the midface
in the deciduous dentition: results covering 3 years out of
treatment. J Craniomaxillofac Surg 17(Suppl 1):17–19

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Tindlund RS, Rygh P (1993) Maxillary protraction: dif-
ferent effects on facial morphology in unilateral and
bilateral cleft lip and palate patients. Cleft Palate
Craniofac J 30:208–221
Tindlund RS, Rygh P, Boe OE (1993a) Orthopedic pro-
traction of the upper jaw in cleft lip and palate patents
during the deciduous and mixed dentition in compari-
son with normal growth and development. Cleft Palate
Craniofac J 39:182–194
Tindlund RS, Rygh P, Boe OE (1993b) Intercanine widen-
ing and sagittal effect of maxillary transverse expan-
sion in patients with cleft lip and palate during the
deciduous and mixed dentitions. Cleft Palate Craniofac
J 30:195–207

519
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_23, © Springer-Verlag Berlin Heidelberg 2013
23
23.1
Early Rehabilitation
Optimal rehabilitation of a child with cleft lip and
palate (CLP) involves the achievement of ideal
speech, facial aesthetics, and dental occlusion.
Dentofacial appearance is of major importance
for the development of a child’s self-esteem
(Stricker et al. 1979 ; Shaw 1981 ; Shaw et al.
1985 ). Early adolescence is a time of change and
uncertainty and a period of special importance
because negative self-esteem developed in these
years is likely to be retained into adulthood
(Alsaker and Olweus 1986 ; Alsaker 1990 ) .
Therefore, early rehabilitation is of major
importance.
Obtaining an optimal treatment result in com-
plete clefts of the lip and palate is dependent on
the prevailing treatment philosophy, clinical
skills, and the interaction of the Cleft Lip and
Palate (CLP)/Craniofacial Team. The orthodon-
tist is mainly concerned with the achievement of
normal long-term facial growth and development,
based on his or her ability to recognize, prevent,
and treat dentofacial anomalies.
Quality assurance and the cost-effectiveness
ratio are important factors that need to be con-
sidered in the systematic delivery of health care.
Quality assurance focuses on the achievement of
the goals and the quality of overall team man-
agement based on the usage of accepted physi-
ological principles. Treatment results are not
always predictable because patients differ in
their facial growth patterns and the nature of the
palatal defect, requiring individualized orthodon-
tic treatment plans depending on the developing
malocclusion. This philosophy is at variance with
the generally held orthodontic strategy, which is
to postpone all orthodontic intervention until the
permanent dentition (Semb and Shaw 1993 ) . The
relative low cost of utilizing interceptive ortho-
pedics at an early age, due to the need for infre-
quent visits with uncomplicated mechanics, is a
reasonable option for the early improvement of
dentofacial appearance. An additional bonus to
performing treatment at this period is that patients
develop a positive attitude toward themselves and
parents to their child’s future status.
The speci fi c aim of this chapter is to present
a CLP treatment program that incorporates inter-
ceptive orthopedics in faces with midfacial retrusion
and demonstrate how a fi xed orthopedic–orthodontic
appliance system may be used for both transverse
widening as well as the protraction of the maxilla.
Interceptive orthopedics is discussed with respect
to treatment timing and anticipated clinical results,
reviewing the limitations, and criteria necessary in
case selection to improve long-term prognosis.
Protraction Facial Mask for Early
Correction of Midfacial
Retrusion: The Bergen Rationale
Rolf S. Tindlund
R. S. Tindlund , DDS, Ph.D.
Department of Orthodontics and Facial Orthopedics,
Faculty of Medicine and Dentistry , University of Bergen ,
Årstadvn. 19 , N-5009 Bergen , Norway
e-mail: rolf.tindlund@odont.uib.no

520
R.S. Tindlund
23.2
Midfacial Retrusion in CLP
Patients
Irrespective of the method used in primary
cleft repair and the surgical skill of the opera-
tor, a certain number of patients will show an
unfavorable growth pattern. Even if one plastic
surgeon performs all surgery utilizing the same
procedures, and the same treatment protocol,
individual outcomes may vary from excellent to
unsatisfactory. The variable results re fl ect indi-
vidual differences in craniofacial type and growth
patterns on which the cleft maxilla is superim-
posed. Also, one needs to consider acquired vari-
ables, such as the degree of prenatal maxillary
hypoplasia and facial asymmetry in cleft embryo
pathogenesis and detrimental growth deviations
related to the surgical procedure and skill of the
surgeon.
Midfacial retrusion may be due to underde-
velopment and/or relative posterior positioning
of the upper jaw to the mandible. The maxillary
growth de fi ciency usually is three-dimensional,
resulting in a shortening of maxillary length and
a decrease in width and height. Midfacial retru-
sion is more often seen in unilateral cleft lip and
palate (UCLP) patients (Ross 1987 ; Semb
1991a ; Tindlund and Rygh 1993a ; Tindlund
et al. 1993a, 1994 ) , whereas in bilateral cleft lip
and palate (BCLP) the initially prominent pre-
maxilla becomes less protrusive over time,
achieving an almost ideal incisor overjet–over-
bite relationship by the late teenage years (Semb
1991b ) .
Patients with an underdeveloped maxilla, which
results in skeletal and/or dentoalveolar discrepan-
cies, often show anterior and/or posterior cross-
bites with a concave soft-tissue pro fi le. Since 1977
the treatment protocol of Bergen Cleft Palate–
Craniofacial Center has included an interceptive
orthopedic treatment phase designed to correct
anterior and posterior crossbites during the decidu-
ous and early mixed dentition and to obtain opti-
mal alveolar cleft space to enhance tooth eruption
and alveolar development. This would ultimately
lead to a favorable functional dental occlusion and
create better conditions for attaining normal mid-
facial growth and development (Tindlund and
Rygh 1982, 1993a, b ; Tindlund 1987, 1989, 1994a,
b ; Tindlund et al. 1993a, b, 1994 ) .
23.2.1 Anterior Crossbite
Anterior crossbite (incidence about 3–5 % in
Scandinavia) may be found in all facial types –
prognathic, orthognathic, and retrognathic – in
combination with varying degrees of hypo- or
hyperplasia of the jaws. Different sagittal skeletal
jaw con fi gurations, some with deep or skeletal
open bite, may be associated with excessive den-
toalveolar mandibular proclination or maxillary
retroclination along with lack of suf fi cient dental
space in the upper arch. Guyer et al. ( 1986 ) found
skeletal maxillary retrusion in two thirds of non-
cleft class III children. This is of great therapeutic
interest since orthopedic in fl uence seems to be
more effective in in fl uencing the sutures of the
maxillary complex than in restraining mandibular
growth (Thilander 1965 ; Delaire et al. 1972,
1976 ; Graber 1977 ; Ishii et al. 1987 ; Tindlund
1987, 1989, 1994a, b ; Rygh and Tindlund 1982 ;
Tindlund et al. 1993a, 1994 ) . However, the long-
term differential diagnosis between mandibular
excess and maxillary retrusion is dif fi cult to deter-
mine before puberty (Tweed 1966 ; Ruhland 1975 ;
Vego 1976 ; Schulhof et al. 1977 ; Campbell 1983 ;
Guyer et al. 1986 ) . For this reason, children with
the appearance of midfacial retrusion and anterior
crossbite may bene fi t from an early interceptive
orthopedic treatment phase. The need for orthog-
nathic surgery is usually determined after puberty,
taking facial appearance as well as dental occlu-
sion into consideration. A family anamnesis of
anterior and posterior crossbite is of particular
interest in the CLP population because maxillary
hypoplasia is a common fi nding in these patients.
23.2.2 Orofacial Function
Optimal orofacial function with adequate incisor
relationship in the primary dentition is an impor-
tant determinant for normal growth and develop-
ment of the anterior part of the maxilla. There is a
generally accepted belief that form and function
are mutually dependent. This interaction in facial
clefts is important because malfunction has been
shown to negatively in fl uence facial growth. Thus,
the facial characteristics of a noncleft child who is
a mouth breather may show some similarities in
appearance to the typical CLP patient (Tindlund

521
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
et al. 1993b, 1994 ) . In CLP, midfacial retrusion
due to de fi cient midfacial growth may be aggra-
vated by increased nasal airway resistance, low
and forward posture of the tongue, and lack of
suf fi cient stimuli from proper masticatory forces.
Early widening of the upper jaw enhances nasal
respiration (Linder-Aronson and Aschan 1963 ;
Harvold et al. 1972, 1973 ; Haas 1973 ) , while
permitting the tongue to assumes a more nor-
mal elevated position within the mouth (Ohkiba
and Hanada 1989 ) . Direction of eruption and the
fi nal position of teeth are closely associated with
the development of the alveolar process, which
in turn is dependent upon the number, size, and
location of teeth (Harvold 1954 ; Subtelny 1957 ;
Ogidan and Subtelny 1983 ) . Early orthopedic
treatment which includes transverse expansion
and anterior protraction of the maxillary complex
will improve the dimensions of the nasal as well
as the intraoral space, permitting the tongue to
elevate and assume a normal posture within the
vault space, thus breaking the vicious circle of
poor function leading to poor form with growth.
23.3
Principles of Orthopedic/
Orthodontic Treatment
in CLP Patients
The orthopedic/orthodontic CLP treatment pro-
tocol in Bergen utilized since 1977 is based on
selective periods of active, controlled, ef fi cient
treatment followed by intervals of fi xed retention,
as recommended by American Cleft Palate–
Craniofacial Association ( 1993 ) . The easily
obtained acceptance of the need for patient coop-
eration along with an excellent cost-effectiveness
assessment ratio supports the use of this philoso-
phy of treatment. The following orthodontic
treatment phases should be considered as viable
options for the individual patient:
1. Presurgical maxillary orthopedics (0–3 months,
used in a few cases only).
2. Interceptive orthopedics (6–7 years, about
20 % of cleft patients) which involves trans-
verse expansion and protraction (facial mask).
3. Alignment of maxillary incisors prior to sec-
ondary alveolar bone grafting.
4. Secondary alveolar bone grafting of the cleft
alveolar process.
5. Conventional orthodontics in the permanent
dentition is always necessary.
6. Dental adjustments dependent on prosthodontic
or orthognathic surgery needs (17–19 years).
Individualizing the timing and sequencing of
treatment is essential due to the wide range of
skeletal malformation associated with dental
malocclusions. It is of utmost importance to indi-
vidualize each treatment plan and to revise this
plan at different ages of dental and skeletal devel-
opment, all of which is conveniently based on a
diagnosis-related checklist.
23.3.1 Checklist for CLP Orthopedic/
Orthodontic Treatment
Objectives
23.3.1.1 Presurgical Orthopedics
The plastic surgeon aims at to obtain optimal
function and appearance and avoid the need for
extensive revisionary surgery by using proven
surgical techniques that result in a minimum of
scarring and palatal growth impairment. In some
cases, presurgical orthopedics can help the plastic
surgeon to unite anatomical structures with a min-
imum of force and stress to the tissue. Individual
decisions are made by the plastic surgeon:
Reposition severely displaced maxillary
•
segments
Reduce width of very wide clefts
•
Improve symmetry of nose and upper jaw
•
(Only used in extreme cases, and in some treat-
ment philosophies, this stage is not necessary.)
23.3.1.2 Interceptive Orthopedics
Transverse expansion followed by anterior pro-
traction of the upper jaw should only be uti-
lized in cases with anterior and/or posterior
crossbite with midfacial retrusion. Treatment
should be instituted early enough to allow the
permanent incisors to erupt spontaneously into
a normal overjet and overbite occlusion
(Fig. 23.1 ):
Eliminate anterior crossbite
•
Eliminate posterior crossbite
•
Create optimal space to permit spontaneous
•
eruption of the incisors
Improve nasal respiration
•
Improve tongue placement
•

522
R.S. Tindlund
Fig. 23.1 Complete UCLP, category 2A. (1–2) At birth,
January 1975; (3–4) after presurgical orthopedics; (5–6)
lip closure at age 3 months; (7–12) at 6 years moderate
anterior and unilateral posterior crossbites with a slight
concave pro fi le; (13–27) interceptive orthopedics from
age 6 years includes transverse expansion for 3 months
using a quad-helix, (14) followed by protraction for
6 months using a facial mask, (17–18) and retention using
a fi xed palatal archwire (15) to encourage spontaneous
eruption of upper permanent incisors into normal posi-
tion. A nice dental smile was achieved without early orth-
odontic alignment of the upper incisors (28–33). Alveolar
bone grafting at 10.5 years. Two right upper lateral perma-
nent incisors erupted into the cleft area; (34) facial pro fi le
at 12 years (35–41); conventional orthodontics at
13.5 years lasting for 18 months. The two upper second
bicuspids were missing, and the supernumerary right
upper lateral permanent incisor was removed; (42–48)
dental occlusion at 18.5 years; (49–50) cephalometric
graphic analysis at 6, after interceptive orthopedics at 15
and at 18 years; (51–53) facial appearance at 15 years;
(54–59) and facial appearance at 18.5 years

523
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
Fig. 23.1 (continued)

524
R.S. Tindlund
Fig. 23.1 (continued)

525
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
Fig. 23.1 (continued)

526
R.S. Tindlund
Fig. 23.1 (continued)

527
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
23.3.1.3 Alignment of Maxillary Incisors
In spite of achieving optimal dental space after
transverse expansion, the permanent incisors often
erupt rotated and retruded, tipped, or retroclined,
placing them in crossbite. After transverse expan-
sion, alignment of the permanent incisors is easily
performed, giving the child a nice dental smile
equal to that of his or her classmates (Fig. 23.2 ; in
Fig. 23.1 , incisor alignment was not needed):
Straightening of malpositioned incisors
•
Creating an optimal aesthetic incisor relation-
•
ship to the facial midline
23.3.1.4 Secondary Alveolar
Bone Grafting
The use of primary periosteoplasty at age 3 months
was rejected after introduction of secondary bone
grafting (Bergland et al. 1986 ) . It is usually per-
formed between 8 and 11 years of age with the
orthodontist selecting the appropriate age:
Eliminate remaining bony clefts and improve
•
bony support of contiguous teeth
Enhance orthodontic closure of the missing
•
incisor space in the cleft area
Stabilize of separated jaw segments
•
Close oronasal fi stulas
•
Provide bony support to alar base in cases with
•
nasal asymmetry
Eliminating mucosal recesses
•
23.3.1.5 Conventional Orthodontics
in the Permanent Dentition
The orthodontic treatment goals are similar to
those for nonclefts, using the same general orth-
odontic principles utilized for noncleft patients:
To establish ideal dental function, facial aesthet-
ics, and speech. Extraction of mandibular teeth to
compensate for a hypoplastic upper jaw is usu-
ally not indicated until after the critical mandibu-
lar growth period has passed. In CLP patients, a
bonded palatal fi xed retainer is often necessary
after treatment involving arch expansion to avoid
relapse of the corrected palatal arch form:
Improve the relationship of the lips
•
Achieve harmonious balance of the dentition
•
in the opposing jaws
Achieve favorable skeletal maxillomandibular
•
jaw relationship
Achieve normal incisor overjet and overbite
•
Correct dental axial inclinations
•
Avoid the use of arti fi cial teeth
•
Achieve functional dental occlusion
•
Achieve optimal nasal breathing
•
23.3.1.6 Dental Adjustments at Ages
16–17 Years for Girls
and 18–19 Years for Boys
In cases with major skeletal jaw discrepancies,
orthognathic surgery may be needed to normalize
the skeletal jaw relationship and achieve a well-
balanced facial appearance with stable dental
occlusion. If two or more teeth are absent in the
same dental segment, a small bridge is normally
needed. However, dental implants are likely to
become an important aspect of future prosthetic
replacements.
23.4
Outline of CLP Treatment
Procedures in Bergen
To appreciate our treatment philosophy, a brief
summary of the treatment approach and concepts
of the Bergen Cleft Palate Center will be pre-
sented. Along with the Oslo CP Center, it serves
a population of fi ve million. Due to demographic
distribution, many patients must travel distances
up to 2,000 km to either center. Hardships are
compounded by the need to travel in very cold
weather during winter; therefore, the planning
and coordination of health services are crucial
for optimal utilization of available resources.
Treatment costs and travel expenditures are cov-
ered by the government’s social security pro-
gram. The Bergen CLP Team treats about 55
newborn babies yearly. Treatment procedures are
coordinated between the Department of Plastic
and Reconstructive Surgery, University Hospital
of Bergen; the CLP Center at the Department of
Orthodontics and Facial Orthopedics, Faculty of
Medicine and Dentistry, University of Bergen;
and the Eikelund Center for Speech Pathology.
23.4.1 Plastic Surgery
Since 1986, in complete clefts of the lip and pal-
ate, a Millard lip closure is performed at 3 months

528
R.S. Tindlund
a
b
e
d
c
f
h
g
Fig. 23.2 ( a – h ) Interceptive orthopedics (Bergen
rationale). ( a , b ) Transverse maxillary widening using a
modi fi ed quad-helix appliance. ( c , d ) Followed by maxil-
lary protraction with a facial mask (Delaire type). ( e , f )
Correction retained with a fi xed palatal arch with brackets
and tubes for early alignment of the upper incisors.
Retention is utilized until deciduous anchor teeth are shed.
( g , h ) A nice dental smile as early as possible

529
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
combined with a single-layer vomerplasty for
closure of the anterior part of the palate. The soft
palate and isolated palatal clefts are closed at
12 months using a von Langenbeck technique.
Alveolar bone clefts are left open until secondary
bone grafting at 8–11 years of age. Between 1971
and 1986, the lip closure was combined with a
periosteoplasty of the cleft alveolar process
(Schjelderup and Johnson 1983 ) .
23.4.2 Interceptive Orthopedics
23.4.2.1 Protraction Facial Mask
Extraoral heavy forces from a facial mask directed
forward and downward from the maxillary cus-
pid area have been shown to correct midfacial
retrusion at an early age (Delaire et al. 1972,
1976 ; Tindlund 1987, 1989, 1994a, b ; Tindlund
and Rygh 1993a, b ; Tindlund et al. 1993a, b,
1994 ) . Protraction from the maxillary cuspid area
produces an adequate horizontal and vertical
force to increase midfacial vertical height as well
as anteroposterior length. In some instances, it
also can reduce an anterior open bite by lowering
the palatal plane. For this reason, early correction
of anterior and/or posterior crossbites during the
deciduous and mixed dentition is highly
recommended:
Bergen rationale:
1. Transverse expansion coupled with
2. Protraction of the upper jaw and
3. The use of fi xed palatal arch retention after
treatment
When considering a treatment plan for young
children who travel long distances, it is important
to consider patient comfort as well as treatment
ef fi ciency.
In cases of marked midfacial retrusion, intercep-
tive orthopedics is started at 6 years and often lasts
for 15 months with an average of six visits (two vis-
its for a transverse expansion of about 10 mm dur-
ing a 3-month period and an additional four visits
for the use of protraction forces for 12 months).
23.4.2.2 Quad-Helix Spring
(with Four Bands and Hooks)
A fi xed palatal expansion appliance can be easily
combined with the use of an extraoral facial mask
(Figs. 23.1 and 23.2 ) (Rygh and Tindlund 1982 )
providing:
1. Controlled transverse expansion when needed
2. Adequate fi xation for anterior protraction by a
facial mask
3. Use with edgewise appliance for the align-
ment of incisors
4. Well tolerated by small children without seda-
tion, causing a minimum of discomfort
5. Minimum of chair time
6. Can be easily kept clean
The creation and use of a modi fi ed quad-helix
[Rocky Mountain: maxillary quad-helix. 0.38
(0.985 mm) Blue Elgiloy (Ricketts)] appliance
(Rygh and Tindlund 1982 ) is shown in Fig. 23.3 .
Four preformed bands with brackets or tubes are
placed on the second deciduous molars and
deciduous cuspids and are soldered to the quad-
helix spring. The fi rst deciduous molars serve as
additional anchorage. Permanent molars are
banded only when the second deciduous molars
are missing. Hooks for elastics are positioned
mesiolingually to the cuspid bands. The elastics
are attached to the protraction facial mask
(Fig. 23.2c, d ). The elastic forces are directed for-
ward and downward from the anterior maxillary
segment, resisting the normal counterclockwise
rotational effect. The quad-helix appliances when
used with brackets and tubes permit alignment of
upper incisors after their eruption (Figs. 23.1 and
23.3j–l ).
23.4.2.3 Transverse Expansion
The modi fi ed quad-helix appliance is removed
from the teeth and adjusted and activated at
6-week intervals (Fig. 23.2a, b ). A resiprocal force
of about 200 g on each side is optimal. The arch
increases in width approximately 3 mm per month,
irrespective of cleft type (Tindlund et al. 1993b ) .
The cuspid segments often need more expansion
than the molar area. Because there is a great ten-
dency for relapse, overexpansion is necessary.
With transverse expansion of the maxillary
arch, a downward clockwise rotation of the man-
dible occurs without any forward movement of
the maxilla (Tindlund et al. 1993b ) . By compar-
ing the use of fi xed quad-helix appliances with
removable expansion plates on noncleft patients,
Hermanson et al. ( 1985 ) found that a fi xed quad-

530
R.S. Tindlund
Fig. 23.3 ( a – l ) Fabricating a modi fi ed quad-helix
appliance. ( a , b ) Bilateral posterior crossbite with lack of
space for erupting lateral permanent incisors. Bands with
brackets or tubes are fi tted to the upper deciduous cuspids
and deciduous second molars and carefully replaced into
an alginate impression. ( c ) Plaster removed underneath
soldering zones. ( d ) Quad-helix arms are precisely
adjusted. ( e , f ) Quad-helix arms are soldered to all four
bands. ( g ) Each arm is individually activated. ( h )
Cemented. ( i – k ) Combined with round labial arches for
alignment of incisors. ( l ) Labial incisor root torque with
rectangular archwire
helix appliance was more effective with fewer vis-
its, less costly, and required shorter treatment time.
Further, a removable plate would not readily resist
the forward-downward traction to the cuspid area
from a facial mask. As a rule, transverse expan-
sion is completed before protraction is started.
23.4.2.4 Protraction
The quad-helix appliance is formed to make pas-
sive contact with the incisors, by bends or by a
soldered-on extension (Fig. 23.2a, b ). In cases
where no transverse expansion is needed, or if the
quad-helix spring is inconvenient after the expan-
sion period, a simple palatal arch is soldered to
four bands on second deciduous molars and cus-
pids (Fig. 23.2e, f ). The intraoral appliance is
used as anchorage for the facial mask (Scheu:
Great Lake Reversed Pull Face Crib, 2500.1
small) (Fig. 23.2c, d ). No other mask fi xation is
needed other than the two intraoral elastics

531
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
[Unitek: Latex ex-oral 1/4”LGT; Unitek/3M:
“Fran” 8oz. 1/4” (404–736)] from hooks in the
cuspid areas. The force used for facial protraction
is about 350 g on each side, totaling 700 g. The
facial mask is used mainly at night for 10–12 h.
Sleeping disturbances have not been reported.
Patient cooperation is excellent in almost all
cases. Within a few days, the children manage to
put on the mask themselves, and complaints
about soreness are very rare. It is important that
the elastics are attached to the anterior segment
and inclined downward and forward about 15° to
the occlusal plane. Several facial masks of vari-
ous designs are now available. If the use of pro-
traction forces is delayed until the permanent
incisors are fully erupted, elastic forces from
hooks placed on the arch wire between the lateral
incisor and cuspid area may be utilized. In most
cases, the incisors should be advanced bodily to
obtain surface bone deposition at subnasal
(A-point) by use of edgewise arch wires with
labial root torque (Fig. 23.3l ).
23.4.2.5 Fixed Retention
The results obtained by early orthopedics must
be stabilized with a passive fi xed palatal arch
wire. The retainer remains until the anchor decid-
uous teeth are lost (Fig. 23.2e ). The palatal arch
wire (or quad-helix appliance) may be combined
with multibracketed appliances to align the per-
manent incisors (Fig. 23.2f ).
23.4.2.6 Treatment Timing
of Interceptive Orthopedics
Proper treatment timing during the late decidu-
ous dentition or early mixed dentition periods is
of utmost importance. Delaire et al. ( 1972, 1976 )
observed that maximum skeletal maxillary
changes occurred when protraction therapy was
instituted before 8 years of age. Tindlund ( 1994a,
b ) found signi fi cantly better skeletal response
when protraction began at 6 years (mean age 6.3).
At this age, the annual sutural growth rate is
nearly as high as that found at the pubertal period
(Bjørk 1968 ) , when development of the heavily
interdigitated sutural systems has already com-
menced (Melsen 1974 ; Melsen and Melsen
1982 ) . Protraction during the deciduous dentition
period minimizes unwanted dentoalveolar procli-
nation of maxillary incisors in the permanent
dentition (Tindlund et al. 1993a, b ) .
Early habilitation of facial appearance and den-
tal functions, preferably before the start of school,
is considered a major goal (Semb 1991a ; Rygh
and Tindlund 1982 ; Tindlund 1987 ) . The coopera-
tion of the young patients is often more predictable
at this age (Tindlund 1994a, b ) . The objective of
having the permanent upper incisors erupt into a
positive overjet and overbite relationship warrants
that orthopedics should be started even earlier in
cases with severe skeletal jaw discrepancies.
Postponement of orthopedic treatment increases
the likelihood that achieving positive effects on the
facial growth pattern will fail to occur.
23.4.3 Treatment Results of Using
a Protraction Facial Mask
23.4.3.1 Clinical Results
The excellent results achieved by the early use of
interceptive orthopedics to correct an anterior
and/or posterior crossbite also have a desirable
effect on improving dentofacial appearance
(Delaire et al. 1972, 1976 ; Tindlund and Rygh
1993a, b ; Tindlund et al. 1993a, b, 1994 ; Tindlund
1994a, b ; Buschang et al. 1994 ) . Treatment out-
comes can vary because success also depends on
inherited craniofacial characteristics and the
severity of the primary and secondary midfacial
malformations related to clefting. Generally, the
treatment response is less favorable in facial types
with increased anterior vertical height and a steep
mandibular plane angle.
Patient cooperation is of major importance for
obtaining a good treatment outcome. Using pro-
traction therapy in 108 CLP patients with anterior
crossbite in the deciduous dentition, Tindlund et al.
( 1993a ) achieved favorable incisor relationships in
98 cases. Signi fi cant increase of maxillary skeletal
prognathism by protraction was found only in the
UCLP group, whereas treatment effects in the
BCLP cases were mainly dentoalveolar (Tindlund
and Rygh 1993a ) . The observation of signi fi cant
differences between the UCLP and BCLP groups
in Bergen is most likely associated with the pri-

532
R.S. Tindlund
mary surgical procedures utilized, which included
a periosteoplasty. A bony fusion of jaw segments in
BCLP on one or both sides may impair treatment
response as well as facial growth.
After protraction treatment, there was no
signi fi cant difference in the maxillary prog-
nathism attained between the UCLP and BCLP
groups (Tindlund and Rygh 1993a ) . The sagittal
position of the upper molars was normalized in
both groups. Increase of the upper facial height
(“n-sp”) and clockwise rotation of the occlusal
plane were signi fi cantly greater in the BCLP
group. The upper incisors were still retroclined in
both groups, which is considered a bene fi cial
state. A later dentoalveolar proclination will com-
pensate for future mandibular development. On
the average, the period of protraction lasted
12 months in the UCLP group and 15 months in
the BCLP group.
The skeletal response to maxillary protraction is
expected to vary considerably as a consequence of
skeletal facial variation, differences in the cleft
defects, and in cleft repair (Tindlund 1994a ).
Favorable response in the sagittal skeletal maxillo-
mandibular jaw relationship was found in 63 %
(mean increase of angle ANB was 3.3°), whereas
favorable response on skeletal forward movement
of the maxilla was found in 44 % (mean advance-
ment 2.4 mm). A combined favorable response of
both the mandible and the forward movement of the
maxilla was found in 35 % (Tindlund 1994a ) . In
this group, the mean increase of the maxillary prog-
nathism was 2.1°, the angle ANB increased 3.7°,
the maxilla moved forward 3.1 mm, and the maxil-
lary dentition was advanced 4.3 mm. In cases where
the sagittal jaw discrepancy was due to overgrowth
of the mandible, the resulting changes accentuated
a mandibular downward/posterior rotation, increas-
ing anterior facial height.
Cephalometric predictors for good orthopedic
treatment response were retrusion of the upper
jaw due to short maxillary length resulting in a
class III skeletal and dental relationship and
counterclockwise inclination of the occlusal
plane. This is associated with a retrusion of the
upper lip and the nose tip (Tindlund 1994b ) .
Favorable increase of a positive ANB angle is
associated
with
mandibular
retrognathism,
whereas skeletal forward movement of the max-
illa with lesser changes in the ANB angle was
more often seen in cases with normal mandibular
prognathism.
23.4.3.2 Limitations
During protraction, the upper permanent incisors
should never be proclined beyond normal tooth
inclination within supporting basal bone, and the
lower incisors should never be retroclined more
than their normal position within the alveolus
(Tindlund et al. 1993a ) . If a normalization of the
maxillomandibular skeletal discrepancy is not
achieved along with normal dental axial inclina-
tions of the permanent incisors, further protraction
should be avoided and orthognathic surgery con-
sidered (see categories 2A and 2B in Sect. 23.4.4 ).
On the other hand, protraction during the decidu-
ous dentition is advocated in every case with an
anterior crossbite, even in cases with a family his-
tory of true mandibular prognathism. The fi nal
diagnosis for orthognathic surgical treatment
should be delayed until approximately 13 years of
age for girls and the late teens for boys.
23.4.3.3 Stability/Relapse
After protraction, the maxilla and mandible appear
to maintain their original growth pattern. Although
there is no relapse of the corrected upper jaw rela-
tionship (Tindlund 1989 ) , the maxillomandibular
relationship often worsens through normal for-
ward growth of the mandible while the maxillary
position relative to the anterior cranial base
appears to remain constant. However, long-term
results show individual variation of this fi nding,
and in cases with moderate midfacial retrusion,
early protraction is often suf fi cient to maintain the
improved inter-incisor relationship with growth
(Fig. 23.1 ) (Rygh and Tindlund 1995 ) .
23.4.3.4 Soft-Tissue Pro fi le
As already stated, the characteristic concave
pro fi le with midfacial retrusion is readily
improved with protraction (Fig. 23.1 ) (Buschang
et al. 1994 ) . The changes were nearly the same in
BCLP and UCLP patients with signi fi cant protru-
sion of the upper lip (mean increase of 3.0° in the
Holdaway angle; mean increase of maxilloman-
dibular lip positioning (SS-N-SM, angle of 2.5°))
(Tindlund and Rygh 1993b ) . Although there is a

533
23 Protraction Facial Mask for Early Correction of Midfacial Retrusion: The Bergen Rationale
close relationship between the soft-tissue pro fi le
and the supporting hard-tissue structures (Segner
1992 ; Tindlund and Rygh 1993b ) , the improved
soft-tissue pro fi le commonly seen after protrac-
tion is more stable than the ANB angle which is
also dependent on mandibular position, size, and
growth (Tindlund 1989 ) .
23.4.4 Long-Term Prognosis After
Interceptive Orthopedics
By age 6 years, the craniodentofacial growth and
development may give some indications of the
facial appearance at adulthood. The CLP patients
with few exceptions can be placed into one of
four categories, irrespective of the type of cleft-
ing (Rygh and Tindlund 1995 ) :
Category 0: Normal skeletal facial morphology
Need of treatment :
Alignment of upper permanent
•
incisors at ages 7–8 years?
Conventional orthodontic treat-
•
ment at ages 11–13 years
Prognosis : Very good
Category 1: Normal skeletal facial morphol-
ogy, except posterior crossbite(s)
Need of treatment :
Interceptive orthopedics: trans-
•
verse expansion of the upper
jaw at ages 6–7 years
Alignment of upper permanent
•
incisors at ages 7–8 years?
Conventional orthodontic treat-
•
ment at ages 11–13 years
Prognosis : Very good
Category 2A: Moderate skeletal facial
discrepancies
Need of treatment :
Interceptive orthopedics: trans-
•
verse expansion and protraction
of the upper jaw at ages
6–7 years
Alignment of upper permanent
•
incisors at ages 7–8 years?
Conventional orthodontic treat-
•
ment at ages 11–13 years
Prognosis : Good/fair for a perma-
nent result
Category 2B: Severe skeletal facial discrepan-
cies, however, cannot be differ-
entially diagnosed from Category
2A until ages 12–15 years
Need of treatment :
Interceptive orthopedics: trans-
•
verse expansion and protrac-
tion of the upper jaw at ages
6–7 years
Alignment of upper permanent
•
incisors at ages 7–8 years?
Conventional orthodontic treat-
•
ment at ages 11–13 years
Combined orthodontic/orthog-
•
nathic surgical correction at
adult age
Prognosis :
After
orthognathic
surgery: good regarding upper
arch form, tooth position, and
soft-tissue pro fi le. Poor perma-
nent result until after orthognathic
surgery with stable retention of
the arch form.
Patients in category 2B may be candidates for
orthognathic surgery at an adult age. However,
this is not a contraindication for early maxillary
protraction provided this does not lead to dentoal-
veolar compensations that undermine the possi-
bility for optimal surgical intervention at a later
age. On the contrary, early orthopedics may cre-
ate a better physical environment for successful
orthognathic surgery. Thus, less maxillary
advancement at the time of surgery may improve
the postsurgical stability. Besides, the child has
greatly bene fi ted from an improved dentofacial
appearance during the important formative years.
Conclusions
The speci fi c aims of early interceptive ortho-
pedics/orthodontics are:
1. To achieve maximum facial aesthetics,
with an adequate incisor overjet–overbite
relationship and “a nice dental smile” with
symmetry of the dental and facial midlines.
2. The elimination of anterior and posterior
crossbite and the recovery of space for the
erupting incisors. This is considered “lege
artis” (standard operating procedure) in
children without clefts, and, obviously, the

534
R.S. Tindlund
same considerations are valid for a child
with a cleft.
3. Early orthopedic–orthodontic correction
generates an optimal skeletal base to
accommodate erupting upper permanent
incisors and improve dental function.
Protraction produced signi fi cant changes: (1)
a more anterior position of the upper jaw and
(2) a more posterior position of the chin point
due to mandibular downward-backward rota-
tion. Signi fi cant increase of skeletal maxillary
prognathism was found only in the UCLP
patients, while in BCLP cases, the treatment
effect was mainly dentoalveolar.
The initial growth pattern reappears after pro-
traction, with the upper jaw’s position relative
to the anterior cranial base remaining stable,
while the mandible’s position changes as it
grows forward and downward. Soft-tissue
pro fi le changes are lasting.
Fixed appliances are indispensable for con-
trolled orthopedic/orthodontic mechanics to
obtain all treatment objectives and for the per-
manent retention of the corrected arch form.
Bonded palatal retainers are frequently
required.
A diagnosis-related checklist is the method of
choice for individualizing orthodontic treat-
ment. Orthopedic/orthodontic intervention
should be based on the same principles that
are valid for noncleft patients.
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537
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_24, © Springer-Verlag Berlin Heidelberg 2013
24
24.1
Surgical Maxillary
Advancement LeFort I
Osteotomy
Not long ago, maxillary advancement seemed a
formidable procedure to many surgeons. Cleft
patients with Class III malocclusion often were
treated by the more familiar method of mandibu-
lar setback, even though the problem, by clinical
and cephalometric examination, could be shown
to be in the maxilla.
Today, the LeFort I osteotomy is a standard
adjunct to the treatment of patients with cleft lip
and palate. No matter how gentle or atraumatic
the original surgery on the lip and palate, there
will probably always be cleft patients who require
the LeFort I procedure. It should be as much a
part of the armamentarium of cleft palate teams as
closure of the lip or palate or a pharyngeal fl ap.
Mandibular growth should be largely completed
before a maxillary advancement is performed; for
girls this age is around 14–15, and for boys perhaps
a year or two older. Most orthodontists advise that
several lateral cephalometric fi lms, taken 6 months
apart, should show no further growth before the
operation is scheduled.
As for timing, it is better to perform the lip
and nasal surgery during separate sessions. If the
alveolus is intact and there are no buccal cross-
bites, expansion of the maxilla is not required,
and the LeFort I osteotomy is a relatively simple
procedure. The nonintubated nostril is packed
with cocaine/epinephrine-impregnated gauze,
as for rhinoplasty, and the upper labial sulcus
is in fi ltrated with a 1:2,000,000 epinephrine/
hyaluronidase solution. The incision is made
above the re fl ection of the sulcus, sparing the
frenulum. The mucosal incision does not extend
beyond the fi rst molar. Subperiosteal dissection of
the anterior maxilla is carried out to the infraor-
bital rims, visualizing the infraorbital nerves,
and then taken posteriorly beneath the mucope-
riosteal tunnel to the pterygomaxillary space. If
the dissection is strictly subperiosteal, there is no
bothersome exposure of the buccal fat. The piri-
form aperture is dissected, sometimes removing a
portion of the nasal spine, and the nasal mucope-
riosteum is dissected back to the hard palate–soft
palate junction. The septum can either be sepa-
rated bluntly from the vomer or a guarded osteot-
ome can be used. The osteotomy is performed
largely with the reciprocating saw, starting later-
ally in the thick bone beneath the buttress of the
LeFort I Osteotomy
S. A. Wolfe and Samuel Berkowitz
S. A. Wolfe , M.D. (*)
Chief, Division of Plastic Surgery ,
Miami Children’s Hospital , Miami , FL 33155 , USA
e-mail: drawolfe@bellsouth.net
S. Berkowitz , DDS, M.S., FICD
Adjunct Professor, Department of Orthodontics ,
College of Dentistry, University of Illinois ,
Chicago , IL , USA
Clinical Professor of Surgery and Pediatrics (Ret),
Director of Research (Ret),
South Florida Cleft Palate Clinic,
University of Miami School of Medicine ,
Miami , FL , USA
Consultant (Ret), Craniofacial Anomalies Program ,
Miami Children’s Hospital , Miami , FL , USA
e-mail: sberk3140@aol.com

538
S.A. Wolfe and S. Berkowitz
zygoma and proceeding medially through thinner
bone. The osteotomy through the piriform aper-
ture and medial wall of the antrum is done with
the saw blade pointed laterally (Fig. 24.1 ).
Sectioning of the palatine bone, the sole attach-
ment of the maxillary tuberosity to the pterygoid
plate of the sphenoid, follows. The lateral osteotomy
can be taken a bit farther back by a few taps on a
straight osteotome, and the medial antral wall can be
further sectioned with a guarded nasal osteotome.
At this point, the only remaining attachment
of the lower maxillary segment is the posterior
wall of the antrum, and fi rm, downward fi nger
pressure on the maxilla is usually enough to pro-
duce a down-fracture. If not, the forceps can be
inserted underneath the nasal mucosa and the
maxilla completely mobilized with a downward
and side-to-side motion. It can be further mobi-
lized with a blunt elevator used as a lever.
The maxilla is then placed in the desired
occlusal relation with the mandible, and both
jaws are placed in the desired relationship with
the rest of the face. An autogenous iliac or cranial
bone graft is used when the face is to be length-
ened, when the degree of maxillary advancement
is more than 5 mm, or when the patient has a
cleft. If the maxilla is shortened, the resected
bone is placed over the osteotomy lines.
Sometimes the alveolus is intact, but the maxilla
needs to be expanded, as may occur in a cleft patient
a
b
c
d
e
f
Fig. 24.1 ( a – f ) Instrumentation for the LeFort I osteot-
omy. ( a ) Reciprocating saw with irrigation (Aesculap).
( b ) Guarded septal and nasal osteotomes. ( c ) Kawamoto
osteotome. ( d ) Rowe forceps with rubber guard on the
palatal arm. ( e ) Nestor (blunt, heavy, periosteal elevator
modi fi ed by Jack Nestor Engineering, Inc., Miami,
Florida). ( f ) Expansion forceps

539
24 LeFort I Osteotomy
who has a buccal crossbite and an alveolar cleft.
This procedure is easily performed from above the
hard palate, and the palatal mucosa is kept intact if
possible. The sectioning is performed with the
reciprocating saw, and an elevator is inserted to
gently pry the two segments apart. Expansion for-
ceps can be used if required. If the palatal mucosa
absolutely prevents expansion, it is divided, creat-
ing an alveolar and anterior palatal cleft.
If there is an alveolar cleft to begin with, the
two maxillary segments are handled independently
and brought into proper occlusion with the man-
dible. The palatal cleft-nasal fl oor defect is bone-
grafted, and if necessary a transportation fl ap is
developed from the buccal sulcus (Burian) to close
the palatal defect. In rare instances, a tongue fl ap is
required. The nasal lining, which will have been
carefully dissected at the beginning, is closed
before the palatal bone graft is inserted.
The procedure has now been re fi ned to the stage
that is the same regardless of whether the alveolus
was initially intact. Miniplates are placed between
the upper and lower portions of the maxilla for
rigid fi xation. If bone grafts are required, they are
placed either between or over the bone cuts.
If the desired maxillary advancement measures
more than 6 mm, bone grafts can be wedged into the
pterygomaxillary gap. This step is facilitated by
using a traction wire placed through the thick bone
beneath the nasal spine. The wire is used to pull the
maxilla to the opposite side, which opens the gap and
allows impaction of the bone graft. Circumzygomatic
wires are almost never used, because they pull the
maxilla back, they are too long (long wires can
“stretch” more than short wires), and they do not pre-
vent the anterior maxilla from rocking downward.
Wolfe ( 1989 ) uses an iliac or cranial bone graft
on all cleft patients, as these patients are likely to
have a maxillary relapse. Generally, the bone can
also be used as an onlay to fi ll out a de fi cient max-
illa. If the advancement is less than 5 mm, bone is
placed only over the anterior osteotomies and in
the alveolar and palatal cleft, if present.
The use of anything other than a fresh autog-
enous bone graft is unsafe. It takes about 15 min
to harvest the needed amount of iliac or cranial
bone. In the former case, the patient will be com-
fortable as far as the hip is concerned within
1–2 weeks. By this time, the autogenous graft
will have consolidated. With cadaver or deminer-
alized bone or with hydroxyapatite, consolidation
may require months, or may never occur.
Like the sagittal splitting procedure for the
mandible, the LeFort I osteotomy, once mastered,
can provide a solution to a number of maxillary
problems. After the horizontal osteotomy, down-
fracture, and mobilization, the maxilla can be:
1. Advanced directly with or without a bone graft
(in the noncleft class III patient).
2. Advanced, or advanced and expanded trans-
versely, with a bone graft (in the cleft patient).
3. Moved superiorly after resection of a mea-
sured amount of maxilla above the horizontal
osteotomy (in cases of “long face,” resulting
from vertical maxillary excess).
4. Moved inferiorly with a bone graft (in cases of
“short face,” or vertical maxillary de fi ciency).
5. Sectioned into multiple segments with teeth
(Wassmund or Schuchardt procedure, done from
above).
6. Moved directly backward, although this is dif fi cult
to do. (The resection should be of the maxillary
tuberosity after extraction of the third molars
rather than of the pterygoid plate.) The same result
can generally be achieved by an associated seg-
mental osteotomy performed more anteriorly.
With the maxilla in the down-fractured posi-
tion, multiple osteotomies can be performed from
above, which, coupled with or without dental
extractions, permit the dental correction of com-
plex malarrangements of the maxilla in one stage.
The circulation of blood to the anterior segment
comes entirely through the palatal mucoperios-
teum, and one must be certain that there are no
protrusive edges from the occlusal splint to
impinge on the anterior palate. Any number of
transverse sagittal osteotomies can be performed,
depending on the requirements of the individual
case.
Attempts to treat an anterior open bite by man-
dibular ramus osteotomies are often unsuccessful
due to relapse caused by the predominance of the
masticatory muscles. Anterior segmental osteot-
omies of the mandible are appropriate when there
is dental crowding and a downward angulation of
the mandibular occlusal plane.
The Schuchardt procedure can be used to
shorten posterior maxillary height, but it is rarely
used in the USA because it requires either an inter-
dental osteotomy or a tooth extraction (Fig. 24.2 ).

540
S.A. Wolfe and S. Berkowitz
If the orthodontist can level the maxillary
occlusal plane, even by accentuating the open bite,
the simplest and most stable solution is the LeFort
I osteotomy. If the position of the maxillary central
incisors relative to the lower vermilion border of the
upper lip is satisfactory beforehand, this relation-
ship is preserved. If desired, the maxillary incisors
can be raised or lowered relative to the upper lip.
After the maxilla has been completely mobi-
lized, intermaxillary fi xation is established and
the maxillomandibular complex seated with fi rm
upward and posterior pressure to set the con-
dyles. Appropriate resection of the posterior
and, if necessary, the anterior maxilla is per-
formed until the desired anterior maxillary
height is obtained. Stabilization of the maxillary
osteotomy is then performed with miniplates,
and the intermaxillary fi xation, if utilized, is
temporarily discontinued to evaluate the occlusal
relationship with the patient; head in a fi xed
position. This examination will reveal whether
the condyles were inadvertently pulled out of
a
b
c
d
e
Fig. 24.2 LeFort I surgical
procedures: various
directions the maxilla can be
moved. ( a ) Inferiorly:
requires bone grafts to
maintain the new position.
( b ) Superiorly: no grafts
required. ( c ) Forward:
requires a posteriorly
supporting bone graft. ( d )
The posterior segment is
moved superiorly while the
anterior segment is moved
posteriorly. When the
premaxilla is retruded it
usually needs to be surgically
widened through the
midpalatal suture between the
central incisors to maintain
good cuspid interdigitation.
( e ) The premaxilla moved
superiorly

541
24 LeFort I Osteotomy
the glenoid fossae. A Class II relationship indi-
cates that the maxilla must be posteriorly repo-
sitioned, either by resecting a portion of
pterygoid plates (which is dif fi cult) or by extract-
ing the maxillary third molars and resecting a
portion of the maxillary tuberosity (which is
easier) (Figs. 24.2 and 24.3 ).
24.2
Stability of Maxillary
Advancement
A disappointing yet frequent sequel to orthognathic
surgery to advance the maxilla is its partial or com-
plete return to the original state (relapse). The max-
illary advancement occurs within a limiting soft
tissue envelope (the skin and muscles). Mandibular
advancement surgery, especially when it involves
the mandibular ligaments, has a great tendency to
relapse. The degree of relapse is often judged by
measuring occlusal or skeletal landmark changes.
Hochban et al. (Hochban et al. 1993 ) in a
review of the literature reported that the use of
miniplates (in rigid fi xations) is superior to wire
fi xation in overcoming the tendency to relapse.
Currently, most reports favor the use of mini-
plates (Ward-Booth et al. 1984 ; Houston et al.
1989 ; Champy 1980 ; Horster 1981 ; Luyk and
Ward-Booth 1985 ; Rosen 1986 ) . Prof fi t and
Phillips ( 1987 ) found a skeletal relapse at 32 %
after midface advancement using wire fi xation
compared with 25 % after miniplate fi xation.
Some investigators believe that the amount of
relapse is directly related to the amount of
advancement (Wolfe and Berkowitz 1989 ;
Houston et al. 1989 ; Carpenter et al. 1989 ) ,
a
c
d
e
b
Fig. 24.3 ( a ) Initial incisions for LeFort I surgery with a
secondary alveolar bone grafting to be performed simulta-
neously. ( b ) The maxilla is moved inferiorly with bone
grafts placed at the surgical cite to support the lengthened
maxilla. Alveolar bone graft placed from the nasal aper-
ture to the alveolar crest. Prior to the use of metal plates
(rigid fi xation) steel sutures were used to stabilized the
separated segments. An acrylic surgical wafer is used to
position the bony segments according to prior mock sur-
gery performed on plaster casts. Intermaxillary fi xation of
the maxilla to the mandible using intermaxillary rubber
bands for 4–6 weeks is recommended in cases with severe
palatal scarring in conjunction with the use of rigid
fi xation. ( c ) Lateral view shows a bone block placed
between the perpendicular plates of the sphenoid and the
maxillary tuberosity with a bone graft to the premaxil-
lary–maxillary junction. ( d ) Buccal segments are superi-
orly positioned to permit mandibular auto-rotation and
reduction of the anterior open bite. ( e ) Posterior maxillary
impaction to close an open bite (Schuchardt). Buccal seg-
ments are superiorly positioned to permit mandibular auto
rotation and closure of an anterior open bite

542
S.A. Wolfe and S. Berkowitz
whereas others think there is no correlation
between displacement of the maxilla and relapse
(Rosen 1986 ; Prof fi t and Phillips 1987 ; Iannette
et al. 1989 ) . Prof fi t and Phillips also believe that
it is important to achieve excellent occlusion fol-
lowing the operation to reduce the tendency to
relapse. Epker (Epker 1981 ) suggests that inter-
positioning of bone grafts increases stability by
enhancing bony consolidation.
It is generally accepted that the tendency toward
relapse starts immediately after surgery and contin-
ues for up to about 6 months after the operation.
After about 1 year, the correction can be considered
stable (Houston et al. 1989 ; Epker 1981 ; Teuscher
and Sailer 1982 ; Persson et al. 1986 ) . Hochban et al.
( 1993 ) , in an excellent review of the subject of post-
operative maxillary relapse, reported cephalometric
analyses of 31 patients preoperatively, postopera-
tively, and 1 year later. Fourteen patients had clefts of
the lip and palate; the others were noncleft patients
with maxillary de fi ciency. All had maxillary advance-
ment by LeFort I osteotomy and miniplate fi xation.
Hochban et al. ( 1993 ) found that the amount of
relapse was between 20 and 25 % in the cleft group
and about 10 % in the noncleft group. The degree of
relapse was related to the amount of advancement,
thus con fi rming the earlier work by Rosen ( 1986 )
and Houston et al. ( 1989 ) . The authors recommended
surgical overtreatment and a good overbite–overjet
relationship after orthodontic treatment.
Berkowitz sometime uses very light Class III
elastics for 6 months to improve bony consolida-
tion when he notices a maxillary relapse occur-
ring. He believes that the muscular drape to the
midface changes very slowly in adapting to skel-
etal changes, and therefore, some overtreatment
is necessary in all instances.
Posnick and Ewing ( 1990 ) studied the out-
comes in 30 adults and adolescents judged skel-
etally mature, who had unilateral cleft lip and
palate and underwent LeFort I advancement. This
group was investigated to determine the amount
and timing of relapse, the correlation between
advancement and relapse, the effect of perform-
ing multiple jaw procedures, the effect of different
types of bone grafts, the effect of pharyngoplasty
in place at the time of osteotomy, and the effec-
tiveness of various methods of internal fi xation.
Friehofer ( 1977 ), also presented results of maxil-
lary advancement in adolescence.
Tracings of preoperative and serial postopera-
tive lateral cephalograms were digitized to calcu-
late horizontal and vertical maxillary changes.
No signi fi cant differences in outcomes were seen
between patients who had maxillary surgery
alone and those who had operations on both upper
and lower jaws, nor did the outcomes vary
signi fi cantly with the type of autogenous bone
graft used or the segmentalization of the LeFort I
osteotomy. Average “effective” advancement was
greater both immediately and 2 years after sur-
gery in patients who did not have a pharyngo-
plasty in place before the operation.
Advancement also was more stable both
immediately and 2 years after surgery in the
patients with miniplate fi xation than in patients
with direct-wire fi xation. Mean downward (verti-
cal) displacement was 2.6 mm with a relapse of
1.4 mm after 2 years. The degrees of relapse and
of advancement or displacement did not correlate
signi fi cantly.
There is another obvious risk factor, the tonic-
ity of the orbicularis oris muscle ring, which
needs to be considered. Unfortunately, there are
no pressure measurements that can be utilized to
improve the success-to-failure ratio.
24.3
Total Maxillary Advancement
and Its Possible Effect on
Speech
Jabaley and Edgerton ( 1969 ) Dez Prez and Kiehn
( 1974 ) , and Bralley and Schoney ( 1977 ) have
reported that speech of cleft and noncleft patients
is unaffected after total maxillary advancement.
Witzel and Munro ( 1977 ) say that is not always
true. Epker and Wolford ( 1976 ) noted that the
speech of patients with clefts who exhibited no
VPI presurgically generally remained unchanged
after maxillary advancement. However, those
patients who have borderline closure or minimal
velopharyngeal incompetence before surgery do
exhibit speech changes following total maxillary
advancement. Schwarz and Gruner (Witzel and
Munro 1977 ; Epker and Wolford 1976 ; Schwarz
and Gruner 1976 ) showed that patients with slight
hypernasality and/or nasal emission before sur-
gery became more hypernasal after maxillary
advancement. They concluded that the degree of

543
24 LeFort I Osteotomy
deterioration was directly related to the extent
of maxillary advancement and observed that
deterioration could also occur in some noncleft
patients. Schendel et al. ( 1979 ) believe the differ-
ences between the two groups are theoretically a
re fl ection of the inherent de fi cit in palatal muscu-
lature and associated soft tissue in the cleft patient
and/or cicatrization associated with surgical repair
of the palatal clefts. Many cleft patients have hyp-
oplastic velar muscles and associated soft tissues.
All of these factors are re fl ected in the shorter soft
palate in the cleft patient. They speculate that the
increase in pharyngeal depth creates a signi fi cant
functional demand which often cannot be met by
cleft patients due to less soft palate length increases
following maxillary advancement. Schendel et al.
( 1979 ) believe that the soft palate lengthens about
one-half of the amount the maxilla is advanced.
They also computed a “need ratio” (pharyngeal
depth divided by soft palate length) in which
a value of 0.68–0.84 is consistent with proper
velopharyngeal function. A need ratio greater than
1.0 indicates possible postsurgical velopharyngeal
incompetence (Figs. 24.4 and 24.5 ).
a
e
g
h
f
b
c
d
Fig. 24.4 ( a – h ) Case JS (AV–64) UCLP showing LeFort
I advancement to correct midfacial retrusion. Treatment:
Increase midfacial height, and widen the palatal arch.
( a – g ) Pre- and postsurgical facial and intraoral photo-
graphs showing changes in the pro fi le and occlusion. Chin
augmentation is usually contraindicated with midfacial
advancement since it may lead to a concave pro fi le after
some maxillary relapse. ( h ) Type of surgery performed