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

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25 Cleft Jaw Deformities and Their Management
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S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_26, © Springer-Verlag Berlin Heidelberg 2013
26
Cleft patients with a permanent osseous defect of
the alveolar arch and maxilla will, even after the
best surgical and orthodontic treatment, be left
with the following de fi ciencies:
1. Limited prospects for orthodontic treatment.
The osseous defect makes a nonprosthodontic
dental rehabilitation impossible and necessi-
tates a dental bridge to close the gap in the
dental arch.
2. Instability of the maxillary segments, particu-
larly of the premaxilla in bilateral clefts.
3. Oronasal fi stulae or mucosal recesses that
impede oral hygiene.
4. Insuf fi cient support of the alar base contribut-
ing to the nasal asymmetry.
Secondary bone grafting of alveolar clefts com-
bined with subsequent orthodontic treatment,
designed to obtain a nonprosthodontic dental reha-
bilitation and also eliminate the other de fi ciencies
attributable to the osseous defect, was started in
Oslo in 1977. Our procedure is based mainly on the
principles laid down by Boyne and Sands (Boyne
and Sands 1972, 1976 ) . Our clinical experience with
more than 1,302 cleft sites has con fi rmed the func-
tional responsiveness of the grafted tissue to tooth
migration and orthodontic movement of teeth.
26.1
Surgical Technique
The cleft area is widely exposed through inci-
sions along the edges of the cleft. The incision on
the vestibular side is made along the gingival bor-
der. Posteriorly, the incision is extended to the
fi rst permanent molar where it is angled up into
the sulcus (Fig. 26.1 ). To provide suf fi cient mobil-
ity of this fl ap, which is going to cover the graft,
it is necessary to cut through the periosteum at the
base of the fl ap. Anteriorly, the incision is
extended along the gingival border to the center
of the cleft-side central incisor. Vertical incisions
are made along the edges of the cleft. On the pala-
tal side, mucoperiosteal fl aps are raised along the
edges of the cleft. A wide exposure of the cleft
area is achieved with these incisions.
During the exposure of the cleft, every effort is
made to avoid traumatizing the thin bone lamellae
that cover the dental roots adjacent to the cleft. The
nasal fl oor is reconstructed, if necessary, and
Secondary Bone Grafting of Alveolar
Clefts
Frank E. Abyholm , Sayuri Otaki
and Masatomo Yorimoto
F. E. Abyholm , M.D., DDS, Ph.D. (*)
Department of Plastic Surgery ,
Rikshopitalet National Hospital ,
Oslo , 0027 , Norway
e-mail: fabyholm@tele2.no
S. Otaki , M.D., DDS, Ph.D.
Department of Plastic Surgery , Tane General Hospital ,
Kujo-minami 1-12-21, Nishi-ku , Osaka-Shi ,
550-0025 , Japan
Department of Plastic Surgery , Osaka City University
Medical School ,
Asahimachi 1-4-3, Abeno-ku , Osaka-Shi ,
545-8585 , Japan
e-mail: otaki@med.osaka-cu.ac.jp
M. Yorimoto , DDS
Yorimoto Dental Clinic ,
Charme-Yusato 105, Nakano 3-11-15,
Higashisumiyoshi-ku , Osaka-Shi 546-0012 , Japan
e-mail: machatomo@leto.eonet.ne.jp

602
F.E. Abyholm et al.
pushed upward. On the palatal side, the mucope-
riosteal fl aps are sutured together with everting
mattress sutures. This leaves a well-de fi ned cavity,
whose walls are periosteum and denuded bone.
While the surgeon is exposing the cleft, an
assistant has harvested cancellous bone from the
anterior iliac crest through a small incision. A trap
door of cortical bone is raised, hinged on the inner
edge of the iliac crest. Chips of cancellous bone
are removed by a sharp spoon, leaving the inner
and outer cortex of the iliac bone intact. The donor
cavity is fi lled with hemostatic felt (collagen).
The lid of cortical bone is replaced and fastened
with sutures.
The alveolar cleft is completely fi lled with
cancellous bone chips. The alveolar crest must be
formed up to the normal height and thickness. To
improve nasal symmetry, suf fi cient chips must be
placed under the alar base.
The lateral mucoperiosteal fl ap is advanced to
cover the cleft and is sutured to the smaller medial
fl ap and to the palatal fl aps. In this way, only
attached gingiva will cover the marginal area of
the cleft site where the canine later will erupt.
In bilateral clefts, both sides are operated at the
same time using the same operative technique.
26.2
Orthodontic Management
26.2.1 Preparation for Bone Grafting
Orthodontic treatment is initiated in the early
mixed dentition. Fixed appliance therapy alone
has been used.
The maxillary incisors, which often erupt
rotated, retroclined, and in anterior cross-
bite, are corrected for aesthetic reasons and to
Fig. 26.1 ( a – e ) Surgical technique: ( a ) Incision lines. ( b )
Schematic drawing of the raised fl aps. ( c) The alveolar
cleft denuded. All soft tissue has been removed. ( d) The
alveolar cleft packed with cancellous chips. ( e ) The poste-
rior fl ap transferred to cover the graft site. Only attached
gingiva covers the inferior part of the alveolar defect

603
26 Secondary Bone Grafting of Alveolar Clefts
facilitate oral hygiene. Treatment generally lasts
3–4 months.
Approximately 25 % of our patients with com-
plete clefts of lip and palate have buccal cross-
bites attributable to segmental displacement.
Segmental repositioning is done just prior to
the bone grafting procedure, and the orthodontic
appliance is worn for 3 months postoperatively
to retain the arch form. After this time, the bone
seems able to retain the transverse dimension of
the basal bone (any dentoalveolar relapse is cor-
rected later). In patients with bilateral clefts, a
mobile premaxilla is stabilized with a heavy rect-
angular arch wire for 3 months postoperatively.
26.2.2 Permanent Dentition
Management
When the cleft-side canine has erupted sponta-
neously, orthodontic treatment is resumed. The
alignment of the permanent teeth follows differ-
ent principles, depending on whether orthodon-
tic or prosthodontic space closure is planned. If
at all possible, we prefer orthodontic space clo-
sure because we consider bridgework in young
adults to be undesirable for a number of rea-
sons. In all patients with a missing lateral inci-
sor in whom orthodontic space closure seems to
be possible, every effort is made to move the
posterior teeth forward. For these patients, we
have found the Delaire-style protraction head
gear to be useful. We regard this face mask as
an adjunct to orthodontics and not as a means of
achieving clinically signi fi cant change in skel-
etal relationships.
In most patients, the treatment period in the
permanent dentition lasts 2 years and is com-
pleted at the age of 15. A bonded palatal retainer
extending to two teeth on either side of the cleft
is placed. The retainer is kept in place as long as
the patient will accept it. Such retainers are unob-
trusive and do not interfere with oral hygiene
(Fig. 26.2 ).
26.3
Optimal Age for Secondary
Bone Grafting
In the discussion of this subject, two factors are of
particular importance: (a) the curve of growth of
the various growth sites in the maxillary complex
and (b) the clinical goal of the bone grafting.
Possible interference with postnatal maxillary
growth must be considered in identifying an opti-
mum or ideal age for secondary bone grafting.
Sagittal and transverse growth of the anterior
maxilla has virtually ceased by the age of
8–9 years (Bjørk and Skiller 1976 ; Sillman 1964 ) .
The vertical growth of the maxilla occurs mainly
as deposition of additional alveolar bone at the
alveolar crest (Bjørk and Skiller 1974 , 1976 ) .
The continuous eruption of teeth is thought to be
the agent that stimulates the formation of alveolar
bone. With a viable donor tissue such as autolo-
gous cancellous chips, the graft is rapidly trans-
formed into functional alveolar bone responding
physiologically to erupting teeth (Fig. 26.3 ). By
spontaneous or orthodontically guided eruption
of the canine, the capacity of erupting teeth to
generate alveolar bone can be utilized to maintain
the general growth in maxillary height.
Cephalometric studies of the Oslo cases have
shown that bone grafting of the alveolar cleft fol-
lowing the principles stated earlier and performed
between the ages of 8 and 11 years had no adverse
effect on anteroposterior or vertical maxillary
growth (Semb 1988 ) .
Some authors advocate bone grafting at the
age of 5–6 years in order to give any lateral
Fig. 26.2 When the orthodontic treatment is fi nished, a
bonded palatal retainer is placed. This retainer is unobtru-
sive and does not interfere with oral hygiene

604
F.E. Abyholm et al.
incisor an opportunity to migrate into and erupt
through the bone graft. This is a strong argument
from a dental point of view. However, further
studies are necessary to prove that bone grafting
at this age does not interfere with maxillary
growth.
A primary goal of secondary bone grafting is
achieving orthodontic closure of the cleft space.
Orthodontic space closure has proven to be easier
when bone grafting is performed prior to the
eruption of the cleft-side canine. In our studies, in
the group in which bone grafting was performed
before the full eruption of the canine, orthodontic
closure of the gap was possible in 93 % of the
cases (335 out of 360). In the group in which the
bone graft was performed in the permanent denti-
tion, the success rate was 72 % (107 out of 149)
(Abyholm et al. 1981 ; Åbyholm and Semb 1992 ;
Bergland et al. 1986a ) .
An evaluation of the height of the interalveo-
lar bony septum also showed a difference between
the two groups with a better height of the interal-
veolar septum in patients who had the bone graft-
ing performed before the full eruption of the
cleft-side canine (Abyholm et al. 1981 ; Åbyholm
and Semb 1992 ; Bergland et al. 1986a ) .
26.3.1 Secondary Bone Grafting
After 25 years of bone grafting in the transitional
dentition, we have analyzed 1,070 patients, of
whom 232 had bilateral clefts, making the total
number of grafted cleft sites 1,302.
Of these, the teeth in the cleft region were in
the fi nal position in 992 cleft sites, and thus,
the interdental septum could be evaluated.
Good bony interdental septum height (3/4 or
more of normal septum height) was found in
96 % when the operation was performed before
the eruption of the canine and in 85 % when the
operation was performed after the eruption of
the cleft-side canine. Failure rate: no bone for-
mation in 1.2 %. A complete dental rehabilita-
tion without prosthodontics was achieved in
93 % of the patients when the bone grafting
was performed before the eruption of the cleft-
side canine.
Fig. 26.3 ( a , b ) The grafted
bone responds physiologi-
cally to the erupting canine:
( a) Alveolar cleft prior to
bone grafting. ( b ) The canine
erupting normally through
the grafted bone

605
26 Secondary Bone Grafting of Alveolar Clefts
In order to investigate the fate of the grafted
bone, we have examined 18 consecutive patients
with unilateral complete CLP with 3D CT scan
20 years after bone grafting (Kolbenstvedt et al.
2002 ) . We found good bony support of the teeth
adjacent to the cleft in all cases, but there was less
bone in the cleft area than on the normal side.
The apertura piriformis was lower on the cleft
side in all cases, and there was hypoplasia of the
maxilla on the cleft side.
26.4
The Grafting Tissue of Choice
When autogenous cancellous bone is transplanted
under optimal conditions, osteogenic cells in the
graft will survive, and new bone formation will
start within a matter of days. Cancellous grafts
subjected to minimal traumatic surgery undergo a
rapid revascularization which is important for the
long-term result (Albrektsson 1979 ) . Fresh autolo-
gous cancellous bone transforms very rapidly into
alveolar bone, which responds normally to tooth
migration and orthodontic movement of teeth.
A cortical bone graft undergoes a slow trans-
formation. The early establishment of nutrition
to the cortical bone cells requires restoration of
fl ow through existing vessels or canaliculi and
ingrowth of capillaries. This is a very slow pro-
cess, and the cortical bone will usually die and
be replaced by invasion of bone cells originat-
ing from the recipient site. This is a fundamen-
tal difference between cortical and cancellous
bone grafts in terms of both cell survival and
vascularization. The slow transformation of a
cortical graft makes the reestablishment of the
tooth-bearing function of the alveolar process
unfeasible.
26.4.1 Donor Sites
For autotransplantation of bone in cleft patients,
several donor sites have been exploited: rib,
tibia, skull, chin, and iliac crest. All of these
sources have been used successfully. We have,
however, found the iliac crest to be the most
suitable donor site.
26.4.2 Complications
Serious complications are rare. Failures (i.e., no
continuous bone bridge across the cleft) are prob-
ably due to poor surgical technique or infection.
External cervical root resorption can occur if the
root cementum is mechanically injured during
the bone grafting procedure. This can be avoided
by delicate surgical technique and by performing
the operation at an age when the cervical region
of the canine is still covered with bone (Bergland
et al. 1986a ) .
26.5
Important Surgical Details
To achieve optimal results, we have found some
details to be of great importance.
26.5.1 Flap Design
It is important that the mucoperiosteal fl aps are
designed in such a way that only attached gingiva
will cover the marginal part of the graft. It is our
clinical observation that a completely normal
periodontium seems to occur mainly in cases
where the fl ap design has ensured an orthotopic
transfer of attached gingiva to cover the marginal
part of the graft.
26.5.2 Good Exposure
The cleft must be widely exposed so that all scar
tissue in the cleft area can be removed. The nasal
fl oor has to be reconstructed if a fi stula is present.
It is important to elevate the nasal fl oor to achieve
a good height of the alveolar crest so that the
canine can be brought into a vertical position in
the cleft area.
26.5.3 Cancellous Bone Only
Only autologous cancellous bone creates bone
that responds normally to eruption and orthodon-
tic movement of teeth.

606
F.E. Abyholm et al.
Conclusion
Autologous cancellous bone grafted to the
alveolar cleft between the ages of 8 and
11 years creates alveolar bone which responds
normally to eruption and orthodontic move-
ment of teeth. A full dental rehabilitation is
possible in the vast majority of cases when
bone grafting is performed prior to the cleft-
side canine eruption, rendering bridgework
unnecessary in cleft patients (Fig. 26.4 ).
Bone grafting performed between the ages
of 8 and 11 years does not restrict maxillary
growth.
This combined surgical/orthodontic treatment
plan requires close cooperation between plastic
surgeon and orthodontist. Fringe bene fi ts include
closure of oronasal fi stulae and elimination of
mucosal recesses, stabilization of maxillary seg-
ments, and improvement of nasal symmetry.
26.6
Optimal Timing for Secondary
Alveolar Bone Grafting
Sayuri Otaki and Masatomo Yorimoto
26.6.1 Introduction
Timing for secondary alveolar bone grafting is
critical to create an area of regenerated bone in
the cleft site so that the adjacent teeth (canine
and sometimes lateral incisor) can erupt sponta-
neously or can be moved orthodontically into it.
Bone grafting before the eruption of these teeth
causes their eruption through the newly grafted
bone (the canine proceeds to lateral incisor posi-
tion when it is missing), inducing additional
bone generation and achieve higher interdental
septum height. Thereafter, the presence and close
Fig. 26.4 ( a – d ) Unilateral complete cleft bone grafted
prior to the eruption of the canine: ( a ) The dental arch
before the bone grafting. ( b ) Radiograph of the cleft prior
to bone grafting. ( c , d ) Dental arch and radiograph after
the completion of the orthodontic treatment

607
26 Secondary Bone Grafting of Alveolar Clefts
approximation of these teeth prevent bone resorp-
tion. In addition, bone grafting before the erup-
tion of these teeth allows the surrounding bone to
protect the cervical region of their roots and thus
prevent resorption. Maxillary growth is not dis-
turbed when bone grafting is performed to facili-
tate canine eruption. Careful planning is
necessary when bone grafting is performed to
facilitate lateral incisor eruption because there is
a possibility of causing a maxillary growth
disturbance.
Secondary alveolar bone grafting using
autogenous marrow and cancellous bone graft
was introduced as a method for restoring tooth-
bearing function (Boyne and Sands 1972, 1976 ) .
Thereafter, the central purpose for secondary
alveolar bone grafting is to create an area of
regenerated bone in the cleft site that is continu-
ous with the rest of alveolus so that adjacent
teeth (canine and sometimes lateral incisor) can
erupt spontaneously or can be moved orthodon-
tically into it. The timing for secondary alveolar
bone grafting is critical to attain this purpose.
There is a margin of time for bone grafting for
other purposes, such as the stabilization of the
maxillary segments, improving the soft tissue
con fi guration to facilitate prosthetic restoration,
preparing bed for the dental endosseous implant
insertion, allowing closure of the oronasal fi stula,
and adding bony support to the alar base.
The timing of secondary alveolar bone graft-
ing will affect the height of interdental septum
at the former cleft site; tooth eruption and move-
ment into former cleft site, which in turn affect
the type of closure of the space in dental arch;
root resorption; and maxillary growth. The opti-
mal timing is going to be discussed with regard
to these factors. Although various authors have
presented the optimal timing based on their
experience and/or investigations (Table 26.1 ),
most practitioners so far accept that the optimal
timing for secondary bone grafting is when the
patient is 9–10 years old, before eruption of the
canine, and the canine root is one-half to two-
thirds formed. The canine eruption seems to
be accelerated when canine root is two-thirds
formed (Vig 1999 ) .
26.6.2 Interdental Septum Height
of the Former Cleft Site
Higher interdental septum height can be achieved
if bone grafting is performed before cleft-side
canine eruption because erupting teeth have the
potential to induce alveolar bone generation
(Abyholm et al. 1981 ; Bergland et al. 1986a ; Vig
1999 ) . This additional bone generation cannot
be expected if bone grafting is performed after
the canine has erupted. This has been character-
ized by many authors, usually with statistical
signi fi cance (Table 26.2 ). Moreover, a higher rate
of alveolar bone heights is obtained if the lateral
incisor is present (Bayerlein et al. 2006 ) . The
presence and close approximation of the teeth
are also important to prevent bone resorption and
maintain the bone height (Bayerlein et al. 2006 ;
Bergland et al. 1986a ; Ozawa et al. 2007 ) .
In addition, bone grafting at a younger age
can take advantage of a younger patients’ prob-
able potential for better vascularization and
osteogenesis.
26.6.3 Type of Closure of the Space
in the Dental Arch
There often is agenesis, aplasia, or malposition of
lateral incisors in patients with an alveolar cleft.
When lateral incisor is missing or not usable and
extracted, the space created in the dental arch
must be closed by one way or another. Two major
treatment options are orthodontic space closure
(mesial movement of the canine to the lateral
incisor position) and prosthetic replacement (use
of a fi xed bridge or endosseous implant). The
autotransplantation of mandibular premolars is
also another treatment option.
Treatment decisions in non-cleft patients are
based on the skeletal pattern, the class of maloc-
clusion, the relationship between the tooth size
and dental arch length, and the color and shape of
the adjacent canine (De Angelis 2008 ; Turpin
2004 ) . Orthodontic space closure does not impede
occlusal and temporomandibular function, and it
is superior to prosthetic replacement with respect

608
F.E. Abyholm et al.
to the periodontal health and patient satisfaction
(Nordquist and McNeill 1975 ; Robertsson and
Mohlin 2000 ) . However, the optimal treatment for
missing lateral incisors in non-cleft patients is still
under discussion because of the lack of evaluation
of endosseous implant replacement in these stud-
ies and the improvement in prosthetic techniques.
However, orthodontic space closure has been
the preferred treatment in patients with cleft lip
and palate whose cleft-side lateral incisor is miss-
ing because of the presence of an alveolar cleft to
be bone grafted. The inherent mesial migration of
teeth makes the canine erupt into the former cleft
site through the newly grafted bone if bone graft-
ing is performed before canine eruption, and
additional bone is induced as it erupts (see
Sect. 26.7.2 ), which eventually enhances the pos-
sibility of subsequent orthodontic space closure.
In addition, bone resorption is signi fi cantly lower
with orthodontic space closure than with pros-
thetic replacement (Schultze-Mosgau et al. 2003 ) .
This correlates with the prevention of bone
resorption by the presence and close approxima-
tion of the teeth (see Sect. 26.7.2 ).
However, there are cases with a missing lat-
eral incisor in which space opening and prosthetic
replacement yield superior aesthetic results in
comparison to the orthodontic closure of the
space (Dempf et al. 2002 ; Enemark et al. 1985 ;
Newlands 2000 ) . The lateral incisor space is
maintained following bone grafting until the fi nal
treatment in these cases, usually after the termi-
nation of growth, which inevitably causes bone
resorption. Endosseous implant replacement usu-
ally requires a regrafting procedure since ade-
quate bone volume and quality is necessary for
Table 26.1 Optimal timing for secondary alveolar bone grafting
Author(s)
Age (years)
Eruption stage
Root development
Boyne and Sands ( 1972 ) 9–11
Before the full eruption of the canine
–
Boyne and Sands ( 1976 ) 7
Before the eruption of the lateral
incisor
–
Abyholm et al. ( 1981 )
–
Before the eruption of the canine a
–
El Deeb et al. ( 1982 )
9–12
–
When 1/4–1/2 of the canine
root has formed
Turvey et al. ( 1984 )
8–10
Before the eruption of the canine
When 1/2–2/3 of the canine
root has formed
Bergland et al. ( 1986a )
9–11
Before the full eruption of the canine a –
Enemark et al. ( 1987 )
–
Before the eruption of the canine a
–
Brattstrom and
McWilliam ( 1989 )
–
After the eruption of the incisors and
before the eruption of the canines a
–
Rune and Jacobsson
( 1989 )
–
When the canine (or lateral incisor) is
in an early stage of eruption
–
Kortebein et al. ( 1991 )
8–10 a
–
When 1/2–2/3 of the canine
root has formed
Lee et al. ( 1995 )
–
Before the eruption of the canine a
–
Kalaaji et al. ( 1996 )
–
Before the eruption of the canine a
–
Denny et al. ( 1999 )
12 a
–
–
Lilja et al. ( 2000 )
7–9
When the lateral incisor or the canine
was covered by a thin shell of bone
–
Newlands ( 2000 )
–
Before the eruption of the canine a
–
Jia et al. ( 2006 )
–
Before the eruption of the canine a
–
Ozawa et al. ( 2007 )
5–7 b
Earlier than the canine eruption time b
–
Rawashdeh and Al
Nimri ( 2007 )
–
Before the eruption of the canine a
–
Precious ( 2009 )
5.5–6 a
At the time of eruption of the central
incisor
–
a Supportive data are presented
b When there is a germ of the lateral incisor

609
26 Secondary Bone Grafting of Alveolar Clefts
endosseous implant placement. The functional
stimulation of the transplanted bone by mastica-
tion can limit the bone resorption following the
insertion of an implant (Dempf et al. 2002 ;
Jansma et al. 1999 ; Kearns et al. 1997 ) .
26.6.4 Root Resorption
The periodontal ligament and cementum on the
root surfaces are in danger of being damaged dur-
ing the bone grafting procedure. These are thought
to be the cause of root resorption at the cementoe-
namel junction. Bone grafting before the root of
the adjacent teeth appears from bone is preferable
to avoid this complication. Great care should be
taken not to injure the cervical region of these teeth
during elevation of the mucoperiosteal fl ap when
bone grafting is performed after the full eruption
of the canine or when there is a useful lateral inci-
sor exposed. There are reports that describe less
root resorption when bone grafting was performed
prior to canine eruption (Table 26.3 ).
26.6.5 Maxillary Growth
Secondary alveolar bone grafting using cancel-
lous bone graft is unlikely to signi fi cantly interfere
with the subsequent maxillary growth because of
Author(s)
Canine not
erupted
Canine erupted
Canine half erupted
Canine fully erupted
Abyholm et al. ( 1981 )
All clefts
13/14 (92.9 %)
10/12 (83.3 %)
33/43 (76.7 %)
Bergland et al. ( 1986a )
Unilateral complete
clefts
97 % ( n = 69)
76 % ( n = 50)
Bilateral complete clefts 91 % ( n = 22)
82 % ( n = 49)
All clefts
96 % ( n = 143)
85 % ( n = 149)
Enemark et al. ( 1987 )
CLA
18/19 (94.7 %)
5/8 (62.5 %)
UCLP
40/55 (72.7 %)
26/52 (50.0 %)
BCLP
28/40 (70.0 %)
7/24 (29.2 %)
Loh et al. ( 1988 )
All clefts
17/25 (68.0 %)
6/33 (18.2 %)
Brattstrom and McWilliam
( 1989 )
UCLP
74/101 (73.3 %)
60/100 (60 %)
Lee et al. ( 1995 )
All clefts
36/49 (73.5 %)
23/52 (44.2 %)
Kalaaji et al. ( 1996 )
CUCLP
13/14 (93 %)
25/33 (76 %)
Jia et al. ( 2006 )
CLA
15/16 (94 %)
23/24 (96 %)
UCLP
42/44 (95 %)
48/58 (83 %)
BCLP
20/22 (91 %)
23/34 (68 %)
Rawashdeh and Al Nimri
( 2007 )
UCLP
20/22 (90 %)
20/25 (80 %)
BCLP
9/16 (56.2 %)
8/14 (57.1 %)
The rates of clefts with a septum height greater than 3/4 of normal height on dental radiographs
(correspond to Bergland types I and II) are shown
CLA cleft lip and alveolus, UCLP unilateral cleft lip and palate, BCLP bilateral cleft lip and
palate, CBCLP complete bilateral cleft lip and palate , CUCLP complete unilateral cleft lip and
palate
Table 26.2 Rates
of suf fi cient bone
formation

610
F.E. Abyholm et al.
the growth pattern of the maxilla, if it is performed
at or over the age of 8 (Abyholm et al. 1981 ) . This
theory is supported by subsequent cephalometric
evaluations (Daskalogiannakis and Ross 1997 ;
Levitt et al. 1999 ; Semb 1988 ; Trotman et al.
1997 ) . Therefore, maxillary growth disturbance is
not a problem when secondary bone grafting is per-
formed to facilitate canine eruption. Careful plan-
ning is necessary when bone grafting is performed
to facilitate eruption of the lateral incisor. The
reported earliest ages for bone grafting to facilitate
lateral incisor eruption are 6.3 years (Lilja et al.
2000 ) and 5 years (Shashua and Omnell 2000 ) .
Few investigations have so far addressed max-
illary growth after earlier secondary alveolar
bone grafting performed under 8 years of age.
Most investigations focused on the growth pat-
tern of patients with cleft lip and palate (operated
or not operated) and more urgent growth distur-
bance after primary bone grafting or gingivope-
riosteoplasty. One study investigated the in fl uence
of earlier secondary alveolar bone grafting on
maxillary growth. Bone grafting between the
ages of 6 years 10 months and 10 years 10 months
does not affect maxillofacial growth during the
fi rst to third postoperative years (Chang et al.
2005 ) . Although further investigation is neces-
sary to determine the long-term effects, there are
no reports of deleterious effects on maxillary
growth by secondary bone grafting at the stage of
mixed dentition using cancellous bone graft.
Optimal timing for secondary alveolar bone
grafting is best determined by eruption stage of
the teeth in the cleft region rather than by the
chronological age. It is evident that bone graft-
ing prior to the eruption of the cleft-side canine
is preferable. There is no consensus on whether
to perform even earlier bone grafting to facili-
tate lateral incisor eruption. Higher interdental
septum height will be achieved and maintained,
and better aesthetic results may be achieved
with the lateral incisor in the arch; however, this
could be associated with possible growth distur-
bance and immaturity of the donor site. Although
some researchers worry about the quality of the
lateral incisors, current restorative techniques
should solve these problems. An increased risk
of canine impaction in relation to earlier bone
grafting is reported but can be solved by surgi-
cal exposure and/or orthodontic assistance (El
Deeb et al. 1982 ; Enemark et al. 1987 ) . Further
evidence showed that bone grafting to facilitate
lateral incisor eruption as early as 5 years of age
does not interfere with maxillary growth, and the
resolution of the donor problem will thus make
it possible to establish the optimal timing for
secondary alveolar bone grafting. Bone graft-
ing should now be performed on patients under
8 years of age only when the bene fi ts overweigh
the risk of possible growth disturbance.
Timing of secondary bone grafting must be
coordinated with orthodontic treatment. This
requires close cooperation between the surgeon
and orthodontist. The use of a nonviable cortical
bone graft requires that arch expansion and orth-
odontic movement of teeth must be fi nished
before bone grafting. A viable bone graft allows
arch expansion and orthodontic movement of
teeth before and/or after bone grafting, although
many surgeons seem to prefer arch expansion
prior to bone grafting to improve access to the
cleft and nasal fl oor.
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Author(s)
Canine not erupted
Canine erupted
Canine half erupted
Canine fully erupted
Enemark et al. ( 1985 )
None in 23 clefts
2 teeth in 33 clefts
Bergland et al. ( 1986a )
None in 143 clefts
15 teeth in 149 clefts
Bergland et al. ( 1986b )
None in 39 clefts
2 teeth in 43 clefts
Enemark et al. ( 1987 )
None in 94 patients
17 patients in 130 patients

611
26 Secondary Bone Grafting of Alveolar Clefts
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Rune B, Jacobsson S (1989) Dental replacement resorp-
tion after bone grafting to the alveolar cleft. Plast
Reconstr Surg 83(4):614–621
Schultze-Mosgau S, Nkenke E, Schlegel AK et al (2003)
Analysis of bone resorption after secondary alveo-
lar cleft bone grafts before and after canine erup-
tion in connection with orthodontic gap closure or
prosthodontic treatment. J Oral Maxillofac Surg
61(11):1245–1248
Semb G (1988) Effect of alveolar bone grafting on maxil-
lary growth in unilateral cleft lip and palate patients.
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Shashua D, Omnell ML (2000) Radiographic determina-
tion of the position of the maxillary lateral incisor in
the cleft alveolus and parameters for assessing its
habilitation prospects. Cleft Palate Craniofac J 37(1):
21–25
Sillman MA (1964) Dimensional changes of the dental
arches: longitudinal study from birth to 25 years. Am
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Trotman C, Papillon F, Ross R et al (1997) A retro-
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389–394
Turpin DL (2004) Treatment of missing lateral incisors.
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613
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_27, © Springer-Verlag Berlin Heidelberg 2013
27
Samuel Pruzansky once said that craniofacial
surgery is “an experiment on nature’s experi-
ment.” This statement is certainly true. All facial
skeletal surgery – in growing or nongrowing
patients – can be regarded as an investigation of
craniofacial growth, form, and function.
Because facial skeletal surgery in growing
children often affects craniofacial growth as well
as function, informed decisions should be made
concerning which structures need to be reposi-
tioned and reformed. Based on these decisions, a
treatment plan is then formulated, and a working
hypothesis for successful treatment is estab-
lished. Three points need to be made at this junc-
ture. First, remembering the value of failures as
learning opportunities, clinicians cannot afford
to forget failures; rather they must thoroughly
analyze them so they are not repeated. Second,
clinical investigators must be able to explain
why some surgical procedures are successful and
others fail. Third, clinicians must be able to fi t
the proper procedure to each individual problem
and be willing to work with the consequences of
their choices.
Not all clefts of the lip and/or palate within the
same cleft type are alike.
1. The collected serial casts and cephalometric
radiographs, beginning with those of the unop-
erated infant and continuing through adoles-
cence presented in this chapter, provide a view
of the wide spectrum of variations encountered
within each cleft type in its untreated state and
a record of the changes that occurred thereafter
resulting from natural growth or speci fi c thera-
peutic procedures. Clinical experience points
out one critically important, fundamental fact:
All clefts cannot be lumped together as a single
phenomenon. Within each type of cleft, there
are great individual differences in the geome-
try and extent of the cleft defect, and these dif-
ferences are clinically signi fi cant.
In a state-of-the-art monograph in 1972,
Spriestersbach and coworkers ( 1973 ) wrote
“Perhaps the greatest drawback to genetical
and epidemiological research on clefts of the
lip and palate has been the unfortunate ten-
dency to lump them together.” Twenty years
prior to that report, the fi rst line in the fi rst
paper to emerge from Pruzansky’s ( 1969 )
research stated “Not all congenital clefts of
the lip and palate are alike.” This statement
was to become the leitmotif of his subsequent
research. He took great care to demarcate
The Need for Differential Diagnosis
in Treatment Planning
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

614
S. Berkowitz
samples according to varying cleft types in
his designs for epidemiological, morphologi-
cal, functional, and genetic research.
2. Current methods of treatment, which favor
staged treatment (i.e., closing the lip at birth
and the palate at a later age, in one or two
stages), offer a more encouraging prognosis
than those that prevailed 50 years ago.
3. The age of the patient and the type of surgery
applied are two variables in determining the
effect of surgery on facial growth. Quantitative
and qualitative characteristics of the cleft
defect, plus the general health and genotype
(facial growth pattern) of the individual
patient are additional determining factors.
Under certain conditions, surgical repair of
the palate is feasible quite early; in others,
optimal conditions for repair will not become
evident until a later age.
4. The natural history of children with clefts
and those with speci fi c syndromes demon-
strates that some improve over time, some
grow worse, and others remain unchanged
despite the surgical effort.
5. Presurgical orthopedics, except for the use of
a facial elastic to ventro fl ex the premaxilla to
aid the surgeon prior to uniting the lip, have
no long-term utility, and primary bone graft-
ing has a deleterious effect on palatal and
facial growth.
6. A critical review of the literature on the clini-
cal management of cleft lip and cleft palate,
together with an evaluation of the cumulative
data from longitudinal palatal growth stud-
ies, has led most orthodontists to the follow-
ing hypothesis: Conservative lip and palatal
surgery facilitates rather than inhibits growth
in both the maxillofacial skeletal complex
and the soft tissue of the labio–facial com-
plex. In cleft palate cases, operative interven-
tion which minimally involves bone growth
potential will guide maxillofacial growth in
the individual in such a way that postopera-
tive “catch-up” growth of the palate will
result in acceptably normal development.
7. Within de fi ned limits of mechanical and pro-
fessional capability, the morphological and
spatial relationships of the cleft palatal seg-
ments and facial growth patterns are the major
determinants of the ultimate occlusion and
arch form (not size). These variables, unique
for each patient, could well be more indicative
of the fi nal treatment outcome than differences
in the treatments employed by surgeons.
8. At the time the palatal cleft is closed, the
relationship of the size and shape of the cleft
space to the amount of available soft (muco-
periosteal) tissue surrounding the cleft, and
the geometric relationship of the palatal pro-
cesses to each other, is basic to determining
the in fl uence that scarring will have on the
palatal arch form and the ability of the palate
to develop normally.
9. Most skeletal malformations in cleft patients
are the result of surgical procedures that have
caused some growth retardation or of osteo-
genic de fi ciencies that lead to maxillary hyp-
oplasia. All maxillary discrepancies are
three-dimensional.
10. The concept that an increase in the amount of
palatal scarring, beyond some critical thresh-
old level, can reduce the palatal growth incre-
ments and cause palatal deformation appears
to be valid because the same surgical proce-
dures, performed by the same surgeon on the
same type of cleft, often lead to different pal-
atal relationships. The reason for the different
outcomes may, therefore, be due to variations
in the palatal deformity at the time of surgery
(i.e., the relative size of the cleft space to the
size of the palatal segments that need to con-
tribute soft tissue for cleft closure). The larger
the cleft space relative to the amount of avail-
able tissue, the larger the area of denuded
bone that must be left when the undermined
palatal mucoperiosteum is moved medially to
close the cleft space. The denuded bone heals
by epithelialization, becoming a scar. The
greater the scarring, the more growth retarda-
tion and palatal deformation.
11. Although the tongue has been found to
occupy the cleft space and be carried high
into the nose at birth, no studies have shown
that abnormal tongue habits negatively affect

615
27 The Need for Differential Diagnosis in Treatment Planning
speech development. It appears that, with the
closure of the palatal cleft between 20 and
30 months, and without the use of an obtura-
tor, children usually develop good speech if
the velopharyngeal closure mechanism is
functionally adequate.
12. There is no documented evidence that the
cleft condition interferes with body growth
or that, in most instances, the palatal defect
cannot be effectively treated without feeding
appliances. However, obturators may be use-
ful in some neurological disturbances when
palatal closure needs to be delayed beyond
3 years of age and parents complain of feed-
ing problems. Most pediatricians and nurses
recommend the use of a soft plastic feeding
bag (e.g., Playtex nurser) or a soft plastic
bottle (e.g., Mead-Johnson’s nurser) with a
crosscut, normal-sized nipple. The use of
Lamb’s and Ross Laboratory nipples is
strongly discouraged because of their abnor-
mal shape and nipple length.
13. A child with a Pierre Robin sequence should
never be given an obturator because the
child’s oral volume is already too small
and an appliance will further compromise
tongue positioning. Because the infant has
a micrognathic mandible, the tongue must
be carried high into the palatal cleft space
during this critical early adjustment period.
If an obturator or early palatal surgery is
utilized for these children, it can force the
tongue downward and backward, possibly
closing off the airway space and interfering
with breathing.
14. The use of a head bonnet with a facial elastic
band or the use of elastic taped to the cheeks
across the lips to reduce palatal distortion are
acceptable methods to help the surgeon
reduce tension at the surgical site. Such
innocuous external facial forces will help
bring the distorted lip and skeletal segments
into a more normal relationship. This mode
of treatment is acceptable to most parents
and clinicians.
15. There is no proof that neonatal maxillary
orthopedic appliances will stimulate palatal
growth or reduce middle ear infections
(Berkowitz 1977 ) , nor has it has ever been
shown that these orthopedic procedures will
prevent the need for future orthodontia and
improve speech development. An obturator
will be of some help if the cleft space remains
open after 3 years of age and neurological
problems interfere with feeding.
16. In many cases, protraction orthopedic forces
can
protrude
the
maxillary
complex
suf fi ciently to negate the need for surgical
advancement. These forces are most ef fi cient
when applied before or during the pubertal
growth spurt. After puberty, the effects
change from orthopedic (bone) to orthodon-
tic (dental) movements. The use of palatal
expansion forces prior to the application of
protraction devices can increase the poten-
tial for orthopedic movement of the
maxilla.
Once midfacial recessiveness occurs at an
early age, for example after premaxillary ortho-
pedic retraction, it will not show increased growth
acceleration to spontaneously improve midfacial
skeletal and dental relationships.
27.1
A New Direction for Cleft
Research
Successful outcomes in the treatment of complete
unilateral cleft lip and palate (CUCLP) and com-
plete bilateral cleft lip and palate (CBCLP) are
not universally obtained, despite signi fi cant
improvements in surgical techniques over the
past three decades. In particular, de fi cient palatal
growth may occur even when treatment is ren-
dered by expert teams. The factors that contribute
most signi fi cantly to unfavorable growth out-
comes remain obscure.
Although the treatment of cleft lip and cleft
palate has progressed markedly in the last 50 years,
there is still a great need for improvement in diag-
nosis and treatment planning. However, to accom-
plish this goal, our current diagnostic categories
may need to be revised. The possibility that clefts
that are similarly classi fi ed may react differently

616
S. Berkowitz
to the same surgical procedure must be examined.
The ultimate aim of future research is to provide a
better objective understanding of the reasons for,
and the characteristics of, these differing out-
comes, and by so doing provide a broader and
more informative knowledge base for making
diagnostic and treatment decisions concerning
cleft lip and cleft palate.
No matter what type of treatment surgeons
have favored, they have not been able to explain
why their surgical method of choice, when per-
formed on similar clefts at the same age, often
yielded different results. Why some cases appear
to show “catch-up growth,” resulting in good
facial and palatal form and functional dental
occlusion, while others show poor facial and pala-
tal development remains an enigma. Among the
speci fi c unanswered questions: Were the different
outcomes due to different levels of skill on the part
of the operators? Were there signi fi cant differ-
ences in the palatal deformity at the time of cleft
closure surgery within each cleft type that should
have been differentially diagnosed? And does pre-
surgical orthopedics in fl uence palatal growth or
does it merely act to reposition palatal segments?
Catch-up growth has been de fi ned by Hughes
( 1982 ) as growth with a velocity above the statis-
tical limits of normality for age during a de fi ned
period of time. Such an increase in the rate of
growth, before and after palatal surgery, with or
without neonatal maxillary orthopedics, may
allow the palate to attain its normal adult size or,
with reduced velocity, the palate may still fail to
do so. The latter case is called “incomplete” catch-
up growth. Wilson and Osbourn ( 1960 ) showed
that the duration and severity of the insult (the
scarring resulting from the surgical procedure
used to close the cleft space in the hard palate)
may positively or negatively affect the ability of
the palate to recover and undergo catch-up growth.
The developmental age of the infant at the time of
the insult and the nature of the insult itself (extent
of denuded bone left after surgery and the result-
ing scarring) will affect the ability of the infant to
achieve complete catch-up growth.
27.2
Clinical Research Feinstein
( 1970 )
Clinical Research Feinstein ( 1970 ) wrote:
In the biostatistical architecture of clinical
research, the fi rst operational principle is to specify
the components and choose the logic of the objec-
tive of the research. The components consist of
a sequence of initial state, maneuver and subse-
quent state. The logic consists of suitable scienti fi c
judgment in the decisions made to demarcate the
diagnostic and prognostic conditions of the initial
state of the population; to identify differentiate and
prognostically correlate the diverse targets of the
subsequent state; and to choose maneuvers that are
satisfactory in potency, comparison, multiplicity
and concurrency.
In speaking of the initial and the subsequent
states, emphasis will be placed on studies of
casts starting at birth and extending through
adolescence.
27.2.1 Initial State
The size and form of the palatal segments are
measured serially starting at birth and divided
into two periods. The fi rst period ends at surgery
to close the palatal cleft. The second period
includes the cleft space with the changing size of
the palatal segments.
Analyses of the initial state prior to palatal
surgery (end of fi rst period) suggest that, under
certain conditions, surgical repair of the palate is
feasible quite early, whereas in other instances,
optimal conditions for repair will not be present
until a later age. In our experience, a selected
number of cases with very small cleft spaces
underwent palatal repair at or before 1 year
of age without detriment to midface and pala-
tal growth. On the other hand, there are cases
where the cleft space is too large, compared to
the amount of available soft tissue, and surgery
needs to be postponed to avoid creating growth-
inhibiting scar tissue. This is an example of indi-
vidualized differential diagnosis and treatment
planning.

617
27 The Need for Differential Diagnosis in Treatment Planning
27.2.2 Maneuver: Presurgical
Orthopedics and Surgical
Procedures Used to Close the
Palatal Cleft
If we assume that quali fi ed surgeons within a
given institution or region, practicing a speci fi c
series of techniques over a given period of time
represent a constant, differences in success or fail-
ure should reside in (1) the initial state (the geo-
metric and size relationship of the palatal segments
to the size and shape of the cleft space, which
re fl ects the degree of skeletal de fi ciency as well as
palatal segment displacement) and (2) the facial
growth pattern. Of course, the sample must sepa-
rate cases subjected or not subjected to presurgi-
cal maxillary orthopedics, as well as cases utilizing
various cleft closure procedures because these
variables can in fl uence the subsequent state.
Of the three components, the maneuver pre-
sented the greatest number of confounding vari-
ables. Differences between surgeons, variance in
the performance by the same surgeon from day to
day and over the course of several years, and dif-
ferences in techniques, which are dif fi cult to iden-
tify and compare, complicate the analysis.
However, our biostatisticians believe that research
objectives to test the in fl uence of presurgical
orthopedic treatment and the relationship of cleft
palate space to surgical outcome can be reached. It
is possible to statistically test and covary for effects
due to differences between and within surgeons.
As Feinstein stated, we too believe that, within
certain de fi ned limits, the success or failure of the
surgical procedure depends more on the initial state
than on the variables inherent in the maneuver. To
put it another way, we expect that subtle differences
among patients will be more prognostic of the sub-
sequent state than differences between surgeons.
Serial facial and palatal growth studies starting
at the newborn period (Berkowitz 1985 ) have
shown that too many factors were operating in
relation to the patients under study to permit the
formulation of simple, all-inclusive rules, such as
any suggestion regarding the age at which clefts of
the palate should be repaired. Berkowitz ( 1985 )
therefore hypothesized that, at the time of palatal
surgery, the ratio of the useful mucoperiosteal tis-
sue available to the size of the cleft space deter-
mined the area of denuded bone left at the surgical
site after the medial movement of palatal soft tis-
sue. This area heals by epithelialization, which in
turn, becomes scar tissue. The degree of scarring
could spell the difference between therapeutic suc-
cess and failure because it in fl uences the palate’s
ultimate size (osseous plus soft tissue) and form.
If presurgical orthopedics enhance palatal
growth and development, the cleft space in the
20–24-month period will be much smaller rela-
tive to the enlarged palatal segments than in cases
that have not been similarly treated. This hypoth-
esis needs to be tested using quantitative mea-
surements. Only in this way will surgeons fi nd
reason to change their focus to include the size
and form of the palate and the extent of the cleft
defect, as well as the surgical orthopedic proce-
dures, in differential diagnosis.
Pruzansky ( 1953 ) frequently stated that his
most important contribution to the cleft palate lit-
erature was the conclusion that “cleft lip and the
palate does not represent a single fi xed entity sub-
ject to generalizations of description and
classi fi cation and least of all to rigid therapeutic
formulas.” Although his clinical reports supported
this conclusion, Pruzansky did not have a suf fi cient
number of cases and proper cast-measuring equip-
ment to study the natural history of cleft palate
growth in relationship to palatal surgery in order
to individualize treatment planning. The question
of the role and importance of tissue adequacy or
inadequacy could not be explored until a highly
accurate three-dimensional measuring tool and
supporting CadCam software became available.
27.3
Palatal Embryopathology
Studies of clefts have produced con fl icting inter-
pretations regarding de fi ciency in mass and/or
displacement of the palatal segments in space, as

618
S. Berkowitz
well as the effects of cleft surgery on palatal
growth. Information relating to the complexities
of embryonic facial development is fundamental
to an understanding of the growth potential of the
primary and secondary palate. Developmental
studies (Slavkin 1979 ; Ross and Johnston 1972 )
have shown that the facial mesenchyme, which
gives rise to the skeletal and connective tissues,
originates from neural crest cells and undergoes
extensive migration and interaction.
Coalescence of the facial processes results in
the formation of the primary palate, which con-
stitutes the initial separation between the oral and
nasal cavities and eventually gives rise to por-
tions of the upper lip and anterior maxilla. The
exact mechanism of primary palate formation is
not clear. However, most clefts of the primary
palate appear to result from variable degrees of
mesenchymal de fi ciency in the facial processes.
The suspected causes of clefts of the secondary
palate are also varied. Slavkin ( 1979 ) proposed
several possible mechanisms:
1. Tongue resistance: The tongue, arched up between
the shelves, delays palatal shelf movement.
2. Decreased shelf forces: Although there are no
examples of mutant genes that can cause this,
there are many teratogens for which this
mechanism has been invoked.
3. Failure to fuse: This possible cause may be
associated with delayed shelf reorientation.
4. Narrow shelves: This theory suggests that the
palatal shelves can move normally enough to
reach the horizontal, yet still be too narrow to
reach each other. This condition could be
explained by a more generalized de fi ciency of
facial mesenchyme reaching the palatal area,
making the hard palatal shelves and soft palate
inherently smaller.
The causative factor has important clinical
implications because it suggests that, in some
unilateral clefts of the lip and palate, the size of
the cleft space may be disproportionately very
large and more variable in shape than in other
clefts of the secondary palate. The velum in this
cleft type also may be de fi cient in muscular tissue
and predispose the child to velopharyngeal
incompetency. Thus, it would be helpful to be
able to identify infants with skeletomuscular
de fi ciencies at an early age (within the fi rst
2 years of life) in order to customize the cleft clo-
sure procedure to enhance proper speech produc-
tion as well as normal palatal growth and
development. Obviously, a child with palatal tis-
sue de fi ciency will have a different set of prob-
lems than a cleft palate patient with adequate
palatal tissue and a cleft caused by failure of
proper shelf force or failure to fuse.
27.4
The Neonatal Palatal Form
in Complete Clefts of the Lip
and Palate
27.4.1 The Effect of Muscle Forces
The normal palatal arch form is determined by
the result of the compressive forces of the orbicu-
laris oris–buccinator–constrictor pharyngis supe-
rioris muscle ring counteracted by the protrusive
and expansive forces of the tongue. However, in
the presence of clefts of the lip and palate, aber-
rant muscle forces cause the lip and palatal seg-
ments to be distorted in space. The lateral pull of
the cleft lip musculature, coupled with the push-
ing forces of the tongue fi tting within the cleft
space, is unrestrained (Subtelny 1990 ) .
27.4.2 The In fl uence of Cleft Surgery
on Palatal Form and Growth
When the cleft lip and/or soft palate are united,
the cleft musculature forces are reversed, causing
the laterally displaced skeletal structures to move
medially into a more normal form. The increased
tension of the facial musculature may vary in
degree among patients and with the type of lip
surgery employed. No attempt will be made to
measure these forces; for the same reasons, they
are not measured in standard orthodontic treat-
ment planning: it is impractical! The role of lip
tension on palatal arch form, however, does
deserve further investigation.
Slaughter et al. ( 1956 ) fi rst recognized the
many anatomic variations within similarly
classi fi ed clefts and suggested that there are great
differences in the amount and quality of palatal
tissue among the several cleft types and within

619
27 The Need for Differential Diagnosis in Treatment Planning
any one type. The amount of palatal tissue rela-
tive to cleft size increases with growth, but the
timing of this growth varies from one person to
another. In some patients, the greatest propor-
tional changes occur earlier than in other patients
so that cleft space closure may have to be delayed
to avoid growth-inhibiting scar tissue; such
fi ndings were veri fi ed by Pruzansky ( 1955, 1957 ) ,
Pruzansky and Lis ( 1958 ) , Pruzansky and Aduss
( 1964 ) , Pruzansky et al. ( 1973 ) , Lis et al. ( 1956 ) ,
and Berkowitz ( 1985 ) . Krogman et al. ( 1979 )
observed postoperative catch-up growth in almost
every case they studied and concluded that, by
the age of 6 years, the maxillary complex is usu-
ally acceptably normal. Berkowitz et al. ( 1974 )
and Mapes et al. ( 1974 ) further reported that,
after palate surgery, there may be a growth lag
from 14 to 20 months, but subsequently the pro-
cesses of orderly development may take over, and
the rate of growth may even accelerate.
Berkowitz’s observations (as Pruzansky and
Aduss ( 1964 ) did earlier) over the last 25 years
have shown that, after the lip is united, the dis-
placed palatal segments will assume various rela-
tionships to each other (some may overlap, others
may butt join, and still others not touch due to
premature contact of the inferior turbinate on the
cleft side with the nasal septum). There seems to
be a correlation of arch form, seen in the decidu-
ous dentition, with the size and geometric rela-
tionship of the palatal segments at birth. For
example, in complete unilateral clefts of the lip
and palate, after the lip is united, cases with a
very long noncleft palatal segment and a short
cleft segment coupled with a small anterior cleft
space are more likely to have the segments over-
lap. Other variables such as steepness of the pala-
tal slopes and the adequacy of tissue need to be
considered as well.
27.5
The Need for Three-
Dimensional Measuring
Techniques
Assessing the geometric form of the palate prior to
closure of the cleft space will enable recommenda-
tions to be made, not only for the most bene fi cial
surgical procedures, but also for the most opportune
time to perform palatal cleft closure surgery. For
example, various surgical procedures to close the
palatal cleft, such as those using the V–Y and the
von Langenbeck surgical techniques, involve both
the anterior–posterior and/or medial movement of
mucoperiosteum from the right and left palatal seg-
ments. Movement of the palatal mucoperiosteum
leaves areas of denuded bone at the line of incision
that heal by contraction and epithelialization (scar-
ring). The concept that an increase in the amount of
palatal scarring, beyond some critical threshold
level, can reduce the palatal growth increments and
cause palatal deformation would appear to have
validity because the same surgical procedure, per-
formed by the same surgeon on the same type of
cleft, but with different cleft space size, often leads
to different palatal relationships. One of the reasons
for the different outcomes, therefore, may be varia-
tions in the palatal deformity at the time of surgery,
more speci fi cally, the size of the cleft space relative
to the size of the palatal segments that contribute
soft tissue for cleft closure.
Quantitative information regarding the normal
palate is noticeably sparse because of measuring
limitations inherent in using various forms of cali-
pers and rulers. Some linear two-dimensional
studies on the form of the newborn arch were per-
formed by Ashley-Montague ( 1934 ) , Sillman
( 1964 ) , Richardson ( 1967 ) , and Brash ( 1924 ) .
Their measurements, limited to maximum breadth,
maximum length, maximum posterior breadth,
and maximum lateral sulcus breadth, produced
two-dimensional tables starting at birth.
Xerographic studies of casts were an advance
over previous measuring systems because they
permitted a more accurate description of two-di-
mensional changes in surface area. Huddart
( 1970, 1985 ) concluded from these measure-
ments that, in complete unilateral clefts of lip
and/or palate (CUCL/P), the palatal surface area
is de fi cient by age 16 compared with a normal
population of the same age. Huddart suggested
that presurgical orthopedics may actually hinder
palatal growth. In 1971, Mazaheri et al. ( 1971 )
reported on changes in arch form and dimensions
associated with unilateral clefts of lip and palate
and cleft palate. They found a signi fi cant pattern
of anteroposterior and lateral growth retardation
immediately after surgical treatment. Stockli

620
S. Berkowitz
( 1971 ) , who was very critical of his own research
approach, reported that there are great limitations
in the use of xerography for the study of cleft pal-
ate casts. He emphasized that arch form must be
considered in the treatment of an infant with
complete cleft of the lip and palate, and he recog-
nized that three-dimensional measurements
would be more appropriate for longitudinal and
comparative studies.
At present in the realm of cleft lip and cleft
palate therapy, treatment planning is at best an
“educated art.” Clinical reports of various treat-
ment protocols, emanating from the many and
widely separated cleft lip and palate treatment
centers, are usually anecdotal and understandably
supportive of the clinics’ own treatment concepts.
Although the protocols may differ signi fi cantly,
the authors tend to be satis fi ed with their own
patients’ facial, dental, and speech outcomes, all
of which encourages few if any innovations in
treatment approaches.
Certain questions inevitably arise: Do several
different surgical procedures yield universally
acceptable results that allow for normal palatal
development? Are the outcome reports self-serv-
ing or can there indeed be a variety of effective
surgical procedures? In cases of undeniable fail-
ure, what were the errors, if any, in diagnosis and
treatment planning? In assessing failures, most
surgeons focus solely on the surgical skills and/or
surgical protocols involved, but this leaves other
possible explanations unexplored. In recent years,
it has been suggested that variations in the physi-
cal characteristics of the deformity – the geomet-
ric relationship of the palatal segments to each
other at birth and the size of the cleft space rela-
tive to the amount of available soft tissue used to
close the cleft spaces – may have an impact on
treatment outcomes (Berkowitz et al. 1974 ;
Stockli 1971 ) . Those authors highlighted the
importance of three-dimensional measurements
and urged that the arch form and the size of the
cleft space at the time of surgery be taken into
consideration in the treatment of infants with
complete clefts of the lip and palate.
Lack of appreciation for the importance of the
geometric relationships of the cleft palatal segments
to each other has been the result, in great part, of the
dearth of longitudinal records, such as serial palate
casts and lateral cephaloradiographs, and an accu-
rate palatal cast-measuring device for quanti fi ca-
tion and computer analysis of the palate’s changing
geometric form. Just as the microscope uncovered
critical differences in tissue pathology, a three-
dimensional measuring instrument could reveal
palatal geometric information that had heretofore
gone unnoticed, and the importance of which has
not been appreciated. Fortunately, such a measur-
ing instrument and a signi fi cant number of dental
casts are now available.
27.6
Studies Using Three-
Dimensional Techniques
(Figs. 27.1 , 27.2 , 27.3 , 27.4 ,
27.5 , 27.6 , and 27.7 )
Berkowitz ( 1971 ) initiated a study to determine
the feasibility of using stereophotogrammetry to
graphically describe the changing con fi guration
of cleft palates. Data from the study supported the
clinical impressions that palatal molding action
with palatal growth, which occurred at the palate’s
Fig. 27.1 An electromechanical digitizer used to extrap-
olate x , y , and z coordinates from a plaster palatal cast

621
27 The Need for Differential Diagnosis in Treatment Planning
M
a
c
e
b
d
M
M
A
A
B
B
C
C
D
D
E
E
IP
IP
IP
V
M
R
L
L
PMA
PMC
PMP
PML
PMR
Right
Left
Alveolar
crest
Alveolar
crest
CAP
P
P
P
P
V
P
PC
PC
PC
AC′
AC′
M′
PC′
PC′
PC′
P′
A′
A′
B′
B′
C′
C′
D′
D′
E′
E′
P′
P′
P′
P′
M′
AC
AC
Alv . cr
Fig. 27.2 ( a – e ) Computer-generated images of various
cleft palate types. ( a ) Complete unilateral cleft lip and pal-
ate. ( b ) Complete bilateral cleft lip and palate. PMA pre-
maxilla anterior, PMP premaxilla posterior, PMC
premaxilla center, PMR premaxilla right, PML premaxilla
left. ( c ) Isolated cleft palate. ( d ) Normal palate: occlusal
view. ( e ) Normal palate: posteroanterior view. P postgingi-
vale comparable to PTM (pterygomaxillary fi ssure on a
lateral cephalograph). It is the posterior border of the hard
palate, PC landmark on the PP line at the cleft, AC anterior
point of the alveolar ridge at the cleft, M the most anterior
point of the palatal segment, IP incisal papilla point, V
highest vault point, A deciduous central incisor, B deciduous
lateral incisor, C deciduous cuspid, D deciduous fi rst molar,
E deciduous second molar. Palatal Surface Area. Before
cleft closure: Bounded laterally by P to AC, P to Pc and
PC9 to P9, P9 to Ac9. After cleft closure: Includes cleft
space bounded by AC to AC9 and PC to PC9. Cleft Space
Area: Anterior limit AC–AC and posterior boundary PC to
PC9. In Bilateral Clefts: Anterior Cleft Space: Bounded
anteriorly by the premaxilla’s outer point of the alveolar
crest RPM or LPM to AC and posteriorly by line AC to
AC9. Posterior Cleft Space: Bounded by AC to AC, AC to
PC, and PC to PC9

622
S. Berkowitz
Fig. 27.3 Serial dental casts for case JH (AQ-74) show:
0–1. Separated palatal segments soon after birth. 0–3.
Palatal segments move together forming a butt joint rela-
tionship 0–7, 0–9, 1–6, and 1–9. What appears to be a
“collapsed” state is not so. 2–1 and 2–6. The buccal teeth
are in an ideal occlusal relationship 10–0, 10–5. and 10–8.
Palatal growth maintains the excellent palatal arch rela-
tionship. The central incisors were brought together at
8 years of age prior to secondary alveolar bone grafts

623
27 The Need for Differential Diagnosis in Treatment Planning
Fig. 27.3 (continued)
0–1
0–3
0–7
0–9
0–10
0–15
1–9
2–1
2–6
3–1
3–5
4–0
4–3
5–6
6–2
6–9
8–6
10–0
10–5
10–8
7–3
8–1
Fig. 27.4 Case JH AQ-74. Computer-generated images of serial casts drawn to scale. This series demonstrates the
decrease in cleft spaces associated with an increase in palatal size

624
S. Berkowitz
0–0–6
0–2
0–6
P
AC
1–0
0.2
0.6
1–0 0.0.6
AC
R
PC′
PC′
pc′
P′
P′
0–9
1–0
1–5
1–8
a
c
b
d
2–1
2–7
3–1
3–5
7–2
R
P
pc
0.2
0.6/0.9
P
V
R
P1.8
2.7/3.5
4.2/5.1
7.2
1–0
R
CAP
r
0.0.2
0.6
0.9
1–0
3–10
4–2
5–1
6–7
Fig. 27.5 ( a ) Computer-created serial casts drawn to
scale from birth to 7 years and 2 months. ( b ) Outline trac-
ings at 6 days, 2 months, and 1 year of age superimposed
on the baseline P–P1 and registered at midpoint of the
line. This illustration shows the medial movement and
changes in size of the palatal segments. ( c ) The same pala-
tal segments are superimposed on the palatal rugae to
show the amount and direction of palatal growth and
movement brought on by uniting the lip. From 2 days to
1 year of age. ( d ) Outline of palatal segments from 1 year
and 8 months of age to 7 years and 2 months. This illustra-
tion shows that most of the palatal growth occurs posteri-
orly with a slight increase in width with little anterior
bony apposition
medial border, effectively diminished the width of
the cleft space. A second study Berkowitz et al.
( 1974 ) was undertaken to further improve the
stereometric technology in order to permit the
investigation of a larger number of casts. A pro fi le
study of nine complete unilateral cleft lip and pal-
ate casts demonstrated that the widths of the vault
space varied greatly between cases. This was fol-
lowed by another investigation using an “optical
pro fi lometer” (Berkowitz et al. 1982 ) designed
and built by National Aeronautics and Space
Administration (NASA) for Berkowitz under a
technology utilization transfer grant. This led to the
use of an electromechanical digitizer as the instru-
ment of choice for analytical studies of serial casts
designed to describe the changing geometry and
size of the palatal vault and the geometrical and size
relationship between the greater and lesser palatal
segments in complete unilateral cleft lip (CUCLP)
and palate and the lateral palatal segments and pre-
maxilla in complete bilateral clefts of the lip and
palate (CBCLP) (Figs. 27.5 and 27.6 ).

625
27 The Need for Differential Diagnosis in Treatment Planning
0 – 0 – 12
a
b
c
0 – 3
1 – 4
1 – 10
2 – 1
2 – 10
3 – 10
5 – 8
6 – 7
7 – 4
8 – 2
P
P
P
V
2.0
V
H
+
+
+
+
+r
+r
+
+
+
+
+
+
r+
r+
PC
PC
4 3 12
PC´
PC´
P´
P´
P´
0.0.12
0.0.12
0.0.12
2.0
3.10
17.4
1.5
0.4
1.11
17.4
3.10
12 – 3
13 – 12
14 – 5
17 – 4
Fig. 27.6 ( a – d ) Case PM (K-22). ( a) Computer-drawn
serial casts of a complete bilateral cleft lip and palate
drawn to scale showing quantitative and geometric palatal
changes as a result of growth and treatment. No presurgi-
cal orthopedics. ( b) Serial casts superimposed on the base
line P to P, registered at V (the point where the vomer
meets the baseline). This shows changes in palatal size
and palatal relationships. ( c) Serial casts from 12 days to
17 years and 4 months. These casts were superimposed on
the rugae points with the PP’ line parallel. Most of the
palatal growth occurred posteriorly, with only a slight
increase in midfacial protrusion compared to the initial
premaxillary protrusion. The width increased in propor-
tion to length

626
S. Berkowitz
1,600
1,400
1,200
1,000
800
10
20
30
40
Age in months
50
60
Unilateral cleft
Bilateral cleft
Surgery
Palate area (mm2)
+
+
+
+
+
Fig. 27.7 Graph showing growth changes in surface area
of 14 CBCLP and CUCLP prior to and after palatal cleft
closure surgery. The palatal growth acceleration in the
CBCLP was greater the fi rst year, then similar in the two
cleft types up to 25 months, just prior to palatal surgery.
At the time of surgery, the cleft space in the CBCLP series
was greater than in the CUCLP series. After surgery, the
palatal growth acceleration curve of the CBCLP series
decreased, while that of the CUCLP series increased. A
modi fi ed von Langenbeck procedure to close the cleft
space was used in both cleft types. The sample of cases is
being increased to determine the in fl uence of cleft size on
future palatal growth and development
2880
d
Right Lateral Segment
Left Lateral Segment
Premaxilla
Total Surface Area
Anterior Cleft Space
Posterior Cleft Space
Total Cleft Space
Total Surface Area + Cleft Space
2700
2520
2340
2160
1980
1800
1620
1440
1260
1080
900
Square millimeter
720
540
360
180
00
8
16
24
32
Months
Surface Areas
Case KK–22
40
48
56
64
72
80
88
96
136 144 152 160 168 176
216
208
200
Fig. 27.6 (continued) ( d) Time sequence analysis of palatal growth in a complete bilateral cleft of the lip and palate.
By 6 years, the palatal growth (including cleft space) more than doubled
Serial three-dimensional palatal growth
studies to date have led Berkowitz to believe
that size and geometric relationship of the pal-
atal segments relative to the size of cleft space
prior to surgery, coupled with the surgical
procedure utilized, may in fl uence the palate’s
subsequent arch form and size (Fig. 27.7 ). If
it does, the surgical skill or technique is not
solely responsible for the different outcomes.
This might explain why different surgical pro-
cedures can be equally successful and, con-
versely, why the same surgical procedure can
cause a different result, especially if extensive
scarring has been produced (Figs. 27.5 and
27.6 ).
The following three-dimensional pala-
tal growth studies were recently completed.
These studies can be considered forerunners
of multicenter efforts still to come that will
re fl ect on the physiological attributes of the
various surgical and orthopedic treatment
procedures.

627
27 The Need for Differential Diagnosis in Treatment Planning
27.6.1 Study 1: Analysis of
Longitudinal Growth of CUCLP
and CBCLP
Patients from Berkowitz’s longitudinal facial–
palatal growth records who did not have neonatal
maxillary orthopedics were the subjects.
Eleven children with unilateral clefts and 14
children with bilateral clefts were measured for pal-
ate area in mm 2 over a period of 5 years. For the
unilateral cleft group, the measurements were made
at approximately 6, 12, 24, 30, and 60 months. Each
child in both groups was surgically treated to close
the cleft area at approximately 24–36 months.
27.6.1.1 Statistical Methods
For each child, the monthly growth rate (in mm 2 /
month) from 6 through 24 months was estimated
by linear regression. In the unilateral cleft group,
the monthly growth rate after surgical interven-
tion was estimated by the change in palate area
from 36 to 60 months. This rate was estimated in
the bilateral cleft group after surgical intervention
over the period of 30–60 months. Mean growth
rates before and after surgical repair were com-
pared within each group by the paired Student’s
t-test. Pre- and postsurgical differences in mean
growth rates between the two cleft types were
compared using the two-sample Student’s t -test.
In addition, growth rates and the change in growth
rate before and after intervention were correlated
with the estimated size of the closure at surgery.
27.6.1.2 Results
The growth rates of the two groups before sur-
gery
(unilateral = 12.9
mm 2 /month,
bilat-
eral = 15.7 mm 2 /month) are not signi fi cantly
different. However, after surgery, the growth rate
of the bilateral group (3.9 mm 2 /month) is
signi fi cantly smaller ( p = .013) than that of the
unilateral group (8.7 mm 2 /month). Comparing
pre- and postsurgery growth rates, the change in
growth rate for the unilateral group (mean = 4.3,
SE = 3.3) was not signi fi cantly different from
zero, whereas the change of growth rate in the
bilateral group (mean = 11.9, SE = 2.3) was
signi fi cantly different from zero.
The estimated size of the “gap” to be surgically
repaired was 80.5 mm 2 in the unilateral group and
112.5 mm 2 in the bilateral group. These cleft sizes
are not signi fi cantly different; however, this may
be due to the small sample size. In a larger sample
size, this difference in cleft space size probably
would be signi fi cant. For all subjects combined,
the remaining gap at surgery was signi fi cantly
negatively correlated with the presurgical growth
rate ( r = 0.52, p = 0.034, one-tailed). For the
unilateral group alone, this correlation was not
signi fi cant ( r = 0.31, p = 0.175, one-tailed), while
it was signi fi cant for the bilateral group ( r = 0.52,
p = 0.029, one-tailed).
27.6.1.3 Discussion
These fi ndings indicate that the two cleft groups
had similar growth rates prior to surgery but dis-
similar cleft gap sizes at the time of surgery.
Following surgery, the unilateral group showed a
greater, but not statistically signi fi cant, difference
in growth rate. We suspect that, if the sample size
is increased, the difference in growth accelera-
tion would be signi fi cant. The bilateral cleft
group showed a signi fi cantly smaller cleft space
than that of the unilateral group. Both groups
started out with approximately the same mean
palate surface area. Before palatal surgery, both
groups had similar growth rates, with the bilat-
eral group slowing in growth after surgery. The
negative correlation of the estimated cleft space
at surgery with the presurgery growth rate is a
measure of the validity of the measurements. To
more closely analyze the patterns of growth
before and after surgery, data points spaced more
closely in time, especially just before and just
after surgery, are planned. These data show that
growth patterns can be measured and analyzed.
27.6.2 Study 2: Quantitative Study
of a Patient with CBCLP Treated
with Presurgical Orthopedics
This study was undertaken to graphically demon-
strate the geometric changes that occurred to a
palate with a CBCLP that had undergone

628
S. Berkowitz
presurgical orthopedic treatment by Kuijpers-
Jagtman at Nijmegen Cleft Palate Center in the
Netherlands. Besides the changes in palatal sur-
face area and cleft space, all other dimensions
can be quanti fi ed and compared with CUCLP
and CBCLP cases that were treated differently at
this and other institutions. A prospective clinical
trial study is now underway. One of the goals of
this research is to verify whether presurgical
orthopedic treatment enhances palatal growth.
27.7
A New Instrument for 3D Facial
and Palatal Cast Study
The Craniofacial Center at the University of
Illinois College of Medicine has undertaken an
extensive facial and palatal growth study using
the latest technology.
Dr. Adriana Da Silveira, Director of Research,
writes: The Vivid700 (Minolta) operates on a
light-stripe triangulation range- fi nder principle.
The subject’s facial surface is scanned from top
to bottom with a projected class 2 laser light
stripe. The position of an illuminated surface
point relative to the viewpoint is obtained by tri-
angulation. The resolution in x and y coordinates
is 200¥200 range points view per scan. The reli-
ability of this method was tested and found to be
accurate. At the Craniofacial Center, 3D images
are routinely captured for initial evaluation and
subsequent methods. Infants are placed in the
sitting position on the parent’s lap. A fl at back-
ground is placed between the infant and the par-
ent. The laser surface scanner is positioned at
1 m distant to the subject, and a series of fi ve dif-
ferent scannings from different views are taken
of the infant’s head. Each scanning takes approx-
imately 1 s. A custom headband is used to pro-
vide a variation in topography of the head. This
allows “stitching” of the images to create a 360°
three-dimensional image with the help of com-
puter software (Polygon Editing Tools, Minolta).
One facial scanning may contain 40,000 points,
and a polygonal mesh is formed of all these
points representing the facial surface. Cartesian
coordinates ( x , y , and z ) from facial landmarks
can be identi fi ed with the surface distance
between them calculated using computer soft-
ware (Measure, Minolta). These landmarks are
standardized points used in physical anthropol-
ogy, and their use in two- and three-dimensional
analysis of facial shapes is well accepted. The
same software can be used to construct axial
images of the head and to measure the area and
volume of the head and face or any other facial
part such as the palate.
Serial palatal casts of palatal casts of cleft lip
and palate subjects are scanned using the same
equipment. The scanner is connected to a turn-
table that rotates every 60º, and scanning is per-
formed at different views to allow for generation
of a 360º composite representing the full cast.
The images are stored in a personal computer and
can be analyzed using the previously mentioned
software programs. Surface distances, areas, and
volumes can be calculated, and images can be
superimposed for better visualization.
References
Ashley-Montague MF (1934) The form and dimensions
of the palate in the newborn. Inst J Orthod 20:
694–704
Berkowitz S (1971) Stereophotogrammetric analysis of
casts of normal and abnormal palates. Am J Orthod
60:1–17
Berkowitz S (1977) Section III: orofacial growth and den-
tistry: state of the art report on neonatal maxillary
orthopedics. Cleft Palate J 14:288–301
Berkowitz S (1985) Timing cleft palate closure-age should
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BR (eds) Samuel Pruzansky Fetschrift. J Craniofac
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analysis of cleft palate casts. Cleft Palate J 11:
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Berkowitz S, Gonzalez G, Nghiem-phu L (1982) An opti-
cal pro fi lometer – a new instrument for the three
dimensional measurement of cleft palate casts. Cleft
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Brash JL (1924) The genesis and growth of deformed
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lip and palate, proceedings of 2nd international
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35:324–363

Part XII
Distraction Osteogenesis

633
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_28, © Springer-Verlag Berlin Heidelberg 2013
28
Patients with severe maxillary de fi ciency secondary
to orofacial clefting present multiple challenging
problems for the reconstructive team. These patients
exhibit multidimensional maxillary hypoplasia and
skeletal clefting with absence of maxillary and alve-
olar bone, as well as scarring, residual fi stulas, and
dental anomalies. Traditional surgical/orthodontic
approaches to treat these patients, while sometimes
successful in obtaining stable occlusal relationships,
often fall short of expectations with respect to facial
balance and aesthetics. The application of maxillary
distraction osteogenesis in the treatment protocol of
patients with severe maxillofacial anomalies offers
a powerful alternative for the reconstructive team.
In this chapter, we present the use of maxillary
distraction osteogenesis for the treatment of
patients with severe maxillary de fi ciency second-
ary to orofacial clefts. The technique of rigid
external distraction, based upon the old concept
of cranial fi xation, has enabled rigid control over
the distraction process allowing for predictable
and highly successful outcomes.
28.1
Materials and Methods
All patients seen at our institution between 1 April
1995 and 1 December 1996, with severe maxillary
hypoplasia (negative overjet of 8 mm or more) were
considered candidates for treatment with maxillary
distraction osteogenesis. Criteria for patient selec-
tion included the following: unilateral or bilateral
cleft lip and palate, severe maxillary hypoplasia
(vertical, horizontal, and transverse planes) with
class III malocclusion, patients requiring horizon-
tal maxillary advancement in excess of 8 mm, nor-
mal mandibular morphology and position, patients
with full primary dentition or older, patients with
severe palatal and pharyngeal scarring, and patients
with airway obstruction and sleep apnea.
Eighteen consecutive patients were selected
based on the above criteria and were treated with
maxillary distraction osteogenesis. There were 10
unilateral cleft lip and palate patients, 6 bilateral
cleft lip and palate patients, and 2 patients with
bilateral cleft lip and palate and severe congenital
facial clefting (Table 28.1 ). The patients’ ages at
the time of surgery ranged from 5.2 to 25.2 years.
Rigid External Distraction: Its
Application in Cleft Maxillary
Deformities
John W. Polley and Alvaro A. Figueroa
J. W. Polley (*)
Craniofacial Clinic, Rush University Medical Center ,
1725 W Harrison Street, Suite 425 ,
Chicago , IL 60612 , USA
e-mail: jpolley@rush.edu
A. A. Figueroa , DDS, M.S.
Rush Craniofacial Center ,
Professional Bldg. I, 1725 West Harrison Street,
Suite 425 , Chicago , IL 60612 , USA
Table 28.1 Number of patients by diagnosis and gender
Diagnosis
n
Male
Female
UCL/P
10
6
4
BCL/P
6
5
1
Facial cleft
2
1
1
Total
18
12
6
UCI / P unilateral cleft lip and palate, BCL / P bilateral cleft
lip and palate

634
J.W. Polley and A.A. Figueroa
All patients underwent a thorough history and
clinical examination as well as a complete dental
and orthodontic examination. Preoperative and
postoperative photographic and cephalometric
records were obtained as reported previously. Time
was spent with the patient and the patient’s family,
explaining the distraction process in detail utilizing
photographs, video imaging, as well as discussions
with other patients and their families who have
undergone the procedure. The patient and parents
were thoroughly familiarized with the distraction
apparatus and its mechanics prior to the procedure.
For this group of patients, a custom-made
intraoral orthodontic splint, which acts as the link
between the maxillary skeleton and distraction
apparatus, was inserted in each patient (Fig. 28.1 ).
Fig. 28.1 ( a ) Intraoral view of original design made
from an orthodontic face bow for the intraoral splint,
anchored to the fi rst molars and further secured with cir-
cumdental wires. ( b ) Facial view of patient wearing the
device prior to surgery and demonstrating the external
traction hooks. ( c ) Patient wearing the Rigid External
Distraction system, note wires connecting traction hooks
from the intraoral splint to the traction screws from the
rigid external distraction device. ( d ) Disassembled dis-
traction device, note posterior screws on the halo, utilized
during midfacial advancement to clear the anterior part of
the halo from forehead. ( e ) Intraoral view of newly
designed intraoral splint with removable external distrac-
tion hooks. Designed in this fashion to avoid the presence
of the hooks at surgery. ( f ) Intraoral splint with remov-
able distraction hooks in place

635
28 Rigid External Distraction: Its Application in Cleft Maxillary Deformities
This intraoral splint was constructed with rigid
0.045 or 0.050 stainless steel orthodontic wire. The
splint was cemented to the fi rst permanent molars
or second primary molars and was further secured
at the time of surgery with circumdental stainless
steel surgical wire. For older children and adults,
the splint was inserted in the clinic prior to the sur-
gical procedure. For young children, the splint was
placed in the operating room after anesthetic induc-
tion and prior to the osteotomy. External traction
hooks were bent under and in front of the upper lip
with the end of the hook ending at the level of the
palatal plane. The splint also included intraoral
hooks that were utilized for the required retention
phase at the completion of active maxillary distrac-
tion. Certain orthodontic tooth movements as well
as orthodontic expansion of the upper arch can be
performed at the time of maxillary distraction by
incorporation of an expansion screw and segmen-
talizing the intraoral splint into two units. In order
to improve rigidity, the splint can be manufactured
by using an orthodontic cervical face bow. The
external bow is bent to create the external traction
hooks. Currently, the intraoral part of the splint uti-
lized at our center is made of heavy 0.045 or 0.050
stainless steel orthodontic wire. In the anterior
region, two square tubes are soldered just medial to
the oral commissures (Fig. 28.1e ). These tubes are
used to house removable traction hooks made of
heavy rectangular wire (Fig. 28.1f ). This design
offers the advantage of not having the external
traction hooks present at the time of surgery facili-
tating anesthesia management and intraoral surgi-
cal manipulation.
All 18 patients in this series underwent a
LeFort I osteotomy with the height of the trans-
verse osteotomy varying depending on the dental
age and aesthetic requirements of each patient. In
patients with transitional dentition, a high trans-
verse maxillary osteotomy was performed, just
below the level of the inferior orbital rim. The
osteotomy circumvents the infraorbital foramen
to prevent injury to the infraorbital neurovascular
bundle and avoids all permanent tooth buds.
Mobilization of the maxillary segments is
achieved, including pterygomaxillary and septal
disjunction. No intraoperative repositioning of
the maxillary segments is performed, and no
autogenous or alloplastic bone grafting or inter-
nal skeletal fi xation hardware is utilized. For the
patients in this series who underwent rigid exter-
nal distraction, the halo portion of the distraction
device was placed immediately after closure of
the intraoral incision. In the fi rst four consecutive
patients with severe cleft maxillary hypoplasia
that we elected to treat with maxillary distraction,
we performed the distraction with elastic traction
as described below. After four consecutive treat-
ment failures in these patients, we abandoned
elastic distraction for rigid external distraction.
Fourteen patients underwent rigid external
maxillary distraction (Fig. 28.1 , Table 28.2 )
(Polley and Figueroa 1997 ) . These patients had
the rigid device placed at the time of surgery and
had their distraction performed through mechani-
cal activation of the distraction device. Four
patients in this series underwent face mask elastic
distraction osteogenesis (Table 28.2 ). An orth-
odontic face mask was utilized with elastics
placed on the intraoral hooks. Up to 2 lb of elastic
force was utilized for each patient through a com-
bination of 8-oz elastics. Patients were instructed
to wear the face mask 24 h a day for a period of
3 months. All patients underwent a latency period
of 4–5 days following the osteotomy and then
began distraction. For the rigid external distrac-
tion group, distraction was performed at the rate
of 1 mm/day. In this group, the distraction device
was kept in place 3–4 weeks following comple-
tion of the distraction process for rigid retention.
An additional 4–6 weeks of face mask elastic
retention at night time only was utilized in this
group. For the rigid external distraction group fol-
lowing the period of rigid retention, the external
distraction device was removed in an of fi ce set-
ting. For the very young patients in this series, the
distraction device was removed with mild
sedation.
Distraction UCL/P
BCL/P BCL/P + FC Total
Rigid
external
9
3
2
14
Face mask
3
1
–
4
UCL/P unilateral cleft lip and palate, BCL/P bilateral cleft
lip and palate, FC facial cleft
Table 28.2 Treatment groups by diagnosis

636
J.W. Polley and A.A. Figueroa
28.2
Cephalometric Evaluation
The preoperative and postretention lateral cepha-
lometric radiographs were utilized for analy-
sis. The radiographs were traced on 0.003-in
acetate paper, and 12 anatomic landmarks were
recorded (Fig. 28.2 ). All tracings were done by a
single experienced investigator (A. A. Figueroa).
Availability of serial radiographs in all patients
permitted landmark veri fi cation. All x-rays
were corrected to 0 % magni fi cation. Based on
the recorded anatomic landmarks, 13 measure-
ments were calculated, 6 angular and 7 linear (4
horizontal and 3 vertical). For the linear mea-
surements, an x-y coordinate system utilizing
the S-N plane as the horizontal was employed.
Linear horizontal changes were measured rela-
tive to a line perpendicular to the S-N plane
passing through sella, and vertical changes were
measured perpendicular to the S-N plane. The
preoperative and postoperative cephalometric
values in the rigid external distraction group were
statistically analyzed by means of a paired t-test.
The numbers in the face mask distraction group
were too small for meaningful statistical analysis
for intragroup and intergroup comparisons.
28.3
Results
Surgery in this series was performed on either an
outpatient or a 23-h admission basis by a single
experienced surgeon (Polley). No patient in this
series was discharged later than the morning after
surgery. Perioperative antibiotics were routinely
used. All patients began routine oral hygiene and
an unrestricted soft diet 24 h postoperatively. No
intermaxillary fi xation was utilized.
There was no surgical morbidity in any of
the 18 patients in this series. There were no
complications of bleeding or infection. No
patients required a blood transfusion, and there
were no problems of dental injury, avascular
necrosis, or gingival injury. In the patients who
underwent rigid external distraction, there were
no complications with wearing the external
device including pain, discomfort, or loosening
of the device during the distraction process. The
intraoral splint remained intact in all patients
through the active and retention phases. None
of the families had dif fi culty following the
guidelines for the distraction, which they car-
ried out at home.
The postdistraction cephalometric radio-
graphs for all patients who underwent either
S
N
PNS
U1A
U1T
L1T
L1A
B
A
ANS
PG
ME
GO
Fig. 28.2 Anatomic landmarks and reference planes.
Anatomic landmarks: sella ( S ), center of sella turcica;
nasion ( N ), most anterior point of the nasal frontal suture;
anterior nasal spine ( ANS ), most anterior point of the
spine; A point ( A ), most anterior limit of the maxillary
alveolar bone at the level of the incisor root apex; poste-
rior nasal spine ( PNS ), intersection between the nasal
fl oor and the posterior contour of the maxilla; apex of
maxillary incisor root ( U1A ), uppermost point of the
incisor root; tip of maxillary incisor crown ( U1T ), maxil-
lary incisor edge; tip of mandibular incisor ( L1T ), man-
dibular incisor edge; apex of mandibular incisor root
( L1A ), lowermost point of the mandibular incisor root; B
point ( B ), most anterior limit of the mandibular alveolar
bone at the level of the incisor root apex; pogonion ( PG ),
most anterior limit of the mandibular symphysis; menton
( ME ), most anterior point of the mandibular symphysis;
gonion ( GO ), the point at the greater convexity of the
mandibular gonial region. Reference planes: sella-nasion
plane ( SN ), palatal plane (line through ANS and PNS ),
maxillary incisor axis ( Ul ) (line passing through U1A
and UIT ); and mandibular plane (tangent to the lower
border of the mandible through ME and GO )

637
28 Rigid External Distraction: Its Application in Cleft Maxillary Deformities
rigid external or face mask distraction were
obtained 4 months following distraction.
The predistraction and postdistraction angu-
lar cephalometric measurements for those
patients undergoing rigid external and face
mask distraction are given in (Table 28.3 ).
The differences in the linear measurements
between the predistraction and postdistrac-
tion cephalometric radiographs for each group
are given in (Table 28.4 ). In all of the patients
who underwent rigid external distraction, the
desired treatment goals were obtained. All
patients in the face mask distraction group
were undercorrected with residual edge to
edge anterior dental relations or remained in
anterior crossbite. The results in all patients in
the face mask distraction group were consid-
ered unsuccessful.
28.3.1 Angular Changes
For patients undergoing rigid external distraction,
the average predistraction S-N-A angle was
77.6°, and the postdistraction S-N-A angle was
85.3°, for an average increase in this group of
7.7° (Table 28.3 ). The average predistraction
A-N-B was –1.2°, and postdistraction was 7.3°
with an increase of 8.6°. For all patients who
underwent rigid external distraction, the skeletal
angle of convexity increased postdistraction by
17.2°. All of these three measurements were sta-
tistically signi fi cant.
In the elastic distraction group, the average pre-
distraction S-N-A angle was 77.5°, and postdis-
traction was 80.3° with only an increase of 2.8°.
The A-N-B angle was –5.4° predistraction, and
postdistraction averaged –1.0° for an increase of
Table 28.3 Predistraction and postdistraction angular cephalometric measurements for rigid external and face mask
distraction groups
Distraction
Measurements
(degrees)
Predistraction Postdistraction Difference (4 months)
Signi fi cance
Rigid
external
( n = 14)
SNA
77.6
±5.6
85.3 ± 5.6
7.7 ± 2.9
**
SNB
78.8
±4.0
77.9 ± 4.1
–0.8 ± 1.8
NS
ANB
–1.2
±3.5
7.3 ± 3.0
8.6 ± 3.6
**
Convexity (NAPg)
–3.5
±7.5
13.7 ± 6.0
17.2 ± 7.3
**
Mand. Pl./SN angle
39.2
±6.7
41.4 ± 5.9
2.2 ± 2.4
*
Ul-P.PL. angle
100.7
±15.7
98.8 ± 14.4
–1.2 ± 11.3
NS
Face mask
( n = 4)
SNA
77.5
±4.3
80.3 ± 5.5
2.8 ± 4.9
SNB
82.9
±4.3
81.3 ± 3.3
–1.6 ± 3.8
ANB
–5.4
±2
–1.0 ± 3.4
4.4 ± 2.7
Convexity (NAPg)
–12.2
±3.5
–3.4 ± 7.4
8.8 ± 5.5
Mand. P1./SN angle
33.2
±4.9
36.5 ± 3.6
3.3 ± 4.3
Ul-P.PL. angle
105.1
±13.1
107.3 ± 10.4
2.2 ± 11.8
* p < 0.01
** p < 0.001
Landmark (axis)
Pre-post distraction change
rigid external (mm)
Pre-post distraction change
face mask (mm)
ANS-x
7.1 ± 3.9*
2.9 ± 1.4
ANS-y
–0.4 ± 3.0
–1.3 ± 1.8
A point-x
8.3 ± 3.3*
2.8 ± 2.1
A point-y
–1.3 ± 3.4
–1.7 ± 2.3
U1-x
11.6 ± 4.6*
5.2 ± 2.1
U1-Y
–1.8 ± 3.5
–1.8 ± 1.2
Overjet
12.7 ± 3.0*
7.2 ± 2.0
* p < 0.001
Table 28.4 Predistraction
and postdistraction linear
cephalometric measure-
ments for rigid external and
face mask distraction groups

638
J.W. Polley and A.A. Figueroa
4.4°. The average change in the skeletal angle of
convexity postdistraction in the face mask group
was 8.8°. The mandibular plane angle changed
2.2° in the rigid external distraction group and
3.3° in the face mask distraction group.
The angular changes in the rigid distraction
group were more than double those in the face
mask elastic distraction group.
28.3.2 Linear Changes
The A-N-S change between predistraction and
postdistraction cephalometric radiographs in the
rigid external distraction group was 7.1 mm, and
in the face mask distraction group, it was only
2.9 mm (Table 28.4 ).
In the rigid external group, the average hori-
zontal advancement of the A point following dis-
traction was 8.3 mm. In the elastic distraction
group, the A point advancement was only 2.8 mm.
The horizontal advancement at the upper incisal
edge averaged 11.6 mm for the patients who
underwent rigid external distraction (Table 28.4 )
and only 5.2 mm for those patients in the face
mask elastic distraction group. Patients in the
rigid external group had a positive correction of
their overjet by 12.7 mm as compared with
7.2 mm in those patients who underwent face
mask elastic distraction. All of the changes in the
horizontal linear measurements in the rigid exter-
nal group were highly signi fi cant between predis-
traction and postdistraction measurements at a
p value of 0.001.
28.3.3 Dental Changes
The dental changes in both groups between predis-
traction and postdistraction cephalograms are also
given in (Tables 28.3 and 28.4 ). In the rigid external
distraction group, the change in the angle of the upper
incisor edge to the palatal plane averaged –1.2° for
all patients. This was not statistically signi fi cant. In
the face mask distraction group, the angular change
in the upper incisor edge to palatal plane measure-
ments was 2.2°. In none of the patients in this series,
including both rigid external distraction and face
mask groups, were spaces created posterior to the
most distal point of anchorage of the intraoral splint.
28.4
Discussion
Maxillary hypoplasia is a common fi nding in
patients with orofacial clefting. It has been esti-
mated that 25–50 % of all patients born with
complete unilateral cleft lip and palate will be
potential candidates for maxillary advancement
to correct the functional deformities and improve
aesthetic facial proportions (Ross 1987 ) . In addi-
tion, it is recognized that the majority of patients
with facial clefts have morphologically normal or
slightly smaller than normal mandibles (Da Silva
Filho et al. 1993 ; Semb 1991 ) . Patients with
severe cleft maxillary de fi ciency are dif fi cult
patients to treat with standard surgical/orthodon-
tic approaches. These patients present with max-
illary hypoplasia (vertical, horizontal, and
transverse dimensions) and often thin or structur-
ally weak bone. The maxillary hypoplasia in cleft
patients is also compounded by residual palatal
and alveolar fi stulas, absent and aberrant denti-
tion, and scarring of the palatal and pharyngeal
soft tissues.
The physical deformities exhibited by patients
with severe maxillary hypoplasia contribute to
multiple functional de fi ciencies as well. These
include severe malocclusions, which result in
compromised mastication, speech abnormalities,
and nasal pharyngeal airway constriction (Witzel
and Vallino 1992 ) . The severe dish-face or con-
cave facial pro fi les in these patients result in
highly detrimental psychosocial rami fi cations as
well (Kapp-Simon 1996 ) . Current protocols
for the treatment of maxillary hypoplasia in
cleft patients rely upon a surgical/orthodontic
approach, including a LeFort I maxillary advance-
ment with concomitant fi stula closure and maxil-
lary and alveolar bone grafting. This surgery
includes rigid internal fi xation hardware for
stabilization of the repositioned maxilla in the
postoperative period. The long-term results of
cleft patients with maxillary de fi ciency treated in
such fashion have been reported by several
authors (Erbe et al. 1996 ; Cheung et al. 1994 ;

639
28 Rigid External Distraction: Its Application in Cleft Maxillary Deformities
Posnick and Dagys 1994 ; Hochban et al. 1993 ;
Eskenazi and Schendel 1992 ) . The mean horizon-
tal maxillary advancement in these reported series
has averaged between 5 and 7 mm, and the mean
long-term horizontal relapse averages between
20 and 25 % (Table 28.5 ). Erbe et al. ( 1996 )
presented a mean follow-up of 59 months for 11
cleft patients who underwent segmental osteoto-
mies with maxillary advancement and simultane-
ous fi stula closure with rigid internal fi xation and
bone grafting. On average, the greater maxillary
segment in these patients was advanced 3.9 mm
and the lesser maxillary segment 5.3 mm. At
nearly 5 years postoperatively, they found that the
horizontal relapse of the maxilla was approxi-
mately 40 %. Cheung et al. ( 1994 ) reported a
consecutive series of 46 cleft patients who under-
went maxillary advancement with rigid internal
fi xation and simultaneous alveolar bone grafting
with fi stula closure. The mean horizontal maxil-
lary advancement in this series was 4.5 mm.
Relapse in the horizontal plane for the unilateral
cleft patients in this series, at a mean of 28 months
postoperatively, was 22 %. Similar horizontal
relapse rates following maxillary advancement
with rigid internal fi xation in cleft patients have
been reported by others as well (Table 28.5 )
(Posnick and Dagys 1994 ; Hochban et al. 1993 ;
Eskenazi and Schendel 1992 ) .
In this series, 14 consecutive patients under-
went successful maxillary advancement at the
LeFort I level through maxillary distraction with
rigid external distraction. Examples of our clini-
cal experience with rigid external distraction are
illustrated in (Figs. 28.3 , 28.4 , and 28.5 ). No rigid
internal fi xation hardware or autogenous bone
grafting was utilized at the time of the osteotomy.
The patients underwent distraction at the rate of
1 mm per day followed by a 3–4-week rigid
retention period. In this group of 14 cleft patients,
the mean effective maxillary advancement was
11.7 mm. The time of the postdistraction cepha-
lometric radiographs analyzed in this article aver-
aged 4 months following completion of the
distraction process. These data have been pre-
sented in this fashion so that the immediate effects
of the distraction process can be measured accu-
rately (Fig. 28.6 ). Many of our patients now have
a follow-up of more than 12 months, and we have
not seen clinical evidence of relapse in any of the
patients to date (Fig. 28.7 ). In the immature
patients, maxillofacial growth will continue, and
we are currently following the development of
these patients.
In the past, it has been dif fi cult to consistently
and successfully treat patients with severe maxil-
lary de fi ciency with maxillary advancement
alone. Patients with large anteroposterior maxil-
lomandibular discrepancies may require mandib-
ular setback surgery in addition to maxillary
advancement for correction of their severe hori-
zontal de fi ciency. With the use of rigid external
distraction, we can now gradually and in a very
stable fashion reposition a severely hypoplastic
maxilla to the exact horizontal and vertical posi-
tion desired. The patients create their own autog-
enous bone during this process, eliminating the
need for a donor site as well as eliminating the
need for rigid internal fi xation hardware. The use
of rigid external distraction has allowed rigid
Table 28.5 Review of long-term results of sagittal maxillary relapse in cleft patients following maxillary advancement
with fi stula closure, bone grafting, and rigid internal fi xation
Author
Erbe et al.
( 1996 )
Cheung et al.
( 1994 )
Posnick and
Dagys ( 1994 )
Hochban et al.
( 1993 )
Eskenazi and
Schendel ( 1992 )
Polley and
Figueroa
( 1997 )
N cleft Pt.
11
46
35
14
12
14
Mean
follow-up
(months)
59
28
12
12
12
4
Mean
maximum
advancement
4.6
4.5
6.9
8
7.8
11.6
Mean relapse
40 %
22 %
21 %
25 %
4 %
–

640
J.W. Polley and A.A. Figueroa
Fig. 28.3 ( a – f ) Nine-year-old boy with right unilateral
cleft lip and palate with severe maxillary hypoplasia and
crossbites. Predistraction ( left ) and postdistraction ( right )
facial and intraoral views demonstrate correction of mid-
face de fi ciency with improved facial proportions and den-
tal relations

641
28 Rigid External Distraction: Its Application in Cleft Maxillary Deformities
Fig. 28.4 ( a – f ) Six-year-old girl with left unilateral cleft
lip and palate and severe maxillary hypoplasia.
Predistraction ( left ) and postdistraction ( right ) facial and
cephalometric radiograph views demonstrate correction
of facial concavity and crossbite

642
J.W. Polley and A.A. Figueroa
Fig. 28.5 ( a – j ) Ten-year-old boy with repaired bilateral
cleft lip and palate with extremely severe maxillary
de fi ciency. His predistraction 1 and 3 years postdistrac-
tion facial views demonstrate the dramatic improvement
in facial pro fi le, balance, and long-term stability. The pre-
and postdistraction cephalometric radiographs demon-
strate the marked maxillary advancement, increase in
airway size, correction of anterior crossbite and class III
skeletal relations. The pre- and postdistraction tracings
( i , j ) demonstrate the degree of maxillary advancement
and the skeletal and soft tissue changes obtained after the
distraction procedure. The postdistraction tracings dem-
onstrate stability of the maxillary position and continued
mandibular growth. Change in incisor position is second-
ary to orthodontic treatment

643
28 Rigid External Distraction: Its Application in Cleft Maxillary Deformities
control over the distraction process and has
enabled us to follow our surgical and aesthetic
guidelines for the reconstruction of these patients
by correcting the entire maxillary skeletal and
soft tissue discrepancy in the region of the hyp-
oplasia only. This expansion of the soft tissue
facial mask yields the most pleasing long-term
aesthetic facial balance and harmony (Rosen
1992a, b ) , particularly in cleft patients.
In this initial consecutive series of patients, we
utilized two different techniques for maxillary
distraction. One group (face mask distraction)
underwent maxillary distraction with the use of
an orthodontic face mask and elastic traction
(Molina and Ortiz-Monasterio 1996 ) . With the
use of the elastic distraction, we were able to
obtain only partial correction of the horizontal
maxillary de fi ciencies in these patients. We con-
sidered all of our face mask patients to have failed
their surgical treatment. We therefore changed
the design of the distraction technique to rigid
external distraction, which utilizes a skeletally
(cranial) fi xed distraction device that allows for
rigid, predictable control over the distraction pro-
cess. This device is readily adjustable, offering
the ability to change the vertical and horizontal
vector of distraction at any time during the dis-
traction process. The rigid control over the
distraction process with rigid external distraction
is evidenced by the greater maxillary movements
obtained with this device as compared with those
patients who underwent face mask elastic dis-
traction. For the patients who underwent rigid
external distraction, the mean effective horizontal
Fig. 28.6 Predistraction ( solid line ) and postdistraction
( broken line ) average tracings for rigid external distraction
group. Note signi fi cant maxillary advancement (effective
incisor advancement 11.6 mm) with correction of overjet,
improvement of skeletal convexity, and minimal changes
in mandibular position. Note signi fi cant soft tissue
changes including the signi fi cant degree of lip and nasal
tip advancement
Fig. 28.7 Postdistraction ( solid line ) and 1 year ( broken
line ) after distraction average tracings of the cleft sample
treated with the Rigid External Distraction system. Note
excellent stability of the advanced maxilla

644
J.W. Polley and A.A. Figueroa
maxillary movement at the upper incisal edge
averaged 11.7 mm. This mean horizontal effec-
tive maxillary movement in the face mask elastic
traction group was only 5.3 mm. Similarly in the
rigid external distraction group, the overjet cor-
rection for each patient averaged 12.7 mm versus
7.2 mm for the elastic traction group. The preop-
erative and postoperative angular cephalometric
measurements for each group showed similar
results. The average change in the S-N-A angle in
the patients who underwent rigid external distrac-
tion was 7.7° versus 2.8° in the face mask elastic
distraction group. The change in the skeletal
angle of convexity in the group who underwent
rigid external distraction averaged 17.2° versus
8.8° in the patients who underwent distraction
utilizing elastics.
Similar fi ndings in the amount of skeletal
maxillary movement with the use of face mask
elastic distraction have been reported by others
(Table 28.6 ) (Rachmiel et al. 1997 ; Diner et al.
1997 ; Hung et al. 1997 ) . Rachmiel et al. ( 1997 )
reported that in their series of 12 patients with
cleft maxillary de fi ciency, 30 % of the patients
were unresponsive to maxillary distraction tech-
niques with face mask elastics. In the 70 % of
patients in whom they were able to obtain maxil-
lary advancement, the cephalometric fi ndings are
similar to our fi ndings in the amount of maxillary
skeletal change seen with face mask elastic trac-
tion. Rachmiel et al. ( 1997 ) report the amount of
maxillary advancement at the A point in their
series to be 4.5 mm, and in our series with face
mask elastic traction the amount of movement at
the A point was 2.8 mm. A point advancement in
our series of patients with rigid external distrac-
tion averaged 8.3 mm. The change in the skeletal
angle of convexity in the (Rachmiel et al. 1997 )
series averaged 5.0° compared with a change of
8.8° in our series of face mask elastic traction and
17.2° in our series of rigid external distraction.
Diner et al. ( 1997 ) obtained only 3 mm of hori-
zontal maxillary advancement at A point in their
series of patients who underwent maxillary dis-
traction osteogenesis with use of a face mask and
elastic traction. The experience of Hung et al.
( 1997 ) was similar with the use of elastic forces
for maxillary advancement in cleft patients. In
their series, they found the mean horizontal max-
illary advancement to be only 5.2 mm. Maxillary
distraction at the LeFort I level with the use of a
face mask and elastic traction is unpredictable
and unreliable, allowing for horizontal advance-
ment in the 4- to 6-mm range only. In our prac-
tice, patients who require only 4–6 mm of
maxillary advancement are not routinely consid-
ered for treatment with distraction osteogenesis.
In these patients, standard orthodontic surgical
approaches at the appropriate age are generally
performed.
Internal distraction devices have also been
reported for use in midface advancement. Most
of these reports have focused on advancements
of the midface at the LeFort III level or above
(Cohen and Burstein 1997 ; Chin and Toth 1997 ) .
Some, however, have advocated the use of an
internal device for maxillary advancement at
the LeFort I level (Cohen and Burstein 1997 ) .
To date, there is no evidence that this technique
affords suf fi cient distraction at the LeFort I
level. Internal devices may require multiple sur-
gical approaches for their placement, a second
operative procedure for their removal, and the
necessity for an exit port for the activating arm
of the device. The vectors of distraction with
the use of internal devices will be limited by
the placement of each device as well as its fi nite
mechanics. Perhaps the greatest disadvantage of
internal devices is in the design of the transverse
maxillary osteotomy. With internal distraction
Table 28.6 Review
of maximum-maxil-
lary sagittal
advancement in cleft
patients undergoing
maxillary distraction
with face mask elastic
traction
Measurements
Rigid external Face mask Face mask
Face mask
Chicago
Chicago
M. C. Rambam ,
[15] Haifa
C. H. A. Trousseau,
[16, 17] Paris
A point advance-
ment (mm)
8.3
2.8
4.5
3
ANB (degrees)
8.6
4.4
4.0
–
Convexity (degrees) 17.2
8.8
5.0
–

645
28 Rigid External Distraction: Its Application in Cleft Maxillary Deformities
devices, the osteotomy must be designed so that
there is enough stable bone above and below the
osteotomy line to allow appropriate placement
and fi xation of the distraction hardware. This
is not required with rigid external distraction.
The osteotomy design with this device is based
upon the aesthetic requirements of each indi-
vidual patient and not based upon the placement
of internal hardware. This allows the transverse
maxillary osteotomy to be carried as high as indi-
cated along the pyriform aperture as well as in
the malar regions, allowing for maximal correc-
tion of the patient’s preoperative facial concav-
ity. Maxillary advancement with rigid external
distraction allows total versatility and fl exibility
in both the amount and direction of the distrac-
tion process. The vectors of distraction can be
and are changed at any time during the distrac-
tion process. In addition, no additional surgical
procedure is required for removal of the rigid
external device.
The use of the cranium as an anchorage point
for the stabilization of maxillofacial surgery is
not a new concept. Cranial stabilization devices
for maxillofacial trauma reconstruction as well
as for elective maxillofacial surgery have been
reported with good success in the past (Stoelinga
et al. 1987 ; Houston et al. 1989 ) . In addition,
our neurosurgical colleagues have used the cra-
nium as a solid fi xation point for the stabiliza-
tion of cervical injuries and reconstructions for
decades. The scalp pins (2–3 per side), which
stabilize the halo component of the rigid exter-
nal distraction device, are discomfort free. Not
even the youngest patients have any complaints
or problems with wearing of the device through-
out the distraction process. No special scalp pin
care is required, and the use of ointments and
creams at the scalp pin interface is discouraged.
The patients simply shampoo and wash their
hair in the shower with the device in place in a
normal fashion. Currently, the device is readily
removed without even local anesthesia in the
clinic following the phase of rigid retention. In
young apprehensive patients, the halo is removed
with mild sedation. No secondary surgical pro-
cedure is required for removal of internal
hardware.
One of the great advantages of distraction
osteogenesis in the craniomaxillofacial skeleton
is that, in theory, there is no limitation to the age
at which patients can be treated. Contemporary
surgical orthodontic approaches for the treatment
of maxillary de fi ciency in cleft patients are
dependent upon the patient having reached skel-
etal maturity before the reconstructive surgery
can be performed. Treating patients in the transi-
tional dentition stage with the use of autogenous
bone grafting and rigid internal fi xation plates
and screws is technically dif fi cult to perform
without injury to the developing permanent tooth
buds. The technique of rigid external distraction
eliminates the negative technical factors associ-
ated with traditional orthognathic surgery in
patients in transitional dental development. With
maxillary rigid external distraction, only an
osteotomy is performed. Repositioning skeletal
segments, internal fi xation hardware, and bone
grafting are not required. The only limitations
with rigid external distraction include adequate
dentition, either primary or secondary, for fi xation
of the intraoral splint, as well as the ability of the
patient to wear the device. Rigid external distrac-
tion now allows treatment of these patients from
the age of 2 years and up. In special circum-
stances in patients with craniosynostosis (Crouzon
and Apert syndromes), we have used the tech-
nique for monobloc advancement as early as
18 months of age. In these cases, the second or
even the fi rst primary maxillary molar has been
used to support the intraoral splint. In addition,
special plates have been developed to connect the
edentulous maxilla to the rigid external distrac-
tion device (Hierl and Hemprich 1999 ) .
This article reports our preliminary experi-
ence with this technique. Three-year follow-up
of this group of patients has demonstrated out-
standing stability in maxillary position (Figueroa
et al. 2004 ) . However, we caution all young
patients undergoing rigid external distraction
that they may require a fi nal “ fi nishing” LeFort
I procedure at skeletal maturity for fi nal arch
alignment.
The advantages of maxillary rigid external
distraction are numerous. This technique allows
an excellent modality for correcting the severe

646
J.W. Polley and A.A. Figueroa
midface concavities, at any age, in patients with
facial clefting and other hypoplastic anomalies
(ectodermal dysplasia, Johanson-Blizzard syn-
drome, etc.). Rigid external distraction follows
the important principals of aesthetic maxillofa-
cial surgery treating only the affected jaw and
offers the multiple bene fi ts of distraction osteo-
genesis, including not only orthotopic bone cre-
ation with expansion of the facial skeleton but
soft tissue expansion as well. The technical
advantages of rigid external distraction are
numerous. The surgery is minor as compared
with traditional orthognathic surgery. Only the
osteotomy is performed, eliminating reposition-
ing of skeletal segments, bone grafting, splints,
intermaxillary fi xation, and intern fi xation hard-
ware. Operative times are signi fi cantly decreased.
Morbidity with rigid external distraction is very
low (in our series zero). Blood transfusions are
not required. Rigid external distraction can be
performed on an outpatient or 23-h admission
basis. Patients begin a soft diet and normal oral
hygiene the morning following surgery. The rigid
external device is removed in the clinical setting
or with mild sedation for the young children. All
of the above has resulted in a signi fi cantly
decreased cost of care for these challenging
patients.
In patients with severe cleft maxillary hypopla-
sia, distraction osteogenesis with rigid external dis-
traction now offers the ability to fully restore facial
convexity through a minimal procedure at almost
any age. In our practice, this has dramatically
changed our treatment philosophies and success for
these patients, who in the past have been extremely
dif fi cult to treat. The technique is currently applied
with extreme success to those patients with severe
maxillary nonsyndromal dentofacial deformities,
as well as patients with severe syndromic condi-
tions such as Apert, Crouzon, and Pfeiffer syn-
drome (Figueroa et al. 2001 ) .
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