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

650
F. Molina
a variety of craniofacial deformities. In the mid-
face animal models with or without osteotomies
(Rachmiel et al. 1995 ; Staffenberg et al. 1995 ) ,
maxillary distraction led to the fi rst clinical trial
of this concept in patients with cleft lip and pal-
ate (Cohen et al. 1997 ; Polley and Figueroa
1997b ; Molina et al. 1998 ) and craniosynostosis
(Arizuki and Ohmori 1995 ; Chin and Toth 1997 ;
Levine et al. 1998 ; Molina 1998 ; Cohen 1999 ;
Arnaud et al. 2003 ) . We will include also our
experience with distraction osteogenesis in cran-
iosynostosis to achieve posteroanterior move-
ment of the whole facial mass and a combined
zygoma-malar rotation with the aim of establish-
ing a proper dental occlusion, of increasing
orbital capacity, and of improving craniofacial
form with a well- balanced proportion.
29.1
Clinical Applications of
Distraction Osteogenesis
29.1.1 Hemifacial Microsomia
Facial asymmetry and microtia are the most impor-
tant clinical fi ndings in a patient. Deviation of the
chin to the affected side, hypoplasia of the soft tis-
sues, and associated disorders of other anatomic
structures such as the maxilla, the zygoma, and the
muscles of mastication are present in a wide vari-
ability. The hypoplasia affects the gonial angle
(grade I) in less severe cases and the angle and the
ascending ramus in others (grade IIA and IIB) and
shows a complete absence of ramus and the condyle
in more severe cases (grade III) (Pruzansky 1969 ) .
The operative technique begins with a 3–5-cm
vestibular incision made under general anesthe-
sia. The periosteum is elevated to expose the
gonial angle, with a side-cutting burr; the cortico-
tomy is done on the lateral aspect of the mandible,
including all the cortex to the cancellous layer. It
extends obliquely from the free mandibular bor-
der to the gonial angle. Then, the corticotomy is
extensively extended inferiorly around the edge
of the angle. In fact, 6–7 mm of the internal corti-
cal layer remains intact, protecting the neurovas-
cular bundle, and in this manner, the whole
cancellous layer, the circulation, and innervation
of the bone are preserved (Fig. 29.1a, b ).
Afterward, a fl exible unidirectional external
device (KLS-Martin, Germany) is inserted. Two
titanium pins are introduce percutaneously through
the whole thickness of the mandible, 4–5 mm in
front and behind the corticotomy. The pins should
be parallel to each other to facilitate the fi xation of
the distraction device. In this moment, we recom-
mend an “intraoperative test” of accuracy: activate
the device 5–6 mm and observe the changes in the
corticotomy. The surgeon must obtain the opening
of the corticotomy segments without dif fi culty and
assess that the elongation system works properly.
If the surgeon identi fi es the presence of cortical
a
b
Fig. 29.1 ( a , b ) Side-cutting
burr and the external-extended
corticotomy from the free
mandibular border to the
gonial angle. The corticotomy
is interrupted as soon as the
cancellous bone is visible.
( b ) At the lingual cortex, the
bone cut is incompletely,
preserving 6–7 mm of the
internal cortical fl ayer at the
site of the neurovascular
bundle

651
29 Remodeling the Mandible by Distraction Osteogenesis
bridges, the lengthening mechanisms will not
work and the corticotomy must to be revised.
The advantage of combining the use of an
external corticotomy and a fl exible device is the
ability to obtain a 3D correction of height, length,
and position of the mandible. In fact, different
zones of bone resistances are encountered, minor
of the angle but major resistance at the alveolar
ridge, that will be elongated differently under a
perpendicular distraction vector (Fig. 29.2a–c ).
The area of new bone formation produces a
better shape of the mandibular angle and modi fi es
the ascending ramus position with a simultane-
ous better relationship of the condyle and the gle-
noid fossae. The initial condyle lateral position
moves into a more central one that is more simi-
lar with the contralateral normal one. All of these
fi ndings are different from those obtained with
linear distractors and osteotomies.
The selection of the vector of distraction is also
a critical decision. The corticotomy and the posi-
tion of the pins determine the distraction vector. It
is different in each patient depending on the grade
of mandibular hypoplasia. In patients with grade I,
the pins must be placed perpendicular to the corti-
cotomy, obtaining an oblique vector that produces
a larger bone elongation in the angle and a minor
bone elongation in the alveolar ridge. In patients
with grade II-A hypoplasia, the distraction process
must remodel and elongate the angle and the ini-
tial portion of the ascending ramus (Fig. 29.3 ). For
this reason, the pins must be inserted in an inter-
mediate position between a vertical and oblique
distraction vector. This group of patients repre-
sents the vast majority of our clinical series.
In patients with grade II-B hypoplasia, the
corticotomy is placed horizontally in the base of
the ramus. The pins must follow a strict vertical
distraction vector in order to obtain more elonga-
tion in the hypoplastic ascending ramus.
Our distraction protocol includes a latency period
of 4–5 days. Distraction commences at a rate of
1.0 mm/day (distraction period). This period is con-
tinued 4–6 weeks until we achieve the desired
a
b
c
Fig. 29.2 ( a ) Location of the corticotomy in a grade II-A
hemifacial microsomia. ( b ) Using an oblique vector, the
new bone formation production is larger at the angle and
minor at the alveolar ridge, also at the initial portion of the
ascending ramus. ( c ) Tridimensional diagram of the regen-
erate bone. The new volumetric bone formation corrects the
height, the length, and position of the mandible. The tooth
buds and neurovascular elements have been preserved
a
b
c
Fig. 29.3 Distraction vectors are the key to obtaining
excellent results. Basically, three distraction vectors are
used to correct a mandibular hypoplasia in hemifacial
microsomia. The oblique vector is used for grade
Pruzansky I, and the vertical vector is used to recreate the
ascending ramus in the grade Pruzansky II-B

652
F. Molina
mandibular lengthening with the correction of the
facial asymmetry, chin position, level of the oral
commissure, and the changes in the dental occlusion.
A very important point is to produce an overcorrec-
tion in the group of growing patients. In the preop-
erative period, the patients present a marked lateral
deviation of the mandibular teeth to the affected side.
After the distraction has been completed, the devia-
tion of the mandibular interincisal line is reproduced
in the opposite direction in the contralateral side as a
result of overcorrection. Also, a posterior open bite
and a crossbite are produced immediately after dis-
traction; for these reasons, posterior bite blocks,
dynamic appliances, and standard orthodontic
maneuvers will easily control the occlusal changes
and will produce some degree of dental occlusion
stability. Bite blocks were required to maintain the
posterior open bite; the blocks were gradually
reduced to allow vertical descent of the maxillary
dentoalveolus. We must always avoid the production
of occlusal disasters as this situation will be impos-
sible to correct later with standard orthodontic
procedures.
The consolidation period is about 8 weeks or
more. It depends on the age of the patient as well
as the amount of bone lengthening. In an adult
patient with a severe hypoplastic ramus, it can be
prolonged for 16 weeks until there is radiographic
evidence of mineralization. At this time, the
device is removed under sedation.
Age is also a critical factor in the treatment of a
hemifacial microsomia patient with mandibulardis-
traction. During the 1990s, the international criteria
were to indicate the procedure at an age of 5–6 years,
including the more severe cases. This decision was
established according to the amount of mandibular
bone stock and the feasibility of using intra- or
extraoral distraction devices. Actually, we know that
patients under 5 years of age, presenting a severe or
moderate deformity, are not good candidates to
elongate the mandible with intraoral devices. The
procedure will result in a failure to achieve the ideal
distraction vector, secondary occlusal disasters, and
the need for future surgical interventions.
In our clinical series, aesthetic results were
excellent. The facial symmetry was restored with
descent of the buccal commissure to the level of
the contralateral normal side; the menton became
horizontal and was located at the midline
(Fig. 29.4a–d ). In all our patients, we noted an
a
b
c
d
Fig. 29.4 ( a ) Preoperative frontal view of
a 9-year-old girl with a Pruzansky II-A
hemifacial microsomia showing facial
asymmetry and chin deviation to the
affected side. ( b ) During the distraction
process, 2 weeks after the initial 16 mm of
mandibular elongation showing an early
improvement of the facial asymmetry.
( c ) Six months after 24 mm of mandibular
distraction showing facial symmetry with
descent of the buccal commissure and
medialization of the chin. ( d ) The patient
12 years later showing stability in the
clinical result. Facial symmetry: a chin
position has been stable in the long-term
result

653
29 Remodeling the Mandible by Distraction Osteogenesis
increase in the soft tissue envelope bulk. This
simultaneous soft tissue expansion is the most
important factor in obtaining the correction of
facial asymmetry, and it is more observed during
the consolidation period. At this time, the device
serves as an external fi xator, and the muscles of
mastication produce contraction forces over the
regenerate bone allowing the molding of the cal-
lus with the increase of the bigonial distance by
the muscles’ pull.
Our clinical series also includes a group of
patients with hypoplasia grade II-B treated
between 18 months and 3 years of age.
Undoubtedly this group of children has better
craniofacial growth and long-term clinical stabil-
ity in the soft tissues. After overcorrection, the
use of dynamic orthodontic appliances and bite
blocks corrected the occlusal changes and the
vertical dimension of the maxilla. All of these
changes occurred very fast and almost spontane-
ously during a period of 2–3 months, compared
with children treated over age of 6 years. For this
reason every day, more and more, we are indicat-
ing the procedure at early ages. It is also impor-
tant to mention that permanent dental injury or
neurovascular damage did not occur. Elongation
was done by the parents with minimal discomfort
during the night without disturbing the children’s
sleep. These children represent the group of
patients with the best results and better tolerance
to the method.
Twelve percent of the patients with hypoplasia
grades II-A and II-B treated after 6 years of age
required a second distraction procedure. The
main reasons for a secondary procedure were
erroneous distraction vector, incomplete consoli-
dation period, and nonsatisfactory overcorrection
criteria. These patients presented an early ten-
dency to retake the original condition of facial
asymmetry and malocclusion as it was observed
after 2–3 years of follow-up (Fig. 29.5a–i ).
If the patient is 12 years old or more at the
time of the second bone elongation, we indicate a
simultaneous
maxillomandibular
distraction.
This technique is also indicated in the adult group
of patients as a primary surgical procedure
(Fig. 29.6a, b ). Additional to the mandibular dis-
traction, we include a subperiosteal dissection of
the maxilla, and then a complete horizontal
osteotomy is made at the level of the pyriform
area in both sides. The pterygomaxillary junction
is freed with a curved chisel and Rowe forceps on
the affected side only. Rowe forceps may be used
softly to assess the completeness of the osteot-
omy, but no attempt is made to mobilize the
midface. The pterygomaxillary junction on the
unaffected side remains intact, and it will serve as
a pivot to safely produce the midface elongation-
rotation movements on the affected side.
The result shows that with the mandibular
elongation, the maxilla follows the mandible
changes, achieving simultaneous elongation,
medial rotation, and advancement. Preoperatively,
the deviation of the occlusal plane from the hori-
zontal varied from 12° to 18°, and after the com-
bined distraction procedure, the clinical and
orthodontic correction was obtained with a mini-
mal slanting of 1–2° in the long-term follow-up.
Preoperatively, the vertical dimension of the
maxilla was very short, and the last mandibular
molar was in a very close relationship with the
malar bone. Postoperatively, the vertical maxillary
increases from 16 to 15 mm, representing a 90 %
correction when compared with the unaffected
side. All of this new bone formation results in a
simultaneous correction of the oblique nasal
fl oor, as well as the deviation of the nasal septum
changing into the more normal position, increas-
ing the volume of the nasal cavity. The preexist-
ing dental occlusion has been preserved; after
the elongation, the superior and inferior midline
incisors have changed and now are positioned in
the central line of the face (Fig. 29.7a–d ).
The chin is always medialized by the distrac-
tion, but in adults it is not always possible to achieve
a normal central position; for this reason, this pro-
cedure does not eliminate the need for a sliding
genioplasty or another extrasurgical procedure, like
a free dermis-fat graft, at the time of the removal of
the device to improve the aesthetic fi nal result.
29.1.2 Micrognathias
Patients with micrognathias present a different
problem because of the bilateral deformity and
because both the mandibular body and the ascend-
ing ramus are affected, requiring bidirectional

654
F. Molina
Fig. 29.5 ( a ) Preoperative frontal view of a 6-year-old
boy with hemifacial microsomia Pruzansky II-A showing
facial asymmetry with deviation of the buccal commissure
and the chin. ( b ) During the distraction process. ( c ) The
patient 6 months after showing facial symmetry. ( d )
Frontal view 10 years later. We can observe excellent
growth of the mandible together with the rest of the cran-
iofacial skeleton. ( e ) Preoperative PA cephalogram. ( f )
During the distraction process showing a low bone density
area between the pins. ( g ) Postdistraction PA cephalo-
gram. Notice the increase in the vertical dimension of the
mandible, the condyle position, and the changes in the
maxilla. ( h ) Preoperative CT scan showing the shortness
of the ascending ramus
a
b
c
d
g
h
e
f

655
29 Remodeling the Mandible by Distraction Osteogenesis
and bilateral distraction. This concept is also true
for patients with Pierre Robin, Nager, Treacher
Collins, and bilateral hemifacial microsomia syn-
dromes. In these cases, two corticotomies were
done: a vertically oriented one in the mandibular
body and a horizontally oriented one in the
ascending ramus. The pins used are as follows: a
central one is introduced at the mandibular angle
between the two corticotomies, a second into the
mandibular body, and a third into the central
aspect of the ascending ramus. One bidirectional
device is used on each side, each one with two
distraction plates to allow independent and more
precise elongation of each segment, using the
central pin as the fi xed pivot for both of them
(Fig. 29.8a, b ).
Most of these patients present the typical “bird
face” deformity with de fi cient soft tissue at the
lower third of the face and at the neck, absence of
the neck angle, and shortened suprahyoid muscles.
With bone distraction, all the tissues from skeleton
to skin are simultaneously elongated without the
inconvenience of osteotomies or skin expansion
(Fig. 29.9a–h ). After conventional osteotomies
and bone grafts, the muscles and the tight skin
envelope present a limiting factor often requiring
multiple procedures and seldom achieving opti-
mal aesthetic results. Tissue expansion increases
the size of the skin cover, but other soft tissues
such as muscles, vessels, and nerves remain
unchanged. The overall functional and aesthetic
results with bidirectional mandibular distraction
have been spectacular. The neck takes a normal
shape with a well-de fi ned angle. The muscles and
soft tissues of the fl oor of the mouth together with
the masticatory muscles got the expansion giving
a better aspect of the neck. The chin takes a more
prominent position.
a
b
Fig. 29.6 ( a ) Diagram showing the mandibular cortico-
tomy with the device in site. An additional horizontal
osteotomy has been performed over the maxilla. After
5 days, an intermaxillary fi xation is indicated with the aim
of obtaining a simultaneous elongation of both bone struc-
tures. ( b ) Areas of new bone formation over the mandible
and the maxillary
i
Fig. 29.5 (continued) ( i ) Postdistraction CT scan show-
ing the increase of the ramus length as well as the new
volumetric change of the gonion

656
F. Molina
a
b
c
d
Fig. 29.7 ( a ) Preoperative
frontal view of an adult
patient with left hemifacial
microsomia. ( b ) Six months
postdistraction frontal view
after a simultaneous
maxillomandibular distrac-
tion. ( c ) The patient showing
the operative occlusion.
Notice the obliquity of the
occlusal plane. ( d ) Six
months after distraction, the
patient shows its occlusion
with the correction of the
occlusal cant
a
b
Fig. 29.8 ( a ) Diagram
showing two corticotomies
for bidirectional elongation.
The central osteotomized
bone fragment must be large
enough to avoid fracture and
back displacement. ( b ) The
horizontal vector always has
to be parallel to the occlusal
plane in order to avoid the
production of an anterior
open bite or other occlusal
disasters

657
29 Remodeling the Mandible by Distraction Osteogenesis
a
b
d
c
f
g
h
e
Fig. 29.9 ( a ) Frontal view of a 22-year-old girl during
the distraction process of a bilateral and bidirectional
mandibular elongation. ( b ) Panorex view showing the
four independent vertical and horizontal distraction vec-
tors. In asymmetrical micrognathias, one mandibular body
can be elongated more than the contralateral in order to
obtain symmetry. ( c ) Preoperative frontal view of the
patient showing the asymmetrical micrognathia second-
ary to a condyle fracture during the early years of life. ( d )
Frontal view 3 years later of the mandibular distraction.
Facial symmetry has been restored. ( e ) Preoperative lat-
eral view showing the classic “bird face.” ( f ) Lateral view
3 years later showing the new mandible with a nice elon-
gation of the soft tissues over the superior third of the
neck. ( g ) PA cephalogram 3 years later showing a very
well-de fi ned mandibular structure. ( h ) Lateral cephalo-
gram 3 years later. After mandibular elongation, the pro-
cedure has obtained a normal anatomy with an ascending
ramus, gonion, mandibular body, and chin. The use of
proper distraction vectors has achieved a normal occlusal
relationship

658
F. Molina
29.1.3 The Temporomandibular Joint
Ankylosis
Studies of the effect of mandibular distraction on
the temporomandibular joint have shown that the
condyle assumes a more normal anatomic size,
shape, and position after distraction (McCormick
et al. 1995 ) . In fact, the process of distraction is
bene fi cial to the condyle structure and its posi-
tion in the glenoid fossae.
Regardless of the etiology of the joint ankylo-
sis, it can be treated using the concept of bone
transport and distraction to generate a neocondyle
and to obtain a normal mandibular anatomy. In
extra-articular ankylosis through a vestibular inci-
sion and subperiosteal dissection, an L-shaped
osteotomy is made from the medial aspect of the
projected condyle down to the posterior aspect of
the ramus. Two pins are inserted, one in the
osteotomized bone fragment and a second at the
angle. The distraction vector is directed to the
empty glenoid fossae (Fig. 29.10a, b ). After a
5-day latency period, the osteotomized segment
of bone is distracted and transported in a vertical
direction until achieving the planned condyle
lengthening. Usually 14–20 mm is enough to
achieve a similar dimension with the contralateral
side. Immediately the patients begin with open-
close exercises, and during this activation period,
the edge of the neocondyle is remodeled into a
smooth, rounded surface. Fibrocartilaginous tis-
sue at the leading edge of this segment acts as a
pseudodisk.
If the patients present an intra-articular
ankylosis (true bony fusion), an arthroplasty is
performed through a preauricular incision. The
surgeon must release the bony fusion, and he will
avoid bone resection reducing the ramus height.
The abnormal bone is remodeled with a burr, and
once this maneuver is completed, the opening of
the mouth is accomplished with the assistance of
a special forceps. Then a very fi ne Silastic layer
(less 1.0 mm) is introduced as a cap on the top of
the projected condyle and fi xed to the surround-
ing scar tissue with two resolvable stitches. We
close the incision, and then we change into the
intraoral route for the L-shaped osteotomy.
This method produces a vertically elongated
mandible with a functioning nonankylosing tem-
poromandibular joint in the short term. The interin-
cisal distance obtained ranged from 35 to 45 mm in
the adult group. This technique will probably become
the treatment of choice of temporomandibular joint
ankylosis. Better diagnostic methods and under-
standing of etiology will be necessary in the near
future to determine the ef fi cacy of this process.
29.1.4 Cleft Lip and Palate Patients
The etiology of midface de fi ciency in cleft patients
is uncertain. The absence of class III malocclu-
sion in untreated clefts suggests that previous
cheiloplasty and palate repair may be related to
this condition (Ortiz-Monasterio et al. 1959 ) .
Ross ( 1987 ) in a longitudinal survey of 528
repaired cleft patients from 15 centers around the
world demonstrated that approximately 25 %
develop maxillary hypoplasia that did not respond
to orthodontic procedures alone.
Fig. 29.10 ( a ) Diagram
showing the “L osteotomy”
over the ascending ramus with
the device in place. ( b ) The
distraction vector must be
directed to the empty glenoid
fossae

659
29 Remodeling the Mandible by Distraction Osteogenesis
At the time of treatment, the ages of patients
ranged between 6 and 12 years (mean 8 years), and
all of them demonstrated clinical and radiographic
evidence of moderate to severe underdevelopment
of the maxilla (sagittal, vertical, and transverse).
They also presented with a fl attened middle third
of the face and class III malocclusion, with partial
or total anterior and posterior crossbite.
The severity of maxillary hypoplasia ranged
from 2 to 10 mm of A-P discrepancy. Class III
malocclusion with anterior and posterior cross-
bite, deep overbite, and in some patients, vertical
skeletal open bite was observed.
Preoperative orthodontics are mandatory to
obtain a minimal occlusal stability. The follow-
ing orthodontic requirements were ful fi lled prior
to maxillary distraction: skeletal and/or dentoal-
veolar transverse expansion of the maxilla, align-
ment of permanent incisors in the cleft area in
some patients, and bone grafting at 8–10 years
old in other cases (Subtelny and Brodie 1954 ;
Tindlund 1989, 1994 ) .
Prior to surgery, a modi fi ed quad-helix fi xed
appliance was placed in the palate. This is made
of a simple lingual arch attached to bands placed
on the second deciduous molars. Anteriorly the
arch maintains passive contact with the incisors
through an acrylic button. In order to maintain
maxillary expansion during the advancement, an
extra transverse arch is fi xed to both premolar
bands which in turn provide the support for the
vestibular hooks.
Under general anesthesia, two maxillary ves-
tibular incisions 3–4 cm long are made, leaving a
2-cm central mucosal bridge between the inci-
sions. Subperiosteal dissection is performed from
the pyriform fossae to the lateral maxillary but-
tress on each side exposing the anterior and lateral
aspects of the maxilla to the level of the infraor-
bital nerve and above the canine roots. Dissection
on the nasal fl oor is limited to the lateral part only.
The nasal septum and the maxillary cleft gap
remain intact. Using a side-cutting burr, a hori-
zontal osteotomy is performed above the roots of
the canines and molar tooth buds as identi fi ed on
the posteroanterior cephalogram and panorex.
Bilaterally, using a 7-mm chisel, the osteot-
omy is extended into the maxillary buttress,
reaching the pterygomaxillary region. Disjunction
with Rowe forceps is not performed, thereby
avoiding unnecessary bleeding and uncontrolled
fractures in the pterygomaxillary junction. At
this time, the surgeon must assess maxillary
mobility by applying gentle downward pressure
to the Le Fort I segment. The mucosa is then
approximated and closed with absorbable sutures.
Following this minimally invasive technique, the
hypoplastic maxilla is ready to be mobilized. As
the nerve function and vascularity have been pre-
served, the mechanical distraction forces will
stimulate the functional matrix to produce new
bone formation.
Using the fi xed intraoral appliance system as
an anchorage for a modi fi ed “petit” facial mask
supported by the forehead and chin, distraction
forces are initiated on postoperative day 5. Two
intraoral elastic bands on each side are linked
from vestibular hooks to a bar on the mask. No
other fi xation is required. The initial mechanical
force used for distraction is about 900 g. The
facial mask is used mainly at night and at some
periods during the day for a total of 16–18 h
every day.
When the vertical length of the maxilla is
de fi cient, a combination of forward and down-
ward distraction forces can be used to simultane-
ously advance and lengthen the maxilla.
Advancement of 2–3 mm is achieved each
week. During the second and third week of dis-
traction, the presence of palatal scars may pro-
duce dif fi culties in further advancement. At this
stage, it is critical to maintain the same elastic
force in order to weaken the resistance of the
fi brous tissue. If necessary, the elastic bands,
which are initially parallel, may be crossed in
order to increase the force of A-P distraction. In
this manner, the projected maxillary advance-
ment and a satisfactory class II molar relation-
ship is obtained. At this point, the amount of
force is decreased to one elastic band on each
side (450 g) for another 2 months (consolidation
period) in order to maintain the maxilla in its
new position.
Radiographic evidence of new bone formation is
observed at approximately 8–10 weeks postdistrac-
tion. The bone step formed by the horizontal distrac-
tion is replaced with mature cortical bone. There
is also evidence of a secondary area of new bone

660
F. Molina
formation at the pterygomaxillary junction. These
fi ndings attest to the skeletal stability and will dimin-
ish the risk of relapse.
The projected advancement was achieved in all
of the patients with results varying from 4 to
12 mm (mean 7 mm). The aesthetic results were
excellent (Fig. 29.11a–f ). The soft tissue pro fi le
changed from concave into a well-proportioned
orthognathic face. Changes also included an
increased nasolabial angle, a more anterior
Fig. 29.11 ( a ) Preoperative three-quarter view of a
9-year-old boy with unilateral cleft of lip and palate and
moderate midface retrusion. ( b ) Postoperative three-quar-
ters view 1 year before 6 mm of advancement and 3 mm of
vertical elongation with maxillary distraction. Notice that
the new position of the maxilla produces a minor anterior
mandibular rotation. The middle third of the face has been
elongated, producing a more appropriate balance of the
middle and inferior thirds of the face. ( c ) A postoperative
three-quarter view 9 years later. ( d ) A preoperative frontal
view. Because the middle third of the face is retruded and
short, an exaggerated anterior rotation is produced in the
mandible. The patient looks prognathic and with a very
long inferior third of the face. ( e ) The face in its thirds
looks well proportioned and balanced. ( f ) Clinical stability
with nice aesthetic results in the long term. ( g ) Preoperative
occlusion showing negative overjet and posterior cross-
bite. ( h ) Orthodontic treatment continues that includes the
alignment of the permanent incisors in the cleft area and
conventional orthodontics. ( i ) The fi nal occlusion
a
b
c
d
e
f
g
h
i

661
29 Remodeling the Mandible by Distraction Osteogenesis
projection of the upper lip, and an improved lip
relationship.
Dental occlusion was changed to a distal sag-
ittal molar relationship with moderate overjet
(Fig. 29.11g–i ) with signi fi cant downward clock-
wise rotation of the mandible. Cephalometrically,
a counterclockwise rotation of 2–7° was achieved.
The increase in the ANB angle varied 1.4–7.4°.
After distraction was completed, it was essential
to stabilize the maxilla with a fi xed palatal arch,
in order to proceed with the orthodontic treat-
ment such as alignment of permanent incisors in
the cleft area and to correct the minor dental
irregularities in the cleft site.
29.1.5 Craniosynostosis
In this clinical series, different osteotomies are
included: Le Fort III, fronto-orbital advancement,
and monoblock. The osteotomies were performed
using a subcranial or an intracranial approach. The
intracranial route is always assisted endoscopically
in order to perform a clean dissection of crista galli
and cribriform plate, to assess for hemostasis and
to verify dura mater disruptions, and most impor-
tantly to preserve vascularity between the dura and
the skull. The surgical technique uses several basic
procedures of the classic craniofacial osteotomies.
Under general endotracheal anesthesia, exposure
of the midface and the orbits is obtained through a
standard coronal incision.
The dissection is carried over the periosteum,
and at the temporal level, the dissection extends to
the deep temporal fascia so that the soft tissue
envelope can be re fl ected off the lateral orbital rim
and zygoma. At this time, the temporal muscle is
sectioned below the temporal crest, and with a lim-
ited dissection 15 mm wide, we reach the lateral
orbital wall until the retromalar area. In fact, we
preserve the vast majority of the temporal muscle
insertion.
Then the dissection is extended to the orbit
superiorly at the orbital roof 8–10 mm from its
apex, laterally until the inferior orbital fi ssure is
clearly visualized, and medially until the nasolac-
rimal groove without disruption of the medial
canthal ligament.
In a patient with previous fronto-orbital
advancement and cranial vault surgery with mid-
face hypoplasia and associated class III maloc-
clusion (Fig. 29.12a, b ), a subcranial Le Fort III
is indicated. The osteotomy is designed includ-
ing the lateral half of the supraorbital rim. Here,
the osteotomy has to preserve 6–8 mm of bony
union at the medial portion. Then the osteotomy
is followed to the external aspect of the lateral
orbital wall and extended down until reaching
the junction of the maxilla and the pterygoid
plate. At this point, an interpterygomaxillary
disjunction is done with a 12-mm chisel. The
intraoral classic route is avoided. Then an oblique
osteotomy is performed at the zygomatic arch.
a
b
Fig. 29.12 ( a ) Osteotomy line of the
modify Le Fort III osteotomy. At the
nasal bones and at the supraorbital
border, the osteotomy preserves some
millimeters of bone attachments,
avoiding the production of long noses
and bone steps at the fronto-orbital
region after the advancement.
Malocclusion in class III is observed.
( b ) After advancement, new bone
formation is observed along the
osteotomy lines, most importantly in
the lateral aspect of facial framework,
the lateral orbital wall, the zygoma,
and pterygomaxillary area. At the nasal
bone and the superior orbital edge, new
bone formation is minimal when
compared with the rest of the
osteotomies. The occlusion has been
corrected

662
F. Molina
Following intraorbitally the bone cut at the
inferolateral angle, it extends from the inferior
orbital fi ssure along the orbital fl oor reaching
medially the posterior aspect of the nasolacrimal
groove. This maneuver allows the advancement
of the nasolacrimal apparatus and medial canthal
tendons anteriorly with the midface.
Over the nasal base, one horizontal osteotomy
is performed connecting the medial orbital wall
osteotomies in both sides. Craniofacial disjunc-
tion is accomplished with Rowe Kiley forceps.
The surgeon must avoid fracturing the remaining
6–8-mm bone union at the supraorbital rim. This
incomplete osteotomy will act as a pivot and will
avoid bone steps in the fronto-orbital area after
the advancement.
The distraction devices are placed in the mid-
face in two different ways: simply supported
behind malar bone or anchored with a hook to
the malar-orbital edge. The device is a sub-
merged type and is made of one hollow plate
with a central perforation to allow the entrance
of a screw running free, 25–30 mm in length.
After the screw thread, the rest of the device has
a smooth surface and can be easily positioned
through the temporalis muscle reaching the
malar’s back or anchoring to the bone edge with
an extra hook. The hollow plate is screwed to the
parietal bone.
To advance the midface, a horizontal vector is
used. The vector has to be parallel to the occlusal
plane, and the midface is advanced until a class II
molar relationship is obtained, and/or the
zygoma-malar-orbit advancement corrects the
exorbitism.
If the patient’s midface is short vertically, then
an oblique vector is the logical indication.
Simultaneously, the bone movement will correct
the midface retrusion and will lengthen its verti-
cal dimension.
The obtained subcranial advancement ranges
from 18 to 30 mm. This distance has been mea-
sured at the orbito-malar region. It is very impor-
tant to observe that the maxillary advancement
ranged from 7 to 12 mm and at the supraorbital
region varied from 10 to 16 mm. Certainly we
have obtained a gradual bone advancement that is
different at the orbit, at the malar, and at the max-
illa allowing the correction of the exorbitism and
of the midface hypoplasia.
This gradual advancement is generated by an
additional rotational movement in the lateral
aspect of the facial framework, more accentuated
at the zygoma-malar area. Probably this addi-
tional movement offers a more satisfactory cor-
rection of the exorbitism and avoids the production
of the long “French noses” as typically are
obtained after Le Fort III advancements.
Aesthetic results were excellent, and a fi nal
facial appearance is comparable with normal,
good-looking individuals (Fig. 29.13a–d ).
In a primary syndromic craniosynostosis
patient (Apert, Crouzon, Pfeiffer, etc.) present-
ing with severe midface hypoplasia and second-
ary respiratory problems, the monoblock
osteotomy is the indicated. The design of this
osteotomy represents a “true monoblock”
because frontal bone, both orbits, malars, and
maxilla move anteriorly together in one single
piece (Fig. 29.14a, b ).
In these cases, the osteotomy is outlined at
the frontal bone and the lateral aspect of the
osteotomy runs down until it reaches the lateral
orbital wall. It then follows in a manner similar
to the subcranial route.
Two or three craniotomies are performed.
Below the outlined osteotomy design, intracra-
nial tunnels are dissected, introducing large fi ne
gauzes in order to protect the meninges. Special
attention must be paid at the tunnels at the
supraorbital area as well as at the crista galli.
At this point, a fl exible endoscope is intro-
duced into the tunnels, and assessment for hemo-
stasis is performed. Also, a safe intracranial
dissection at the more dangerous area must be
completed under vision; this maneuver is espe-
cially important in patients in which the dura is
fi rmly attached to the internal cortex. The maneu-
ver will avoid meningeal disruptions.
This sort of intracranial dissection preserves
vascular attachments between the frontal bone
and the dura along with the preservation of the
bone vascularity. In reality we are generating
bone fl aps that will produce a healthy new bone
formation along the osteotomy lines very quickly.
The preserved vascularity will avoid intracranial

663
29 Remodeling the Mandible by Distraction Osteogenesis
dead spaces and secondary bone necrosis, often
observed after the classic advancements with
osteotomies.
The frontal osteotomy is performed with an
oscillatory saw. A fi ne brain retractor is intro-
duced into the tunnels over the gauzes, and then
the cut is completed safely. Over the orbital roof
and the medial wall, a curve osteotome is used to
complete the osteotomy.Of signi fi cant impor-
tance is completion of the bone cut at the crista
galli. This maneuver is done with two 7-mm chis-
els. The fi rst one is introduced through the central
craniotomy and endoscopically positioned in
front of the crista galli; then with gentle hammer-
ing, the osteotomy is begun. Immediately there-
after, the second chisel is positioned exactly in
front of the fi rst one, and the osteotomy is com-
pleted medially and laterally until the bone cut
reaches the orbital roof.
At this point, a Rowe Kiley forceps is used to
complete the monoblock disjunction, and maxil-
lary disimpaction forceps can be used in an effort
to facilitate the anterior midface advancement
with simultaneous stretching of the overlying soft
tissue envelope.
A pair of distraction devices are used to
advance the whole bone mass in one piece. Using
the extra hooks, the devices are anchored to the
fronto-orbital union edge, through the temporalis
muscle, and screwed to the parietal bone.
The postoperative course in this group of
patients has been very satisfactory. Monoblock
advancements ranged from 20 to 30 mm in the
fronto-orbital region and from 10 to 18 mm in
the maxillo-malar area.The exorbitism has been
corrected in all cases. It is our impression that
simultaneous advancement of the roof, the
fl oor, and the medial and lateral walls of the
orbit produces a more anatomical correction
(Fig. 29.15a–d ). In the frontal region, gradual
advancement of the frontal bone has produced
good results, both in the contour of the fore-
head and cranium and in the relationship with
the facial skeleton.
Extradural dead spaces between the frontal
bone and the frontal lobes have not been observed
a
b
c
d
Fig. 29.13 ( a ) A 4-year-old girl
with Crouzon disease. A fronto-
orbital advancement has been
performed at age of 12 months.
Exorbitism and severe midface
retrusion with sleep apnea are still
unresolved problems in this patient.
( b ) At the end of the distraction
process, malar-zygoma advance-
ment was 19 mm, solving the
exorbitism. The maxillary position
has corrected the airway problem.
Facial proportions now are well
balanced. ( c ) Preoperative lateral
cephalogram showing the retruded
midface and the rigid fi xation
system, mini-plates, and wires used
in the fronto-orbital area during the
surgical procedure. Notice the fi ne
airway secondary to the severe
maxillary hypoplasia. ( d )
Postdistraction lateral cephalogram
showing the bone advancement and
the position of the devices. An
oblique vector has produced the
bone advancement. It has been
gradual and different at the orbital
level and at the maxilla level

664
F. Molina
in any of our patients. Also, irregular contour in
the forehead secondary to partial bone absorp-
tion has been eliminated with the distraction
advancement.
We link together the orbito-cranial and maxil-
lary problems because their primary malformation
occurs simultaneously and its correction is critical
to obtain excellent functional results.
29.2
Discussion
Distraction osteogenesis is a technique that is
becoming popular for the reconstruction of
de fi cient mandibles and has simpli fi ed the treat-
ment for congenital mandibular hypoplasia.
Technically, it is a minor surgical procedure that
preserves the integrity of the nerves and vascular
supply. Careful planning of the corticotomy and
the position of the pins produces a distraction
vector that follows closely the direction of nor-
mal mandibular growth (McCarthy et al. 1992 ;
McCormick et al. 1995 ; Pensler et al. 1995 ; Diner
et al. 1996 ; Klein and Howaldt 1996 ; Polley and
Figueroa 1997a ; Hoffmeister et al. 1998 ) .
Vertical and sagittal mandibular elongation
was obtained in all patients. During the early
stages of our clinical work, we assumed that the
elongation would always result in a posterior
open bite. However, it did not occur in many of
the cases due to dentoalveolar adaptation at the
maxillary level (Molina and Ortiz-Monasterio
1993, 1995 ; Molina 1994, 1999 ; Molina et al.
1997). This vertical growth change was docu-
mented cephalometrically, suggesting that the
maxilla liberated from the constricting effect of
the small mandible and de fi cient soft tissue can
reach its normal growth potential. Murray and
Mulliken (1979) have reported the same increased
vertical maxillary growth after chondrocostal
grafting of the ascending ramus.
An enormously important bene fi t of bone
distraction is the simultaneous expansion of the
surrounding soft tissue of the face (Molina et al.
1995, 1997). In fact, we were surprised to see
the rapid descent of the buccal commissure to a
normal position, the horizontalization of the
chin, the increase in the distance between buccal
commissure and the external canthus and in the
distance between buccal commissure and the
inferior orbital rim in the unilateral cases. Also,
once the distraction is completed, we have
observed some additional increase in the vol-
ume of the cheek, which is probably related to
improved muscular activity.
All the patients with micrognathia presented
the typical “bird-like” facial deformity with
de fi cient soft tissue in the lower third of the
face and the neck, causing absence of the neck
angle, with shortened suprahyoid muscles. The
a
b
Fig. 29.14 ( a ) The “true
monoblock” osteotomy.
Dotted line shows the
single-piece osteotomy that
includes the frontal bone, the
orbits with their four walls,
the lateral and medial walls,
and the fl oor, the pterygomax-
illary junction, and the
zygoma. ( b ) After distraction,
new bone formation is
observed along the osteotomy
lines included at the
pterygomaxillary tuberosity

665
29 Remodeling the Mandible by Distraction Osteogenesis
overall aesthetic results obtained have been
spectacular, beyond both the patients’ and our
expectations. The neck takes on a normal shape
with a well-de fi ned angle, the muscle and soft
tissue of the fl oor of the mouth expand, the
masseter insertion and the muscle volume
increase,
and
the
chin
becomes
more
prominent.
Slow distraction of the mandible following
corticotomies results in increased mandibular
mass and length simultaneously with soft tis-
sue (skin, muscles, ligaments, blood vessels,
and nerves) expansion. This adaptation occurs
over a period of 8–12 weeks. Elongation of the
mandible results in an increase in size as well
as changes in its positions and shape that would
a
b
c
d
Fig. 29.15 ( a ) Preoperative third-quarter view of a
14-month-old girl with Apert syndrome showing a severe
supraorbital depression, fronto-orbital deformity, and
midface retrusion. ( b ) Postdistraction clinical changes.
The “true monoblock” has corrected frontal deformity,
exorbitism, and midface retrusion. Oxygen saturation is
normal during sleep. ( c ) A preoperative CT scan of a
14-month-old young girl with Apert syndrome, brachy-
cephaly with a severe fl attened supraorbital region is
observed together with severe midface retrusion. Oxygen
saturation drops during the sleep of the patient.
( d ) Postdistraction CT scan shows the new position of the
midface with the simultaneous correction of the orbits
position and the frontal bone after a “true monoblock”
advancement. New bone formation is observed in the lat-
eral aspect of the frontal bone, in the lateral orbital wall,
the zygoma, and at the pterygomaxillary area. On the
frontal bone, an extra remodeling is observed in the patient
during the consolidation period. The brain expansion
force produces a round shape on the frontal bone achiev-
ing a structure very closely to the normality

666
F. Molina
not be possible using conventional orthog-
nathic surgery such as a sagittal split osteotomy
procedure (Converse et al. 1973 ; Kaban et al.
1988 ; Ortiz-Monasterio 1982 ) .
The early treatment of midface retrusion in
children with C.L.P. has to be considered a major
goal. Early correction of the maxillary hypopla-
sia minimizes the psychological problems as well
as provides bene fi ts related to improved occlu-
sion, masticatory, and respiratory functions.
Advancing the maxilla with distraction forces
requires only a minimal surgical procedure pre-
serving vascularity and nerve integrity. This tech-
nique presents exciting treatment possibilities
eliminating the need for rigid fi xation systems,
blood transfusions, prolonged orthodontic treat-
ment, and intermaxillary fi xation.
When the maxilla is properly positioned, it can
grow in a near normal manner, allowing the tongue
to assume a physiological position. In this situa-
tion, the permanent maxillary incisors erupt spon-
taneously into a normal overjet and overbite
(Subtelny and Brodie 1954 ; Tindlund 1989, 1994 ) .
The use of distraction vectors is fundamental
to achieve optimal advancements. Vectors are
obtained through the combination of the position
of the bar on the facial mask and the direction of
the rubber bands. There are three possibilities of
maxillary distraction vectors: upward, forward,
and downward. The most commonly used is the
forward one, in which the horizontal vector must
be parallel to the occlusal plane to avoid produc-
ing an anterior open bite.
Overcorrection with a class II molar relation-
ship is always performed, especially in patients
with severe deformity or in patients treated dur-
ing 6–9 years of age. This point is critical because
distraction does not alter the inherent cellular
growth pattern. Following early maxillary dis-
traction in patients with severe midface retrusion,
the individual growth pattern often reverts to the
original tendency of reduced maxillary growth
and an anterior crossbite may become reestab-
lished. Overcorrection is therefore necessary to
achieve an equilibrium between maxillary and
mandibular growth. The use of intraoral func-
tional correctors (Frankel III) also plays an inte-
gral role by adding an additional stimulus for
maxillary growth.
Gradual maxillary advancement with distrac-
tion produced functional changes affecting respi-
ration. Nasal breathing was improved as well as
the air fl ow and patency of the nasal airway. These
changes are produced by an opening in the naso-
labial angle and the increase of volume of the
nasal and pharyngeal airway as demonstrated in
the preoperative and postoperative lateral
cephalograms.
Two relevant points must be considered to pre-
dict the dif fi culties with the midface distraction
technique: fi rst, the quality of palatal tissue and
palatal scarring. Due to the tendency for retrac-
tion and relapse, fi xed retention is mandatory.
Secondly, preoperative skeletal and dentoalveolar
transverse maxillary expansion, as well as dental
compensations, may be necessary to prevent
occlusal instability. Clinical experience has
proven that these factors determine the long-term
stability of the maxillary advancement in this
series.
Also, with maxillary distraction, a simultane-
ous soft tissue expansion is observed, and the
skin, fat, and muscles have a more favorable peri-
oral, perinasal, and infraorbital distributions. The
nasal base remains unchanged, and the position
of the lips, teeth, and tongue is in better relation-
ship when the patient smiles.
In treating craniosynostosis, conventional
osteotomy surgery is limited by the resistance of
the soft tissue envelope which can be managed
only by gradual advancement or multiple surgical
procedures. The results of midface osteotomy
advancement with rigid fi xation typically fall
short of the desired goal (Tessier 1967, 1971a, b,
1976 ; Ortiz-Monasterio et al. 1978 ; Van der
Meulen 1979 ; McCarthy et al. 1990 ) .
It is well known that the growth of the cranial
vault is directly in fl uenced by the brain, the
growth of the orbit directly induced by the growth
of the eye, and the growth of the maxilla linked to
the eruption of teeth (Latham 1970 ) . Normally,
until 4 years of age, the cranial base, like the
vault, follows the rapid and even pseudotumoral
growth of the brain. In addition, between the ages
of 2 and 7 years, the cranial base follows the
development of the face; the later depends on
dental eruption and masticatory movements
(Tessier 1971b ) .

667
29 Remodeling the Mandible by Distraction Osteogenesis
These are very important observations to indi-
cate early midface surgery in patients with cran-
iosynostosis. Moreover, after 7 years of age, the
development of the frontal bone, the ethmoid,
and the sphenoid depends on their pneumatiza-
tion. The growth of the anterior cranial base
appears, therefore, to be induced mainly by that
of the brain and the maxilla.
These two last facts are very interesting to
analyze since distraction osteogenesis in these
patients produces areas of new bone formation
over the anterior cranial base and the brain expan-
sion after the procedure has produced a second-
ary remodeling of the frontal bone. The brain
expansion molds the regenerate.
At present, when the operative risk has been
reduced to the minimum, when most of the major
complications can be prevented and minor com-
plications can be controlled, and when good
functional results are usually obtained, more of
our efforts must be directed toward better cos-
metic results. The ideal goal in craniofacial sur-
gery would be to produce a normal appearance in
all patients (Arizuki and Ohmori 1995 ; Chin and
Toth 1997 ; Molina 1998 ; Cohen 1999 ) .
Conventional osteotomy surgery is limited by
the resistance of the soft tissue envelope, which
can be managed only by gradual advancement or
multiple surgical procedures (Whitaker et al. 1987 ;
Tessier 1977 ; Ortiz-Monasterio et al. 1990 ) .
The advantage of distraction in midface
advancement is thus an increase in the amount of
correction that can be achieved in a single proce-
dure, enabling a more complete anatomic correc-
tion and possibly sparing the patient multiple-stage
procedures (Chin and Toth 1997 ; Molina 1998 ;
Cohen 1999 ; Arnaud et al. 2003 ) .
Distraction osteogenesis also can offer excel-
lent aesthetic possibilities. During the process,
the surgeon can perform some extra changes or
adjustments during the elongation period to
fi nally obtain the proper position of the different
segments. In fact, we can obtain a harmonious
relationship between the thirds of the face, pro-
ducing a normal appearance in many patients.
Other advantages to treating a craniosynosto-
sis with distraction are: it allowed the advance-
ment to be performed without the need of bone
grafting, thereby decreasing the length of the
procedure and the donor-site morbidity. It had
signi fi cantly lower relapse rates than standard
midface advancement in cleft lip and palate
(Cohen et al. 1997 ; Polley and Figueroa 1997b ;
Molina et al. 1998 ) , presumably because the soft
tissue, which traditionally resists midface
advancement, was also gradually distracted
along with the bone. The lack of initial mobiliza-
tion signi fi cantly decreased the time needed for
postoperative recovery. There is a signi fi cant
decrease in blood loss and postoperative pain
after this procedure, and patients are typically
able to be discharged from the hospital earlier.
Gradual advancement using distraction allows
the displacement of skeletal fragments over
greater distances because the soft tissue enve-
lope is allowed to accommodate gradually. The
magnitude of advancement is almost twice that
obtained with traditional advancement proce-
dures and has the possibility of adding a vertical
midface lengthening, correcting the shortness of
this structure.
All of these features will diminish morbidity
and will produce excellent functional changes
and the possibility of better craniofacial growth.
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Ross RB (1987) Treatment variables affecting facial
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Subtelny JD, Brodie AG (1954) An analysis of orthodon-
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Synder CC, Levine GA, Swanson HM, Browne EZ (1973)
Mandibular lengthening by gradual distraction.
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671
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_30, © Springer-Verlag Berlin Heidelberg 2013
30
30.1
Introduction
The maxillary deformities in growing cleft
patients could be a hypoplastic maxilla, down-
ward and/or laterally displaced premaxilla in
bilateral clefts, wide alveolar cleft and fi stula, or
combinations of the above deformities. It is a
challenge for both orthodontist and surgeon to
treat a hypoplastic maxilla with wide alveolar
cleft in a growing unilateral or bilateral cleft
patient or a downward or laterally displaced pre-
maxilla with wide alveolar cleft and fi stula in a
growing bilateral cleft patient.
Several new clinical techniques based on the
principles of distraction osteogenesis, either nonsur-
gical orthopedic or surgical approaches, have been
developed for managing the maxillary deformi-
ties in growing cleft patients. These techniques are:
1. Effective maxillary orthopedic protraction for
the treatment of hypoplastic maxilla (Liou and
Tsai 2005 ) and for minimizing alveolar cleft
(Liou and Chen 2003 ) in unilateral or bilateral
cleft patients
2. Premaxillary orthopedic intrusion for the cor-
rection of a downward displaced premaxilla in
bilateral cleft patients (Liou and Chen 2003 ;
Liou et al. 2004 )
3. Premaxillary orthopedic medial repositioning
for the correction of a laterally displaced pre-
maxilla in bilateral cleft patients (Liou and
Chen 2003 )
4. Interdental distraction osteogenesis for the
approximation of a wide alveolar cleft in uni-
lateral or bilateral cleft patients (Liou et al.
2000 )
30.2
Orthopedic Management
of Hypoplastic Maxilla
in Growing Unilateral
or Bilateral Cleft Patients
The combined use of rapid maxillary expansion
and facemask is a contemporary orthopedic man-
agement for maxillary protraction in cleft patients
(Kawakami et al. 2002 ; Tindlund 1994 ; Tindlund
and Rygh 1993 ) . It is assumed that rapid maxil-
lary expansion disarticulates the circumaxillary
sutures so that facemask protraction of maxilla
could be easier (Haas 1970 ; McNamara 1987 ;
Turley 1988 ) . Rapid maxillary expansion is
sutural expansion osteogenesis of the intermaxil-
lary suture and has been recognized as a form of
distraction osteogenesis (Liu et al. 2000 ) .
Facemask protraction of maxilla is sutural pro-
traction osteogenesis of the circumaxillary
sutures. In the absence of a completely intact
Management of Maxillary
Deformities in Growing Cleft
Patients
Eric J. W. Liou and Philip K. T. Chen
E. J. W. Liou , DDS, MS (*)
Department of Orthodontics & Craniofacial Dentistry,
Chang Gung Memorial Hospital,
199 Tung-Hwa North Road , Taipei 105 , Taiwan
e-mail: lioueric@ms19.hinet.net
P. K. T. Chen
Section of Craniofacial Surgery,
Department of Plastic and Reconstruction Surgery ,
Chang Gung Memorial Hospital ,
199 Tung-Hwa North road , Taipei 105 , Taiwan
e-mail: philip@adm.cgmh.org.tw

672
E.J.W. Liou and P.K.T. Chen
intermaxillary suture in cleft patients, disarticulation
of the circumaxillary sutures through rapid max-
illary expansion would play an important role in
maxillary protraction.
However, it remains controversial to what
width the expansion should reach to disarticulate
the circumaxillary sutures. In noncleft patients,
some reported that 5 mm of expansion is good
enough (Alcan et al. 2000 ) , while some others
reported at least 12–15 mm (Haas 1980, 2000 ) .
Both for the cleft and noncleft patients, it seems
that wider expansion exerts greater tension/stress
on the circumaxillary sutures and disarticulates
maxilla better than a smaller expansion. However,
the expansion should be to displace the maxilla
anteriorly and to disarticulate circumaxillary
sutures rather than to overexpand the maxilla. To
disarticulate circumaxillary sutures without over-
expansion, a technique called effective maxillary
orthopedic protraction has been developed for
orthopedic management of the hypoplastic maxilla
in growing cleft patients (Liou and Tsai 2005 ) .
30.2.1 Effective Maxillary
Orthopedic Protraction
This technique includes three parts:
1. A double-hinged rapid maxillary expander for
a greater amount of maxillary anterior
displacement
2. A protocol of alt ernate ra pid m axillary e xpan-
sions and c onstrictions (Alt-RAMEC) of max-
illa for a better disarticulation of maxilla
3. A pair of intraoral maxillary protraction springs
for noncompliant maxillary protraction
30.2.1.1 Double-Hinged Rapid
Maxillary Expander
Several types of rapid maxillary expanders have
been used for maxillary protraction. They are the
fan-type (Suzuki & Takahama 1989 ; Levrini &
Filippi 1999 ) or hyrax-type built with two acrylic
resin halves (Haas 1970 ) , splints (McNamara
1987 ) , or in a hygienic design (Biederman and
Chem 1973 ) . These expanders expand the max-
illa in a V-shaped manner (Vardimon et al. 1998 )
with a center of rotation around the posterior
nasal spine (Lee et al. 1997 ; Braun et al. 2000 ) .
The expansion force distributes not only in the
maxilla but also into the circumaxillary struc-
tures (Chaconas and Caputo 1982 ; Itoh 1985 ) . It
is postulated that this would entail bone resorp-
tion behind the maxilla and, consequently, result
in posterior displacement of maxilla (Biederman
and Chem 1973 ) (Fig. 30.1a, b ). In contrast, it is
postulated as well that this would entail the cir-
cumaxillary structures such as pterygoid plates to
displace the maxilla forward (Haas 1961, 1965 )
(Fig. 30.1c ).
These two assumptions explain why some of
the clinical studies on hyrax-type expanders
reported anterior displacement of maxilla (Haas
1970 ; Wertz 1970 ; Akkaya et al. 1999 ) , while
some others reported no signi fi cant displace-
ment (Da Silva Filho et al. 1991 ; Pangrazio-
Kulbersh et al. 1998 ) or posterior displacement
of maxilla (Sarver and Johnston 1989 ; Cozza
et al. 2001 ) . The posterior displacement of max-
illa compromises the maxillary protraction in
cleft patients.
The double-hinged rapid maxillary expander
(US Patent No. 6334771 B1) is developed for a
greater amount of anterior displacement of max-
illa (Liou and Tsai 2005 ; Liou and Chen 2003 ) .
Its con fi guration is similar to a W-appliance and
has two hinges of rotation. It consists of a jack-
screw in the center, two bolts holding the screw, a
body holding the bolts at anterior and two hinges
of rotation at posterior (Fig. 30.2a, b ). The ratio-
nale for its greater amount of anterior displace-
ment of maxilla is it expands and rotates each
half of the maxilla laterally and anteriorly through
the two hinges of rotation located beside the
molars bilaterally. This kind of expansion entails
the circumaxillary structures to displace the max-
illa anteriorly with less possibility of bone resorp-
tion behind the maxillary tuberosity (Fig. 30.1d ).
Maxillary fi rst premolars and molars are
banded and maxillary impression is taken for
the fabrication of the double-hinged expander.
The expander is oriented perpendicular to the
central incisors and is soldered to the molar and
premolar bands. Two anterior extension arms
(0.051-in. stainless steel wires) extend bilaterally
from the premolar bands toward central incisors

673
30 Management of Maxillary Deformities in Growing Cleft Patients
A point
Intermaxillary
suture
PNS
Pterygoid
plate
Pterygoid
plate
Tuberosity
Tuberosity
A point:
Posterior displacement
Intermaxillary
suture
Bone resorption
at Tuberosity
Bone resorption
at Tuberosity
PNS
(Center of Rotation)
Pterygoid
plate
Pterygoid
plate
A point:
anterior displacement
A point:
anterior displacement
Intermaxillary
suture
PNS
(Center of Rotation)
Pterygoid
plate
Pterygoid
plate
Resistance
Resistance
Intermaxillary
suture
PNS
Pterygoid
plate
Pterygoid
plate
Tuberosity:
(Center of Rotation)
Tuberosity:
(Center of Rotation)
a
b
c
d
Fig. 30.1 ( a – d ) Schematic illustrations of the postulated
maxillary displacement during rapid maxillary expansion.
( a ) The maxilla before expansion: the semicircles repre-
sent the right and left maxillae; the rectangles represent
the pterygoid plates. ( b ) Posterior displacement of the
maxilla after expansion by a hyrax expander: each half of
the maxilla rotates outward and backward around the pos-
terior nasal spine ( PNS ), which entails bone resorption
behind the maxillary tuberosities and results in posterior
displacement of maxilla. ( c ) Anterior displacement of the
maxilla after expansion by a hyrax expander: each half of
the maxilla rotates outward and backward around the
PNS, which entails the circumaxillary structures to dis-
place the maxilla forward and results in anterior displace-
ment of maxilla. ( d ) Anterior displacement of the maxilla
after expansion by a double-hinged expander: each half of
the maxilla rotates outward and forward around the maxil-
lary tuberosities, which geometrically results in anterior
displacement of maxilla without the possibility of entail-
ing bone resorption behind the maxillary tuberosities
Fig. 30.2 ( a , b ) The con fi guration of the double-hinged rapid maxillary expander ( a ) and the assembly of the device
in a clinical case ( b )

674
E.J.W. Liou and P.K.T. Chen
(Fig. 30.2b ). The premolar and molar bands and
the anterior extension arms are sandblasted before
cementation. After cementation of the expander,
the anterior extension arms are bonded to the
anterior teeth with composite resin. One day after
cementation, the double-hinged expander is acti-
vated according to the protocol of Alt-RAMEC.
30.2.1.2 Alternate Rapid Maxillary
Expansions and Constrictions
(Alt-RAMEC) of Maxilla
The Alt-RAMEC is a protocol of repetitive
weekly alternate rapid maxillary expansions and
constrictions (Liou and Tsai 2005 ; Liou and Chen
2003 ) (Table 30.1 ). It lasts for 7–9 weeks until
the maxilla is loosened. The weekly (every
7 days) sequence is 7 mm of expansion, 7 mm of
constriction, 7 mm of expansion, 7 mm of con-
striction, 7 mm of expansion, 7 mm of constric-
tion, 7 mm of expansion, 7 mm of constriction,
7 mm of expansion, etc. Each day, the maxilla is
expanded or constricted 1 mm/day (four turns in
one activation). This protocol allows better disar-
ticulation of circumaxillary sutures without over-
expansion of maxilla. Its rationale is similar to
simple tooth extraction in which we repeatedly
rock the tooth buccally and lingually until the
tooth is disarticulated out of the alveolar socket.
Patients are seen once a month. The maxilla is
examined clinically for its loosening by holding
the patient’s head with one hand and rocking the
expander with maxilla up and down with another
hand. The maxilla is ready for protraction only
once loosening of the maxilla has been observed
clinically.
30.2.1.3 Maxillary Protraction Springs
for Effective Maxillary
Orthopedic Protraction
The maxillary protraction device is a pair of non-
compliant, tooth-borne, intraoral maxillary pro-
traction spring (US patent 6273713 B1) (Liou
and Tsai 2005 ; Liou and Chen 2003 ) (Fig. 30.3 ).
It is a 0.036-in. b-nickel-titanium helix spring.
Ball pins are used to mount the spring on the
maxillary and mandibular headgear tubes. The
spring is activated by the lower jaw move-
ment. It is passive and in 180° when the man-
dible opens (Fig. 30.3a ). While the mandible
closes, it is compressed to 100–120° and gener-
ated 300–400 g of horizontal and upward force
on the maxilla (Fig. 30.3b ). A 0.036-in. b- nickel-
titanium mandibular lingual holding arch with
built-in lingual crown torque is used for splinting
the mandibular dentition as an anchor unit for the
protraction (Fig. 30.3c ).
30.2.1.4 Treatment Protocol for Effective
Maxillary Orthopedic
Protraction
The treatment protocol for effective maxillary
orthopedic protraction includes 7–9 weeks of
Alt-RAMEC and 4 months of maxillary protrac-
tion using intraoral maxillary protraction springs.
The total treatment protocol is 6 months. The
patients are seen every 4 weeks for adjusting or
replacing the intraoral maxillary protraction
springs when they are distorted or broken. The
expander and protraction device are removed at
the end of 6th month.
30.2.1.5 Treatment Results and Effects
of Effective Maxillary
Orthopedic Protraction
The differences between Alt-RAMEC and a sin-
gle course of rapid maxillary expansion (RME)
have been evaluated in a clinical cephalometric
study (Liou and Tsai 2005 ) . Twenty-six consecu-
tive cases of unilateral cleft lip and palate patients
with hypoplastic maxillae (SNA < 82) were
Table 30.1 Clinical protocol for alternate rapid maxillary
expansions and constrictions
Alternate weekly
sequence
Weekly amount
of expansion/
constriction
(mm)
Daily amount of
activation (mm)
Expansion
7
1
Constriction
7
1
Expansion
7
1
Constriction
7
1
Expansion
7
1
Constriction
7
1
Expansion
7
1
Constriction
7
1
Expansion
7
1

675
30 Management of Maxillary Deformities in Growing Cleft Patients
included for maxillary protraction. Their ages
ranged from 9 to 12 years old. The group of RME
(7 days, 1 mm/day) was the fi rst 16 consecutive
cases. The group of Alt-RAMEC was the next ten
consecutive cases. The expander used in both
groups was the double-hinged expander, and the
protraction appliance was the intraoral maxillary
protraction springs.
The amount of maxillary anterior displace-
ment by the double-hinged expander in the Alt-
RAMEC group was 3.0 ± 0.9 mm at A point. This
was signi fi cantly greater than the 1.6 ± 1.0 mm in
the RME group. The amount of maxillary
advancement with intraoral protraction springs in
the Alt-RAMEC group was 2.9 ± 1.9 mm at
A point and was signi fi cantly greater than the
0.9 ± 1.1 mm in the RME group. The overall
amount of maxillary advancement in the Alt-
RAMEC group was 5.8 ± 2.3 mm at A point. The
clinical and cephalometric results are shown in
Fig. 30.4 . The protraction results remained stable
without signi fi cant relapse after 2 years (5.8 ± 2.3
vs. 5.7 ± 3.0 mm).
The protocol of Alt-RAMEC displaces the
maxilla anteriorly twice and facilitates maxil-
lary protraction three times better than a single
course of RME. This indirectly proves that the
protocol of Alt-RAMEC disarticulates cir-
cumaxillary sutures better than a single course
of rapid maxillary expansion. Because the cir-
cumaxillary sutures are protracted three times
faster than usual, the protraction results could be
an orthopedic process of “sutural protraction
osteogenesis,” which is similar but less vigorous
than sutural expansion distraction osteogenesis.
The maxillary protraction by using the double-
hinged expander, repetitive weekly protocol of
Alt-RAMEC, and the intraoral protraction
springs is effective with stable results at 2 year
follow-up.
Fig. 30.3 ( a – c ) The intraoral maxillary protraction spring ( a , b ) and removable b-nickel-titanium mandibular lingual
holding arch ( c ) for effective maxillary orthopedic protraction

676
E.J.W. Liou and P.K.T. Chen
Fig. 30.4 ( a – g ) The clinical results of effective maxillary
orthopedic protraction in a 12-year-old bilateral cleft
patient. The treatment was 9 weeks of Alt-RAMEC,
1 month of active maxillary protraction, and 3 months of
maintenance. The amount of maxillary protraction at
A point was 6.5 mm and the mandible rotated downward
and backward for 5 mm. ( a – c ) The lateral facial pro fi le,
occlusion, and cephalogram before treatment. ( d – f ) The
lateral facial pro fi le, occlusion, and cephalogram after
treatment. ( g ) Cephalometric superimposition before and
after treatment

677
30 Management of Maxillary Deformities in Growing Cleft Patients
To obtain good stability, our clinical experi-
ence revealed that the timing for effective maxil-
lary orthopedic protraction is around the onset of
puberty (age 11–13). Early treatment is not rec-
ommended because of the unpredictable man-
dibular growth. The onset of puberty could be
evaluated by using vertebral bone age on cepha-
logram (Mito et al. 2003 ; Franchi et al. 2000 ) .
30.3
Orthopedic Management
of a Downward Displaced
Premaxilla in Bilateral Cleft
Patients
In growing bilateral cleft patients, one of the
most common premaxillary deformities is a
prominent and downward displaced premaxilla
with or without wide alveolar clefts (Fig. 30.5a ).
The vertical discrepancy between the premaxilla
and buccal segments results in an unaesthetic
“equine appearance,” anterior deep overbite, and
also makes the alveolar bone grafting dif fi cult or
impossible (Hayward 1983 ) .
In a cephalometric study, Liou et al. inferred
that the downward displaced premaxilla is not
because of overgrowth of the premaxilla or over-
eruption of the maxillary incisors (Liou et al.
2004 ) . The premaxilla might have been down-
ward distorted in the early age of life after the
primary surgical repairs. Several studies indicated
that the prominence of premaxilla becomes less
pronounced during the growth period and gradu-
ally resolves into the adulthood (Pruzansky 1955 ;
Harvold 1961 ; Narula and Ross 1970 ; Friede and
Pruzansky 1972 ; Vargervik 1983 ; Trotman and
Ross 1993 ) . It is recommended that the premaxil-
lary deformities be left untreated until adulthood
(Friede and Pruzansky 1985 ) . However, to leave
the deformities unsolved until adulthood may
complicate the alveolar bone grafting and impact
the young patients psychosocially.
The contemporary surgical interventions of
the downward displaced premaxilla in bilateral
cleft patients include removal of the primary
maxillary incisors in order to improve the appear-
ance and temporarily reduce the dentoalveolar
prominence (Vargervik 1983 ) , and surgical repo-
sition of the premaxilla in conjunction with alve-
olar bone grafting (Harvold 1961 ; Freihofer et al.
1991 ; Bardach et al. 1992 ; Heidbuchel et al.
1993 ; Iino et al. 1998 ) . However, the premaxilla
in the growing subjects having surgical reposi-
tioning grows at a very low rate and becomes
retrusive progressively in the older age (Vargervik
1983 ; Smahel 1984 ) .
30.3.1 Premaxillary Orthopedic
Intrusion
A better treatment modality, therefore, is to repo-
sition the premaxilla and approximate the alveo-
lar cleft nonsurgically and orthopedically so that
Fig. 30.5 ( a , b ) Two of the most common premaxillary
deformities in bilateral cleft lip and palate. ( a ) A promi-
nent and downward displaced premaxilla with or without
wide alveolar clefts. ( b ) A laterally displaced premaxilla
with a wide alveolar cleft on one side

678
E.J.W. Liou and P.K.T. Chen
the growth of premaxilla would not be disturbed
and the alveolar bone graft could be performed
successfully. A new nonsurgical technique called
premaxillary orthopedic intrusion has been devel-
oped for correcting the downward displaced pre-
maxilla in growing patients with bilateral cleft
(Liou and Chen 2003 ; Liou et al. 2004 ) .
30.3.1.1 Orthodontic Preparation
Before initiating orthopedic intrusion of premax-
illa, the maxillary incisors are well aligned
orthodontically so that a segment of 0.016 by
0.022 stainless steel arch wire can be placed. The
maxillary fi rst permanent molars or the second
primary molars are banded, and the band is welded
with an orthodontic triple tube. The triple tubes
are for holding the orthopedic intrusion device.
A fan-type rapid maxillary expander, if necessary,
could be placed for repositioning the collapsed
buccal segments. A transpalatal arch and/or a seg-
ment of stainless steel arch wire (0.016 by 0.022)
are placed on the buccal teeth for consolidating
the buccal segments as an anchor unit for the
orthopedic intrusion of premaxilla.
30.3.1.2 Device for Premaxillary
Orthopedic Intrusion
No headgear, extraoral device, or surgery is used
for the intrusion. The device for orthopedic intru-
sion of the downward displaced premaxilla is a
pair
of
tooth-borne
distraction
devices
(Fig. 30.6a ). The device anchors on the maxillary
buccal teeth and delivers an intermittent intrusion
force to the premaxilla through the maxillary
incisors. The U-shaped connector of the device is
inserted into the headgear tube on the molar band
and secured with a 0.012-in. ligature wire. The
extension arm of the device is secured with 0.012-
in. ligature wires onto the segmental arch wire on
the central incisors (Fig. 30.6b–e ).
On both sides, the devices are activated
0.3 mm/day until the premaxilla has been upward
repositioned to the desired position. The devices
are then maintained for another 3 months before
their removal. After removal of the intrusion
devices, an orthodontic arch wire is placed for
further maintenance, and alveolar bone grafting
is then performed within 3 months.
30.3.1.3 Treatment Results
of Premaxillary Orthopedic
Intrusion
The treatment results have been evaluated in a
cephalometric study on ten consecutive cases
(Liou et al. 2004 ) . The orthopedic intrusion of
premaxilla was completed within 4 weeks in all
the patients. After the intrusion, the occlusal
planes and gingival lines of the premaxilla and
buccal segments were leveled clinically. The
facial appearance during resting and smiling
improved and had no “equine appearance.” The
clinical results are shown in Fig. 30.7 .
The cephalometric study revealed that there
was no signi fi cant vertical movement of the max-
illary buccal segments, and the premaxilla was
signi fi cantly intruded (Fig. 30.7d ). The nasal
bone was also signi fi cantly brought forward and
upward at the nasal tip, but its amount was
signi fi cantly less than the orthopedic intrusion of
the premaxilla.
The correction of the premaxillary deformity
mainly came from three aspects: orthopedic
intrusion of the premaxilla, dental intrusion of
the maxillary incisors, and shortening of the pre-
maxillary dentoalveolar height. The orthopedic
intrusion of the premaxilla (3.0 mm) and dental
intrusion of the maxillary incisors (3.5 mm) gave
a total amount of 6.5 mm upward repositioning at
the tip of the maxillary incisor. The shortening of
the premaxillary dentoalveolar height (3.5 mm)
could be due to the dental intrusion of the maxil-
lary incisors, which was expected when a tooth-
borne distraction device was used. The correction
was 46 % (3.0/6.5) orthopedic effect and 54 %
(3.0/6.5) dentoalveolar effect.
The orthopedic intrusion of the premaxilla
remains relatively stable in the 1-year observa-
tion after treatment. However, the dental intru-
sion of maxillary incisors seems unstable. The
dental relapse of the maxillary incisors tends to
elongate the premaxillary dentoalveolar height
and compromise the result of premaxillary ortho-
pedic intrusion. For this reason, it is recom-
mended to maintain the dental intrusion with an
orthodontic arch wire and perform alveolar bone
grafting shortly after removal of the intrusion
devices (Fig. 30.7c ).

679
30 Management of Maxillary Deformities in Growing Cleft Patients
Fig. 30.6 ( a – e ) The device for premaxillary orthopedic intrusion ( a ) and the assembly of the device in a clinical case ( b – e )

680
E.J.W. Liou and P.K.T. Chen
30.3.1.4 Mechanisms of Premaxillary
Orthopedic Intrusion
The possible events that may occur during
orthopedic intrusion of premaxilla include
mechanical upward displacement of the pre-
maxilla and vomeronasal septum complex,
sutural contraction osteogenesis (Castello et al.
2000 ) and/or osteolysis (Kawakami et al. 1996 )
in the vomero-premaxillary suture, or bend-
ing/remodeling of the vomeronasal septum
complex:
1. Mechanical upward displacement without bend-
ing/remodeling of the vomeronasal septum com-
plex and no sutural contraction osteogenesis/
osteolysis in the vomero-premaxillary suture
2. Sutural contraction osteogenesis/osteolysis in
the vomero-premaxillary suture without bending/
remodeling/mechanical upward displacement
of the vomeronasal septum complex
3. Bending/remodeling
without
mechanical
upward displacement of the vomeronasal sep-
tum complex and no sutural contraction osteo-
genesis/osteolysis in the vomero-premaxillary
suture
4. Any combinations of 1, 2, or 3
By the analysis on the lateral and posteroan-
terior cephalometric radiographs, it was implied
what occurred during the orthopedic intru-
sion of premaxilla was mostly similar to the
sutural contraction osteogenesis/osteolysis in
the vomero-premaxillary suture combined with
slightly mechanical upward displacement of the
vomeronasal septum complex and nasal bones
(Fig. 30.8 ).
Fig. 30.7 ( a – d ) The premaxillary orthopedic intrusion.
The equine appearance of the premaxilla prior treatment
( a ), after 1 month of orthopedic intrusion ( b ), 5 months
after the orthopedic intrusion ( c ), and cephalometric
superimposition before and after premaxillary orthopedic
intrusion ( d )

681
30 Management of Maxillary Deformities in Growing Cleft Patients
30.4
Orthopedic Management
of a Laterally Displaced
Premaxilla in Bilateral Cleft
Patients
In growing bilateral cleft patients, another com-
mon premaxillary deformity is a laterally displaced
premaxilla with a wide alveolar cleft on one side
(Fig. 30.5b ). The laterally displaced premaxilla
results in an unaesthetic appearance with a skewed
premaxilla and dental midline and uneven width
of the alveolar cleft beside the premaxilla.
The alveolar bone grafting and closure of oro-
nasal fi stula could be dif fi cult without surgical
repositioning the laterally displaced premaxilla.
However, the premaxilla in growing subjects having
surgical repositioning grows at a very low rate
and becomes retrusive progressively as they age
(Vargervik 1983 ; Smahel 1984 ) .
30.4.1 Premaxillary Orthopedic Medial
Repositioning
A better treatment modality, therefore, is to repo-
sition the premaxilla and approximate the alveo-
lar cleft nonsurgically and orthopedically so that
the growth of premaxilla would not be disturbed
and the alveolar bone graft could be performed
successfully. A new nonsurgical technique called
premaxillary orthopedic medial repositioning has
been developed for correcting the laterally dis-
placed premaxilla in growing patients with
bilateral cleft (Liou and Chen 2003 ) .
Fig. 30.8 ( a – d ) The cephalometric radiograms of the
same patient in Fig. 30.7. ( a , b ) The lateral cephalo-
gram before and after premaxillary orthopedic intrusion.
( c , d ) The posteroanterior cephalogram before and after
premaxillary orthopedic intrusion. Note the premaxilla
and incisors were intruded without further deviation of
the vomer bone and nasal septum

682
E.J.W. Liou and P.K.T. Chen
30.4.1.1 Orthodontic Preparation
Similar to the clinical procedures for the premax-
illary orthopedic intrusion, the entire maxillary
dentition is aligned orthodontically so that a
0.016 by 0.022 stainless steel arch wire could be
placed before the orthopedic repositioning. The
maxillary fi rst permanent molars are banded, and
the band is welded with an orthodontic triple
tube. For the anchorage, a transpalatal arch is
placed for consolidating both of the buccal seg-
ments as an anchor unit for the orthopedic reposi-
tioning of premaxilla.
30.4.1.2 Device for Premaxillary
Orthopedic Medial
Repositioning
No headgear, extraoral device, or surgery is used
for the repositioning. The device for orthopedic
medial repositioning is an intraoral tooth-borne
distraction device (Fig. 30.9 ). It consists of a
body, a screw, and an extension arm. There are
two bolts on the body for holding the screw. The
fi xed bolt is attached on the front of the body for
holding the head of the screw. The sliding bolt
rides and slides on the sliding bar of the body for
holding the tail of the screw. The U-shaped con-
nector at distal end of the body is inserted into the
headgear tube on the molar band and secured
with a 0.012-in. ligature wire. The extension arm
is adjusted to hook distally to the maxillary inci-
sors so that the premaxilla is being pushed toward
the midline when the device is activated. The
arch wire is a track guiding the premaxilla to
slide in a linear curvature direction during the
orthopedic repositioning.
The screw is activated 0.3 mm/day until the
maxillary dental midline has been overcorrected
for 2–3 mm. The device is then maintained for
another 3 months before its removal. After the
removal, orthodontic elastics or ligature wire is
placed for further maintenance before the next
treatment on the alveolar cleft.
30.4.1.3 Treatment Results
of Premaxillary Orthopedic
Medial Repositioning
The treatment results have been evaluated in a
cephalometric study on four consecutive cases
(Liou and Chen 2003 ) . The clinical results are
shown in Fig. 30.10 . The age of the patients were
9–12 years old at the time of treatment. Before
the treatment, the angular deviation of premaxilla
and nasal septum ranged from 15° to 25°, and the
linear deviation of dental midline ranged from 5
to 8 mm as measured on the posteroanterior
cephalograms.
The orthopedic medial repositioning of pre-
maxilla was completed within 2–3 weeks in all
the patients. All the patients tolerated the device
well, and no pain was reported by any of the
patients. The maxillary dental midline was over-
corrected for 2–3 mm. The overall correction of
the dental midline ranged from 7 to 11 mm.
During the maintenance period (3 months), the
premaxilla and maxillary dental midline gradu-
ally moved back toward the mandibular dental
midline. The smile facial appearance was
improved, and the premaxilla and dental midline
were repositioned on the midline.
30.4.1.4 Mechanisms of Premaxillary
Orthopedic Medial
Repositioning
The posteroanterior cephalometric and occlusal
radiographs before and 3 months after the reposi-
tioning were evaluated. It was revealed that both
the deviated nasal septum and premaxilla were
all straightened (Fig. 30.11 ). The straightening of
the nasal septum and premaxilla could be due to
bone bending and remodeling of the vomer bone.
The angular correction of the premaxilla and
Fig. 30.9 The device for premaxillary orthopedic medial
repositioning

683
30 Management of Maxillary Deformities in Growing Cleft Patients
Fig. 30.10 ( a – c ) Premaxillary orthopedic medial reposi-
tioning. The skewed premaxilla and wide alveolar cleft
before the orthopedic repositioning ( a ), after 3 weeks of
orthopedic repositioning ( b ), and after effective maxillary
orthopedic protraction of the lateral segments for mini-
mizing the alveolar cleft and alveolar bone graft ( c )
Fig. 30.11 ( a , b ) The posteroanterior cephalograms reveal straightening of the vomer bone after premaxillary
orthopedic medial repositioning ( a before; b after medial repositioning)

684
E.J.W. Liou and P.K.T. Chen
nasal septum ranged from 10° to 20°, and the
linear correction of the premaxilla ranged from 5
to 10 mm, as measured on the radiographs.
30.5
Managements of a Wide
Alveolar Cleft and Fistula
Although premaxillary orthopedic intrusion or
orthopedic medial repositioning is able to cor-
rect the downward or laterally displaced premax-
illa, the alveolar cleft might still be too wide to
be bone grafted. Using oral mucosa at a distant
site, such as rotation advancement fl ap of buc-
cal mucosa or tongue fl ap (Jackson 1972 ) , could
close a wide alveolar cleft. By such approach, the
alveolar cleft is not bone grafted and the maxil-
lary segments are not approximated. Neither the
buccal mucosa nor the tongue mucosa is a good
substitute for the attached gingiva. Attached
gingiva is essential for the subsequent tooth erup-
tion, orthodontic tooth movement, or dental pros-
theses after alveolar bone grafting and closure of
fi stula (Jackson 1972 ; Boyne 1974 ) .
Another approach is to approximate the
alveolar cleft through LeFort I osteotomy and
advancement so that both the soft and bony tis-
sue could be well approximated and bone grafted
(Posnick and Tompson 1995 ) . However, LeFort I
advancement might disturb the growth of maxilla
in young patients (Nanda et al. 1983 ) .
30.5.1 Protocol for Approximating
a Wide Alveolar Cleft
We have developed a protocol for minimizing or
approximating a wide alveolar cleft (Liou and
Chen 2003 ) :
1. For an alveolar cleft less than a tooth width,
effective maxillary orthopedic protraction of
the maxillary lateral segments and alveolar
bone grafting is the treatment of choice.
2. For an alveolar cleft wider than a tooth width,
interdental distraction osteogenesis (Levrini
and Filippi 1999 ) and alveolar bone grafting
or gingivoperiosteoplasty is the treatment of
choice.
30.5.2 Minimize Alveolar Cleft by
Effective Maxillary Orthopedic
Protraction
The lateral segments of maxilla are orthopedi-
cally protracted toward the premaxilla to mini-
mize the alveolar cleft. The rationales and
mechanisms are similar to entire maxillary pro-
traction by using effective maxillary orthopedic
protraction. The total treatment protocol is
6 months, including 8–9 weeks of Alt-RAMEC
followed by 4 months of orthopedic protraction
of the lateral segments of maxilla. The expander
is a double-hinged rapid maxillary expander, and
the protraction appliance is the intraoral maxillary
protraction springs.
30.5.2.1 Clinical Procedures for Effective
Maxillary Orthopedic
Protraction of Lateral Segments
of Maxilla
Maxillary molars and primary canines (or fi rst
premolars) are banded, and maxillary impression
is taken for fabricating the double-hinged rapid
maxillary expander. The expander is oriented
perpendicular to the central incisors. The expander
anchors only on lateral segments of maxilla, and
there is no extension arm on the premaxilla. The
inner surfaces of the bands are sandblasted before
cementation. One day after the cementation, the
double-hinged expander is activated according to
the protocol of Alt-RAMEC and then is left in
place for orthopedic protraction of the lateral seg-
ments of maxilla. A 0.036-in. b-nickel-titanium
mandibular lingual holding arch with built-in lin-
gual crown torque is used for splinting the man-
dibular dentition as an anchor unit for the
orthopedic protraction. Patients are seen every
4 weeks for adjusting or replacing the intraoral
maxillary protraction springs when they are dis-
torted or broken. The expander and the springs
are then removed at the end of the 6th month.
30.5.2.2 Treatment Results
Three of the four patients who had premaxil-
lary orthopedic medial repositioning received the
treatment. The treatment results were evaluated clin-
ically and cephalometrically (Liou and Chen 2003 ) .

685
30 Management of Maxillary Deformities in Growing Cleft Patients
All of the alveolar clefts were successfully mini-
mized, and the gingival and mucosal tissue beside
the alveolar clefts was approximated after the ortho-
pedic protraction (Fig. 30.12 ). All of the patients
received orthodontic treatment after removal of the
expander and protraction springs. The alveolar bone
grafting was then performed shortly after the maxil-
lary dentition was well aligned.
On the cephalometric evaluation, the lateral
segments of maxilla were protracted for 2–3 mm.
The buccal teeth on the maxillary lateral seg-
ments were also moved forward for 2–3 mm. The
alveolar clefts were all minimized to 2–3 mm as
measured on the radiographs. No retrusion or
retraction of the premaxillae was observed. The
overjet at anterior teeth was maintained positive
throughout the treatment.
The maxillary lateral segment orthopedic
protraction by Alt-RAMEC is an effective
nonsurgical technique for minimizing the alveo-
lar cleft in patients with BCLP. This technique is
much less invasive relative to the surgical reposi-
tioning of premaxilla. The treatment effects are
both the orthopedic protraction of the maxillary
lateral segments and forward movement of the
buccal teeth.
30.5.3 Interdental Distraction
Osteogenesis for Approximating
Alveolar Cleft Wider
Than a Tooth Width
The closure of an alveolar cleft wider than a tooth
width is a challenge not only because of the
dif fi culty in complete closure by using local
attached gingiva but also the great volume of
bone grafting. Interdental distraction osteogene-
Fig. 30.12 ( a – d ) Minimize alveolar cleft less than a
tooth width. The skewed premaxilla and alveolar cleft
before the orthopedic repositioning ( a ), after 3 weeks of
orthopedic medial repositioning ( b ), during effective
maxillary orthopedic protraction of the lateral segments
( c ), and after the orthopedic protraction and alveolar bone
graft ( d )

686
E.J.W. Liou and P.K.T. Chen
sis (IDO) has been proposed to approximate wide
alveolar clefts and to achieve bony union across
the clefts without bone grafting, either in unilat-
eral or bilateral cleft (Liou et al. 2000 ) . It is a
technique of dentoalveolar lengthening through
soft callus distraction osteogenesis. The dentoal-
veolus is osteotomized interdentally and then
transported toward the cleft so that the cleft could
be approximated by growing local alveolus and
attached gingiva at a distant site to the cleft
(Fig. 30.13 ). Its advantages include eliminating
the need for extensive alveolar bone grafting, cre-
ating dental space (the regenerate alveolus and
attached gingiva) for relieving dental crowding,
as well as avoiding worsening the velopharyngeal
insuf fi ciency.
30.5.3.1 Presurgical Orthodontic
Preparations
All the maxillary teeth are bonded and banded,
and then they are well aligned so that a 0.016 by
0.022 (or thicker) stainless steel arch wire could
be placed. A transpalatal arch could be placed for
consolidating buccal segments as one unit when
it is necessary. One of the purposes of orthodon-
tic tooth alignment before interdental distraction
osteogenesis is to well align all the maxillary
teeth so that the osteotomized dentoalveolus can
slide along the arch wire during distraction.
Besides the distraction device, the stainless steel
arch wire also is a guiding track for interdental
distraction osteogenesis. The distraction device
has a linear track, but the arch wire guides the
osteotomized dentoalveolus to be distracted along
the arch wire in a linear curvature direction
(Fig. 30.13b ).
An interdental space is opened orthodonti-
cally at the selected distraction site by using an
open coil spring or similar mechanisms. This is
to separate the dental roots and increase the
thickness of the interdental alveolar bone so that
interdental osteotomy could be performed with-
out damaging or stripping the adjacent dental
roots.
30.5.3.2 Interdental Distraction Site
Although the selection of distraction site varies
regarding different clinical situations of the cleft,
there are certain guidelines:
1. The osteotomized segment of dentoalveolus to
be distracted should have adequate blood sup-
ply from adjacent gingival or oral mucosa and
adequate bone volume to sustain a successful
distraction osteogenesis. A width of at least
two teeth is recommended.
2. The interdental distraction site should be wide
enough for interdental osteotomy and to avoid
damaging or stripping the adjacent dental
roots during interdental osteotomy. At least
3 mm is recommended.
3. At least 1.0 mm thickness of interdental alveo-
lar bone should be preserved beside the adja-
cent dental roots after interdental osteotomy.
Inadequate thickness could result in severe
Fig. 30.13 ( a , b ) Model illustrations of interdental dis-
traction osteogenesis. The dentoalveolus is osteotomized
interdentally ( a ) and transported toward the cleft by the
distractor ( b ). The orthodontic arch wire also is a guiding
track. The osteotomized dentoalveolus slides on the arch
wire in a linear curvature direction

687
30 Management of Maxillary Deformities in Growing Cleft Patients
periodontal problems, such as exposure of the
adjacent dental roots and insuf fi cient volume
and height of the regenerate.
4. The interdental distraction site should have enough
attached gingiva for a primary closure. Exposure
of the osteotomy site would result in wound infec-
tion, sequestrae, and distraction failure.
30.5.3.3 Surgical Procedures
The surgical procedures are performed under
naso-endotracheal anesthesia. A horizontal
intraoral incision is made along the buccal vesti-
bule of the maxilla. Superior based mucope-
riosteal fl aps are re fl ected, exposing the site of
horizontal maxillary osteotomy on the buccal
side. A vertical mucoperiosteal tunnel extending
upward from the interdental attached gingiva to
the horizontal incision is made to expose the site
of vertical interdental osteotomy. Another small
incision, on the palatal side, is made inside the
gingival sulcus, exposing the site of interdental
osteotomy. Care is taken to avoid re fl ecting or
stripping all of the palatal mucosa.
By estimating on the radiographs, the anatomic
position of the dental roots, sites of interdental and
horizontal maxillary osteotomies, and permanent
tooth buds are marked on the alveolar bone with
surgical marking pens. Complete horizontal osteot-
omy is performed with a cutting saw, 3–5 mm away
from the dental root apex and tooth buds. Complete
interdental osteotomy is then performed with a
small round bur and followed by a thin osteotome,
cutting through the buccal and palatal cortical
plates respectively. As the cutting round bur
encounters the cancellous bone, the thin osteotome
is then used for cutting carefully through the inter-
dental cancellous bone buccolingually. After the
horizontal maxillary and interdental osteotomies,
the distal segment of the osteotomized dental arch
is completely mobile. The orthodontic arch wire
holds the osteotomized segment in place after
osteotomies and prevents medial collapse of the
segment when the distraction device is placed.
The distraction device is a bone-borne device
(Martin & KLS, USA) (Fig. 30.14a ). The vertical
bars of the bone-borne distractor are bended into
the desired shape to avoid any possible compres-
sion to the gingival adjacent to the vertical osteot-
omy sites (Fig. 30.14b ). The direction of the
distractor needs careful adjustment to ensure a
correct vector for bony movement. It also needs
great care to avoid any compression of the dis-
tractor to the buccal mucosa. The distractor is
then fi xed to maxilla with unicortical screws. The
incisions are irrigated and closed with absorbable
sutures (Fig. 30.14c ). A very important point in
wound closure is closing the attached gingiva
over the interdental osteotomy sites to avoid any
possible wound separation complicated with den-
tal root exposure in the vertical osteotomy site.
30.5.3.4 Distraction Protocol
The latency period is 7 days. This allows enough
time for the formation of soft callus and primary
healing of the attached gingiva and oral mucosa.
The soft tissue wound healing is critical for the
distraction results. Soft tissue wound dehiscence
during distraction could result in severe bone
resorption, gingival recession, and exposure of
the dental root. The distraction device is activated
1 mm/day until both ends of the alveolar cleft has
been approximated. After completion of inter-
dental distraction, the device is left in place for
3 months for maintenance and postdistraction
orthodontic tooth movement through regenerate.
30.5.3.5 Postdistraction Maintenance
and Orthodontic Tooth
Movement Through
the Regenerate
Two weeks after completion of the interdental
distraction, the tooth/teeth right adjacent to the
interdental distraction, either the mesial or distal
one or both, are moved orthodontically into the
regenerate. This is to eliminate the interdental
space created by distraction, or to utilize the cre-
ated space for relieving dental crowding.
Orthodontic elastic chains or nickel-titanium
coil springs are used for moving tooth/teeth into the
regenerate. They are placed between the moved
tooth/teeth and the vertical bars of the bone-borne
distraction device (Fig. 30.15 ). The bone-borne dis-
traction device holds the distracted segment through
several bone screws, while the tooth/teeth at the dis-
tracted segment are being moved through the regen-
erate without shortening the width of the regenerate.
The bone-borne distraction device is left in place
for not only maintenance but also is an anchor for

688
E.J.W. Liou and P.K.T. Chen
Fig. 30.15 Postdistraction orthodontic tooth move-
ment. Orthodontic nickel-titanium coil spring is attached
between the maxillary fi rst molar and the vertical bar of the
distractor for moving the fi rst molar into the regenerate
Fig. 30.14 ( a ) The bone-borne distractor for interdental distraction osteogenesis. ( b , c ) The vertical bars are bended
into a bayonet step to avoid compression to the gingival tissue
postdistraction orthodontic tooth movement. This
is similar to the implant orthodontics that uses bone
screws or plates as anchorage for orthodontic tooth
movement (Lin and Liou 2003 ) . After the tooth/
teeth have moved into the regenerate, the adjacent
tooth/teeth are then moved subsequently into the
left space. The postdistraction orthodontic tooth
movement usually can be completed in 3 months
because the regenerate is still soft.
30.5.3.6 Postdistraction Alveolar
Bone Grafting or
Gingivoperiosteoplasty
After the interdental distraction osteogenesis and
postdistraction orthodontic tooth movement,
either conventional alveolar bone grafting or gin-
givoperiosteoplasty can be performed as the fi nal
treatment procedure for closing the wide alveolar
cleft. Soft tissue approximation of the alveolar

689
30 Management of Maxillary Deformities in Growing Cleft Patients
cleft does not mean bony approximation of the
alveolar cleft. Occlusal or periapical fi lm is
needed for revealing the remaining width of the
bony alveolar cleft:
1. The alveolar bone grafting is performed in
cases where the bony gap between the alveolar
cleft is still wider than 2 mm after interdental
distraction osteogenesis.
2. The gingivoperiosteoplasty is performed in
cases where the bony gap between the alveo-
lar cleft is less than 2 mm after the interdental
distraction osteogenesis.
Fig. 30.16 ( a – f ) Approximation of a wide alveolar cleft
by interdental distraction osteogenesis in a 12-year-old
unilateral cleft patient. The alveolar cleft is bone grafted
after the distraction. ( a – c ) The clinical photos before,
immediately after distraction, and 2 years after distrac-
tion. ( d – f ) The occlusal fi lms before, immediately after
distraction, and 2 years after distraction

690
E.J.W. Liou and P.K.T. Chen
30.5.3.7 Treatment Results
Twenty-one patients, including 13 unilateral and
8 bilateral clefts who had interdental distraction
osteogenesis for approximating their wide alveo-
lar cleft in 1998–2002 were reviewed for their
treatment results (Fig. 30.16 ). The follow-up
period was 4–5 years. There were 29 alveolar
clefts and the average width was 10 mm.
The distracted segments of the dental arches were
moved almost bodily toward the cleft as revealed
on the panoramic and cephalometric radiographs.
The average amount of distraction, as measured
on the radiographs, was 12 mm with a range of
10–20 mm. The relapse was 0.5 mm in the fi rst
3 months after removal of distraction device.
Clinically, 28 out of 29 alveolar clefts were
approximated completely by soft tissue contact
after interdental distraction osteogenesis. Thirteen
out of the 29 alveolar clefts were successfully bone
grafted, and 16 out of the 29 alveolar clefts had
gingivoperiosteoplasty that resulted in bony union
across alveolar cleft. The 4- to 5-year follow-up
revealed the treatment results were stable.
30.6
Summary
In this chapter, we introduced three new orth-
odontic and orthopedic techniques and one sur-
gical distraction osteogenesis for the management
of maxillary deformities in growing unilateral
and bilateral cleft patients. These techniques are
the effective maxillary orthopedic protraction
for correcting a hypoplastic maxilla and mini-
mizing alveolar cleft, premaxillary orthopedic
intrusion for correcting a downward displaced
premaxilla, premaxillary orthopedic medial
repositioning for correcting a lateral displaced
premaxilla, and interdental distraction osteogen-
esis for approximating a wide alveolar cleft.
These techniques utilize principles of distraction
osteogenesis. The orthopedic approaches could
be a form of sutural expansion or protraction
osteogenesis, and their treatment effects are
mostly orthopedic and partly orthodontic. The
interdental distraction is a form of callus
distraction osteogenesis. The clinical and radio-
graphic evaluations have revealed their success-
ful applications for solving maxillary deformities
in growing cleft patients.
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DOI 10.1007/978-3-642-30770-6_31, © Springer-Verlag Berlin Heidelberg 2013
31
31.1
Preventing Relapse Following
Distraction Osteogenesis for
the Cleft Midface in Adults
Distraction osteogenesis is an accepted form of
treatment in the management of midface
de fi ciency in patients with cleft. However, it is
well known that some amount of relapse is inevi-
table in patients who undergo this procedure (Cho
and Kyung 2006 ) . The problems is ampli fi ed in
some patients because of excessive scarring and
fi brosis resulting from previous operations. This
chapter aims to discuss protocols to control long-
term relapse rates and optimize results. It ana-
lyzes the mechanism and rate of relapse in adults
and discusses inputs in terms of treatment plan-
ning pre- and postoperative orthodontic manage-
ment, operative and distraction techniques as
well as retention strategies to minimize and over-
come the tendency to relapse.
31.1.1 The Dynamics of Cleft Midface
Growth and Relapse Following
Distraction
As discussed in the previous chapters in this book
(Chap. 3 ), it is an accepted fact that cleft lip and
palate repair affects the three-dimensional growth
of the maxilla (Ross 1987 ; Houston et al. 1989 ;
Panula et al. 1993 ; Figueroa et al. 1999 ) . The fi rst
evidence of distraction osteogenesis for maxil-
lary advancement was reported in animals in
1993 (Rachmiel et al. 1993 ) . Distraction osteo-
genesis of the maxilla to correct the maxillary
hypoplasia was fi rst described for children and
young adults in 1997 (Polley and Figueroa 1997 ) .
Following this, there have been several reports
regarding its ef fi cacy, advantages, as well as
shortcomings including the high relapse rate
(Wang et al. 2005 ; Kozák et al. 2005 ; Cheung and
Chua 2006 ; Cheung et al. 2006 ; Nout et al.
2006 ) .
There are several reports which state 25–70 %
of cleft patients have midface retrusion out of
which 40 % require surgical treatment for cor-
rection of midface de fi ciency (Mars et al. 1992 ;
Williams et al. 2001 ) . The probable reasons for
this are the scarring and fi brosis following surgi-
cal trauma and the intrinsic inability of the max-
illa to grow normally (Figueroa et al. 1999 ;
Williams and Sandy 2003 ; Lilja et al. 2006 ) .
This results in a midface de fi ciency with a Class
III malocclusion and reverse overjet, which
manifests during the initial growth phase of the
child and becomes more pronounced as the child
Preventing Relapse Following
Distraction Osteogenesis
for the Cleft Midface in Adults
N.K. Koteswara Prasad , Syed Altaf Hussain,
and Jyotsna Murthy
N. K.K. Prasad , MDS., FCFD (*)
Department of Orthodontics, Faculty of Dental Sciences,
Cleft and Craniofacial Centre ,
Sri Ramachandra University ,
Chennai , 600116 , India
e-mail: mailkotiprasad@gmail.com
S. A. Hussain , M.S., FRCS, DNB
J. Murthy , M.S., Mch (plastic)
Department of Plastic Surgery,
Cleft and Craniofacial Centre ,
Sri Ramachandra University ,
Chennai , 600116 , India
e-mail: sa_hussain@hotmail.com;
murthyjyotsna@gmail.com

694
N.K.K. Prasad et al.
grows into adolescence. In cleft patients, the
anterior nasal spine and the pyriform margins
which form the bony platform for the nose are
posteriorly placed in relation to the skull base
resulting in inadequate projection of the midface
and relative prognathism of the mandible.
Additionally, because of the nature of the cleft
and its repair, the alveolar arches may be col-
lapsed and the teeth may be malpositioned or
rotated. Some patients may also have associated
problems like poorly repaired lip and palate,
multiple palatal surgeries, and velopharyngeal
incompetence. All these may contribute to an
accelerated and increased deposition of palatal
scar tissue, and when compounded further by
the surgical insult and the trauma of the distrac-
tion process, together, they will add to the quan-
tum and rate of midfacial relapse (Cheung and
Chua 2006 ) .
31.1.2 Patient Selection
Our indications for distraction osteogenesis as
against conventional orthognathic surgery in cleft
patients who have attained skeletal maturity are
as follows: (a) Those requiring advancement of
8 mm of the maxilla or more, (b) patients with
severe fi brosis of the lip and palate following
multiple surgeries and (c) those with a previous
pharyngeal fl ap.
31.1.3 Planning and Assessment
Several of our patients are referred to us for the
fi rst time for correction of the midface de fi ciency,
having had several primary and secondary oper-
ations previously. Before we begin orthodontic
preparation, we try to get the tissues in the best
condition possible. Fistulae if they are present
are repaired. Alveolar bone grafting (ABG)
should be done 6 months before distraction
(Krimmel et al. 2001 ) . In bilateral cases, we
complete alveolar bone grafting preferably on
both sides or at least on one side before taking
the patient up for distraction. In unilateral and
bilateral patients whose alveolar arch is in cross-
bite, it is corrected by an expansion appliance,
and in selected cases, this can be done simulta-
neously during midfacial distraction. We prefer
to retain the expansion device during the period
of distraction and retention, as it gives additional
support to the hemi-maxillae and facilitates
symmetrical distraction of the segments. We try
and preserve the third molar since if it does
erupt, it may provide much needed posterior
occlusion to the advanced maxilla. It is essential
to evaluate and record preoperative speech sam-
ples and perform a naso-endoscopy or video-
fl uoroscopy if needed. If corrective surgery for
velopharyngeal incompetence (VPI) needs a
pharyngeal fl ap, it is best to defer it after dis-
traction and consolidation as it can have a bear-
ing on the initial relapse. The amount of
advancement needed and the vector of distrac-
tion were established by mock surgery by the
orthodontist.
31.1.4 The Dynamics of Distraction
Osteogenesis and Its Relevance
to Subsequent Relapse
Distraction is gradual stretching of callus
(deformed maxilla) after a horizontal osteotomy
of the maxillary bone. The callus responds to
gradual stretching over few days by regenerat-
ing new bone. This has been shown by Ilizarov
in his pathbreaking study on reparative regen-
eration in dogs (Ilizarov et al. 1969 ) . Several
microscopic studies have shown that after about
10 days of distraction (15th post-op day), there
is a central zone within the osteotomy with pro-
liferating mesenchymal cells and capillaries
resulting from angiogenesis and paracentral
zones with large amount of wavy collagenous
fi bers (Karp et al. 1992 ; Aronson et al. 1997 ;
Bell and Guerrero 2007 ) . After 15 days of com-
mencing distraction, there is appearance of
mineralization, and at 20 days, the trabeculae of
the newly formed delicate woven bone are ori-
ented along the distraction lines and become
continuous with nondistracted bone. The trabe-
culae also get rimmed by osteoblasts and are
followed by remodeling. Another study with

695
31 Preventing Relapse Following Distraction Osteogenesis for the Cleft Midface in Adults
dispersive x-ray microanalysis has shown pro-
gressive mineralization with increase in cal-
cium and phosphorus content occurring from
3 weeks until 1 year (Rachmiel et al. 1998 ) .
From these, one may conclude that the regener-
ated bone has physical and physiological prop-
erties unique to it. Unless it is protected during
this prolonged consolidation period of nearly a
year or longer, it is susceptible to relapse and
deformation.
31.1.5 Operative Technique
Standard low Le-Fort I level cuts of the maxil-
lary bone with osteotomies of the nasal septum
and the lateral nasal walls and pterygomaxil-
lary disjunction are performed. Minimal amount
of mobilization is made, just to ensure that the
osteotomy is complete. Extensive down fracture
is best avoided since this may cause excessively
fl oating segments which may hinder a bony
union (Yamauchi et al. 2006 ) . We prefer an exter-
nal distraction device (RED II) anchored to the
maxilla with 26-G stainless steel (SS) wires. This
suf fi ciently allows the vectors to be adjusted as
the distraction proceeds, and patients tolerate it
reasonably during the prolonged consolidation
phase.
31.2
The Distraction Process
After a latency period of 5 days, distraction is
advanced at 0.5 mm twice a day until the required
advancement of the midface is achieved. We dis-
tract about 20–25 % more than the requirement to
allow for the expected relapse (Cheung and Chua
2006 ) . Depending on the education and motiva-
tion level of the patient, the distraction can be
done either on an inpatient or outpatient basis. We
keep the patient under close surveillance (at least
twice a week) during the period of distraction.
31.2.1 Orthodontic Consideration
and Retention
This is followed by a consolidation period of
2 months during which the RED II device is
retained in place. After 6–8 weeks of consolidation
is completed, the device is removed and postopera-
tive orthodontics is commenced. The advancement
is maintained by retention devices like reverse pull
headgear or strategically placed class III elastics to
be worn at all times except when going to school
or to work for 6 months and only at night for a
further period of 6 months (Fig. 31.1a, b ). Large
distractions of more than 15 mm may bene fi t from
postdistraction surgical stabilization with rigid
a
b
Fig. 31.1 ( a , b ) Reverse pull
headgear given for retention

696
N.K.K. Prasad et al.
internal fi xation using plates and screws since the
tendency to relapse in these patients is signi fi cantly
higher (Gulsen et al. 2007 ) .
Minor complications are common during the
distraction process and may have a bearing on
the subsequent relapse rates (Hussain 2009 ) .
They need to be identi fi ed and managed as dis-
traction proceeds. Incomplete osteotomy is the
commonest cause of failure of distraction and a
high rate of relapse. The commonest sites of
incomplete osteotomy are the posterior-medial
part of the maxillary tuberosity, the vertical plate
of the palatine bone in the lateral nasal wall, and
incomplete disjunction of the pterygoids. These
areas need to be addressed with care while com-
pleting the osteotomy. Incomplete osteotomy
even while allowing distraction to proceed ini-
tially may present as gradual increase in pain
over the maxillary bone during the course of dis-
traction. If this is not identi fi ed early and re-
osteotomy performed, it may result in failure of
anchorage of the distraction device and incom-
plete distraction. In some instances, distraction
may continue by deformation of the unosteoto-
mized part of the bone resulting in failure of dis-
traction after some amount of advancement. It
may rarely be possible to complete the distrac-
tion process, and if done, it will likely lead to a
higher relapse rate in the postdistraction period.
If one side is not osteotomized, it may result in
asymmetrical advancement or increased unilat-
eral relapse resulting in asymmetry. The other
causes of asymmetrical distraction are improper
adjustment of the device causing asymmetric
movement of maxillary segments and dense
fi brosis involving one segment. This needs to be
identi fi ed, and the vector and the rate of distrac-
tion have to be adjusted deferentially. Another
complication is the loosening of the pins holding
the halo frame to the skull.
Consequences of the inevitable relapse are
minimized by overcorrection. We routinely over-
distract by 20–25 % to compensate for the
expected relapse (Cohen et al. 1997 ; Cheung and
Chua 2006 ) . Open bite is another complication
which can occur as distraction progresses and
may be minimized by varying the vector of dis-
traction. When this is not effective, postoperative
orthodontics needs to be provided by using temporary
anchorage devices to achieve a stable bite.
31.2.2 Evaluation of Relapse: Materials
and Methods
We have evaluated the maxillomandibular skele-
tal changes including the relapse rates in adults
following maxillary distraction with a mean fol-
low-up of 3 years. This study was carried out at
our University Hospital Craniofacial Center (Sri
Ramachandra
University,
Chennai,
India).
Example of a case treated with rigid external dis-
traction is illustrated in Fig. 31.2a–o .
Eighteen adult patients, eight men and ten
women, who underwent maxillary advancement
by distraction osteogenesis using an external
frame distractor were studied for a mean period
of 3 years. All the patients were operated by a
single surgeon. The mean age was 24.8 years,
with ages ranging between 18 years and 34 years.
Twelve patients had unilateral cleft lip and pal-
ate, and six patients had bilateral cleft lip and pal-
ate. The inclusion criteria were as follows:
Patients who had maxillary malformation with
skeletal Class III malocclusion with a negative
overjet ranging from −6 to −15 mm and a cervi-
cal maturation indicator 6 or more (CVMI 6
completed).
31.2.3 Serial Cephalometric Evaluation
Lateral cephalograms were used to determine
and follow the maxillary position of overtime,
taken at intervals: (1) Before commencement of
distraction (T1), (2) immediate postdistraction
period (T2), (3) 1 year following completion of
distraction (T3), and (4) 3 or more years after
completion of distraction (T4). T1, T2, and T3
radiographs of a bilateral cleft lip and palate

697
31 Preventing Relapse Following Distraction Osteogenesis for the Cleft Midface in Adults
Fig. 31.2 a – o . ( a , b ) Pretreatment frontal and pro fi le photographs. ( c , d ) frontal and pro fi le photographs at the start
of distraction
a
b
c
d

698
N.K.K. Prasad et al.
e
g
h
f
( e , f ) frontal and pro fi le photographs at end of treatment. ( g – i ) Pretreatment photographs
Fig. 31.2 (continued)

699
31 Preventing Relapse Following Distraction Osteogenesis for the Cleft Midface in Adults
i
j
k
l
m
o
n
Intraoral photographs. ( j – l ) Post Distraction photograph. ( m – o ) End of treatment
Fig. 31.2 (continued)