Role of an Orthodontist in the Management of Cleft Maxilla With Anterior Maxillary Segmental Distraction (AMD)- A Clinical overview

Abstract

The main clinical and radiological defect in cleft maxilla is localised at the region of nasomaxillary complex and thereby the increased focus on maxillary interventional correction. During the period of development, the affected individual undergoes a series of periodic treatment approaches aimed towards normalisation of the function and aesthetics. However, such interventional procedures can have otherwise effects on the restriction of growth. Surgical and facial orthopaedic interventions can cause protrusion of the premaxilla. This influences the depth and height of the upper jaw and thus the total height causing clockwise rotation of the face. Similarly, the depth of the posterior maxilla is found to be reduced in CLP cases. The advancement of the anterior maxilla with callus distraction for correction of the cleft maxilla was first reported by KraKasis and Hadjipetrou in 2004. The technique has been used since then with variable success and less predictability. The present table clinic is targeted to showcase the key features of various stages critical in planning the anterior maxillary distraction in adult maxillary hypoplasia cases. The requirement of precision in planning and treatment is high in such cases to minimize the adverse effects. The novel methodology discussed here is the combination of CBCT, face bow transfer and stereolithography for surgical planning and simulation. With the use of CBCT diagnostic capacity is enhanced, enabling visualisation of the defect. It also helps to simulate surgical procedure virtually and/or with the application of stereolithography. Use of the face bow facilitates biomechanical planning. The registration of the maxillomandibular relation to the cranial base serves as a guide to position the distractor. This is a critical step, as it dictates the direction of the distraction force vectors. Precise orientation and planning enable predictable movement of the anterior maxilla and control the extent of anterior open bite opening, in most cases. This contrasts with the overbite created with counter clockwise jaw rotation, reducing the post distraction orthodontic management. This table clinic presentation also draws home the key points in identifying and mitigating the potential complications during and after the distraction. The use of the present methodology enables a predictive treatment outcome for the cases with minimal complications associated with distraction with a marked reduction in the magnitude of callus molding. Therefore, with the application of this novel clinical paradigm for AMD, a predictable result can be achieved, which helps in the reduction of the treatment time and gives a stable outcome