Anterior Maxillary Distraction Research Articles

Interim use of Hyrax Screw Assembly for Single-Step Closure of Small Alveolar Cleft before Anterior Maxillary Distraction Osteogenesis

Anterior maxillary distraction osteogenesis (AMDO) is often used for the correction of maxillary retrognathia in select cleft lip and palate cases. The restoration of alveolar arch continuity is desirable before the initiation of AMDO in these cleft maxillary deformities; however, AMDO is technically difficult in a patient with coexisting alveolar cleft where there is a discontinuity of the defect that presents a challenge in terms of adequate vector control of the movement of the anterior segment and the potential risk of tipping of teeth, which already have compromised anchorage/bone support on the cleft side. The treatment becomes more challenging when ongoing management is compounded by failed previous alveolar cleft grafting procedures, along with the patient’s reluctance to undergo further grafting of alveolar clefts. This technical note demonstrates a novel application of the modification of the Hyrax screw where an initially fully opened Hyrax screw was utilised as an interim assembly for accomplishing the single-step closure of a small alveolar cleft before the commencement of anterior maxillary distraction osteogenesis. This technique may prove to be feasible for patients presenting with alveolar cleft defects of smaller widths of up to 5 mm and relatively well-aligned upper arches. Keywords: Distraction Osteogenesis; Cleft Palate; Cleft Alveolar; Maxillary Osteotomy; India.

Cleft Maxillary Hypoplasia: Comparison of Techniques and Proposal of a Novel Treatment Protocol for Management.

This study was designed to compare different techniques of managing cleft maxillary hypoplasia and to propose a treatment protocol taking patient's age of presentation, amount of maxillary hypoplasia, and presence/absence of velopharyngeal insufficiency (VPI) into consideration. Five treatment modalities, viz. facemask therapy (Group I), anterior maxillary distraction (Group II), total maxillary distraction osteogenesis using rigid external distraction devices (Group III) and internal distraction devices (Group IV), and conventional orthognathic surgery (Group V), were assessed retrospectively using lateral cephalograms (taken at 3 intervals) and speech records (studied pre- and post-operatively). The results were subjected to statistical analysis. A P value of less than 0.05 was considered statistically significant. The mean advancement achieved in groups I, II, III, IV, and V was 4.2±1.54, 9.03±2.62, 11.82±1.18, 10.41±1.42, and 7.24±2.44mm, respectively. The mean horizontal relapse noted in Groups I, II, III, IV, and V was 2.3mm (n=8), 2.1mm (n=14), 3.4mm (n=10), 1.4mm (n=5), and 2.4mm (n=24), respectively. Compared to other groups, group II had fewer patients exhibiting relapse, a statistically significant observation. Similarly, statistically significant improvement in speech outcomes was found only in group II compared to other groups. Based on the results, a treatment protocol was proposed. The authors conclude that the proposed protocol would enable surgeons to decide the most appropriate treatment modality paying attention to not only the age of presentation and amount of advancement but also presence/absence of VPI which is instrumental in deciding upon the most appropriate treatment.

Orthodontic Challenges and Management In Anterior Maxillary Distraction Osteogenesis In Cleft Lip And Palate

Orthodontic Challenges and Management In Anterior Maxillary Distraction Osteogenesis In Cleft Lip And Palate

Anterior Maxillary Distraction Osteogenesis With Bone-borne Intraoral Buccal Devices for Maxillary Hypoplasia With Cleft Lip and Palate.

Anterior maxillary distraction osteogenesis (AMDO) surgery for cleft lip and palate involves distraction of a segment of the anterior maxilla and advancement using 2 intraoral buccal bone-borne distraction devices. The anterior part of the maxilla is advanced anteriorly with less relapse which increases maxillary length and does not affect speech. We aimed to evaluate the effects of AMDO, including lateral cephalometric changes. Seventeen patients who had undergone this procedure were included in this retrospective study. The distractors were activated by 0.5mm twice a day after a 3-day latency period. Lateral cephalometric radiographs were evaluated preoperatively, after distraction and removal of distractors, which were compared using the paired Student's t test. Anterior maxillary advancement was obtained in all patients with a median of 8.0mm. Complications included nasal bleeding and loosening of distractors; however, there was no tooth damage or abnormal movement. The mean sella-nasion-A point (SNA) angle increased significantly, from 74.91° to 79.66°, the A point-nasion-B point angle from -0.38° to 4.34°, and the perpendicular line from nasion to Frankfort Horizontal (NV)-A point from -5.11 to 0.08mm. The mean anterior nasal spine-posterior nasal spine length increased significantly from 50.74 to 55.10mm, and the NV-Nose Tip from 23.59 to 26.27mm. The mean relapse rate of NV-A was 11.1%. AMDO with bone-borne distractor resulted in less relapse and effectively corrected the maxillary retrusion.

Easy low-cost surgical guide for anterior maxillary distraction osteogenesis with intraoral buccal devices

Easy low-cost surgical guide for anterior maxillary distraction osteogenesis with intraoral buccal devices

Effects of anterior maxillary distraction compared to LeFort-1 osteotomy and total maxillary distraction osteogenesis for treating hypoplastic maxilla in patients with cleft lip and palate- A systematic review and meta-analysis

ObjectiveTo compare the treatment outcomes and effectiveness of Anterior Maxillary Distraction (AMD) with the LeFort I Osteotomy and Total Maxillary Distraction Osteogenesis (TMDO) to treat cleft maxillary hypoplasia. Methods(PROSPERO CRD42020223345) Thorough electronic search of seven databases, unpublished gray literature, and a hand search of the relevant studies reference lists was done. Studies assessing mid-facial skeletal, dentoalveolar, and soft-tissue outcomes of AMD in patients >8 years of age, hypoplastic cleft maxilla, and with either TMDO/LeFort 1/ both as control groups were included. Seven included articles were assessed for the study characteristics and qualitative synthesis. Three studies were analyzed quantitatively using the RevMan 5.4 software. The quality of studies was assessed using Cochrane ROB2 and the overall certainty of evidence using GRADE. ResultsAMD was performed in 241 subjects, LeFort 1 in 145 subjects, and TMDO in 42 subjects. Maxillary advancement for AMD and LeFort 1 groups showed no statistically significant difference (Mean Difference, MD -0.64°) while TMDO showed statistically significant advancement than AMD (MD -1.44°). Statistically significant upward rotation of anterior maxilla was noted with AMD (MD -6.15 degrees) than Lefort 1. Upper incisor inclination improved in both AMD and TMDO groups (MD 1.5°). Improvement in the maxilla-mandibular relationship, convexity of face, lip and nose, and marked dentoalveolar changes in overjet and upper incisor position were noted in all the three groups. Discernible airway alterations were noted in LeFort 1 and TMDOs. Total relapse was the least with AMD. ConclusionDistraction osteogenesis exhibited better dento-skeletal outcomes and minor skeletal relapse than LeFort 1. TMDO is a preferred modality in treating severe maxillary hypoplasia associated with CLP than AMD. Further long-term prospective comparative studies are required, possibly involving the patient-centric merits.

Modified anterior maxillary distraction using “Winged Osteotomy”: A technical note

Hypoplasia of the maxilla is common in cleft lip and palate (CLP) deformities. Orthognathic surgery has been the traditional method of correction in such developmental anomalies since 1970's, with Le-Fort I advancement as its long-established management modality, which results in significant speech alteration and relapse rate. In contrast, anterior maxillary distraction (AMD) has the advantage of lesser chances of relapse, velopharyngeal insufficiency, and alteration of speech. This modified AMD technique carries a handful of its advantages as it is an easier procedure compared to the Le-Fort I osteotomy as it gives positive soft tissue changes by improving the projection of the nose and the upper lip, normalizes naso-labial angle, and changes the facial prominence from concave to convex simultaneously as it gives nasolabial and sub-malar prominence post-operatively due to the extension of horizontal cuts up to to the zygomatic region, leading to lesser complications. Also, the hollowing caused by the conventional AMD osteotomy cuts is eliminated by the extension of the winged osteotomy.

Comparison of conventional Le-fort I advancement, anterior maxillary segmental distraction, and distraction osteogenesis of maxilla for surgical management of cleft maxillary hypoplasia: A systematic review

This systematic review compares conventional Le-fort I advancement (CLO), anterior maxillary segmental distraction (AMD) and distraction osteogenesis of maxilla (DOM) for the treatment of cleft maxillary hypoplasia in terms of the amount of maxillary advancement achievable, relapse, residual velopharyngeal incompetence and soft tissue changes. All patients with maxillary hypoplasia secondary to cleft palate repair were taken into consideration irrespective of their gender, age and ethnic background. Literature research was done in databases PubMed, Ovid and Google scholar beta. From the original 429 articles identified, 17 articles were finally included, which passed the critical appraisal checklist and met the inclusion criteria. The mean advancement ranged from 6.59 mm to 16.5 mm for DOM, 6–14.28 mm for AMD and 5.17–7.2 mm for CLO. Relapse was 8.24%–45% for DOM, 4.6%–7% for AMD and 21.63%–63% for CLO. Velopharyngeal insufficiency increased significantly following Le-fort I advancement, while there was no significant change after anterior maxillary distraction and DOM. The ratio of soft tissue to hard tissue changes was greatest with AMD, followed by DOM and then CLO. Distraction osteogenesis of the maxilla and AMD are plausible treatment options for cleft maxillary advancement. Due to less stability and restricted amount of possible advancement, Le-fort I osteotomy should be reserved for minor skeletal discrepancies in cleft patients.

Minimally-invasive anterior maxillary distraction technique in patients with cleft lip and palate and maxillary deficiency: an evaluation of 106 patients.

Our aim was to evaluate the feasibility of a minimally-invasive surgical technique for anterior maxillary distraction osteogenesis to correct maxillary hypoplasia in patients with clefts. A modified Y distractor was placed intraorally in 106 patients with cleft- associated maxillary deficiency to facilitate protraction of the maxilla. Subsequently the patients had an anterior maxillary osteotomy through a minimally invasive incision, followed by activation of the appliance at the rate of 0.8mm/day until positive overjet was achieved. The patient's lateral cephalograms were evaluated preoperatively (T1), after activation (T2), and one year postoperatively (T3). Collected data were assessed with the paired t test, and probabilities of < 0.001 were accepted as significant. A mean (SD) of 10.4 (2.58) mm anterior maxillary advancement was obtained in all patients after 10-13 days of distraction. The sella-nasion-point A (SNA) angle increased from 75.37° to 83.01°. When we compared the cephalometric variables at T1 and T2, the mean maxillary length and overjet at T2 were significantly higher (p<0.001). The comparison of mean values at T2 and T3 was not significant. Minimally invasive anterior maxillary distraction with the modified Y distractor resulted in changes after activation that were consistent one year postoperatively, making it a conservative, less traumatic, and effective treatment of cleft-related maxillary deficiency.

A retrospective analysis of complications associated with tooth-borne anterior maxillary distraction for managing cleft maxillary hypoplasia: A 12-year experience

PurposeTo evaluate the intra- and post-operative complications of tooth-borne anterior maxillary distraction in management of cleft maxillary hypoplasia over a 12-year period, and to establish whether the procedure involves a learning curve. Materials and methodsAll patients with cleft maxillary hypoplasia satisfying the inclusion and exclusion criteria and undergoing anterior maxillary distraction with a tooth-borne palatal distractor between June 2007 to June 2018 were retrospectively studied by retrieving their individual medical records, which included radiographic (lateral cephalogram analysis at three different intervals) and speech assessment records. The presence of intra- and post-operative complications developing in this study period was noted. Furthermore, the frequency of intra- and post-operative complications occurring from years 2007–2018 were evaluated to study whether there was a decrease in the frequency of complications with increasing time. This was done to establish whether there was a learning curve associated with the surgical procedure. The results thus obtained were tabulated using SPSS 25.0 (SPSS Inc., Chicago, IL) and subjected to statistical analysis using the chi-squared test. A p value of less than 0.05 was considered statistically significant. ResultsOut of the 458 patients included in the study, 78.82 % (n = 361) had no complications. In the remaining 97 patients, a total of 137 complications (46 intra-operative and 91 post-operative) were observed, making up for a complication rate of 21.17%. The intra-operative complications noted were appliance dislodgement (n = 19), palatal mucosal tears (n = 12), hemorrhage (n = 8), dental injuries (n = 6) and inadvertent fracture of the anterior segment (n = 1). The post-operative complications noted were anterior open bite (n = 24), gingival inflammation (n = 14), appliance dislodgement (n = 13), dental injuries (n = 10), relapse (n = 8), hemorrhage (n = 5), soft tissue infections (n = 4), palatal fistula (n = 3), speech impairment (n = 3), wound dehiscence not related to infection (n = 3), need for re-operation (n = 2), avascular necrosis of the anterior segment (n = 1) and maxillary sinusitis (n = 1). A statistically significant decrease (p < 0.001) in the frequency of complications with each passing year from 2007 to 2018 was observed. Most complications were seen to occur in the first 4 years (i.e. 2007–2010; a total of 74 complications in 54 patients), making up 11.79% of the complications. In the following 8 years (i.e. 2011–2018), 63 complications were noted in 43 patients, making up the remaining 9.38 % of the complications. These observations indicate that a learning curve was involved before carrying out the procedure without many complications. ConclusionTooth-borne anterior maxillary distraction in managing cleft maxillary hypoplasia is associated with a wide range of complications: some avoidable and related to surgeon's experience; some related to the surgical procedure itself; and some unavoidable and related to the distractor appliance. Understanding potential complications allows the surgeon to ensure safe care through early intervention and to correctly inform the patient in the pre-operative discussion. The procedure involves a learning curve before it can be accomplished safely without many complications.

Correction of maxillary hypoplasia using modifi cation of Anterior maxillary distraction device in a patient with Binder’s Syndrome- Case report

This is the case report of a 20year old female, affected by Binders Syndrome reported to our hospital and was operated for maxillary hypoplasia using modifications of the standard Anterior Maxillary Distraction (AMD) device.

Correction of maxillary hypoplasia using modifi cation of Anterior maxillary distraction device in a patient with Binder’s Syndrome- Case report

This is the case report of a 20year old female, affected by Binders Syndrome reported to our hospital and was operated for maxillary hypoplasia using modifications of the standard Anterior Maxillary Distraction (AMD) device.

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

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

Relapse rate after surgical treatment of maxillary hypoplasia in non-growing cleft patients: a systematic review and meta-analysis

Maxillary hypoplasia in cleft lip and palate is a complex deformity. Despite surgical improvements, postoperative relapse persists. This systematic review was performed to determine the mean horizontal relapse rates for the surgical techniques used to treat maxillary hypoplasia: Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis. This study followed the PRISMA statement. The PubMed, Embase, Science Direct, and Web of Science databases were searched through to June 2018. Studies on non-growing cleft lip and palate patients who had undergone one of the three surgical procedures and who had postoperative horizontal maxillary changes assessed at >6 months post-surgery were included. Stata SE was used to estimate pooled means, heterogeneity, and publication bias. The search strategy identified 326 citations, from which 24 studies were selected. Relapse rates following Le Fort I osteotomy with rigid fixation, Le Fort I distraction osteogenesis, and anterior maxillary distraction osteogenesis were 20%, 12%, and 12%, respectively. Relapse rates with and without bone grafting were 19% and 66%, respectively. The relapse rate following distraction osteogenesis with internal distraction was lower than that with external distraction. Study limitations were heterogeneity, which was above moderate, the low number of high-quality studies, and unidirectional assessment of postoperative maxillary movement.

Nasolabial and Interincisal Angle Evaluation in Anterior Maxillary Distraction Osteogenesis: A Case Study:

Maxillary hypoplasia is a common developmental problem in cleft lip and palate deformities. These deformities have traditionally been corrected by means of orthognathic surgery. Management of skeletal deformities in the maxillofacial region has been a challenge for maxillofacial surgeons and orthodontists. Distraction osteogenesis (DO) is a surgical technique that uses body's own repairing mechanisms for optimal reconstruction of the hard and soft tissues. We present four cases of anterior maxillary distraction osteogenesis with tooth-borne distraction device— Hyrax, which were analyzed retrospectively using cephalometrics. Changes in nasolabial angle and interincisal angle after distraction of anterior maxillary segment were studied to conclude that there was no much change in the the nasolabial angle while the interincisal angle showed marked improvement.

Anterior Maxillary Segmental Distraction Osteogenesis for Treatment of Maxillary Hypoplasia in Patients With Repaired Cleft Palate

Anterior Maxillary Segmental Distraction Osteogenesis for Treatment of Maxillary Hypoplasia in Patients With Repaired Cleft Palate

Nasopharyngoscopic Analyses through Anterior Maxillary Distraction Osteogenesis for Adolescent Patients With Cleft Palate

Anterior maxillary distraction osteogenesis (AMDO) is a novel technique for correcting hypoplastic maxilla by sagittal expansion of the maxilla. Recent reports suggest that AMDO does not have an effect on fragile velopharyngeal function in patients with cleft palate. Furthermore, no studies have evaluated the impact of AMDO on velopharyngeal function.We adopted AMDO to correct severe hypoplastic maxilla in adolescent patients with cleft palate and evaluated its impact on velopharyngeal space and function in 8 patients aged 12 to 21 years who underwent AMDO from 2006 to 2014. All the patients had received treatment for cleft palate; however, they still exhibited marginal velopharyngeal insufficiency. The mean activation of the distractor was 10.9 ± 0.9 mm.We determined changes in velopharyngeal closure ratio and closure pattern via nasopharyngoscopy. Additionally, skeletal changes were evaluated using lateral cephalograms.The mean horizontal advancement in the cephalogram obtained 1 year after the distraction was +6.4 mm. Nasopharyngoscopic examination revealed that no deterioration of velopharyngeal gap had occurred after AMDO in all 8 patients. The velopharyngeal closure pattern changed from coronal to circular in 1 patient.Our results indicate that AMDO achieved correction of hypoplastic maxilla without deterioration in velopharyngeal gap and function. Therefore, AMDO is an effective and optimal approach for correcting hypoplastic maxilla especially in patients with fragile velopharyngeal function, such as those with cleft palate.

Anterior maxillary distraction osteogenesis for cleft lip and palate patients - A case series

Anterior maxillary distraction osteogenesis for cleft lip and palate patients - A case series

Residents' journal review

Residents' journal review

Anterior Maxillary Distraction − a Boon to Treat Cleft Maxillary Hypoplasia

We describe our experience of using anterior maxillary distraction for the correction of cleft related maxillary hypoplasia. Clear historical overview and meticulous description of the surgical technique are given. The technique is described step-by-step from the type of incision to the prosthetic rehabilitation. An advantage of anterior maxillary distraction over the other conventional techniques is reasoned. The paper is illustrated both the view of intra-oral tooth-borne screw appliance and four representative cases. This technique provides excellent well-predicted result and can be widely recommended in anterior maxillary distraction.