Anterior Maxillary Segmental Distraction Research Articles

Maxillary anterior segmental distraction osteogenesis to correct maxillary hypoplasia and dental crowding in cleft palate patients: a preliminary study

BackgroundThe aim of this study was to present comprehensive skeletal, dental and facial aesthetic outcomes and long-term stability of maxillary anterior segmental distraction osteogenesis (MASDO) for the treatment of maxillary hypoplasia in CLP.Materials and methodsSix patients with maxillary hypoplasia treated with MASDO by a miniscrew assisted intraoral tooth-borne distractor were included. Cephalometric radiographs were obtained before distraction (T1), after the consolidation period (T2) and after orthodontic treatment or before orthognathic surgery (T3). Thirty-one cephalometric variables (12 skeletal, 9 dental, and 10 soft tissue variables) were used to evaluate changes in the dentofacial structures and the soft tissue profile. Friedman and Wilcoxon tests were applied to identify significant differences in hard and soft tissue changes during the T1–T2, T2–T3, and T1–T3 periods.ResultsAll patients successfully underwent MASDO without serious complications. From T1 to T2, forward movements of ANS and A (FH ⊥ N–A, VRL–ANS and VRL–A) were significant (p < 0.05). Significant increases in SNA and ANB were noted. Significant upward movement of points ANS (CFH–ANS) and A (CFH–A) was observed (p < 0.05). After distraction, a significant decrease in overjet and an increase in overbite were obtained (p < 0.05). Anterior tipping of the upper incisors (U1/ANS–PNS and U1/SN) was observed (p < 0.05). The soft tissue points of Pn, Sn, Ss, and ls showed significant anterior movement (p < 0.05). In addition, a significant increase in the nasolabial angle was measured (p < 0.05). All of the above data showed no statistically significant changes between T2 and T3 (p > 0.05).ConclusionMASDO using a miniscrew assisted tooth-borne distractor presented significant maxillary advancement and favorable long-term stability in treating CLP patients with maxillary hypoplasia.

The Midfacial Soft Tissue Changes After Anterior Maxillary Segmental Distraction Osteogenesis in Patients With Cleft: A 3-Dimensional Volumetric-Based Subunit Analysis.

Maxillary hypoplasia is common in patients with cleft lip and palate. In this study, the authors investigated the soft tissue changes in midfacial regions after anterior maxillary segmental distraction osteogenesis (AMSDO) in patients with cleft. Eight patients with cleft lip and palate who underwent AMSDO were enrolled in this study. Spiral computed tomographic images were taken before surgery and 6-12 months after surgery to evaluate soft tissue changes after AMSDO. The midfacial area was divided into 6 regions of interest according to anatomical subunits. The average movements of each region were calculated using volumetric changes and preoperative region surface areas. The upper lip on both sides has the most anterior movement (5.22±0.86 and 5.14±0.84mm), supracommissural regions have a little less movement (4.11±0.55 and 3.81±0.67mm), paranasal regions have the least movement (3.37±0.47 and 3.15±0.36mm). The corresponding regions of interest showed no significant difference on the cleft side versus the noncleft side. Anterior maxillary segmental distraction osteogenesis can improve the soft tissue profile in patients with cleft, and there was no significant difference in soft tissue changes between the cleft side and the noncleft side.

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.

Pre-bent Buccal Distractor Made from a 3D Model for Maxillary Anterior Segmental Distraction Osteogenesis for Precious Fit and Decreasing Surgical Time.

Maxillary anterior segmental distraction osteogenesis surgery involves a distraction segment that is made at the anterior part of the maxilla. Although bending and fitting the distractor during surgery is a complex procedure, we present here a usefulness of the pre-bent distractor made with a 3D model for precise fixing and reducing the operative time.

Skeletal, dental and facial aesthetic changes following anterior maxillary segmental distraction by tooth-borne device in patients with cleft lip and palate

Maxillary skeletal deficiency secondary to cleft lip and palate (CLP) remains a significant challenge. The aim of this study was to present the comprehensive skeletal, dental and facial aesthetic outcomes of anterior maxillary segmental distraction osteogenesis (AMSDO) for treatment of maxillary hypoplasia in patients with CLP. Twelve patients with maxillary hypoplasia treated with AMSDO by a customized tooth-borne distractor were included. Three-dimensional changes of anterior maxillary segment, upper incisor and pharyngeal space were measured by three-dimensional reconstruction derived from cone beam computed tomography (CBCT) data. Length and width of dental arch during distraction were determined in dental casts. Nasolabial angle, soft-tissue convexity and patient’s subjective satisfaction were assessed to evaluate facial aesthetic improvements. Nasopharyngoscopic evaluation and speech assessment were also performed before and after distraction. All patients successfully received AMSDO without serious complications. Following AMSDO, the anterior maxillary segments moved forward 5.56±0.28mm and slightly upward 1.15±0.13mm. AMSDO significantly lengthened maxillary dental arch, generated new bone to relieve dental crowding and improved patients’ facial aesthetic without worsening velopharyngeal closure and speech quality. AMSDO by tooth-borne distractor is an effective surgical alternative for the advancement in patients with cleft maxillary hypoplasia.

How Is the Created Alveolar Space Finally Restored After Maxillary Anterior Segmental Distraction Osteogenesis?

Maxillary anterior segmental distraction osteogenesis (MASDO) for cleft and palate patients is the alternative treatment option to correct malocclusion with maxillary arch deficiency and severe crowding. After MASDO, prosthetic considerations are crucial for patients with cleft lip and palate because it is related to facial esthetics and occlusal function. The objectives of this study were to investigate the final restoration type for created alveolar space by MASDO. Thirteen patients with cleft lip and palate who underwent MASDO and orthodontic treatment from the years 2000 to 2010 in Yonsei University were examined. Final restorations are classified as dental implants, conventional prosthesis, and orthodontic space closure. The relationship between the distracted areas and final restoration type was investigated. The authors evaluated lateral cephalograms obtained at predistraction osteogenesis (pre-DO; T1), postdistraction osteogenesis (post-DO; T2), and debond (T3), and measured changes from T1 to T2 and from T2 to T3. There was no significant difference of final restoration percentage of dental implants, conventional prosthesis, and space closure with orthodontic treatment. However, dental implants and conventional prostheses were applied more frequently in the posterior area and in the anterior area, respectively. The relapse rate was observed as 36.7% and 22.4% in the values of N-A distance and ANB angulation in T2-T3 stage. The MASDO site should be decided, based on final restoration goal. Among the created alveolar spaces, implants were applied mainly to the posterior site and the conventional prostheses were mostly restored to the anterior site. For space closure by orthodontic approach, the area could be both anterior or posterior.

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

Virtual Surgical Planning Assisted Management for Cleft-Related Maxillary Hypoplasia.

Maxillary hypoplasia is a common developmental deformity affecting patients with cleft lip and palate. Various surgical techniques including conventional orthognathic surgery, total maxillary distraction osteogenesis, and anterior maxillary segmental distraction have been applied to address the deformity. With the evolution of 3D computed tomography imaging, the visualization of skeletal complexities in different perspectives is greatly enhanced and comprehensive surgical planning is achieved. Intraoperative efficiency is also improved with the fabrication of 3D-printed templates. The study aims to present different surgical techniques with virtual surgical planning (VSP) and 3D-printed surgical templates and the solution of representative cases. From January 2014 to January 2019, VSP was transferred to actual surgery or distraction precisely in 80 adult patients with cleft-related maxillary hypoplasia. The accuracy was analyzed and the relapse was also estimated and observed in 18 patients after 1-year follow-up. Based on our experience, VSP provides a more reliable and effective option to conventional model surgery. It facilitates the preoperative planning and accurately transfers the virtual plan to correct the cleft-related maxillary hypoplasia.

Accuracy of virtual surgical planning-assisted management for maxillary hypoplasia in adult patients with cleft lip and palate

Management of maxillary hypoplasia in patients with cleft lip and palate (CLP) remains a significant clinical challenge. The objective of this retrospective study is to evaluate the accuracy of virtual surgical planning (VSP) with different maxillary advancement techniques. Ninety adult patients with cleft-related maxillary hypoplasia between April 2010 and April 2016 were enrolled in our study. Various surgical techniques including conventional orthognathic surgery, total maxillary distraction osteogenesis, and anterior maxillary segmental distraction were used according to the characteristics of patients. All the cases were aided with VSP and three-dimensional (3D)-printed surgical splints. The virtual surgical plan was compared with the postoperative surgical results by analyzing the positions of several landmarks and planes relative to reference planes. Both the profile and occlusion were improved significantly in all the cases. VSP was successfully transferred to actual surgery with the help of 3D-printed surgical splints in different surgical techniques. Management of cleft-related maxillary hypoplasia requires both comprehensive surgical planning and accurate execution. VSP serves as a viable alternative to conventional model surgery with high accuracy in patients with adult CLP.

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

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

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

Cephalometric changes in nasopharyngeal area after anterior maxillary segmental distraction versus Le Fort I osteotomy in patients with cleft lip and palate.

Objective:The present study was designed to compare the effects of two surgical methods, anterior maxillary segmental distraction (AMSD) versus conventional Le Fort I osteotomy, on cephalometric changes of velopharyngeal area of patients with cleft lip and palate.Materials and Methods:This study was conducted on 20 CLP in two groups. The first group had classic Le Fort I maxillary advancement and the second group had AMSD with a modified hyrax as an intraoral tooth-borne distractor. In the second group, 1 week after the surgery, activation of hyrax screw was started with the rate of 2 times a day for about 10 days. Initial and final lateral cephalograms were traced and analyzed by OrthoSurgerX software.Results:The changes in variables evaluating velopharyngeal status showed a significant difference between the two groups. In Group A (conventional), the mean of nasopharyngeal area and Nasopharynx floor length showed a significant increase (P < 0.05) after the surgery, while in Group B (DO), the trend of changes was vice-versa. The changes in SNA, overjet, and soft-tissue convexity were similar in both groups.Conclusion:AMSD can improve facial profile, almost similar to the conventional Le Fort I advancement, while there is a significant decrease in nasopharyngeal; hereby there is no increase in the velopharyngeal sphincter.

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

This study is to present experiences of using anterior maxillary segmental distraction osteogenesis (AMSDO) with internal distractors for treatment of maxillary hypoplasia in patients with repaired cleft palate. A total of 42 patients of maxillary hypoplasia with repaired cleft palate were included in this study, and underwent AMSDO. Cephalometric analysis and speech quality assessments were performed to evaluate the changes after AMSDO and its long-term effect on stability. All cases had successfully accomplished AMSDO. The average SNA (°), NA-FH (°), ANS-PNS (millimeter), and Overjet (millimeter) have change to 80.41°, 89.51°, 55.64 mm, and 2.52 mm, respectively (P < 0.01). Maxillary advancement has reached 13.80 mm on average (ranging from 10.0 mm to 20.0 mm). Speech quality assessment demonstrated that nasal resonance, speech articulation, nasal emission, intelligibility, and velopharyngeal function did not get worse after AMSDO. AMSDO has unique advantages as follows: can effectively correct maxillary hypoplasia in patients with repaired cleft palate; can create a space for postoperative orthodontic treatment to solve the crowding teeth situation; the postoperative velopharyngeal function and speech quality show no significant change. The results shown AMSDO is an effective and appropriate treanment for curing maxillary hypoplasia in patients with repaired cleft palate.

Efficacy of Maxillary Anterior Segmental Distraction Osteogenesis in Patients With Cleft Lip and Palate.

To evaluate the effects of maxillary anterior segmental distraction osteogenesis (MASDO) in patients with cleft lip and palate (CLP) and to identify risk factors for increased relapse. A retrospective study. Thirty-one Japanese patients with CLP who underwent MASDO were eligible for study inclusion. We evaluated lateral cephalograms obtained before (T1), at 3 months (T2), and at 1 year (T3) after MASDO, and measured changes from T1 to T2 (δT1T2), from T2 to T3 (δT2T3), and from T1 to T3 (δT1T3). We also evaluated the risk factors associated with an increased relapse. Overall (δT1T3), MASDO improved retrusion of the maxilla. We measured a significant advancement (6.1 mm) of the anterior maxillary segment in δT1T2 (A-McNamara classification) and increases in the overjet and the SNA, ANB, and nasolabial angles. However, skeletal relapse was evident in δT2T3, and the median percentage of relapse was 10%. To explore the risk factors, we subdivided patients with a δT1T2 of >5 mm into 2 groups based on the percentage of relapse (>15% vs ≤15%). There were significant differences between these groups in the vertical positions of the anterior nasal spine and point A, and the angle formed by the SN and palatal planes (SNPP), suggestive of intraoperative counterclockwise rotation of the maxilla. MASDO is effective for correcting midfacial deficiencies, but counterclockwise rotation of the maxilla during surgery may cause relapse.

Cephalometric evaluation of patients treated by maxillary anterior segmental distraction

Background: Maxillary hypoplasia secondary to repaired cleft lips and palates is common. The extent of hypoplasia is dependent on several factors. It is not possible to correct maxillary hypoplasia by conventional orthodontics and relapse is common after orthognathic advancement of the maxilla with or without grafts. Distraction osteogenesis (DO) offers a promising alternative for the management of congenital and acquired facial deformities that require bone lengthening. It is less invasive than traditional surgical techniques, requires less surgical time, and eliminates the need for a donor site operation. In addition, simultaneous soft-tissue expansion may improve long-term skeletal stability. DO allows the body's natural healing mechanisms to generate new bone for augmenting or lengthening bone. The purpose of this study was to enumerate and compare dental, skeletal, and soft-tissue changes, and postoperative stability using cephalometric analysis following anterior maxillary DO in cleft patients. Aims and Objectives: (i) The aims and objectives of this study were to enumerate and compare dental, skeletal, and soft-tissue changes, and postoperative stability using cephalometric analysis following premaxillary DO and (ii) to draw clinical inference from the above results. Methods: Seven female patients underwent anterior maxillary DO with a mean age of 19 years, and the anterior movement of premaxillary segment was generated by tooth-borne distractor with a rapid maxillary expansion screw. The distraction of the premaxilla was stopped after achieving a positive profile and sufficient space to align the maxillary dentition. After the consolidation period, the distractor was removed and orthodontic treatment was started with fixed appliances to level the teeth. Cephalometric data of patients were collected before treatment (T1), after distraction (T2), and 6 months after distraction. Comparison between time periods T1–T2, T1–T3, and T2–T3 were done to evaluate the dental, skeletal, and soft-tissue changes brought by DO. Results: In all the patients, the treatment objective was achieved with a positive overjet and improved profile without changing the position and intermaxillary relation of the posterior. There was a significant horizontal increase of the premaxilla with a definite gain in the maxillary dental arch length for alignment of the maxillary dentition with a downward and backward movement of the mandible. Conclusion: Maxillary DO offers an effective technique to transpose the maxilla forward and downward in moderate-to-severe maxillary retrusion. DO offers better stability due to the gradual expansion and lengthening of the soft tissue in response to the gradual traction. It avoids the complication of acute reconstructive surgical methods and minimal trauma when compared to other alternative surgical methods. It also shortens the overall treatment time due to reduced need for comprehensive treatment time.

Treatment of severe maxillary hypoplasia with oligodontia and complete bilateral cleft lip and palate by maxillary anterior segmental distraction osteogenesis

Effective maxillary advance treatment is difficult to achieve without impairing velopharyngeal function in patients with severe maxillary deficiency. We describe successful orthodontic treatment using maxillary anterior segmental distraction osteogenesis (MASDO) in a patient with cleft lip and palate. A 20-year-old woman with bilateral cleft lip and palate, multiple congenitally missing teeth, reduced maxilla, concave soft-tissue profile, and skeletal Class III jaw relationship was treated with a combination of orthodontic treatment and MASDO. After treatment, the anterior maxilla was displaced forward with new bone formation induced in the distraction gap for insertion of dental implants. Maxillary hypoplasia was successfully treated while preserving the velopharyngeal function with MASDO. We suggest that MASDO is useful for patients with severe maxillary hypoplasia.

Anterior maxillary segmental distraction in the treatment of severe maxillary hypoplasia for CLP patients

Anterior maxillary segmental distraction in the treatment of severe maxillary hypoplasia for CLP patients

Anterior segmental distraction osteogenesis in the hypoplastic cleft maxilla: report of five cases

Orthognathic surgery and distraction osteogenesis play a prime role in the correction of maxillary hypoplasia in patients with cleft lip and palate (CLP). Advancement of the anterior maxilla alone without interfering with the velopharyngeal sphincter may be advantageous in cleft patients, who more commonly have speech deficits and dental crowding. We present a case series of anterior maxillary segmental distraction for maxillary hypoplasia in 5 CLP patients with a one-year follow-up. A custom-made tooth-borne distraction device with a hyrax screw positioned anteroposteriorly was used. The evaluation comprised of hard and soft tissue analysis and speech assessment. A stable occlusion with positive overjet and correction of dental-crowding without extraction was achieved at one year post-distraction. Facial profile and lip support improved. There was no deterioration in speech.

Anterior Segmental Distraction Osteogenesis in the Hypoplastic Cleft Maxilla : Report of Five Cases = إفتراق التكون العظمي للفاصل الأمامي في مرضى نقص تنسج فلج الفك العلوي : عرض لخمس حالات

Orthognathic surgery and distraction osteogenesis play a prime role in the correction of maxillary hypoplasia in patients with cleft lip and palate (CLP). Advancement of the anterior maxilla alone without interfering with the velopharyngeal sphincter may be advantageous in cleft patients, who more commonly have speech deficits and dental crowding. We present a case series of anterior maxillary segmental distraction for maxillary hypoplasia in 5 CLP patients with a one-year follow-up. A custom-made tooth-borne distraction device with a hyrax screw positioned anteroposteriorly was used. The evaluation comprised of hard and soft tissue analysis and speech assessment. A stable occlusion with positive overjet and correction of dental-crowding without extraction was achieved at one year post-distraction. Facial profile and lip support improved. There was no deterioration in speech.

Maxillary Anterior Segmental Distraction Osteogenesis With 2 Different Types of Distractors

Maxillary anterior segmental distraction osteogenesis (DO) has been the alternative treatment option for patients with midfacial retrusion. To investigate a potentially more effective maxillary anterior segmental DO, a newly designed intraoral alveolar distractor was applied. The objectives of this study were to investigate the skeletal and dental effects of maxillary anterior segmental DO and the relapse pattern. The study was carried out for 8 patients with unilateral cleft lip and palate (mean age, 16 years 7 months). Four patients were treated with an intraoral appliance (IA), and the remaining with a rigid external distractor (RED). Dental and skeletal measurements were obtained for both groups. These measurements were compared for different time points including pre-DO (T1), post-DO (T2), postconsolidation (T3), and 1-year follow-up (T4). Horizontal change of A point was significantly larger after distraction period (T2) in the RED group (mean, 11.0 mm; median, 10.1 mm) than in the IA group (mean, 6.6 mm; median, 7.4 mm) (P < 0.05). Relapse of A point was observed in both RED (mean, -2.3 mm; median, -2.3 mm) and IA groups (mean, -2.6 mm; median, -1.5 mm) at T4. The vertical position of the anterior nasal spine was found to have moved downward in the RED group (mean, 5.5 mm; median, 4.9 mm) but upward in the IA group (mean, -2.5 mm; median, -2.7 mm) after distraction, showing a significant difference between groups (P < 0.05). Axis of upper incisor increased at T2 in the IA group (mean, 10.4 degrees; median, 11.3 degrees), but decreased in the RED group (mean, -10.2 degrees; median, -9.0 degrees) (P < 0.05). It recovered in the RED group at T4. Maxillary anterior segmental DO is effective for the treatment of patients with cleft lip and palate. The alveolar space is regained, and the facial profile is improved without velopharyngeal problems. Superior results are obtained using the RED appliance for maxillary anterior segmental DO relative to the use of the intraoral distractor appliance.