Cleft Maxillary Hypoplasia Research Articles

Bone-anchored maxillary protraction in cleft maxillary hypoplasia: An evaluation of dentoskeletal, soft-tissue, and functional effects

ABSTRACT Introduction: Maxillary hypoplasia is a common finding secondary to cleft lip and palate. The resultant Class III skeletal pattern worsens during adolescence due to unaffected mandibular growth. Bone-anchored maxillary protraction (BAMP) involves the intraoral use of orthopedic Class III intermaxillary elastics by means of skeletal anchorage to the zygoma and anterior mandible bilaterally. Aim: The aim of this study was to assess the facial esthetic and functional effects of 1-year of BAMP therapy in growing cleft individuals. Subjects and Methods: Eighteen subjects (mean age: 11.9 years) with cleft maxillary hypoplasia were selected for BAMP. Cephalometric facial assessment of 26 parameters (by an orthodontist), perceptual and lateral videofluoroscopic instrumental speech analyses (by a speech-language pathologist), and clinical temporomandibular joint (TMJ) evaluation were performed before (T1) and after 12 months of BAMP therapy (T2). Paired t-test and Pearson’s Chi-squared test were used for the statistical analyses of the quantitative and qualitative variables, respectively. Pearson’s correlation coefficients were used to assess the associations between cephalometric parameters. Results: Twenty cephalometric variables showed significant change from T1 to T2 toward positive dentoskeletal and soft-tissue Class III facial correction. The mean increase in “SNA” was 3.03°, and maxillary length (“Ptm-A”) and sagittal maxillary position (“N-perp to A”) increments were 3.65 mm and 4.02 mm, respectively. The mean improvement in the dental overjet was 3.86 mm. Backward positioning of the mandible was noted with a mean reduction of “SNB” and “N-perp to Pog” by 1.38° and 1.16 mm, respectively, with a mean 3.8° closure of the gonial angle. The airway changes were insignificant. Speech and TMJ observations remained constant from T1 to T2. Conclusions: BAMP therapy in cleft patients exhibited significant orthopedic maxillary protraction with effective sagittal and vertical mandibular growth control. The positive esthetic effects of BAMP did not have any negative influence over the functions of airway, velopharyngeal (speech) mechanism, and the TMJ in the stipulated 12-month period.

Speech following Le Fort I Maxillary Advancement in Cleft Maxillary hypoplasia - an objective and subjective outcome analysis.

To objectively evaluate the effect of maxillary advancement on speech and VPI using video-fluoroscopy (VFS), direct nasoendoscopy, and speech evaluation and subjectively assess patients and their peer's perception regarding their speech outcome. 27 cleft patients who underwent Lefort 1 maxillary advancement were divided into 2 groups- Group A with 4-7mm of advancement and Group B with 8-13mm advancement. VFS in lateral view, nasoendoscopy, and speech recordings were performed pre and 6 months postoperatively. VFS assessed the relative position of velum in relation to the pharyngeal wall, speech was evaluated for changes in nasal emission, resonance, and articulation along with nasal endoscopy to assess the overall function of the velopharyngeal valve. Subjective speech evaluation was done with a Patient-Reported Outcome Measure [PROM] questionnaire. As per VFS, for every 1mm maxillary advancement, the velopharyngeal gap at rest increased by 1.75mm in group A and 1.58mm in group B. The compensatory changes in group B were more pronounced. Post-operative VFS showed velar closure remained the same as preoperative closure in 86.7%, and worsened in 13.3% in group A whereas it remained unchanged in 66.7%, improved in 25%, and worsened in 8.3% in group B. In nasoendoscopy, the closure pattern showed no change in 86.6%, improved in 6.7%, and deteriorated in 8.3% in group A while there was no change in 83.4%, improved in 8.3%, and deteriorated in 8.3% in group B. Dental and labiodental articulation statistically improved [p < 0.05] after surgery. PROM reported 85.7% of patients with improved speech, 82.1% improved sound quality along with 89.3% improvement in articulation. The primary cause for functional impairment and poor aesthetics in cleft deformity is the maxillary hypoplasia and therefore, should be the focus during correction. The pre-operative VP status or the amount of maxillary advancement could not predict the postoperative VP status. Maxillary advancement over 10mm did not seem to significantly affect the final VP status. Articulation improves due to increased tongue space and favorable dental segment positioning. Mild to moderate immediate post op changes in nasality improves or even reverts to their preoperative status in the majority of the cases in about six months.

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.

Crouzon Syndrome Spanning Three Generations: Advances in the Treatment of Syndromic Midface Deficiency.

Crouzon syndrome is an autosomal dominant genetic disorder characterized by craniosynostosis, midface retrusion, and exophthalmos. Over the past century, the treatment of craniofacial disorders like Crouzon syndrome has evolved significantly. An institutional review board-approved retrospective study was conducted to ascertain the treatment of three individuals with Crouzon syndrome from one family, complemented with a series of literature searches to examine the evolution of craniofacial surgical history. Dr. David Williams Cheever developed the Le Fort I level to correct malocclusion, maxillomandibular malformations, and midface hypoplasia. Later, Dr. Paul Tessier introduced the Le Fort II and III osteotomies to treat syndromic midface hypoplasia. In 1978, Dr. Fernando Ortiz-Monasterio and Dr. Antonio Fuente del Campo published the first series of monobloc osteotomies, allowing for simultaneous correction of supraorbital and midface malformations, although complicated by blood loss and high infection rates. In 1992, McCarthy et al introduced the concept of gradual distraction to the craniofacial skeleton. In 1995, Polley et al performed the first monobloc advancement using external distraction. Subsequently, in 1997, Polley and Figueroa introduced a rigid external distraction device with multiple vector control to manage severe cleft maxillary hypoplasia. The technique was further refined and applied to treat syndromic midface hypoplasia, reducing complication rates. Currently, either external or internal distraction approaches are used to safely treat this challenging group of patients. The treatment of syndromic midface deficiency has significantly evolved over the past 50 years, as evidenced by this report of three generations of Crouzon syndrome.

Protocols in the management of cleft lip and palate: A systematic review

AimTo identify clinical decisions on surgical as well as non-surgical modalities for the treatment of CLP patients based on randomized controlled trials (RCTs). Materials and methodsPubMed, Ebscohost, and Cochrane Library were searched and 20 articles based on RCTs conducted on cleft patient management were identified. ResultsThe topics explored were infant orthopedics, lip and palate repair, alveolar bone grafting, and management of cleft maxillary hypoplasia. Nasoalveolar molding (NAM) was found to have great benefits when carried out within one month of birth. Fisher and Mohler's lip repair technique and use of recombinant human bone morphogenetic protein-2 (rh-BMP2) for alveolar bone grafting showed promising results. rh-BMP2 for alveolar bone grafting appears to be a promising alternative to autografts. ConclusionEarly commencement of NAM in neonatal life is of great benefit to cleft patients. There is a need for more multicentre collaborations, mainly to identify the ideal surgical technique to reduce the variability in treatment and to ensure that the patient receives appropriate evidence-based treatment.

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.

Does the Rigid External Distraction Device Alter Maxillary Pitch in Cleft Maxillary Distraction?

Statement of problemCorrection of cleft maxillary hypoplasia remains a controversial topic. Surgical correction can be accomplished through Le Fort I orthognathic correction, internal distraction osteogenesis, or external distraction osteogenesis.1 Proponents of rigid external distraction (RED) osteogenesis describe the ability of multi-vector directional distraction control as opposed to univector internal distraction. There are currently limited data on the ability of the RED system to alter the maxillary occlusal pitch.The purpose of this study is to address the following clinical question: “Among cleft patients presenting with severe maxillary hypoplasia and treated with rigid external distraction, does the rigid external distraction system result in alteration of the maxillary pitch?”The study hypothesis is: among cleft patients presenting with maxillary hypoplasia treated with RED, the investigators hypothesize that there is no change in maxillary pitch with distraction.The study's specific aims are to design a retrospective cohort study and enroll a sample composed of cleft patients with maxillary hypoplasia treated with RED: 1) identify a cohort of patients with cleft maxillary hypoplasia, 2) quantify the degree of pre-operative maxillary hyperplasia, 3) measure changes in maxillary position achieved through RED. Materials and methodsTo address the research objectives, the investigators designed a retrospective cohort study. The study sample was derived from the population of patients with cleft maxillary hypoplasia who underwent RED by the Department of Oral and Maxillofacial Surgery at the University of Alabama - Birmingham from June 2007 to August 2019. Subjects eligible for study inclusion had cleft maxillary hypoplasia and underwent RED. Subjects were excluded if there were incomplete data collection or their records were not available for review.Demographic and radiographic variables were recorded. Demographics included gender, age at date of surgery, and history of ULCP vs. BLCP. Radiographic variables included standard cephalometric data recorded prior to distraction (T1) and after completion of distraction (T2). Methods of data analysisDescriptive statistics were computed for all study variables. Due to the potential for both positive and negative occlusal pitch change, a paired 2-tailed T-test was used to compare T1 and T2. The level of statistical significance was set at P < .05. ResultsThe study sample was composed of 45 subjects with a mean age at surgery of 12.2+3.4 years. Twenty-two (49%) were BCLP and 27 (60.0%) were male. At T1, mean SNA was 76.35+/-6.4 degrees, and the maxillary occlusal plane to Frankfort horizontal plane was 8.18+/-6.9 degrees. The mean anterior-posterior distraction distance was 11.4+/-5.7 mm. At T2, the mean SNA was 86.0+/-7.5 degrees, and the occlusal plane to FH was 3.78+/-7.3 degrees. The average maxillary occlusal pitch change was -4.4+/-5.8 degrees (P = .005). ConclusionFor cleft lip and palate patients with maxillary hypoplasia, surgical advancement with RED results in counterclockwise rotation of the maxillary occlusal plane.

Skeletal and Dental Correction and Stability Following LeFort I Advancement in Patients With Cleft Lip and Palate With Mild, Moderate, and Severe Maxillary Hypoplasia.

This study evaluates skeletal and dental outcomes of LeFort I advancement surgery in patients with cleft lip and palate (CLP) with varying degrees of maxillary skeletal hypoplasia. Retrospective study. Lateral cephalograms were digitized at preoperative (T1), immediately postoperative (T2), and 1-year follow-up (T3) and compared to untreated unaffected controls. Based on the severity of cleft maxillary hypoplasia, the sample was divided into 3 groups using Wits analysis: mild: ≤0 to ≥-5 mm; moderate: <-5 to >-10 mm; and severe: ≤-10 mm. Fifty-one patients with nonsyndromic CLP with hypoplastic maxilla who met inclusion criteria. LeFort I advancement. Skeletal and dental stability post-LeFort I surgery at a 1-year follow-up. At T2, LeFort I surgery produced an average correction of maxillary hypoplasia by 6.4 ± 0.6, 8.1 ± 0.4, and 10.7 ± 0.8 mm in the mild, moderate, and severe groups, respectively. There was a mean relapse of 1 to 1.5 mm observed in all groups. At T3, no statistically significant differences were observed between the surgical groups and controls at angle Sella, Nasion, A point (SNA), A point, Nasion, B point (ANB), and overjet outcome measures. LeFort I advancement produces a stable correction in mild, moderate, and severe skeletal maxillary hypoplasia. Overcorrection is recommended in all patients with CLP to compensate for the expected postsurgical skeletal relapse.

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

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.

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.

Cephalometric Analysis of Hard and Soft Tissue Changes Following Anterior Maxillary Osteotomy Distraction in Cleft Maxillary Hypoplasia.

Nonsyndromic unilateral CLAP patients despite the best surgical efforts present with variable degree of maxillary hypoplasia after cleft palate repair. AMOD is an extension of anterior maxillary osteotomy where the resulting segment anterior to the chosen site of vertical corticotomy cut is distracted with the help of hyrax screw through a tooth-borne appliance. To analyze the hard and soft tissue profile changes following AMOD. To determine the ratio of soft tissue changes to the given extent of hard tissue movements. Study group consisted of 25 patients with cleft maxillary hypoplasia reporting to the Department of OMFS, Coorg Institute of Dental Science. The preoperative and postoperative radiographs were taken followed by prediction tracing. In comparison of pre-op and post-op ceph mean improvement in hard tissue profile was seen at N-A by 2.84mm, N-A-Pg by 2.52, ANS-Gn by 2.28mm, N-ANS by 0.68mm, 1-Nf by 0.32 and at PNS-ANS was 4.2mm signifying improvement in middle third of face. Mean improvement in soft tissue profile at G-Sn-Pg angle by 1.2, G-Sn was 3.92mm, nasolabial angle by 10.92, incisor exposure (Stm-1) by 0.24mm and interlabial gap by 0.56mm. On ratio and correlation of soft tissue changes to given extent of hard tissue change, with movement of point A and U1 resulted significant changes in Sn and Ls. Movement of ANS resulted in significant changes in pronasale and columella. In our study significant improvement was seen in hard and soft tissue facial profile. In conclusion, AMOD is one of the emerging techniques to correct cleft maxillary hypoplasia which will have a defined definitive role to play in future.

Aberrations in Maxillary Anatomy of Adult Patients with Cleft Maxillary Hypoplasia: A Computed Tomographic Study.

The aim of this study was to evaluate the maxillary anatomy in patients with cleft maxillary hypoplasia using computed tomogram. A cross-sectional observational study was carried out in all cleft patients reporting to our department for the correction of secondary cleft deformities. A preoperative computed tomogram of the midface (from the superior orbital rim to the maxillary occlusal plane) was recorded to assess the parameters which evaluate the maxillary and pterygomaxillary anatomy in cleft maxillary hypoplasia patients. A total of 18 adult patients (female-5; male-13) were included in the study, which includes 15 unilateral and 3 bilateral cleft lip and palate patients. All the patients had undergone palatoplasty in their early childhood. Evaluation of the circum maxillary and pterygo-maxillary anatomy on the computed tomogram revealed that the average width of maxillary tuberosity was (mean-6.91mm on cleft side, 4.51mm on noncleft side); distance between medial and lateral pterygoid plateswas (mean-6.45mm on cleft side, 5.94mm on noncleft side); distance from greater palatine foramen to posterior palatal borderwas (mean-5.6mm on cleft side, 6.1mm on noncleft side); distance from greater palatine foramen to pterygoid process was (mean-4.83mm on cleft side, 5.6mm on noncleft side); distance from pyriform rim to greater palatine foramen was (mean-30.0mm on cleft side, 31.8mm on noncleft side); inter pterygoid distance between medial pterygoid plates at the level of pterygoidhamulus was (mean-3.3cms = 33mm); inter pterygoid distance between medial pterygoid plates at skull basewas (mean-3.0 = 30mm). Maxillary hypoplasia in adult cleft patients distorts the circum maxillary and pterygomaxillary anatomy with cleft side being more hypoplastic compared to the noncleft side which needs to be evaluated prior to planning maxillary advancement.

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.

A comprehensive management protocol to treat cleft maxillary hypoplasia

AimTo describe a comprehensive management protocol to treat cleft maxillary hypoplasia specific to the patient's age, degree of hypoplasia and presence or absence of velopharyngeal incompetence (VPI). Materials and methodsA total of 359 patients suffering from cleft maxillary hypoplasia were retrospectively studied from January 2004 till June 2015. Lateral cephalograms were taken to assess the degree of deformity and advancement achieved at three intervals. Patients were treated by four treatment modalities: Facemask therapy, Anterior maxillary advancement, Total maxillary osteogenesis and LeFort I advancement. Results359 patients of cleft maxillary hypoplasia were treated and followed up for a mean of 25 ± 3.6 months. Group I had 20 patients, all in the pre-pubertal age group with less than 11 mm discrepancy. 25% of patients in this group had relapse; Group II: 196 patients who were all above 11 years of age and included all grades of hypoplasia, only 6.25% patients had relapse; Group III had 36 patients all with severe form of hypoplasia and were above 5 years of age. Relapse in this group was 16.6%; Group IV had 102 patients who were above 16 years of age and had mildmoderate severity of hypoplasia. Relapse rate was 18.75%. ConclusionExtensive literature search and our institutional study has helped us formulate a protocol that delineates the most appropriate treatment modality for a specific age group and degree of hypoplasia also considering the effect of treatment on velopharyngeal incompetence.

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.

Use of repeat anterior maxillary distraction to correct residual midface hypoplasia in cleft patients.

ObjectivesThe study was designed to evaluate the efficacy of performing a second, repeat anterior maxillary distraction (AMD) to treat residual cleft maxillary hypoplasia.Materials and MethodsFive patients between the ages of 12 to 15 years with a history of AMD and with residual cleft maxillary hypoplasia were included in the study. Inclusion was irrespective of gender, type of cleft lip and palate, and the amount of advancement needed. Repeat AMD was executed in these patients 4 to 5 years after the primary AMD procedure to correct the cleft maxillary hypoplasia that had developed since the initial procedure. Orthopantomogram (OPG) and lateral cephalograms were taken for evaluation preoperatively, immediately after distraction, after consolidation, and one year postoperatively. The data obtained was tabulated and a Mann Whitney U-test was used for statistical comparisons.ResultsAt the time of presentation, a residual maxillary hypoplasia was observed with a well maintained distraction gap on the OPG which ruled out the occurrence of a relapse. Favorable movement of the segments without any resistance was seen in all patients. Mean maxillary advancement of 10.56 mm was achieved at repeat AMD. Statistically significant increases in midfacial length, SNA angle, and nasion perpendicular to point A distance was achieved (P=0.012, P=0.011, and P=0.012, respectively). Good profile was achieved for all patients. Minimal transient complications, for example anterior open bite and bleeding episodes, were managed.ConclusionAddressing the problem of cleft maxillary hypoplasia at an early age (12–15 years) is beneficial for the child. Residual hypoplasia may develop in some patients, which may require additional corrective procedures. The results of our study show that AMD can be repeated when residual deformity develops with the previous procedure having no negative impact on the results of the repeat procedure.

Tooth-Borne Anterior Maxillary Distraction for Cleft Maxillary Hypoplasia: Our Experience With 147 Patients

To evaluate the results of anterior maxillary distraction for its efficacy and long-term stability in the management of cleft maxillary hypoplasia in a large series of patients with a long-term follow-up extending to 4years. One hundred sixty-four patients at least 10years old with cleft maxillary hypoplasia who presented to the authors' unit from January 2009 through October 2014 were evaluated retrospectively, irrespective of gender, type of cleft lip and palate, and amount of advancement needed. Anterior maxillary distraction using a tooth-borne distractor appliance was carried out in all patients and all patients were followed up to 4years (range, 1 to 4yr) to evaluate the stability of the procedure and to document any relapse using digitalized lateral cephalograms taken before distraction, immediately after distraction (T2), and at the last follow-up visit (T3; range, 1 to 4yr). Seventeen patients were subsequently lost to follow-up; therefore, a complete set of records was available for 147 patients. In a subset of 50 patients, perceptual speech assessment was carried out preoperatively and 6months postoperatively by 2 speech pathologists using the Perkins scoring system that allowed the evaluation of 5 parameters (velopharyngeal insufficiency, resonance, nasal air emission, articulation, and intelligibility). None of these patients underwent speech therapy during the course of evaluation. The development of complications intra- or postoperatively was noted. The data were tabulated and analyzed. An advancement ranging from 4.0 to 13.1mm (mean, 9.42mm) was achieved in all patients. One hundred forty patients (95.23%) showed stable results on lateral cephalograms and when T2 values were compared with T3 values. Seven patients (4.76%) exhibited skeletal relapse in various linear and angular measurements assessed on lateral cephalograms. At 6-month follow-up, improvements of 62% (n= 31), 64% (n= 32), 50% (n= 25), 68% (n= 34), and 70% (n= 35) in velopharyngeal insufficiency, resonance, nasal air emission, articulation, and intelligibility, respectively, were observed, with worsening of all parameters in 1 patient (2%). An overall complication rate of 25.17% (n= 37) was noted, with bleeding being the most common intra- and postoperative complication noted in 15 patients (10.2%). No serious consequences related to any complication were noted. Anterior maxillary distraction can be considered a suitable treatment option for the management of mild to moderate cleft maxillary hypoplasia because the anteroposterior deficiency can be addressed at a young age, immediately after the eruption of the maxillary second premolars. Stable long-term results with negligible skeletal relapse are possible with this technique, with an added advantage of unhampered or even improved velopharyngeal function.

Perceptual Speech Assessment After Anterior Maxillary Distraction in Patients With Cleft Maxillary Hypoplasia

To assess speech outcomes after anterior maxillary distraction (AMD) in patients with cleft-related maxillary hypoplasia. Fifty-eight patients at least 10years old with cleft-related maxillary hypoplasia were included in this study irrespective of gender, type of cleft lip and palate, and amount of required advancement. AMD was carried out in all patients using a tooth-borne palatal distractor by a single oral and maxillofacial surgeon. Perceptual speech assessment was performed by 2 speech language pathologists preoperatively, before placement of the distractor device, and 6months postoperatively using the scoring system of Perkins etal (Plast Reconstr Surg 116:72, 2005); the system evaluates velopharyngeal insufficiency (VPI), resonance, nasal air emission, articulation errors, and intelligibility. The data obtained were tabulated and subjected to statistical analysis using Wilcoxon signed rank test. A P value less than .05was considered significant. Eight patients were lost to follow-up. At 6-month follow-up, improvements of 62% (n= 31), 64% (n= 32), 50% (n= 25), 68% (n= 34), and 70% (n= 35) in VPI, resonance, nasal air emission, articulation, and intelligibility, respectively, were observed, with worsening of all parameters in 1 patient (2%). The results for all tested parameters were highly significant (P ≤ .001). AMD offers a substantial improvement in speech for all 5 parameters of perceptual speech assessment.

Evaluation of Treatment Outcome in Cleft Maxillary Hypoplasia Treated by Rigid External Distractor

The aim of the study was to cephalometrically evaluate hard and soft tissue changes in cases of cleft-induced maxillary hypoplasia treated by distraction osteogenesis using rigid external distractor (RED). Fifteen cases of cleft-induced maxillary hypoplasia were selected applying the inclusion and exclusion criteria. The cases were operated on under general anesthesia for distraction osteogenesis using RED. Cephalometric evaluation was done at the end of presurgical orthodontics (C1), 1 week after removal of RED (C2), and at the end 12 months postoperatively (C3). The hard tissue parameters considered were Sella Nasion point A angle, Point A-Nasion-point B angle, distance from condylion to point A, anterior nasal spine-menton to Nasion-menton ratio, and upper incisor distance to N vertical. The soft tissue parameters included facial contour angle, nasolabial angle, upper lip to E-line, and lower lip to E-line. There were 8 males and 7 females with an average age of 13.07 years. The range of maxillary advancement was 8 to 24.5 mm with an average of 14.46 mm. The cephalometric data were compared using paired t test and 1-way analysis-of-variance test. All the hard tissue changes except SNB were statistically highly significant (P > 0.0001). The percentage of relapse was 13.72% at SNA, 13.3% at ANB, 9.83% for maxillary depth, 8.99% for distance of the upper incisor to N perpendicular and 20.73% for facial contour angle, 2.16% for nasolabial angle, 25.69% for distance of UL to E-line, and 25.12% for distance of LL to E-line. Soft tissue relapse except nasolabial angle after 1 year was more as compared with hard tissue. All the cephalometric parameters except SNB angle showed significant improvement. However, the significant percentage of relapse should be considered in the preoperative planning.

Management of Cleft Maxillary Hypoplasia with Anterior Maxillary Distraction: Our Experience.

Maxillary hypoplasia is a common developmental problem in cleft lip and palate deformities. Since 1970s these deformities have traditionally been corrected by means of orthognathic surgery. Management of skeletal deformities in the maxillofacial region has been an important challenge for maxillofacial surgeons and orthodontists. Distraction osteogenesis is a surgical technique that uses body's own repairing mechanisms for optimal reconstruction of the tissues. We present four cases of anterior maxillary distraction osteogenesis with tooth borne distraction device-Hyrax, which were analyzed retrospectively for the efficacy of the tooth borne device-Hyrax and skeletal stability of distracted anterior maxillary segment.