Severe Maxillary Deficiency Research Articles

A skeletal Class III young adult with severe maxillary transverse deficiency treated with maxillary skeletal expander.

This case report describes correction of maxillary constriction using a maxillary skeletal expander (MSE) in a 15-year-old female with a skeletal Class III pattern and asymmetry. The maxillary expansion device with four mini-implants was used to correct the constricted maxilla, bilateral crossbite of the posterior teeth, and crowding of the dentition. Comparison of cone-beam computed tomography scans before and after treatment showed that the majority of maxillary expansion was orthopedic, with minimal alveolar bone bending and tooth tipping. Fixed appliances were used to correct the crowding and malocclusion. Stable and satisfactory maxillary expansion was obtained by using MSE non-urgically.

An evaluation of three-dimensional facial changes after surgically assisted rapid maxillary expansion (SARME): an observational study

BackgroundThe abnormal facial features in maxillary transverse deficiency (MTD) are minimal and limited to a deficiency of the middle facial third, narrow nares and nasal base, and deepened nasolabial folds. The surgical expansion of the narrow maxilla has most obvious effects on widening of the maxillary dental arch and expansion of the maxillary and palatal structures in the transverse plane, however sagittal changes also occurs. The purpose of this observational study was to evaluate the three-dimensional (3D) facial soft tissue changes following surgically assisted rapid maxillary expansion (SARME).MethodsIn 15 skeletally mature patients with severe maxillary transverse deficiency, the planned maxillary expansion (on average 8.8 mm ± 2.3 mm) was achieved with a bone-borne palatal distractor. The 3D optical scans of the facial surface were obtained before and six months after SARME. In the first part, we defined different anatomical landmarks on both scans and compared cephalometric measurements. In the second part, we registered both 3D scans in the same workplace using the regional best-fit method (forehead, supraorbital and nasal root regions were selected for the superimposition) and conducted surface analysis.ResultsThe largest differences between the pre- and post-operation scans were observed in the paranasal and cheek area (1.4 ± 1.0 mm). Significant differences occurred for an increased nasal width, a decreased upper-face height with an unchanged lower height, an increased vertical philtrum height and an increased nasolabial angle. A significant increase in the facial profile angle was also observed, resulting in an increased facial convexity and anterior displacement of the upper-lip area.ConclusionsThe widening of the nose and increased projection in the cheek and paranasal area in the lateral direction after maxillary expansion were confirmed; moreover, facial convexity increases, reflecting the underlying advancement of the maxilla.

Multidisciplinary Rehabilitation of an Adult with a Cleft Lip and Palate: An Illustration of a Dental Substitution Approach for the Management of Unilateral Agenesis of Central and Lateral Incisors

Cleft lip and Palate (CLP) is the most common craniofacial condition. Management of patients with clefts often requires multi-disciplinary rehabilitation of the orofacial structures. This case report demonstrates the multi-disciplinary management of an adult with a cleft lip and palate, highlighting the benefits of 3-Dimensional (3D) diagnosis, treatment planning and clinical execution of the plan. The patient presented with a severe maxillary deficiency, mandibular asymmetry, and congenitally missing maxillary right central and lateral incisors. This case report demonstrates an alternative approach for the management of cases with ipsilateral missing central and lateral incisors. The maxillary right canine substituted the congenitally missing maxillary right central incisor, while the maxillary right first premolar substituted the congenitally missing right lateral incisor, eliminating the need for prosthetic replacements. Total treatment time was 19 months, and the burden of care for the patient was minimized. An acceptable occlusion was achieved, and the patient’s esthetics improved significantly at the end of treatment. More importantly, the patient reported a marked improvement in his quality of life.

An Alternative Internal Le Fort I Distractor: Early Results With a New Trans-Nasal Device.

To report the early experience using a new internal trans-nasal Le Fort I distractor in patients with cleft lip and palate. Patients with cleft lip and palate and severe maxillary deficiency, who were treated with the trans-nasal Le Fort I distractor, were retrospectively reviewed. Cephalometric images were evaluated preoperatively and at least 6 months postoperatively. Speech outcomes were measured before and at least 6 months after surgery. Patient experience with the device was documented and complications were recorded. Five male patients with bilateral cleft lip and palate (ages 11-19) underwent the maximum advancement allowed by the device (25 mm). Follow-up averaged 2 years. Average SNA changed from 75.5°preoperatively to 84.6°postoperatively. Average ANB angle changed from -2.8° to 7.4°, or a tendency to Class 2 overcorrection. There was an overall increase in upper anterior facial height by 7.5 mm. All patients achieved acceptable postoperative occlusions. Two patients with borderline velopharyngeal function preoperatively developed velopharyngeal insufficiency postoperatively that did not resolve 6 months postoperatively, necessitating further surgery. Families reported ease of turning with minimal discomfort reported by patients. All patients maintained normal mouth opening during and after the distraction phase. Two of the patients developed localized pin site infections after the distraction phase that were treated successfully with oral antibiotics. The trans-nasal Le Fort I distractor can be an effective device to advance the deficient maxilla and is well tolerated by patients.

Surgically-assisted rapid maxillary expansion (SARME): indications, planning and treatment of severe maxillary deficiency in an adult patient.

ABSTRACTIntroduction: Maxillary deficiency, also called transverse deficiency of the maxilla, may be associated with posterior crossbite, as well as with other functional changes, particularly respiratory. In adult patients, because of bone maturation and the midpalatal suture fusion, rapid maxillary expansion has to be combined with a previous surgical procedure to release the areas of resistance of the maxilla. This procedure is known as surgically-assisted rapid maxillary expansion (SARME). Objective: This study discusses the indications, characteristics and effects of SARME, and presents a clinical case of transverse and sagittal skeletal maxillary discrepancy treated using SARME and orthodontic camouflage.

Rapid correction of constricted maxillary arch in a class III patient using a corticotomy assisted expansion technique

This case report introduces a noval approach of corticotomy-assisted rapid maxillary expansion for treating a severe maxillary transverse discrepancy in an adult patient. This approach uses piezo-bone perforation in conjunction with a fixed appliance and expanded jockey arch wire. This report describes the treatment of an 18-year-old male with a severe maxillary transverse discrepancy. He had a straight profile, mild maxillary crowding, severe maxillary transverse deficiency and a Class III skeletal relationship. The treatment protocol commenced with active orthodontic therapy, after leveling and aligning surgical intervention with Piezocision assisted bone perforation was performed. Immediately after the piezo assisted bone perforation on bilateral buccal side of the maxilla, active expansion force was given with expanded jockey arch wire. The expanded jockey wire was left in place for 3 months. Proper overbite and overjet, facial balance, and occlusion were achieved. The case is in final stage of finishing. This treatment approach considerably reduced the treatment time and gained bony volume. This approach is a good alternative to surgical rapid palatal expansion for treating a severe maxillary transverse deficiency in an adult patient. Key words: Corticotomy, osteotomy, accelerated orthodontics, Piezocision

Adult patient with bilateral cleft lip and palate treated using bone graft followed by lateral distraction: A case report

This is a case report of comprehensive treatment describing the management of an adult patient with bilateral cleft lip and palate who showed severe maxillary transverse deficiency caused by bilateral alveolar clefts. Since the residual alveolar clefts were extremely wide, we performed bone graft into the alveolar clefts first and then expanded the asymmetrically narrowed maxilla by asymmetric transverse distraction osteogenesis, in which an incision for osteotomy was made at the repaired bone bridge. The treatment accomplished successful reconstruction of the dental arches and occlusion. Aesthetic improvement was noted, with no discernible post-treatment relapse of occlusion after two years’ retention.

Experience with a New Internal Distractor in Patients with Cleft Lip and Palate: The Transnasal Device

Le Fort I distraction is indicated in a patient with severe maxillary deficiency, when the anticipated magnitude of the bony movement is deemed likely to be unstable using conventional orthognathic surgery. This is particularly the case in patients with cleft lip and palate. Distraction can be performed using external or internal devices with a multitude of designs, each having certain advantages and disadvantages. Preference is operator-dependent. It is the purpose of this presentation to introduce a new internal transnasal Le Fort I distractor.

Stability of orthodontic treatment in the patients with cleft lip and palate

Severe maxillary deficiency is often seen in cleft lip and palate patients due to multiple factors such as congenital defect, traumatic effect of surgeries and constriction of scar tissue, which causes moderate to severe crowding and anterior and posterior crossbite. Orthodontic treatment is usually difficult and time consuming. Upper arch expansion and maxillary protraction are often carried out to release transverse and sagittal intermaxillary discrepancy. Orthodontic treatment for cleft patients is different from that of non-cleft patients. Special management is needed and the stability of treatment should be considered. Relapse usually occurred after upper arch expansion especially in canine and premolar area. Over expansion should be cautious and orthognathic surgery may reduce the unstability of expansion. Maxillary protraction can improve the facial esthetics of the children with cleft. Alveolar bone grafting could improve the protraction effect and reduce the side effect such as clockwise mandibular rotation and upper incisor proclination. Forward movement of maxilla by protration is stable and continuous growth of the mandible is the most liable factor causing relapse. High mandibular angle and over growth of mandible are the risk factors of unstability of maxillary protraction.

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.

Management of severe maxillary hypoplasia with distraction osteogenesis in patients with cleft lip and palate

Maxillary hypoplasia is a common finding in patients with cleft lip and palate. Clinically, this manifests as a concave profile, midface deficiency, and Class III skeletal malocclusion. Management is in accordance with the severity of the malocclusion. In the case of moderate to severe skeletal discrepancy, combined orthodontic and surgical correction is required to obtain optimal results. In most instances, definitive orthognathic surgery is pursued at skeletal maturity. In the most severe cases however, early surgical correction has been achieved with Le Fort I osteotomy and distraction osteogenesis. The technique enables successful correction of a large maxillomandibular discrepancy in a growing patient with stable results. There are also applications in a skeletally mature patient with severe maxillary deficiency.

上下顎同時骨延長術を施行した著しい垂直的上顎劣成長を伴う下顎前突症の1例

When maxillary downgraft is performed for patients with severe maxillary deficiency, postoperative stability is sometimes insufficient. We report a case of mandibular protrusion with excessive vertical maxillary deficiency treated with simultaneous maxillo-mandibular distraction osteogenesis using alveolar distractors.A 25-year-old male patient visited our orthodontic clinic for treatment of his chief complaint that his upper incisors were invisible upon smiling. Upon examination, he was diagnosed as mandibular overgrowth with excessive vertical maxillary deficiency. Simultaneous maxillo-mandibular distraction osteogenesis was performed for considerable downward movement of the maxilla. Le Fort I osteotomy and bilateral inverted L osteotomy of the mandible were performed under general anesthesia. Bilateral alveolar distractors were set to the maxilla. After maxillo-mandibular fixation, distraction osteogenesis was performed downward by 10.5mm. Although slight relapse occurred 1 year after surgery and the final total amount of distraction was 9.0mm, the facial height and profile were improved and adequate exposure of the upper incisors was obtained.

Orthodontic considerations for maxillary distraction osteogenesis in growing patients with cleft lip and palate using internal distractors.

The orthodontist plays a key role in the selection of the optimal treatment for patients followed by a craniofacial team. For patients with cleft lip and palate, the need for multidisciplinary treatment planning and sequentially staged treatment is essential for successful patient outcomes. The technique of Le Fort I distraction osteogenesis of the maxilla using an internal device is potentially a predictable, stable, and convenient option for the correction of severe maxillary hypoplasia. It is an alternative option for treatment of maxillary hypoplasia in growing patients. In this article, the authors describe the orthodontist's approach to the management of cleft patients with severe maxillary deficiency with the use of an internal distraction device. The information is presented with a focus on the clinical aspects of treatment, using case illustrations and appropriate literature.

The distraction osteogenesis in midfacial hypoplasia.

Distraction osteogenesis (DO) can generate new bone in a gap between 2 vascularized bone surfaces in response to application of graduated tensile stress across the bone gap. The authors present the clinical result in a cleft patient with severe maxillary deficiency treated by a rigid external distraction (RED) device. A boy complained of both masticatory and psychological problems because of cleft with severe midfacial retrusion. The treatment aimed to create a well-balanced facial profile, increase maxillary incisal display, create proper overjet and overbite, and align his dentition. By the RED system, the traction is applied to the maxilla through the dentition by an intraoral splint. A complete Le Fort I osteotomy was performed, including pterygomaxillary and septal disjunction, with mobilization. Once osteotomy was completed, the halo portion of the RED device was adjusted for the width of the neurocranium and was rigidly fixed around the head with 2 scalp screws on each side. A well-balanced facial profile and a good alignment of the dentition were obtained. The patients had considerable improvement in his self-esteem. Clinical reports have suggested that maxillary advancements achieved by distraction are more stable than those achieved with orthognathic surgery with a minimal influence on velopharyngeal competence.

Mandibular effects of maxillary distraction osteogenesis in cleft lip and palate

Maxillary distraction osteogenesis (DO) is a reliable treatment for severe maxillary deficiency in cleft lip and palate (CLP). The objective was to analyze its long-term effects on the mandible. A retrospective study of 24 CLP treated with maxillary DO using the Polley and Figueroa technique was done; patients were followed for more than 4 years. Preoperative (T0), 6–12 months postoperative (T1), and ≥4 years postoperative (T2) cephalometric radiographs were evaluated. A classical cephalometric analysis was used to assess treatment stability, and a Procrustes superimposition method was used to assess local changes in the shape of the mandible. The mean age of patients at T0 was 15.4±4.1 years. SNA increased at T1 and T2 (P<0.001), with no significant relapse between T1 and T2, indicating stability at 1 year after treatment (T0=72.4±5.3°; T1=81.3±6.2°; T2=79.9±6.1°). SNB, facial angle, gonial angle, and symphyseal angle remained stable. Long-term analysis of the mandible demonstrated a minimal counter-clockwise rotation of the body (mandibular plane=−0.2±3.2°) and ramus (−0.6±4.3°). Maxillary DO in CLP had no significant effect on the shape or rotation of the mandible. The maxillary advancement remained stable after 1 year.

The Correction of Maxillary Deficiency with Internal Distraction Devices: A Multidisciplinary Approach

The purpose of this case report is to present the orthodontic, surgical and restorative treatments in the case of an operated cleft lip and palate and severe maxillary defciency in a 14-year-old female patient. Only orthodontic treatment could be ineffcient for cleft lip and palate patients characterized with maxillary hypoplasia. Orthodontic and surgical treatment shows suffcient results, especially with severe skeletal defciency. A cleft lip and palate patient required complex multidisciplinary treatment to preserve health and restore esthetics. Dental leveling and alignment of the maxillary and mandibular teeth were provided before the surgery. Maxillary advancement and clockwise rotation of the maxillary-mandibular complex was applied by a Le Fort 1 osteotomy with two internal distraction devices. After the active treatment including orthodontic treatment and orthognathic surgery, upper full mouth ceramic restoration was applied. This report shows the efficiency of internal distraction devices in cleft lip palate patients and exemplifes the multidisciplinary care required for such diffcult cases. Clinical signifcance: Stable improved occlusion and skeletal relations were observed after a follow-up examination period of 12 months.

Class III malocclusion with severe anteroposterior discrepancy

This study aims at reporting the clinical case of a patient with Class III skeletal malocclusion with severe maxillary deficiency, producing a reduced midface associated with severe mandibular prognathism. The pre-surgical orthodontic preparation was composed mainly by dentoalveolar expansion and repositioning of the incisors in the lower arch. Then, a combined maxillary and mandibular orthognathic surgery was performed. The treatment objectives were achieved, with significant improvement in facial esthetics and occlusion, followed by post-treatment stability. This case was presented to the Brazilian Board of Orthodontics and Facial Orthopedics (BBO), as part of the requirements for obtaining the title of Diplomate by BBO.

Interdisciplinary treatment of an adult with complete bilateral cleft lip and palate

Interdisciplinary treatment was used for an adult patient born with complete bilateral cleft lip and palate. He had a severe maxillary deficiency with a wide cleft involving the alveolar and maxillary bone and palate. Reconstruction of the arches and occlusion in patients who missed the optimal treatment time is a difficult task for orthodontists. The clinical examination showed severe hypogenesis of the maxillary bone with a total crossbite. The maxillary dental arch was extremely narrow, and the maxillary incisors showed extensive caries caused by improper oral hygiene. Fixed and removable expansion appliances were used to improve the lateral crossbite. Alveolar bone grafting and unilateral LeFort I maxillary osteotomy were performed on the right side for alignment of the maxillary arch. Mandibular setback with bilateral sagittal split ramus osteotomy was also performed to correct the anteroposterior skeletal discrepancy. After postsurgical orthodontic treatment, prosthetic treatment was carried out for final reconstruction of esthetics and orthognathic function. Interdisciplinary treatment was necessary for this patient to achieve a proper occlusion and better esthetics.

Nonunion of the External Maxillary Distraction in Cleft Lip and Palate: Analysis of Possible Reasons

Distraction osteogenesis (DO) is an effective way to treat severe maxillary deficiency in patients with cleft lip and palate. It has been reported to have long-term stability and low relapse rate compared with conventional maxillary osteotomy in large maxillary movement. However, complications such as nonunion are seldom reported. While developing our external distraction techniques, we had 4 nonunion cleft lip and palate (CLP) patients. The aim of this study is to analyze the possible reasons for these conditions by comparing them to patients successfully treated at 1 craniofacial institute. Fifty-six patients with CLP deformities treated with external maxillary distraction from 2000 to 2006 in 1 craniofacial center were reviewed. Among them, 17 had full records and follow-up time of more than 1 year. They had rigid external halo distraction with dental splint after a high Le Fort I osteotomy. Distraction was started at 5 days with a rate of 1 mm per day until the maxilla acquired the planned correction. Consolidation time ranged from 4 weeks to 3 months. Patients' general information, DO protocol, and cephalometric radiograph measurements before DO, immediately after DO, and follow-ups were evaluated. Thirteen of 17 patients successfully completed DO, whereas 4 others developed dental occlusion relapse 2 to 3 months after device removal. Later jaw surgery showed nonunion at the distraction sites. These were our first patients treated with external distraction. Their consolidation time was from 4 to 6 weeks with a mean of 5.2 weeks. After increasing the consolidation time up to 12 weeks, all of the other 13 patients had successful results without nonunion. Their mean consolidation time was 9.8 weeks. The nonunion group had significantly shorter consolidation time, older age, and larger distraction osteogenesis (DO) advancement than the successful group statistically. There was also a greater percentage of bilateral CLP patients in the nonunion group than in the successful treatment group. Among the 4 nonunion patients, 2 had failed alveolar bone graft before DO, and 3 did not have face mask retention therapy after device removal. The horizontal relapse rate in the 13 successful patients was 1 to 3 mm (mean, 11.9%) after 1 to 3 years of follow-up. All of these patients had good occlusion in the short-term follow-up (1 yr). Five developed end-to-end or Class III malocclusion in the long-term follow-up (1-3 yrs) because of maxillary relapse and continued mandibular growth that required jaw surgery later. A short consolidation time can cause nonunion, and should be lengthened to 12 weeks or more for a stable maxilla. Older age, bilateral CLP, large DO advancement (>15 mm), and compromised bone healing are the risk factors for nonunion.

Orthodontic-surgical treatment of Class III malocclusion with extraction of an impacted canine and multi-segmented maxillary surgery

Establishment of a treatment plan is based on efficacy and easy application by the clinician, and acceptance by the patient. Treatment of adult patients with Class III malocclusion might require orthognathic surgery, especially when the deformity is severe, with a significant impact on facial esthetics. Impacted teeth can remarkably influence treatment planning, which should be precise and concise to allow a reasonably short treatment time with low biologic cost. We report here the case of a 20-year-old man who had a skeletal Class III malocclusion and impaction of the maxillary right canine, leading to remarkable deviation of the maxillary midline; this was his chief complaint. Because of the severely deviated position of the impacted canine, treatment included extraction of the maxillary right canine and left first premolar for midline correction followed by leveling, alignment, correction of compensatory tooth positioning, and orthognathic surgery to correct the skeletal Class III malocclusion because of the severe maxillary deficiency. This treatment approach allowed correction of the maxillary dental midline discrepancy to the midsagittal plane and establishment of good occlusion and optimal esthetics.