Premaxillary Distraction Osteogenesis Using an Intraoral Appliance for Unilateral Cleft Lip and Palate: Case Report

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

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

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Management of the protuberant premaxilla: where does it fit in?

PURPOSE OF REVIEW

To discuss multidisciplinary treatment options for the protuberant premaxilla associated with bilateral cleft lip and palate. Lessons have been learned throughout the years regarding the effect of growth restriction after early and aggressive therapy. Multiple surgical and orthodontic interventions are discussed. Recent literature will be highlighted and discussed.

RECENT FINDINGS

A paucity of long-term studies was noted. Recent literature revealed numerous studies introducing innovative presurgical orthopedic devices as less expensive and easier to use alternatives to nasoalveolar molding. Multiple approaches to premaxillary setback were presented, offering multiple approaches to improve success rates and minimize burden to the patient. Novel orthodontic and advanced microvascular procedures were discussed as additional tools for treatment of the malpositioned premaxilla once skeletal maturity is reached.

SUMMARY

Multidisciplinary team management of the protuberant premaxilla and bilateral cleft lip and palate is becoming increasingly embraced worldwide. Numerous surgical procedures and orthodontic treatments are required to optimally reposition the premaxilla; however, these interventions can inhibit growth, resulting in maxillary retrusion. Long-term follow-up studies are needed to determine what protocol is best. Studies should also include ways to overcome barriers to treatment success, such as late intervention, resource disparity, and limited access to care.

Intraoral Premaxillary Distraction in a Patient With Maxillary Retrognathic Cleft Lip and Palate: A Case Report

Patients with cleft lip and palate sometimes have a retruded maxilla. Here, we describe the case of a young man in whom crowding of the maxillary teeth and an anteroposterior discrepancy of the maxilla were resolved by premaxillary distraction osteogenesis (DO) using 3 individual intraoral distractors. Our experience in this patient confirms that premaxillary DO with 3 intraoral distractors and preoperative simulation can achieve stable maxillary advancement and arch expansion without impairing velopharyngeal incompetence.

Use of mandibular chin bone for alveolar bone grafting in cleft patients

BACKGROUND

We evaluated and compared the outcomes of different ossification processes in patients with alveolar cleft in whom correction was performed using endochondral bone graft or intramembranous bone graft.

METHODS

The patients were divided into two groups: the endochondral bone (iliac bone or rib bone) graft group and the intramembranous bone (mandibular bone) graft group. Medical records and radiologic images of patients who underwent alveolar bone grafting due to alveolar cleft were analyzed retrospectively. Through postoperative and follow-up radiologic images, the height of the interdental bone septum was classified into four types based on the highest point of alveolar ridge. Then, the height of the interdental bone septum and the area of the bone graft were evaluated according to the type of bone graft. In addition, the occurrence of complications and the need for an additional bone graft, the result of postoperative orthodontic treatment, and the eruption of impacted teeth were investigated.

RESULTS

Thirty patients were included in this study. There was no significant difference in the change of the interdental bone height and the area of the bone graft according to the type of bone. There was no significant difference in the success rate of the surgery according to the type of bone. One patient underwent an additional bone graft surgery during the follow-up period.

CONCLUSIONS

The outcomes of alveolar bone grafting were not significantly different according to the type of bone graft. If appropriate to the size of the recipient site, the chin bone is a useful graft material in alveolar cleft, as is the iliac bone.

Unilateral Le Fort I Osteotomy for Rehabilitating the Large Alveolar Cleft and Vertical Malocclusion With the Distraction Technique

Rehabilitation of the large alveolar clefts with autogenous graft or distraction osteogenesis is one of the most common treatment choices. Depending on the clinical situation such as vertical deficiencies, linear transport of the segment does not always ensure a proper closure of the cleft space. In this report, the authors present a patient in whom large unilateral cleft and vertical alveolar deficiency were closed by unilateral Le Fort I osteotomy and distraction technique using the orthodontic elastics.