Download Seminars in Orthodontics

Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
EDITORIAL BOARD
Rolf G. Behrents, St. Louis, MO (2010)
Samir E. Bishara, Iowa City, IA (2010)
James Caveney, Wheeling, WV (2009)
Harry L. Dougherty, Van Nuys, CA (2011)
Andre Ferreira, Birmingham, AL (2010)
John Grubb, Chula Vista, CA (2009)
Robert J. Isaacson, Edina, MN (2009)
Alexander Jacobson, Birmingham, AL (2010)
Lysle E. Johnston, Jr., Ann Arbor, MI (2009)
Donald R. Joondeph, Bellevue, WA (2009)
Gregory J. King, Seattle, WA (2011)
Richard Kleefield, Norwalk, CT (2009)
Vincent G. Kokich, Tacoma, WA (2009)
Steven J. Lindauer, Richmond, VA (2009)
James A. McNamara, Jr, Ann Arbor, MI (2010)
Eliakim Mizarahi, Ilford, England (2009)
Elliott M. Moskowitz, New York, NY (2009)
Ravindra Nanda, Farmington, CT (2010)
Peter Ngan, Morgantown, WV (2009)
Perry M. Opin, Milford, CT (2011)
Sheldon Peck, Newton, MA (2010)
C.B. Preston, Buffalo, NY (2011)
William R. Proffit, Chapel Hill, NC (2009)
Eugene Roberts, Indianapolis, IN (2009)
Emile Rossow, Dallas, TX (2011)
Cyril Sadowsky, Chicago, IL (2011)
James L. Vaden, Cookeville, TN (2009)
Robert L. Vanarsdall, Jr., Philadelphia, PA (2009)
Katherine Vig, Columbus, OH (2010)
Christos Vlachos, Homewood, AL (2011)
Timothy T. Wheeler, Gainesville, FL (2009)
INTERNATIONAL
Adrian Becker, Jerusalem, Israel (2010)
José Alexandre Bottrel, Rio de Janeiro, Brazil
(2009)
Jack Dale, Toronto, Ontario, Canada (2010)
W.G. Evans, Johannesburg, South Africa (2010)
Roberto Justus, Mexico City, Mexico (2009)
George Skinazi, Paris, France (2008)
William A. Wiltshire, Winnipeg, Manitoba, Canada
(2009)
Björn U. Zachrisson, Oslo, Norway (2009)
Seminars in Orthodontics
VOL 15, NO 4
DECEMBER 2009
Craniofacial Orthodontics
Pedro E. Santiago, DMD, and Barry H. Grayson, DDS
Guest Editors
Introduction
Pedro E. Santiago and Barry H. Grayson
219
Development of Craniofacial Orthodontics as a Subspecialty at New York
University Medical Center
Joseph G. McCarthy
221
Role of the Craniofacial Orthodontist on the Craniofacial and Cleft Lip
and Palate Team
Pedro E. Santiago and Barry H. Grayson
225
Management of Severe Cleft and Syndromic Midface Hypoplasia
Alvaro A. Figueroa and John W. Polley
Intraoral Distraction of Segmental Osteotomies and Miniscrews in
Management of Alveolar Cleft
Eric J.W. Liou and Philip K.T. Chen
Surgical/Orthodontic Treatment of Mandibular Asymmetries
Pamela R. Hanson and Michael B. Melugin
244
257
268
Seminars in Orthodontics
VOL 15, NO 4
DECEMBER 2009
Introduction
t is both a privilege and a pleasure to write a
brief history of Craniofacial Orthodontics, its
evolution and approval as a formal postresidency
fellowship training program of dentistry and
orthodontics in the United States of America.
On January 30, 2009, the Commission on
Dental Accreditation (CODA) of the American
Dental Association (ADA) approved the proposed standards for the postresidency fellowship
training program in Craniofacial and Special
Needs Orthodontics. According to the ADA,
Craniofacial Orthodontics is that area of orthodontics that treats patients with congenital and
acquired deformities of the integument and its
underlying musculoskeletal system within the
maxillofacial area and associated structures. Special care (SC) is that area of orthodontics that
treats patients with special needs, including patients with disabilities and medically compromised patients who require comprehensive
treatment.
Although Craniofacial Orthodontic Fellowship programs have existed in a limited number
of craniofacial centers around the United States,
the quality of training and clinical experience
has varied widely. The formal recognition and
accreditation standards by the ADA and the
American Association of Orthodontists (AAO)
will result in an increased number and quality of
training opportunities for graduates from orthodontic residency programs around the world.
The standards will require that institutions provide a uniformly high level of training and competence in this newly specialized area of orthodontics.
The goals of these fellowship programs are
to provide comprehensive clinical and didactic
training for the orthodontist, who will work with
a craniofacial team treating patients with a broad
I
© 2009 Elsevier Inc. All rights reserved.
doi:10.1053/j.sodo.2009.07.005
scope of craniofacial deformities and special
needs.
The clinical experience will include ADA accreditation standards:
1. Experience with acceptable forms of presurgical orthopedics for infants born with cleft
lip and palate
2. Orthodontic therapy for patients with craniofacial deformities from the primary through
adult dentition
3. Orthodontic management of patients with
cleft or craniofacial anomalies (CFA) and surgical/orthodontic treatment planning
4. Pre- and postsurgical orthodontic management
5. Surgical splint design and construction, and
observation of surgical fixation splints in the
operating room to ensure appropriate placement
6. Orthodontic treatment for patients who are
medically compromised or have disabilities
and/or special needs
7. Participation in interdisciplinary dental care,
clinical support, and appropriate guidance
for dentists, providing restorative services for
CFA and SC patients
8. Rotations to plastic and craniofacial surgery,
oral and maxillofacial surgery, Sleep Disorders Clinic, Genetics Clinic, Speech and Language Pathology Clinic, and Pediatric Dentistry for additional exposure to management
of CFA and SC patients
9. Supervised participation in craniofacial team
activities
It is particularly rewarding to see this specialized
fellowship training program gain recognition, as
the impetus for moving this proposal onto the
agenda of the Council of Dental Education of
the American Association of Orthodontists came
approximately 10 years ago in the form of letters
and oral communications by the co-guest editors
of this issue of Seminars in Orthodontics to members of the Council. The proposal to consider
Seminars in Orthodontics, Vol 15, No 4 (December), 2009: pp 219-220
219
220
Santiago and Grayson
recognition of craniofacial orthodontics and
standards for Fellowship training was passed on
from one Council president to another. Over
the period of 10 years, several committed orthodontic scholars have contributed to the final
version of the document that was approved by
the Board of Trustees of the American Association of Orthodontists and eventually by the
Commission on Dental Accreditation of the
American Dental Association.
Craniofacial orthodontics is an emerging and
challenging field that demands creative and innovative thinking to deal with often unique and
very difficult clinical problems. We look forward
to witnessing the evolution of this field and to
the many advances that will be made by present
and future craniofacial orthodontists. We believe that this issue of Seminars in Orthodontics
presents outstanding evidence of this creativity
and clinical protocols for treatment of patients
with cleft lip and palate, CFA, and special needs.
Pedro E. Santiago, DMD
Barry H. Grayson, DDS
Guest Editors
Development of Craniofacial Orthodontics as
a Subspecialty at New York University
Medical Center
Joseph G. McCarthy, MD
This is a brief personal history of craniofacial orthodontics as reported by Dr
Joseph G. McCarthy, Professor of Plastic Surgery and Director of the Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York. He describes early collaborations with research orthodontists who were, at the time, studying the development in patients
experiencing severe anomalies of craniofacial growth. From these early
collaborations came an appreciation for the role of orthodontists in the
interdisciplinary treatment team that was caring for patients with complex
craniofacial problems as well as those patients who presented with cleft lip
and palate. Both the distraction osteogenesis of the craniofacial skeleton
and nasoalveolar molding are clinical innovations that came forth from the
close collaboration of surgeon and orthodontist at New York University
Medical Center. The story of this collaboration is described with attention to
clinical and laboratory research, multidisciplinary team practice, and the
development of a Fellowship in Craniofacial Orthodontics. This short history
of how a Fellowship in Craniofacial Orthodontics came about at the New
York University Langone Medical Center is fitting in its now-timely relationship to the action of the American Dental Association and the American
Association of Orthodontics and Dentofacial Orthopedics to recognize
standards for fellowships in Craniofacial and Special Needs Orthodontics.
(Semin Orthod 2009;15:221-224.) © 2009 Published by Elsevier Inc.
resh from completing a residency in general surgery, with a strong background in
abdominal surgery, I arrived at New York University in 1971 as a first-year plastic surgery resident. Under the tutelage of Dr John Converse, I
became interested in plastic surgery of the face,
a discipline that was evolving into what we now
call craniofacial surgery. I immediately became
aware of my woefully inadequate background in
the dental sciences. I knew little about dental
F
From the Institute of Reconstructive Plastic Surgery, New York
University Langone Medical Center, New York, NY.
Address correspondence to Joseph G. McCarthy, MD, TCH
1148, 550 First Ave, New York, NY 10016; Phone: (212) 2635208; Fax: (212) 263-6002; E-mail: [email protected]
© 2009 Published by Elsevier Inc.
1073-8746/09/1504-0$30.00/0
doi:10.1053/j.sodo.2009.07.003
anatomy or orthodontics, but recognized that I
had to rectify this problem.
I was fortunate to arrive at a plastic surgery
unit that had the tradition of a strong collaboration between the orthodontist and the plastic
surgeon. My predecessor, John Converse, had
worked for many years with Dr Sid Horowitz,
who went on to become the Professor of Orthodontics at the School of Dental Medicine at
Columbia University. On his leaving, Dr Converse had recruited Dr Peter Cocarro from the
National Institute of Dental Research. Dr Cocarro also became one of my mentors; and I
would keep him late into the evening, after we
had each put in a full workday, so that he could
teach me about the role of orthodontics in surgical diagnosis, planning, and follow-up. Dr Cocarro and I worked on several primate research
projects, including the role of the sphenozy-
Seminars in Orthodontics, Vol 15, No 4 (December), 2009: pp 221-224
221
222
McCarthy
gomatic suture in the etiology of craniofacial
synostosis.1 We also studied the growth of the
midface in the unoperated patient with syndromic craniosynostosis.2 It was the latter
project that introduced me to the important
role of cephalometrics in craniofacial surgery.
I quickly recognized that it was an invaluable
tool in diagnosis, treatment planning, and
long-term follow up.
At the same time, I was impressed by the role
of other orthodontists in the evolution of this
surgical field. The late Sam Pruzansky was a
towering figure. As craniofacial surgery took off
in the 1970s, Pruzansky was the recognized arbiter of what should and should not be done
surgically; and, believe it or not, the surgeons
listened! Like Bruce Ross of Toronto, another
orthodontist, he had recognized that early cleft
palate repair had resulted in midface hypoplasia. On the basis of these findings, he feared that
early skeletal surgery in patients with severe
craniofacial anomalies would impair subsequent
craniofacial growth and development. However,
the study that Cocarro and I had conducted
demonstrated that even the unoperated patient
with syndromic craniosynostosis could not expect normal midface development.2 I used to say
at meetings that the surgeon and orthodontist
would be waiting for “a train that would never
come to the station.”
Much to my chagrin, Dr Cocarro decided to
retire, and I began to look for his replacement.
My search led me to the University of Puerto
Rico and to my fortuitously recruiting Dr Barry
Grayson in 1978. This was the beginning of a
remarkable and rewarding collaboration. My
orthodontic education then continued under the
guidance of Dr Grayson. Working with Dr Barry
Zide, a craniofacial surgery fellow, Barry Grayson published a three-part paper on the practical application of cephalometric technique in
craniofacial surgery, a primer for all of plastic
surgery.3-5 This was then followed by the development of a three-dimensional cephalometric
analytical technique, an invaluable resource in
planning surgery in the patient with asymmetry,
such as unilateral craniofacial microsomia.6,7
These articles showed that a craniofacial midline
could be established that could serve as a reference in the planned skeletal movements.
These studies then progressed with the addition of Dr Court Cutting, another craniofacial
surgery fellow on our team. Dr Cutting, who is a
first-rate mathematician as well as an innovator
in computer graphics, worked with Drs Grayson
and Bookstein, resulting in the publication of
classic papers, such as tensor cephalometric
analysis,8 and the use of the medial axis analysis
in defining the pathologic mandible by quantitative analysis. We were aided in this work by Dr
Fred Bookstein, a morphometrician and stellar
mathematician from the University of Michigan.9
In the 1980s it became apparent that, at the
Institute of Reconstructive Plastic Surgery, we
should have a separate craniofacial anomalies
team and a separate cleft lip and palate team. I
assigned Dr Cutting to lead the latter, which
turned out to be a wise decision. Drs Cutting and
Grayson had an incredibly productive working
relationship that resulted in a major innovation
in cleft care: nasoalveolar molding.10,11 This type
of interdisciplinary work resulted in a treatment
paradigm shift in neonatal skeletal and cartilage
molding and tissue expansion. Moreover, it made
the work of the plastic surgeon in cleft lip repair
much easier and resulted in an incremental improvement in the quality of the surgical result.
In the mid-1980s, I became interested in the
principles of distraction osteogenesis. Studies in
our canine laboratory demonstrated the feasibility of distraction osteogenesis of the mandible,
and this led to a report of the first patient to
undergo craniofacial distraction in 1989 —an 18month-old boy with unilateral craniofacial microsomia.12,13
The development and evolution of the field
of craniofacial distraction are another example
of collaboration between the craniofacial surgeon and the orthodontist. From the beginning,
Barry Grayson and I realized that each patient who
was facing distraction and who was to undergo
orthognathic surgery should be approached in a
manner, similar, on a daily basis. We would meet
jointly to analyze the deformity and to work out a
treatment plan. Gradually, we recognized the
critical role of vector planning in craniofacial
distraction. This resulted in publications on the
role of vector planning in unilateral and bilateral craniofacial microsomia as well as in midface hypoplasia.14-16 Another article on molding
of the regenerate highlighted the role of orthodontic techniques during the activation and
consolidation phases of distraction to optimize
Development of Craniofacial Orthodontics as a Subspecialty
skeletal movement and the occlusion.17,18 Working together, we also published the development
of a new distraction device for the mandible.19
Ours was a combined journey by the orthodontist and surgeon in research studies and the
clinical application of craniofacial distraction.
Over the years, the collaboration has been
not only on the faculty level but also on the
fellow level. In July of 1995, we established a
formal 12-month Craniofacial Orthodontic Fellowship Program. The first fellow who graduated
from this program was Dr Pedro E. Santiago,
who went on to become the director of the
Orthodontic Graduate Program and Center for
Craniofacial Disorders at the School of Dental
Medicine, University of Puerto Rico. Just as Dr
Grayson and I have worked together, the craniofacial orthodontic and craniofacial surgical fellow work on a daily basis. If one reviews the
publications on craniofacial distraction from our
unit, the names of the craniofacial orthodontic
fellows stand prominently, especially on our
reports on intermediate and long-term follow-up studies of mandibular and midface distraction.16,20-26 All of us on the team have been
assiduous in the careful gathering and analysis
of clinical and radiographic records to evaluate
clinical outcomes and to improve treatment
methods.
From my perspective, what began as a collaborative professional relationship almost 40 years
ago has evolved into an incredible story. I have
been witness to the genesis of a new professional
discipline— craniofacial orthodontics—recently
recognized as a Postgraduate Fellowship in
Orthodontics by the Commission on Dental Accreditation of the American Dental Association
and the American Association of Orthodontists.
I have been privileged to work with Dr Barry
Grayson, to see him bring this field into reality,
and to see the graduates of the craniofacial orthodontic fellowship assume prominent leadership positions around the world. I always look
forward to hearing their papers at the international craniofacial surgery meetings. Most of all,
what heartens me the most is the interdisciplinary collaboration and goodwill that have made
for such a productive working environment, the
improved clinical outcomes for patients, and the
friendships made along the way.
223
References
1. McCarthy JG, Coccaro P, Epstein F, et al: Early skeletal
release in craniofacial dysostosis. Plast Reconstr Surg
62:335, l978
2. Coccaro PJ, McCarthy JG, Epstein F, et al: Early and late
surgery in craniofacial dyostosis: A longitudinal cephalometric study. Am J Orthop 77:421, l980
3. Zide BM, Grayson BH, McCarthy JG: Cephlaometric
analysis and preoperative planning, part I. Plast Reconstr
Surg 68:816, 1981
4. Zide BM, Grayson BH, McCarthy JG: Cephalometric
analysis and preoperative planning, part II. Plast Reconstr Surg 68:961, 1981
5. Zide BM, Grayson BH, McCarthy JG: Cephalometric
analysis and preoperative planning, part III. Plast Reconstr Surg 69:155, 1982
6. Grayson BH, Cutting CB, Bookstein FL, et al: The threedimensional cephalogram: Theory, technique and clinical application. Am J Orthod Dentofac Orthop 94:327337, 1988
7. Grayson BH, LaBatto F, McCarthy JG: The basilar multiplane cephalometric analysis. I—Landmark identification and tracing methodology. II—Method of analysis
and its application to the study of craniofacial anomalies.
Am J Orthod Dentofac Orthop 88:503-516, 1985
8. Grayson BH, Mueenuddin T, Bookstein FL, et al: Mean
tensor cephalometric analysis of cleft palate patients.
Cleft Palate J 24:267-277, 1987
9. Grayson BH, Bookstein FL, McCarthy JG: The mandible
in mandibulofacial dysostosis: A cephalometric study.
Am J Orthod 89:393-398, 1986
10. Grayson B, Cutting C, Wood R: Preoperative columella
lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 92:1422-1423, 1993
11. Grayson BH, Cutting C: Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip and
alveolus of infants born with unilateral and bilateral
clefts. Cleft Palate Craniofac J 38:193, 2001
12. Karp NS, Thorne CHM, McCarthy JG, et al: Bone lengthening in the craniofacial skeleton. Ann Plast Surg 24:23l,
l990
13. McCarthy JG, Schreiber JS, Karp NS, et al: Lengthening
of the human mandible by gradual distraction. Plast
Reconstr Surg 89:l, l992
14. Grayson BH, McCormick S, Santiago PE, et al: Vector of
device placement and trajectory of mandibular distraction. J Craniofac Surg 8:473, 1997
15. Shetye PR, Boutros S, Grayson B, et al: Midterm follow-up of midface distraction for syndromic craniosynostosis: A clinical and cephalometric study. Plast Reconstr Surg 120:1621, 2007
16. Dec W, Peltomaki T, Warren SM, et al: Mandible response to unilateral distraction osteogenesis. Plast Reconstr Surg 121:2084, 2008
17. Luchs JS, Stelnicki EJ, Rowe NM, et al: Molding of the
regenerate in mandibular distraction. I—Laboratory
study. J Craniofac Surg 13:205, 2002
18. McCarthy JG, Hollier LH, Grayson BH: Molding of the
regenerate in mandibular distraction. II—Clinical experience. Plast Reconstr Surg 112:1239, 2003
224
McCarthy
19. McCarthy JG, Williams JK, Grayson BH, et al: Controlled
multiplanar distraction of the mandible. I. Device development and clinical application. J Craniofac Surg 9:323,
1998
20. Grayson BH, Santiago PE: Distraction osteogenesis. Semin Orthod 5:9-24, 1999
21. Peltomaki T, Grayson BH, Vendittelli BL, et al: Molding of the generate to control open bite during mandibular distraction osteogenesis. Eur J Orthod 24:639645, 2002
22. Stelnicki EJ, Lin WY, Lee C, et al: Long-term outcome
study of bilateral mandibular distraction: A comparison
of Treacher Collins and Nager syndromes to other types
of micrognathia. Plast Reconstr Surg 109:1819-1825,
2002
23. Hopper RA, Altug AT, Grayson BH, et al: Cephalometric
analysis of the consolidation phase following bilateral
pediatric mandibular distraction. Cleft Palate Craniofac
J. 40:233-240, 2003
24. Shetye PR, Grayson BH, Mackool R, et al: Long-term
stability and growth following unilateral mandibular distraction in growing children with craniofacial microsomia. Plast Reconstr Surg 118:985, 2006
25. Peltomaki T, Vendittelli BL, Grayson B, et al: Attainment of
facial symmetry by unilateral distraction osteogenesis in
hemifacial microsomia patients. Eur J Orthod (in press)
26. Altug AT, Grayson B, McCarthy JG: The comparison of
skeletal and soft-tissue changes following unilateral mandibular distraction osteogenesis. Plast Reconstr Surg
121:1751, 2008
Role of the Craniofacial Orthodontist on the
Craniofacial and Cleft Lip and Palate Team
Pedro E. Santiago, DMD, and Barry H. Grayson, DDS
Patients born with a craniofacial deformity and their families experience significant psychosocial effect as they deal with physical appearance that has been
esthetically and functionally compromised. The deformity usually involves skeletal and soft-tissue elements, which often affect facial symmetry and esthetics.
As the dentition is directly related to the jaw structures, a wide variety of
malocclusions may result. As patients with craniofacial anomalies present with
multiple dental and medical conditions, an interdisciplinary team approach is
highly recommended to accurately diagnose and to properly customize a treatment plan. Craniofacial Orthodontics is the area of orthodontics that treats
patients with congenital and acquired deformities of the integument and its
underlying musculoskeletal system within the craniofacial area and associated
structures. As part of the craniofacial and cleft teams, the craniofacial orthodontist is involved in data collection, clinical examination, diagnosis, treatment
planning, and orthopedic or orthodontic treatment of the craniofacial disorder.
The craniofacial orthodontist has been shown to play an intrinsic role in the
care of patients with craniofacial anomalies and cleft lip and palate. (Semin
Orthod 2009;15:225-243.) © 2009 Elsevier Inc. All rights reserved.
he family’s initial visit takes place after identification of a craniofacial disorder, often on
a prenatal ultrasound (Fig. 1). If prenatal diagnosis was not performed, the initial visit with the
interdisciplinary cleft palate or craniofacial team
occurs during the first postnatal days. Parent counseling is initiated by the cleft palate or craniofacial
team and a parent support group. The family is
provided with information regarding the etiology
and the clinical management of the condition
T
From the Department of Orthodontics, School of Dentistry, The
University of North Carolina at Chapel Hill, Chapel Hill, NC,
Department of Surgery, Division of Plastic Surgery, Duke University
Medical Center, Durham, NC, Center for Craniofacial Disorders,
School of Dental Medicine, University of Puerto Rico, San Juan,
Puerto Rico, Institute of Reconstructive Plastic Surgery, NYU School
of Medicine, New York University Langone Medical Center, New
York, NY, and Department of Orthodontics, New York University
College of Dentistry, New York, NY.
Address correspondence to Pedro E. Santiago, DMD, Department
of Orthodontics, School of Dentistry, 201 Brauer Hall, Campus Box
7450, Chapel Hill, NC 27599-7450; Phone: (919) 966 4428; Fax:
(919) 843 8864; E-mail: [email protected]
© 2009 Elsevier Inc. All rights reserved.
1073-8746/09/1504-0$30.00/0
doi:10.1053/j.sodo.2009.07.004
from infancy through adulthood. Audiovisual aids
are used to facilitate their understanding of the
proposed treatment and to lower their anxiety
levels through education and reviewing clinical
photographs of pre- and post-treatment outcomes.
This orientation provides the parents with information and an incentive that enhances their ability
to commit to the treatment program. The parents’
enthusiastic involvement with the treatment is essential to its success.
The craniofacial orthodontist is actively involved in the life of a patient born with a craniofacial deformity and/or cleft lip and palate from
birth through skeletal maturity. This may include
infant presurgical orthopedics, early mixed dentition
treatment, dentofacial orthopedics and orthodontics, preparation for alveolar bone graft procedures,
adolescent/adult orthodontics, preprosthetic orthodontics, and pre- and postsurgical orthodontics.
Presurgical Nasoalveolar Molding for
Patients with Cleft Lip and Palate
In an infant, the presence of a cleft is observable
shortly after birth. At the end of the initial ap-
Seminars in Orthodontics, Vol 15, No 4 (December), 2009: pp 225-243
225
226
Santiago and Grayson
Figure 1. (A) Three-dimensional ultrasound of an
infant with right unilateral cleft. (B) Photo of the
same infant after birth. (Color version of figure is
available online.)
pointment, clinical examination is performed
and photographs, intraoral and nasal impressions, and 3-dimensional (3D) stereophotogrammetry images (Fig. 2), if possible, are obtained to
document and evaluate the deformity and establish a treatment plan.
The initial extraoral examination is performed
by members of the cleft palate team. We observe
the deformity and record various measurements
that describe and quantitate the cleft lip, nose,
and alveolar process. In the past, some surgeons
have requested molding of the alveolar ridges to
close the alveolar gap and to reduce the protrusive position of the alveolar processes. It is believed that the improved alignment of the underlying alveolar anatomy would enhance the
surgeon’s ability to achieve a refined primary lip
repair. Although this is true, some orthodontists
have also reported that presurgical infant orthopedics (alveolar molding) improved feeding, speech,
and occlusion.1,2 It has been shown that alveolar
molding alone does not deliver most of these benefits. In recent studies, Prahl et al3 found a small
but significant improvement in speech development. They also concluded that infant orthopedics (passive plate) has no effect on early esthetic outcome and that it does not have a
positive or negative influence on arch form.4 It is
important to note that this study did not include
a population of children that had nasoalveolar
molding. In 1987, Ross5 reported that “pre-surgical orthopaedics in the neonatal period has no
apparent long-term effect on facial growth in
height and depth.” Ross5 presents an important
observation that alveolar molding does not have
a negative impact on growth of the midface.
Although the major national and international
studies on presurgical infant orthopedics (alveolar
molding plate) have found no significant positive
or negative impact on speech, nutrition, occlusion,
or growth of the midface, these findings cannot
be extrapolated or applied to nasoalveolar molding. The introduction of nasal stents to the conventional alveolar molding plate is considered a
paradigm shift in cleft care, as it addresses correction of the severe and stigmatizing nasal deformity. For the first time, the dentist has an
opportunity, during the first 3-4 months of life,
to significantly improve the projection of the
nasal tip and to achieve correction of the alar
cartilage distortion and asymmetry.6-12 In the
case of a bilateral cleft lip and palate, the
clinician can use the nasal stents to gradually
lengthen the deficient columella.6-9,13 The columella created in this manner grows normally
and results in improved nasal tip projection.
This is important because conventional surgical correction of the deficient columella re-
Role of the Craniofacial Orthodontist
227
Figure 2. (A-C) Three-dimensional stereophotogrammetric images of an infant with a unilateral cleft lip and
palate. (Color version of figure is available online.)
sults in scar tissue that diminishes growth of
the columella and nasal tip projection and
leads to the typical appearance of the broad
and flat cleft nose. This results in the need for
one or more nasal surgical revisions and the
associated expenditure and risks. When the
authors combine presurgical infant orthopedic molding of the nose and alveolar processes, it is called nasoalveolar molding.6-14 As
it has been shown that presurgical alveolar
molding has no impact on orthodontic or surgical outcome,3 arch form,4 and maxillary
growth,5 it can be used to approximate the
cleft alveolar segments. As the alveolar segments come together, the cleft lip segments
more easily approximate one another at rest.
Under these circumstances, the surgical closure heals under less tension, resulting in a
fine scar and improved alignment of the vermillion border.8,13 In addition, closure of the
228
Santiago and Grayson
Figure 3. (A) Pre-alveolar molding study model of
alveolar ridges in an infant with left unilateral cleft
lip and palate. Note the asymmetry and displacement
of the greater alveolar segment. (B) Molding plate
adhered to the palatal shelves and alveolar processes.
(C) Post-alveolar molding study model of alveolar
ridges showing improved arch symmetry and reduction in the size of the alveolar gap. (Color version of
figure is available online.)
alveolar gap, through molding, reduces the
nasal deformity to a degree that enables the
initiation of more precise nasal molding.
It is important to recognize the distinct differences between the conventional presurgical
infant orthopedics (or molding plate therapy)
and nasoalveolar molding. In the former case,
the direct benefit is the approximation of the
cleft alveolar segments to facilitate primary surgery of the lip. In contrast, nasoalveolar molding
has been shown to be a major advance for the
surgical repair of the lip and nose, particularly in
restoration of the deficient columella in the bilateral cleft lip and palate. Although these benefits have been demonstrated in multiple clinical
publications,6-14 there is no doubt that a need
for long-term and perhaps federally supported
clinical trials exist.
In the unilateral cleft lip, alveolus, and palate,
the preferred presurgical infant orthopedic treatment plan is to mold the greater alveolar segment toward the mid-sagittal plane, in the direction of the lesser alveolar cleft segment (Fig. 3).
Correction of the alveolar deformity will improve bony symmetry and support of the softtissue nasal base. This often facilitates a more
symmetric surgical correction of the lip and
nose. By reducing the size of the cleft lip gap in
repose, the surgical scar will heal under less
tension and should be less visible (Fig. 4).
Severity of the nasal deformity is often correlated with the magnitude of the lip and alveolar
Role of the Craniofacial Orthodontist
229
Figure 4. (A) Patient with a left unilateral cleft lip and
palate before alveolar molding. (B) Patient after alveolar molding. Note the lips are in close proximity when
at rest, facilitating primary lip surgical repair. The quality of the scar is usually best when the healing occurs
under minimal tension. (C) Patient 12 months after
primary lip repair. Note the fine alignment of the
vermillion borders and the nearly absent scar. (Color
version of figure is available online.)
cleft gaps. The lower lateral alar cartilage on the
cleft side is often concave where it ought to be
convex. The nostril apex is low on the cleft side,
and the alar rim is stretched in the horizontal
plane (Fig. 5).
To acquire a precise anatomical maxillary
alveolar model, an impression tray is selected
from a series of preformed acrylic trays. Polyvinylsiloxane impression material is used for
the initial impression. The impression is taken
in a hospital setting with a surgeon as an integral part of the impression team to manage
the limited risk of airway obstruction. The impression should include the height of the alveolar ridge up to the vestibular folds showing
the buccal and labial freni. It should be
poured in a dense and durable material, such
as dental gypsum (gypsum) or dental stone to
fabricate the permanent cast.
The molding plate and attached retention buttons are constructed using one of various materials
and techniques. The most common material is a
methylmethacrylate (self-cured acrylic). Retention
button(s) deliver force to the molding plate and
the alveolar processes from a system of elastic
bands and cheek tapes. In addition, it serves to
retain the molding plate to the palate and alveolar
processes.
Activation of the molding plate occurs through
selective addition and reduction of hard and soft
acrylic to the external and internal walls of the
appliance. These adjustments are performed in
small increments of approximately 0.5-1.0 mm
to maintain appliance retention without causing
breakdown and ulceration of the soft tissues
(Fig. 6). Ideally, the infant’s response to treatment should be observed and the appliance activated weekly.
General treatment objectives for the unilateral patient involve approximation of alveolar
and lip segments and correction of the distorted
nasal cartilages to facilitate the primary lip, alveolar, and nasal surgical repair.
In the patient with bilateral clefts, the goal is
to retract and align the protrusive premaxilla
and prolabium while elongating the deficient
230
Santiago and Grayson
Figure 5. (A) Patient born with a right unilateral cleft
lip and palate and its associated nasal deformity. (B)
Nasal deformity associated with unilateral cleft lip and
palate: (a) concave lower lateral alar cartilage, (b)
depressed nasal tip, (c) dropped nostril apex, (d)
columella base deviated to the noncleft side, (e) deficient columella length on the cleft side, (f) wide
alveolar gap, and (g) large interlabial gap. (Color
version of figure is available online.)
columella. As in the unilateral case, this will also
facilitate primary lip, alveolar, and nasal surgical
repair.
In the patient with a unilateral cleft, a nasal
stent is added to the molding plate appliance
when the alveolar cleft width has been reduced
to ⬍ 5 mm. The nasal stent consists of a wire
armature (0.036⬙ or 0.040⬙) that projects from
the labial flange of the molding plate and terminates in an intranasal portion. The intranasal
portion of this wire is covered with hard and soft
methylmethacrylate. Gradual weekly modifications of the stent are made to mold the lower
lateral alar cartilage, to stretch the nasal lining,
and to achieve projection of the nasal dome before
the primary surgical repair (Fig. 7).
In the patient with bilateral clefts, the protruding premaxilla (Fig. 8A) is very gradually
retracted into the space between the alveolar
segments by modifications of the molding plate
and application of gentle elastic forces. Bilateral
nasal stents (Fig. 8B) are inserted into the nasal
apertures to achieve nasal tip projection, Columella elongation, correction of the lower lateral
alar cartilage deformity, and increase in the surface area of the nasal mucosa. The differential
forces exerted by the nasal stents, surgical tapes,
and a horizontal band placed across the columella, provide for these changes (Figs. 8C-8E).
After the presurgical orthopedic treatment has
been completed, the primary lip or nose surgery
is performed with or without a gingivoperiosteoplasty (GPP). It has been reported that when a
GPP is performed in the primary surgery with
the alveolar segments in close proximity, there is
a 60% reduction in the need for a secondary
bone graft.15 It has been shown16,17 that GPP has
no effect on the position of the skeletal midface
(ANS-PNS in relation to cranial base SN) up to
the age of 12 years16 and 18 years.17 This surgery
is followed by a palate repair at 12-15 months of
age. From this surgical event and until the child
is 5-6 years old, special attention is focused on
speech development, oral hygiene, pediatric
dentistry, and skeletal growth guidance.
Early Mixed Dentition Treatment and
Dentofacial Orthopedics
The craniofacial orthodontist evaluates the patient and records any significant dental, facial,
and skeletal findings in annual follow-up visits
with the cleft palate team. Primary areas of interest and concern are the presence of anterior
and/or posterior skeletal and dental cross-bites,
malocclusion, supernumerary teeth, and oronasal fistulae.
A functional lateral shift of the mandible
caused by premature occlusal contacts during a
prolonged period of active facial growth may
lead to asymmetrical maxillary or mandibular
development. This could affect facial esthetics
and psychosocial development if facial symmetry, balance, and proportion are severely affected. Anterior dental cross-bites could lead to
Role of the Craniofacial Orthodontist
231
Inadequate growth of the premaxilla may
present as an anterior dental cross-bite with normal occlusion in the buccal segments. In such
cases, a 2- or 3-way bonded palatal expander is
indicated, to protract the premaxilla and, if
needed, to widen the posterior segments (Fig.
10). If both anterior and posterior skeletal crossbites are present, maxillary deficiency is most
likely manifested in all 3 dimensions: transverse,
sagittal, and vertical (Fig. 11A). This scenario
often includes a Class III dental occlusion, a
midface skeletal deficiency, and a straight or
concave facial profile. In such cases, either a
Figure 6. Diagram showing the alveolar spaces inside
the molding plate before treatment (top left). Arrows
indicate the sites at which hard acrylic is removed (top
right). The resulting space allows for growth and
molding of the alveolar processes. Striped area indicates the location for addition of soft acrylic liner. A
soft acrylic liner applies a gentle force to the alveolar
ridge, molding it in the desired direction. Gradual
hard and soft acrylic modifications result in approximation of the alveolar ridges (bottom left). Eventually, the acrylic is removed between the greater and
lesser alveolar segments, permitting contact of the
facing alveolar walls (bottom right). Note that the
outer wall of the molding plate has been gradually
modified to follow the changes occurring on the interior surfaces. (Color version of figure is available
online.)
anterior posturing of the mandible, with resulting impact on the temporomandibular joint and
mandibular growth. A small reduction in maxillary dental arch width is often accommodated by
a mandibular lateral shift, resulting in a posterior dental cross-bite. Premature dental contacts
and excessive occlusal wear can result from malocclusions associated with skeletal and dental
cross-bites.
Posterior cross-bites are usually corrected by
the use of palatal expanders. The most common
expanders use screws, that is, Hyrax (Fig. 9A) or
a Quad Helix (Fig. 9B). If a cross-bite is limited
to the anterior buccal segment, ie, canines and
the deciduous molar(s), then a “fan expander”
might be indicated both in unilateral (Figs. 9C
and 9D) and bilateral (9F) cases. This appliance
rotates around a posterior hinge, resulting in differential amount of expansion, more anterior than
posterior (Figs. 9E and 9G). The selection of the
expansion appliance is based on the characteristics
of the clinical problem as well as on the orthodontist’s personal preference and experience.
Figure 7. (A) Nasoalveolar molding (NAM) appliance showing intraoral molding plate, retention button, and nasal stent attached to the labial flange. (B)
Patient with molding plate that is retained by a system
of elastics and tapes, engaging the retention button.
Note the symmetry of the nasal domes and alar rims.
(Color version of figure is available online.)
232
Santiago and Grayson
Figure 8. (A) Patient with bilateral cleft lip and palate showing protrusion and eversion of the premaxilla and
prolabium. Note the nearly absent columella. (B) A bilateral NAM appliance showing 2 intranasal stents and the
horizontal columella band. (C) Patient showing bilateral NAM appliance. Note the 2 intranasal stents, the
horizontal columella band, and the elastic traction system in place. Note also the vertical tape on the prolabium
that places gentle but constant force on the prolabium and columella soft tissues. This force, in conjunction with
the gradual increase in the height of the columella band and the forward projection of the nasal stents, is
responsible for elongation of the deficient columella. (D) After the retraction of the premaxilla and prolabium.
Note the increase in columella length. (E) The same patient after primary surgical repair. Note the scar-free
columella and nasal tip projection. (Color version of figure is available online.)
Hyrax or bonded expander with hooks for a
protraction face mask is indicated (Fig. 11B).
The patient is instructed to activate the expander
and to wear the face mask for at least 14 hours per
day. The goal is to achieve transverse expansion
while overcorrecting the skeletal anteroposterior
(A-P) deficiency and to attain an overjet of approximately 2.0 mm to compensate for anticipated
maxillary growth deficiency (Fig. 11C).
Preparation for Alveolar Bone Graft
Procedures
Most unilateral and bilateral alveolar clefts are
associated with deficient bone, soft tissue, and
missing or abnormally formed (peg, scoliosed)
teeth. The most commonly missing tooth is the
maxillary lateral incisor, although a central inci-
sor or canine could be absent or deformed as
well. When a complete alveolar cleft is present,
a secondary bone graft procedure is recommended to facilitate the eruption of the teeth
(central, lateral, or canine) found along the
margin of the alveolar cleft. If this procedure
occurs before the eruption of the adjacent permanent tooth, then there will be adequate bone
for its support and acceptable alveolar crest
height in the area. The bone graft is usually
harvested from the cancellous or marrow portion of the iliac crest.
Orthodontic and orthopedic preparation for
the secondary alveolar bone graft procedure
usually involves arch width coordination by
means of a maxillary expander, fixed orthodontic appliances, or both. If oronasal fistulae are
present, the amount of expansion is limited by
Role of the Craniofacial Orthodontist
233
Figure 9. (A) Modified Hyrax appliance for transverse maxillary expansion. (B) Quad Helix expansion appliance. Through selected activation of the loops, rotation of first permanent molars, and transverse and anterior
expansion can be achieved. (C) Fan expander in closed position. (D) Appliance bonded to occlusal surface of
the maxillary dentition. (E) Fan expander opened half way through the activation period. The appliance will
expand the anterior part of the palate considerably more than the posterior. (F) Patient with a bilateral cleft lip
and palate showing an anterior collapse of the lateral alveolar segments causing a maxillary constriction. (G) A
fan expander was used to expand the anterior part of the palate, as the posterior transverse dimension was
adequate. Notice the amount of correction achieved and the increased intercanine width. (Color version of
figure is available online.)
234
Santiago and Grayson
Figure 10. Three-way expander bonded to the occlusal
surface of molars. Notice the appliance in contact with
the lingual surface of maxillary incisors. Upon activation, molding of anterior teeth and alveolar ridge is
achieved. (Color version of figure is available online.)
the surgeon’s ability to close such fistulae. Consultation with the surgeon is indicated during
the active phase of palatal expansion in order
for the surgeon to evaluate the increase in size of
the oronasal fistulae. After the proper maxillary
arch width and form are achieved, a surgical
splint is fabricated and inserted before the completion of the surgical procedure (Fig. 12). The
splint should maintain the previously expanded
arch width and occlusion, prevent food from
affecting and contaminating the surgical site,
and remind the patient to take appropriate care
of the affected area while eating and of performing oral hygiene.
Adolescent/Adult Orthodontics
At the outset of phase II (complete adult dentition) orthodontics, the patient, family, surgeon,
and orthodontist must meet and discuss the
treatment alternatives, which may include orthodontics alone, or orthodontics in conjunction
with orthognathic surgery. At present, the objective is to assess the patient’s skeletal pattern and
to determine the best way to meet that patient’s esthetic and functional needs. A decision should be made as to whether the objectives can be achieved by compensation of the
dentition or by decompensating and aligning
the dentition to their respective skeletal bases.
In the mildest skeletal deformities, a normal
functional occlusion can be achieved with
minimal compromise and good facial esthetics.
In mild-to-moderate skeletal deformities, a normal
functional occlusion can be achieved with more
significant dental compensations and moderate-topoor facial esthetics. In these cases, a combined
surgical/orthodontic treatment plan is recommended. However, some patients might decline
this recommendation for psychological, financial, or health reasons. The most severe cases
require an orthodontic/surgical approach that
cannot be compromised by simple orthodontic
compensation of the dentition. Many, if not
most, of these patients present with severely
crowded teeth, significantly deformed, supernumerary, small, or missing teeth. Therefore, the
orthodontic treatment plan should be formulated in consultation with a prosthodontist. The
prosthodontist will help to determine the location of future implants, veneers, and possibly
bridges. The preservation or creation of space
for these prosthetic restorations should be part of
the orthodontic treatment plan from the beginning (Fig. 13A). Whenever possible, the
prosthodontist is asked to restore the full anatomical size of dwarf or peg teeth before or
during treatment with fixed orthodontic appliances. This helps to preserve the appropriate
amount of space within the dental arch for the
final restoration of full size and natural-looking dentition (Fig. 13B).
Presurgical Orthodontics
Most craniofacial disorders present a complex
3D skeletal, soft-tissue, and dental deformity. To
provide an accurate diagnosis and treatment
plan that could address and resolve the encountered clinical abnormalities, the orthodontist
must gather precise, standardized diagnostic
records. These include, but are not limited to, a
thorough clinical examination (including the
dynamics of the functional relationship between
teeth and lips), clinical photographs (conventional and 3D if available), articulated dental
casts, cephalograms (lateral and posteroanterior), and panoramic x-rays. Where there is ambiguity regarding 3D skeletal/dental relationships that are important to the diagnosis and
treatment plan, 3D computed tomography or
3D cone beam images are highly recommended.
Complete records are usually taken at the patient’s initial visit with the craniofacial or cleft
team. If orthodontics is recommended as part of
the patient’s surgical/orthodontic treatment plan,
Role of the Craniofacial Orthodontist
235
Figure 11. (A) Patient showing a Class III skeletal and dental relationship previous to protraction mask therapy.
(B) Patient with protraction mask, showing elastics entering the oral cavity and attaching to hooks on the bonded
maxillary acrylic appliance. (C) Intraoral photograph during active protraction mask therapy showing the
bonded maxillary expander appliance with hooks for mask elastics. Note the amount of maxillary advancement
and overjet achieved. (Color version of figure is available online.)
follow-up records are taken to assess progress
in preparation for surgery. Postsurgical records
should also be taken to evaluate the orthodontic
and surgical outcomes. These records are reviewed by the surgeon and orthodontist, with
comparisons made to the surgical prediction,
splint construction mounted models, and the
original treatment plan.
After the initial records are completed, they are
evaluated and discussed by the Cleft or Craniofacial team members, and a treatment plan is formu-
lated to address the patient’s functional, esthetic,
and psychosocial needs. When a combined orthodontic and surgical treatment is recommended,
the orthodontist and surgeon should discuss and
agree upon a carefully designed and customized
integrated treatment plan. This will include common understanding and agreement on the clinical
and radiographic findings, treatment objectives,
limitations, and risks. When dealing with an actively growing patient, a combined plan might involve one or more orthodontic and surgical inter-
236
Santiago and Grayson
jet and overbite relationships from canine to
canine with acceptable coordination of midlines. To achieve these esthetic and functional
goals, it may be necessary to restore the size and
shape of the individual incisors or to open a
space that is large enough to accommodate an
implant or prosthesis (ie, missing lateral incisor). The decision pertaining to space distribution and prosthetic replacement or reconstruction is made with the prosthodontist
during the development of the initial orthodontic treatment plan. Sometimes temporary
restorations of tooth shape and size are performed before orthodontic brackets are
placed on the teeth. This avoids having to maintain space with coils around peg or malformed
teeth throughout the course of orthodontic
treatment. The objective of this orthodontic
surgical or prosthodontic plan is to strive for a
functional occlusion with good lip and incisor
relationship, appropriate amounts of gingival
show at smile, and balance in the various com-
Figure 12. (A) Alveolar bone graft splint. (B) Intraoral view of patient after alveolar bone graft surgery
and placement of splint. (Color version of figure is
available online.)
ventions at different stages of the child’s
development. If one definitive surgical procedure
is the treatment of choice, orthodontic and surgical overcorrection might be indicated to anticipate
the changes expected from residual craniofacial
growth.
The presurgical orthodontic treatment objectives should achieve a functional and esthetic
occlusion that is consistent with the correction
of both skeletal and soft-tissue components of
the face. This is usually accomplished by the
removal of existing dental compensations and by
positioning teeth in an ideal relationship to basal
bone. Dental extractions might be required to
reduce crowding and to improve alignment of
teeth over the alveolar crest. It is also critical to
achieve coordination of transverse and anteroposterior maxillary and mandibular arch form.
In addition, we attempt to establish Class I over-
Figure 13. (A) Patient showing a small lateral incisor in
which adequate space was created to allow a full final
restoration of the anatomy. (B) Restored small lateral
incisor. (Color version of figure is available online.)
Role of the Craniofacial Orthodontist
237
Figure 14. (A) Mandibular distraction stabilization appliance. The mandibular appliance consists of a lower
lingual arch attached to 4 bands with soldered hooks on the lingual and brackets on the labial/buccal surfaces.
(B) The maxillary appliance is often an expander or palatal arch attached to 4 bands with soldered hooks on the
palatal and brackets on the labial/buccal surfaces. Intermaxillary elastics are used to optimize the position of the
mandible throughout the activation phase of distraction osteogenesis. (C and D) Use of cross-tongue elastics.
The vector of elastic force results in a couple with the vertical ramus distraction vector. The net effect of these
balancing forces maintains the dental midline under the skeletal mid-sagittal plane, while the ramus lengthens
vertically and a posterior open bite occurs on the distracted side of the mandible. (Color version of figure is
available online.)
ponents of the craniofacial skeleton. These presurgical orthodontic and prosthodontic corrections are assessed by repeated orthodontic study
models. The models are hand-articulated into the
predicted postsurgical occlusal relationship and
studied to determine the necessary presurgical
orthodontic and/or prosthetic adjustments. After the planned occlusion is achieved, the patient is then a candidate for surgery.
Appliances
A multitude of orthopedic and orthodontic
appliances may be used in the pre- and post-
surgical orthodontic treatment stages. These
include conventional fixed orthodontic appliances, palatal expansion appliances (including surgically assisted rapid palatal expansion [SARPE]),
intra-alveolar distraction appliances, temporary anchorage devices, and plates used for temporary
anchorage.
During mandibular distraction, the distraction-stabilization appliance described by Hanson and Melugin18 is often used in conjunction with orthodontic intermaxillary elastics
(Figs. 14A and 14B). This appliance is one of
several that enable the craniofacial orthodontist and surgeon to mold the regenerate and
238
Santiago and Grayson
Figure 15. (A) Predistraction patient with hemifacial microsomia. Note the oral commissure
cant and the short mandibular ramus on the
right side. (B) Patient after unilateral mandibular distraction using the distraction stabilization
appliance (Figs. 14A and 14B) and cross-tongue
elastics (Fig. 14D), showing improved facial symmetry. (C) Intraoral photograph showing the
open bite on the side of vertical ramus distraction (right side). (Color version of figure is available online.)
control the direction of distraction (Figs. 14C
and 14D).
The goal in unilateral mandibular distraction
is to place the mandibular body and symphysis into
a more normal relationship with the skeletal midsagittal plane and to achieve symmetry of ramus
height, the position of gonions (left and right),
and a leveled mandibular occlusal plane (Figs.
15A and 15B). In the growing child, overcorrection of each of these relationships is attempted in
anticipation of losing some of the corrections
due to subsequent asymmetrical growths. In this
treatment protocol, it is common to create a
posterior open bite on the side on which the
ramus is lengthened in the vertical plane (Fig.
15C). It is important to note that the open bite
corresponds directly with the development of
the regenerate found in the ramus. As the regenerate is exposed to the compressive forces
applied by the muscles of mastication, it is vulnerable to resorption and loss. Therefore, a bite
block is placed at the end of the activation phase
that completely fills the open bite on the distracted side, providing for bilateral balanced occlusion and protection of the regenerate from
the compressive forces of the muscles of mastication (Figs. 16A-16F). The impression for the
construction of this bite plate is performed before the placement of distraction devices, as the
patient is often unable to tolerate intraoral impressions at the end of the distraction activation
phase. Instead, a silicone bite record is made
documenting the open bite at the end of the
activation phase. This silicone bite is used to
Role of the Craniofacial Orthodontist
239
Figure 16. (A) Intraoral photograph of another patient showing the open bite on the side of vertical ramus
distraction (left side). (B) Intraoral view of bite block, providing bilateral balanced occlusion, and protection of
the newly formed regenerate. (C and D) The bite block is gradually adjusted to allow for descent of the
dentoalveolar structures until teeth reach the mandibular occlusal plane. Note the use of attachments on the
teeth and splint that are engaged by elastics to accelerate the downward growth of teeth and alveolar process. (E
and F) Intraoral photograph before (E) and after (F) closure of the open bite on the side of vertical ramus
distraction. (Color version of figure is available online.)
mount the predistraction study models for fabrication of the bite plate.
When performing midface distraction osteogenesis using a rigid external distractor, control
of the position of the midface is achieved by
using an intraoral tooth-borne appliance that
connects directly to the distraction device (Figs.
17A-17G). Control of the dentition and skeletal
midface is achieved by altering the vectors that
are applied to the appliance through adjustment
made in the activation components of the rigid
external distractor device. The craniofacial orthodontist and surgeon establish esthetic, skeletal,
dental, and functional goals. These goals are
based on shared observations, review of the clinical
examination, the chief complaint, and records obtained from collaborating clinicians (ie, otolaryngologist, speech therapist, pediatrician, internist,
cardiologist, etc). These records usually include
cephalograms, CT scans, cone beam scans, and
2D/3D medical photographs. With the analysis
of these records and a global perspective of the
240
Santiago and Grayson
Figure 17. (A) Intraoral appliance of the rigid external distractor (RED) device consisting of an occlusal
splint fabricated on a mesh metal plate and coupling
device. (B and C) Extraoral RED device with the intraoral splint attached to the head frame. (D) Patient
with Crouzon syndrome before the midface distraction
procedure. (E and F) Show the RED device attached to
the intraoral appliance during the activation phase.
This intraoral appliance can be used to achieve controlled skeletal midface distraction. (G) The patient
after distraction. Note the improved facial convexity
because of controlled Le Fort III midface advancement. (Color version of figure is available online.)
patient’s problem, an integrated interdisciplinary treatment plan has been formulated. The
presurgical orthodontic component of this treatment plan is initiated. After the presurgical dental relationships are achieved, prediction tracings are performed and mock surgery on newly
collected records: articulated study models, photographs, radiographs, and sometimes stereolithographic models. The predicted surgical outcome is discussed first with the surgeon and
finally with the patient and the patient’s family.
After all agree with the proposed treatment
plan, surgical splint construction is begun on the
articulated dental study models. If two-jaw surgery is indicated, intermediate and final splints
will be constructed. In some Craniofacial/Cleft
Palate teams, the trained craniofacial orthodontist fabricates these splints and assists the surgeon by inserting and tying in the splint during
surgery.
Postsurgical Orthodontics
Shortly after surgery, when the patient is able
to tolerate postsurgical records, cephalograms
are performed to determine whether the surgical treatment plan has been achieved. The
surgeon and orthodontist discuss these findings and the surgeon makes a final determination regarding this outcome. Intermaxillary
elastics may be used to facilitate or guide the
mandibular dentition into the splint bite.
However, after midface surgery, the patient
may temporarily have difficulty breathing
through the nose due to edema and swelling.
After the patient is able to breathe through
the nose (approximately 5 days from surgery),
intermaxillary elastics will be initiated. In the
case of distraction osteogenesis, the craniofacial orthodontist might apply intermaxillary
elastics during the activation phase to modify
Role of the Craniofacial Orthodontist
241
Figure 17. (continued)
the vector of distraction and to achieve a more
precise occlusal outcome. If the objective of
mandibular distraction is to achieve vertical
ramus lengthening (resulting in posterior
open bite), the orthodontist will insert a bite
block to fill the posterior open bite at the end
of the distraction activation phase. This bite
block can also be adjusted to progressively
erupt the maxillary dentoalveolar process
downward toward the newly positioned mandibular occlusal plane.19
Oral functional physical therapy is often necessary after orthognathic surgery, temporomandibular joint ankylosis release and mandibular
distraction to re-establish normal range of motion and masticatory function. There is a wide
range of commercially available devices designed to increase the range of motion and to
provide strength training for the muscles of mastication (ie, bite opening devices). In addition,
some clinicians use therapies that employ heat/
cold and electrical stimulation among others. In
patients with hypotonic orbicularis oris and lip
incompetency, a program to enhance lip muscle
function may be initiated. In patients who present
with an anterior skeletal open bite in conjunction
with a prominent tongue thrust, therapy to correct the habit (swallowing exercises) may be im-
242
Santiago and Grayson
plemented before and/or after surgery. If this
habit persists, it could potentially cause dental
and/or skeletal relapse.
Changes in the mature facial skeleton become progressively more stable during the period of 12 months after surgery. In the year after
surgery, retaining the surgically repositioned
components of the craniofacial skeleton and refining dental occlusion are focused upon. This is
especially true for patients who have had large
skeletal movements or when advancing the midface of a patient with a repaired and scarred cleft
palate. Therefore, intermaxillary elastics and
face mask therapy are used to balance the forces
of relapse as needed.
After the orthodontic and postsurgical treatment objectives have been met, fixed appliances
are removed and orthodontic retainers placed. As
in conventional orthodontic therapy, retention appliances are designed to prevent relapse of the
original condition. In craniofacial orthodontics,
often patients with severe dental and skeletal deformities are treated. Therefore, increased attention is given to retention appliance design and
long-term stability. Patients with a cleft palate deformity, who required maxillary expansion during
treatment, must be retained with a device, such as
the Hawley appliance that provides support to the
palatal shelves and dentition. In view of the potential for relapse in the transverse and sagittal dimensions, lifetime retention is highly recommended.
Craniofacial and Special Needs
Orthodontics as a Formal Postresidency
Fellowship Training Program of Dentistry and
Orthodontics
Children born with a craniofacial disorder often
present with a multitude of medical and dental
problems. Consequently, it is advantageous to treat
these individuals as part of an interdisciplinary
team program, which includes medical, dental,
psychological, genetics, speech, audiology,
and social service professionals. It is desirable
that the specialists in this team have subspecialty
training, if available, in craniofacial anomalies
and cleft lip and palate. Specialized postresidency fellowship training in Craniofacial and
Special Needs Orthodontics has recently been
recognized by the American Dental Association
and the American Association of Orthodontists.
Patients born with craniofacial disorders
are often treated by the craniofacial orthodontist from infancy to adulthood. The earliest
form of treatment may be presurgical infant
orthopedics. This might be followed by dentofacial orthopedics or collaboration with the
surgeon in early interventions. Many of these
children will need some form of orthodontic/
orthopedic therapy during primary and mixed
dentition (ie, palatal expanders, face mask
therapy, preparation for bone graft). Finally,
presurgical and preprosthetic orthodontics
are initiated around the period of facial/skeletal maturation, in preparation for the definitive craniofacial surgical reconstruction and
prosthetics. By the time the postsurgical orthodontic therapy is completed, the craniofacial
orthodontist may have formed a very special
20-year experience with the patient and the
patient’s family. This relationship, combined
with the important clinical contribution to
their lives, results in great personal and professional satisfaction.
References
1. MacNeil CK: Orthodontic procedures in the treatment
of congenital cleft. Dent Rec 70:126, 1950
2. Gnoinski WM: Infant orthopedics and later orthodontic monitoring for unilateral cleft lip and palate patients in Zurich, in Bardach J, Morris HL (eds): Multidisciplinary Management of Cleft Lip and Palate.
Philadelphia, WB Saunders, 1990, pp 578-585
3. Prahl C, Prahl-Anderson B, van’t Hof MA, et al: Infant
orthopedics and facial appearance: a randomized clinical
trial (DutchCleft). Cleft Palate Craniofac J 43:659, 2006
4. Prahl C, Kuijpers-Jagtman AM, van’t Hof MA, et al: A
randomized prospective clinical trial into the effect of
infant orthopaedics on maxillary arch dimensions in
unilateral cleft lip and palate (Dutchcleft). Eur J Oral Sci
109:297-305, 2001
5. Ross B: Treatment variables affecting facial growth in
unilateral cleft lip and palate. Part 2: presurgical orthopedics. Cleft Palate J 24 1:24, 1987
6. Grayson BH, Santiago PE: Presurgical orthopedics for cleft
lip and palate, in Aston S, Beasley R, Thorne CH (eds):
Grabb and Smith’s Plastic Surgery, (5th ed). Philadelphia,
Lippincott-Rave, 1997, pp 237-244
7. Grayson BH, Santiago PE, Brecht LE, et al: Pre-surgical
Naso-alveolar molding in patients with cleft lip and palate.
Cleft Palate Craniofac J 36:486-498, 1999
8. Grayson BH, Cutting C: Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip and
alveolus of infants born with unilateral and bilateral clefts.
Cleft Palate Craniofac J 38:193, 2001
Role of the Craniofacial Orthodontist
9. Grayson BH, Maull D: Presurgical nasoalveolar molding
for infants born with clefts of the lip, alveolus and palate.
Clin Plast Surg 31:149-158, 2004
10. Maul DJ, Grayson BH, Cutting CB, et al: Long-term
effects of nasoalveolar molding on three-dimensional
nasal shape in unilateral clefts. Cleft Palate Craniofac J
36:391-397, 1999
11. Singh GD, Levy-Bercowski D, Santiago PE: Three-dimensional nasal changes following nasoalveolar molding in
patients with unilateral cleft lip and palate: geometric morphometrics. Cleft Palate Craniofac J 42:403-409, 2005
12. Singh GD, Levy-Bercowski D, Yanez MA, et al: Three-dimensional facial morphology following surgical repair of
unilateral cleft lip and palate in patients after nasoalveolar
molding. Orthod Craniofac Res 10:161-166, 2007
13. Cutting CB, Grayson BH, Brecht LE, et al: Presurgical
columellar elongation and primary retrograde nasal
reconstruction in one-stage bilateral cleft lip and nose
repair. Plast Reconstr Surg 101:3-10, 1999
14. Lee C, Garfinkle J, Warren S, et al: Nasoalveolar molding
15.
16.
17.
18.
19.
243
improves appearance of children with bilateral cleft lip and
cleft palate. Plast Reconstr Surg 122:1131-1137, 2008
Santiago PE, Grayson BH, Cutting CB, et al: Reduced
need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty. Cleft Palate
Craniofac J 35:77, 1998
Lee CT, Grayson BH, Cutting CB, et al: Prepubertal midface growth in unilateral cleft lip and palate following
alveolar molding and gingivoperiosteoplasty. Cleft Palate
Craniofac J 41:375-380, 2004
Garfinkle J, Grayson BH, Brecht LE, et al: Long-term effects on midface growth of gingivoperiosteoplasty with presurgical infant orthopedics in unilateral cleft lip and palate.
Prog Am Cleft Pal Craniofac Assoc 63:100, 2006
Hanson PR, Melugin MB: Orthodontic management of
the patient undergoing mandibular distraction osteogenesis. Semin Orthod 5:25-34, 1999
Grayson BH, Santiago PE: Treatment planning and biomechanics of distraction osteogenesis from an orthodontic Perspective. Semin Orthod 5:9-24, 1999
Management of Severe Cleft and Syndromic
Midface Hypoplasia
Alvaro A. Figueroa, DDS, MS, and John W. Polley, MD
Distraction osteogenesis has become an alternative treatment to treat severe craniofacial skeletal dysplasias. A rigid external distraction device has
been successfully used to advance the maxilla as well as the maxillary,
orbital, and forehead complex (monobloc) in children as young as 2 years,
adolescents, and adults. This approach has provided reduced morbidity, and
predictable and stable results in this challenging group of patients. With the
experience gained, the technique has been successfully applied to patients
with isolated dentofacial deformities. Distraction techniques can be applied
by themselves or as an adjunct to conventional orthognathic and craniofacial surgical procedures. (Semin Orthod 2009;15:244-256.) © 2009 Elsevier
Inc. All rights reserved.
he conventional treatment of dentofacial deformities includes both orthodontic treatment and orthognathic surgery. The key surgical
procedures required for the correction of these
conditions include the LeFort I osteotomy, sagittal
split mandibular ramus osteotomies, and occasionally a genioplasty using rigid fixation techniques.
With this approach, successful and predictable correction of these conditions is usually obtained.
Some of these classic orthognathic surgical techniques can be appropriately applied to patients
with cleft-related secondary deformities, especially those presenting with maxillary hypoplasia. However, the use of these classical orthognathic surgery techniques in patients with severe
conditions, related to either clefts or syndromic
deformities, may not achieve the expectations, as
this particular group of patients include additional
challenges.
It is a well-known fact that orthognathic surgery in which multiple segments are required for
the correction of the deformity represent a
T
From the Rush Craniofacial Center and Department of Plastic
Surgery, Rush University Medical Center, Chicago, IL.
Address correspondence to Alvaro A. Figueroa, DDS, MS, Rush
Craniofacial Center, 1725 W Harrison St, Suite 425 POB 1,
Chicago, IL 60612; Phone: (312) 563-3000; Fax: (312) 563-2514;
E-mail: [email protected]
© 2009 Elsevier Inc. All rights reserved.
1073-8746/09/1504-0$30.00/0
doi:10.1053/j.sodo.2009.07.001
244
higher risk for the patient.1 These complications
may include instability of segments, loss of teeth
or a segment, including multiple teeth, as well as
bone secondary to vascular compromise. It has
recently been reported that the risks for complications after LeFort I maxillary surgery are about
4% in noncleft patients. However, the risk for
complications in patients with orofacial clefts
and other deformities increases to about 25%.2
It is also known that the stability of a maxillary
advancement in a cleft patient is not stable and
the tendency for long-term relapse is quite high
compared with that in noncleft patients.3-6 Cleft
patients usually present unfavorable situations,
such as maxillary deficiency in the horizontal,
vertical, and transverse planes and thin and
structurally weak bone. In addition, residual alveolar and palatal fistulas compound the severity
of the maxillary deformity, as well as absent or
aberrant dental conditions, pharyngeal flaps,
palatal and pharyngeal scarring, and compromised blood supply because of previous surgeries.7
On the basis of the above-stated complications, it appears that undertaking conventional
orthognathic surgical procedures in this challenging group of patients needs to be done with
the utmost care; and, preferably, alternative
treatments should be sought out to eliminate
potential complications. In 1992, McCarthy et
al8 introduced the use of distraction osteogene-
Seminars in Orthodontics, Vol 15, No 4 (December), 2009: pp 244-256
Management of Severe Cleft and Midface Hypoplasia
sis (DO) in the craniofacial skeleton. Since then,
the technique has been successfully applied to
all of the bones of the craniofacial skeleton. The
use of DO has been selected as an alternative to
treat patients with previously unsuccessful conventional orthognathic surgery procedures. It is
now the treatment of choice for patients with
syndromic conditions, such as Crouzon and Apert syndrome,7,9-12 hemifacial microsomia, 8,13-15
and mandibular-facial dystosis.
In addition, the technique has successfully
been applied to patients with severe maxillary
hypoplasia secondary to orofacial clefts.16-21 It
has now been applied in infants presenting
with obstructed airway problems secondary to
mandibular hypoplasia22-24 and in cases with
large bone defects because of tumor resection
or trauma.25 More recently, the technique has
been applied to speed up orthodontic tooth
movement,26,27 to reconstruct deficient alveolar
bone in the vertical and transverse dimensions,
and to increase the circumference of the maxillary and mandibular dental arches.28,29
Molina and colleagues30,31 were the first to suggest maxillary advancement after a maxillary osteotomy, using DO, by means of applying traction
with an orthopedic face mask and elastic traction.
Although this approach appeared promising,
the results were disappointing.21 Our group in
Chicago, then developed the use of an external
cranially fixed halo as a point of anchorage to
advance the maxilla that was connected through
the dentition by an intraoral splint to the halo
device. The use of this technique has provided
impressive results in situations that otherwise
would have been difficult to manage. In addition, the technique has been applied to children, adolescents, and adults. It has demonstrated to be relatively simple, predictable, and
has shown long-term stability.7,16,17,20,21,32,33
The protocol for maxillary distraction using a
rigid external distraction (RED) device includes
presurgical orthodontic alignment of the dentition and the fabrication of an intraoral splint
(AOA Laboratories, Sturtevant, WI). The splint
is secured to the dentition and also to the anterior maxillary bone with orthodontic anchorage
screws (KLS Martin, Jacksonville, FL). The splint
has 2 square tubes, just medial to the oral commissures, that are used to secure the rectangular
extraoral traction hooks that will be used to
connect the intraoral splint to distraction screws
245
mounted on to the halo system.34 After the intraoral splint is fitted in the clinical setting, the
patient is ready to undergo surgery. During surgery, the surgeon further secures the intraoral
splint by placing 2 orthodontic bone anchorage
screws on the anterior maxilla bilaterally and
suspends it with surgical wire (Fig. 1). Thereafter, a complete LeFort I osteotomy with pterygomaxillary disjunction is completed. The maxilla
is not down fractured, as is usually done during
conventional orthognathic surgery, but the surgeon must assure that the maxillary bone is completely loose. The surgeon can position the height
of the osteotomy to include the base of the malar
bones and also the lateral aspect of the nasal
bones. In this way, the paranasal and infraorbital
regions can be significantly improved (Fig. 2). After closure of the incision, the halo or the RED
device (KLS Martin, Jacksonville, FL) is secured
to the cranium using specialized safety cranial
pins. The surgeon must be careful to position
these pins on the thickest part of the temporalparietal bones, usually about 3-6 cm above the
earlobe. The halo is usually positioned parallel
or slightly upward to the Frankfort plane. The
vertical anterior bar used to secure the distraction screws is placed parallel to the facial plane
and 3-6 cm, anterior to it. The traction hooks
attached to the intraoral device and the distraction system are not assembled until 3-7 days after
surgery. In this way, the anesthesiologist does
not have any interference with masking and ventilation of the patient in the postoperative period.
Patients are on a liquid diet 24 hours after
surgery and a progressive soft diet afterward.
When the desired latency period is completed,
the distraction device is assembled in the clinical setting without discomfort to the patient.
Twisted surgical wire is used to connect the eyelets
from the traction hooks to the distraction screws
mounted to the halo. The rate of distraction is
usually between 1 and 2 mm per day, depending
on the severity of the condition. Most patients are
corrected in a period of about 2-3 weeks. After
that, they enter the phase of consolidation that is
usually 4-8 weeks, depending on the clinical stability of the maxilla. On occasion, some patients
demonstrate resistance to advancement toward
the end of the distraction period; in these situations, a second bar with distraction screws is
mounted on the vertical bar of the distractor
246
Figueroa and Polley
Figure 1. (A) Intraoral splint (top left) with removable external traction hooks (top right) used during maxillary
advancement using the rigid external distraction (RED) system. Note bilateral square tubes (double arrows) and
retention face mask hooks (single arrow) soldered into the splint. The horizontal part of the traction hook
(double arrow) is inserted into the square tube of the splint; the vertical part has an eyelet at its end for
connecting the splint to the distractor. Clinical photographs (bottom) demonstrate the intraoral splint in place
(left) and with the attached external traction hooks (right). (B) At surgery, the anterior aspect of the splint is
further secured with 2 suspension wires to bone anchorage screws placed in the anterior aspect of the maxilla
for additional rigidity (double arrows). (Color version of figure is available online.)
Management of Severe Cleft and Midface Hypoplasia
247
Figure 2. Modified high Le Fort I osteotomy, including the base of the malar bone as well as the inferior aspect
of the lateral nasal wall (top left) (modified with permission from Polley JW, Figueroa AA: Atlas Oral Maxillofac
Surg Clin North Am 7:15-28, 1999). Unilateral cleft lip and palate patient with secondary maxillary hypoplasia
before (bottom left), during (top right), and after (bottom right) maxillary advancement with the RED system.
Note correction of upper lip retrusion, paranasal, and infraorbital deficiencies (arrows). (Color version of figure
is available online.)
and 2 additional distraction screws are
mounted and directly connected to the hooks
previously soldered to the intraoral splint with
surgical wires. This provides a 4-point traction
system that is significantly stronger and overcomes any soft-tissue resistance (Fig. 3). A patient with bilateral cleft lip and palate in whom
the RED system has been used to correct a
cleft-related maxillary hypoplasia is presented
in Figs. 3 and 4.
After it is determined that the maxilla is consolidated, the halo and the distraction system are
removed in the clinical setting. Usually, in teenage and adult patients, there is no need for local
anesthesia to remove the cranial pins. In young
children who might be apprehensive, it is advisable to remove the halo in the operating room
under light sedation.
After the halo is removed, the traction hooks
attached to the intraoral splint are also removed,
and an orthopedic face mask is used at night to
promote additional retention. The face mask is
attached to hooks soldered into the intraoral
splint (Fig. 1) with elastics exerting a total force
248
Figueroa and Polley
Figure 3. Patient with bilateral cleft lip and palate with secondary severe maxillary hypoplasia with Class III
skeletal and dental relations (top right) undergoing maxillary advancement with a RED device. At the start of
treatment, a single distraction bar is used (top left). Toward the end of distraction, as resistance increases, an
additional traction bar can be added to overcome any soft-tissue resistance to the maxillary advancement
(bottom left). Note correction of the maxillary hypoplasia and Class III relationship (bottom right). (Color
version of figure is available online.)
of 400-500 g. The face mask is used for 6-8 weeks
or until the clinician notes that the maxilla is
stable in its new position. At this point, the intraoral splint can be removed, and orthodontic
treatment can be continued to finalize the occlusion of the patient.
In patients in whom the maxillary advancement is extreme, clinicians might note mobility
of the maxillary bone even after 3 months of
halo and face mask consolidation. If the motion
of the maxilla is uncomfortable for the patient,
the surgeon may elect to place rigid fixation
plates to further secure the maxillary bone.
However, in patients with delayed consolidation
of the maxilla, the motion of the bone is usually
in the vertical and transverse planes, and there is
minimal or no tendency for anterior and/or
posterior movement.
Management of Severe Cleft and Midface Hypoplasia
249
Figure 4. Cephalometric radiographs revealing the presence of maxillary hypoplasia with anterior dental cross
bite (top left). After RED treatment, the skeletal convexity is restored and the anterior cross bite corrected (top
right). Note bone formation posterior and superior to last maxillary molars (solid arrows) and stretching of the
soft palate (dashed arrow). Panoramic radiograph after treatment demonstrates continued eruption of the
upper right third molar (single arrow) and new bone formation posterior to the left upper left third molar
(double arrows) (bottom right).
In cases with severe craniofacial syndromes in
which there is significant frontal, orbital, and maxillary deficiency, the RED system has also proved
extremely effective to safely and predictably improve the severe midface deficiency. Rather than
acutely advancing the whole midface and frontal
bone (monobloc advancement),35 the segment
is advanced gradually. The main disadvantages
of the acute advancement include cerebral spinal fluid leakage, creation of an intracranial
dead space vulnerable to infection, and need for
extensive bone grafting and bone fixation. The
procedure is clinically demanding; the advancement can be limited due to soft-tissue restrictions;
there is a need for blood transfusions; and the
long-term stability of this procedure has been questionable. The advantages of gradual advancement
of the monobloc segment with a RED system using
the principles of DO include a predictable and
stable midface advancement, reduction of complications especially infection, reduction of intra- and postoperative morbidity, simpler procedure, no need for bone grafts or rigid fixation,
significantly decreased operative time and morbidity, and reduction in the number of cases
requiring blood transfusion.
The technique for midface advancement at
the monobloc level follows similar steps to that
of maxillary advancement in cleft patients. The
first step is to have the orthodontist prepare an
250
Figueroa and Polley
intraoral splint similar in design to that used in
cleft patients (Fig. 1).34 At the time of surgery,
the splint is further secured to the maxillary
bone with bone anchorage screws. During surgery, the classical monobloc osteotomy is performed, and the surgeon must ensure complete
mobilization of the skeletal segment. After fixating the frontal bone flap to the supraorbital rim
with rigid fixation plates and screws, the surgeon
places 2 additional plates above the supraorbital
rim. These specialized plates (KLS Martin, Jacksonville, FL) contain 3 perforations. The 2 lateral ones are for fixation to the supraorbital
bone with screws, and the central perforation
has a thread for future placement of the superior traction pin screw that will come through
the skin at the level of the eyebrow (Fig. 5). After
the supraorbital traction pins are placed, the
Figure 5. Supraorbital and dental traction points during monobloc advancement with the RED system. After
completing the monobloc osteotomies and rigidly fixing the frontal bone flap, 3 holed plates are placed over
each supraorbital rim (top left). The lateral holes are used to fixate the plate to the bone; the central one is
threaded and is used to insert a percutaneous pin (top right) that will be used as upper anchorage during the
monobloc advancement. Note lower traction hooks attached to the intraoral device (bottom left) and pins
through both eyebrows (bottom right), all connected with wires to the distraction system. Four traction points
should be used for maximal control of the large monobloc osseous segment. (Color version of figure is available
online.)
Management of Severe Cleft and Midface Hypoplasia
251
Figure 6. Pre- and postsurgery lateral facial and intraoral photographs of a patient with Crouzon syndrome who
underwent monobloc advancement with a RED device followed by a finishing Le Fort I osteotomy and
genioplasty. Note severe exorbitism, midface deficiency, and malocclusion with dramatic correction after
treatment. (Color version of figure is available online.)
coronal incision is closed and the surgeon places
the RED halo. In cases with craniofacial syndromes or previous surgery, the surgeon must be
careful with the placement of the fixation cranial pins, as many of these patients do have
cranial defects from the condition itself or from
previous operations. It is important that the halo
is properly anchored to solid bone. The anterior
part of the halo is positioned about 2-3 cm ahead
of the forehead and the halo is placed either
parallel to the Frankfort plane, or with a slightly
upward inclination, and 3-6 cm above the ear
(Fig. 3). After surgery, the patient returns to the
clinical setting in 5-7 days to have the distraction
device assembled with 4 points of distraction, 2
at the supraorbital level through the traction
pins and 2 at the dental level by the traction
hooks connected to the intraoral device (Fig. 5).
The distraction protocol is similar to that in cleft
patients, with a 1-2-mm advancement per day until
correction of the skeletal deformity is achieved.
However, if only the anterior screws are activated,
the face will eventually touch the vertical bar;
therefore, the screw system mounted on the
posterior portion of the halo needs to be activated to maintain a comfortable distance between the face and the anterior component of
the halo and vertical bar system. After this, the
halo is left in place during the consolidation
period of 6 and 12 weeks. In patients undergoing monobloc advancement, it is not possible to
use a face mask for retention; therefore, it is
recommended that the consolidation period be
longer than in cleft patients or until the clinician
is assured of stability of the skeletal segment by
radiographic and clinical examination.
This procedure has proved to be simpler,
more predictable, and more stable than conventional methods. The following case report illustrates the technique, which was used to correct
asyndromiccraniofacialdeformity(Figs.5-7).The
development of an infant halo has allowed
monobloc advancement in children as young as
2 years of age who had severe ocular and respiratory problems.
The long-term stability after maxillary advancement in cleft patients and midface advancement in
patients with syndromic conditions has been excellent.17,36 The reason why the technique is stable in
both cleft and syndromic patients is that a significant amount of bone is formed in the pterygomaxillary area. This area has been known to be
key concerning stability after maxillary and midface advancements. The bone found in this area
252
Figueroa and Polley
Figure 7. Cephalometric radiographs before distraction demonstrate extent of midface and maxillary deficiency. Correction is evident after monobloc distraction with RED followed with conventional maxillary advancement. Severely impacted third molars (arrow) and missing second molars because of previous failed attempt with
conventional midface advancement. Note bone and space created posterior to the maxillary first molars after
monobloc advancement with RED (double arrows). Panoramic radiographs after RED demonstrate significant
new bone anterior to the pterygomaxillary region (triple arrows). Note fixation hardware after finishing
orthognathic surgery and extraction of all third molars.
through histologic and radiographic examination has been found to be dense lamellar
bone.17,37 The creation of new bone in the posterior maxillary region is such that it not only
provides stability but also provides additional
space for dental eruption (Figs. 4, 7, and 10).
With experience, the RED technique has
been applied to other conditions in which it was
thought that conventional orthognathic surgery
might not be sufficiently stable to provide the
desired outcome. In addition, in patients with
severe conditions, we have used the technique in
combination with conventional orthognathic
surgery. In some instances, because of directional movement limitations of the distraction
technique, it becomes necessary to finalize the
case with conventional orthognathic surgery
(Figs. 5-7). The benefit of combining the 2 techniques resides in the fact that the distraction
component of the intervention attains most of
the correction and with the conventional orthognathic technique, the surgeon refines the
position of the bones and the occlusion, usually
with minor, safe, predictable, and stable skeletal
movement. Our experience has helped us to
apply the technique to patients with isolated
severe dentofacial deformities (Figs. 8-10).
It is the opinion of the authors that, at this
time, several challenges remain to be solved for
patients requiring distraction for the correction
of maxillary and midface hypoplasia. Some of
these challenges are technical, whereas others
are related to the patient’s response to treatment. On the technical side, we have issues concerning surgical technique that pertain mainly
to case selection, such as use of distraction alone
or in combination with conventional orthognathic surgical techniques. The other includes
hardware. For example, when to use RED system
like the one presented in this article, or when to
use an internal distraction system that, although
more appealing because it is concealed, does have
significant limitations concerning adjustment and
degree of advancement. New devices are in development at our unit to assist the surgeon in the use
of versatile internal devices.38,39
Despite the obvious benefits of distraction to
correct the severe challenges presented by cleft
and syndromic patients, and the widespread use
of the technique by craniomaxillo-facial sur-
Management of Severe Cleft and Midface Hypoplasia
253
Figure 8. Photographs of a 17-year-old boy with idiopathic severe maxillary hypoplasia undergoing maxillary
advancement with RED. (Color version of figure is available online.)
geons around the world, a small number of clinicians still continue to suggest that conventional surgery is the only way to treat this group
of patients.40,41 Their rationale for not using the
technique is based on obvious misinterpretation
and misunderstanding of the published data,
lack of actual clinical experience with the distraction technique, as well as personal bias. Of
course, they are few, and hopefully they will
embrace distraction techniques, such as the one
described in this article, to the benefit of their
most challenging patients.
Figure 9. Lateral facial and intraoral photographs before treatment, after orthodontic preparation with extraction of maxillary first bicuspids and after maxillary advancement with RED of a patient with isolated maxillary
hypoplasia. Note improvement on facial balance and excellent occlusion after maxillary advancement. (Color
version of figure is available online.)
254
Figueroa and Polley
Figure 10. Cephalometric radiographs demonstrating worsening of malocclusion after orthodontic preparation
and correction of skeletal balance after maxillary advancement. Note absence of fixation hardware. Panoramic
radiograph before treatment reveals unerupted maxillary third molars (single arrow). After maxillary advancement with RED, creation of new bone posterior to the third molars is evident, as well as spontaneous eruption
of the maxillary third molars (double arrows).
Other issues that still remain a challenge include the length of the consolidation period,
which has been noted to be age specific; younger
patients have a shorter consolidation period. However, if the bone is significantly advanced, it has
been observed that the time required for consolidation can be extremely long and impractical. Therefore, the close cooperation between
clinicians and researchers to decrease this very
important stage in the distraction process is critical. Recent advancements in the use or delivery
of bone morphogenetic proteins, growth factors,
and the use of ultrasound appear to be addressing this concern.42-45
Although evaluated by some clinicians, more
needs to be known concerning the soft-tissue
responses to the gradual movement of bone with
its attached soft tissues. Some of these changes
appear to be more favorable, using distraction
techniques, such as an improved lip and nose
response after maxillary advancement with distraction when compared with conventional orthognathic surgery.18,46 In addition, the response of the velopharyngeal tissues appears to
be more favorable in the gradual advancement
than in the acute advancement.47,48
Finally, little is known on what the patient’s
emotional and psychological response is to this
gradual advancement compared with the acute
change. How much do the distraction devices
interfere in the short- and long-term psychosocial well-being of the patient?49 What is the effect
of an intervention with reduced morbidity? Does
having family and patient participation in activating the device benefit their psychosocial wellbeing when dealing with a challenging facial
difference?
Conclusions
DO has now been applied to all the bones of the
craniofacial skeleton with remarkable success.
The technique of RED for maxillary and midface advancement in cleft and craniofacial syndromic patients has proved to be simpler, highly
effective, predictable, and stable. The clinical
knowledge available at this time indicates that
distraction is an alternative approach to the
management of conditions that, in the past,
were a challenge for conventional surgical techniques. The use of distraction techniques does
not preclude the combined use of conventional
Management of Severe Cleft and Midface Hypoplasia
surgical techniques with the new distraction approach. Although the benefits of distraction are
well recognized, challenges remain to further
improve the incorporation of the technique for
the clinical management of cleft and syndromic
patients. These include the development of new
hardware, surgical designs, and technique; reduction of the consolidation period through cytokines and other approaches; the understanding of soft-tissue response to gradual distraction;
and the psychosocial aspects of the technique on
the overall well-being of the patients.
References
1. Thomas PM, Sarver DM, Tucker MR: Prevention and
management of complications, in Proffit WR, White RP,
Sarver DM (eds): Contemporary Treatment of Dentofacial Deformity. St. Louis, MO, Mosby, 2003, pp 677-709
2. Kramer FJ, Baethge C, Swennen G, et al: Intra- and
perioperative complications of the LeFort I osteotomy: a
prospective evaluation of 1000 patients. J Craniofac Surg
15:971-977, 2004; discussion 978-979
3. Erbe M, Stoelinga PJ, Leenen RJ: Long-term results of
segmental repositioning of the maxilla in cleft palate
patients without previously grafted alveolo-palatal clefts.
J Craniomaxillofac Surg 24:109-117, 1996
4. Hochban W, Ganss C, Austermann KH: Long-term results after maxillary advancement in patients with clefts.
Cleft Palate Craniofac J 30:237-243, 1993
5. Cheung LK, Samman N, Hui E, et al: The 3-dimensional
stability of maxillary osteotomies in cleft palate patients
with residual alveolar clefts. Br J Oral Maxillofac Surg
32:6-12, 1994
6. Posnick JC, Dagys AP: Skeletal stability and relapse patterns after Le Fort I maxillary osteotomy fixed with
miniplates: the unilateral cleft lip and palate deformity.
Plast Reconstr Surg 94:924-932, 1994
7. Figueroa AA, Polley JW, Ko E: Distraction osteogenesis for
treatment of severe cleft maxillary deficiency with the RED
technique, in Samchukov ML, Cope JB, Cherkashin AM
(eds): Craniofacial Distraction Osteogenesis. St Louis, MO,
Mosby, 2001, pp 485-493
8. McCarthy JG, Schreiber J, Karp N, et al: Lengthening the
human mandible by gradual distraction. Plast Reconstr
Surg 89:1-8, 1992
9. Satoh K, Mitsukawa N, Hosaka Y: Dual midfacial distraction osteogenesis: Le Fort III minus I and Le Fort I for
syndromic craniosynostosis. Plast Reconstr Surg 111:
1019-1028, 2003
10. Fearon J: Halo distraction of the Le Fort III in syndromic
craniosynostosis: a long-term assessment. Plast Reconstr
Surg 115:1524-1536, 2005
11. Meling TR, Due-Tonnessen B, Hogevold HE, et al:
Monobloc distraction osteogenesis in pediatric patients
with severe syndromal craniosynostosis. J Craniofac Surg
15:990-1000, 2004
255
12. Polley JW, Figueroa AA, Charbel FT, et al: Monobloc
craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: a preliminary
report. J Craniofac Surg 6:421-423, 1995
13. Figueroa AA, Polley JW: Mandibular distraction osteogenesis. Operat Tech Otolaryngol Head Neck Surg 13:
17-28, 2002
14. Molina F: Mandibular distraction osteogenesis: clinical
analysis of the first 10 years, in Samchukov ML, Cope JB,
Cherkaskin AM (eds): Craniofacial Distraction Osteogenesis. St. Louis, MO, Mosby, 2001, pp 196-205
15. Ortiz Monasterio F, Molina F, Andrade L, et al: Simultaneous mandibular and maxillary distraction in hemifacial microsomia in adults: avoiding occlusal disasters.
Plast Reconstr Surg 100:852-861, 1997
16. Figueroa AA, Polley JW: Management of severe cleft
maxillary deficiency with distraction osteogenesis: procedure and results. Am J Orthod Dentofacial Orthop
115:1-12, 1999
17. Figueroa AA, Polley J, Friede H, et al: Long-term skeletal
stability after maxillary advancement with distraction osteogenesis using a rigid external distraction device in
cleft maxillary deformities. Plast Reconstr Surg 114:
1382-1392, 2004
18. Harada K, Baba Y, Ohyama K, et al: Maxillary distraction
osteogenesis for cleft lip and palate children using an
external, adjustable, rigid distraction device: a report of
2 cases. J Oral Maxillofac Surg 59:1492-1496, 2001
19. Hierl T, Hemprich A: Callus distraction of the midface
in the severely atrophied maxilla—a case report. Cleft
Palate Craniofac J 36:457-461, 1999
20. Polley JW, Figueroa AA: Management of severe
maxillary deficiency in childhood and adolescence
through distraction osteogenesis with an external, adjustable, rigid distraction device. J Craniofac Surg
8:181-185, 1997
21. Polley JW, Figueroa AA: Rigid external distraction: Its
application in cleft maxillary deformities. Plast Reconstr
Surg 102:1360-1372, 1998
22. Denny AD, Talisman R, Hanson PR, et al: Mandibular
distraction osteogenesis in very young patients to correct
airway obstruction. Plast Reconstr Surg 108:302-311,
2001
23. Denny AD: Distraction osteogenesis in Pierre Robin neonates with airway obstruction. Clin Plast Surg 31:221229, 2004
24. Monasterio FO, Drucker M, Molina F, et al: Distraction
osteogenesis in Pierre Robin sequence and related respiratory problems in children. J Craniofac Surg 13:7983, 2002; discussion 84
25. Klein C: Bone transport for mandibular anterior defect
reconstruction: a case report, in Samchukov ML, Cope
JB, Cherkashin AM (eds): Craniofacial Distraction Osteogenesis. St Louis, MO, Mosby, 2001, pp 368-371
26. Liou EJ, Figueroa AA, Polley JW: Rapid orthodontic
tooth movement into newly distracted bone after mandibular distraction osteogenesis in a canine model. Am J
Orthod Dentofacial Orthop 117:391-398, 2000
27. Liou EJ, Huang CS: Rapid canine retraction through
distraction of the periodontal ligament. Am J Orthod
Dentofacial Orthop 114:372-382, 1998
256
Figueroa and Polley
28. Contasti G, Guerrero C, Rodriguez HL, et al: Mandibular widening by distraction osteogenesis. J Clin Orthod
35:165-173, 2001
29. Guerrero CA, Bell WH, Contasti GI, et al: Mandibular
widening by intraoral distraction osteogenesis. Br J Oral
Maxillofac Surg 35:383-392, 1997
30. Molina F, Ortiz Monasterio F, de la Paz Aguilar M, et al:
Maxillary distraction: aesthetic and functional benefits
in cleft lip-palate and prognathic patients during mixed
dentition. Plast Reconstr Surg 101:951-963, 1998
31. Molina F, Ortiz-Monasterio F: Maxillary distraction:
three years of clinical experience, in: Proceedings of the
65th Annual Meeting of the American Society of Plastic
and Reconstructive Surgeons, Plastic Surgical Forum
(vol XIX). Chicago, IL, 1996:54
32. Polley JW, Figueroa AA: Maxillary distraction osteogenesis with rigid external distraction. Atlas Oral Maxillofac
Surg Clin North Am 7:15-28, 1999
33. Polley J, Figueroa AA: Rigid external maxillary distraction, in McCarthy JG (ed): Distraction of the Craniofacial Skeleton. New York, NY, Springer-Verlag, pp 321-336
34. Figueroa AA, Polley JW: Orthodontics in cleft lip and
palate management, in Mathes SJ (ed): Plastic Surgery.
Philadelphia, PA, W. B. Saunders, 2006, pp 271-310
35. Ortiz-Monasterio F, del Campo AF, Carrillo A: Advancement of the orbits and the midface in one piece, combined
with frontal repositioning, for the correction of Crouzon’s
deformities. Plast Reconstr Surg 61:507-516, 1978
36. Polley JW, Figueroa AA, Gomez DF: Midface advancement with external distraction osteogenesis: technique
and analysis. Presented at: Program International Society of Craniofacial Surgery, Xth International Congress;
September 21-24, 2003; Monterey, CA
37. Kusnoto B, Figueroa AA, Polley JW: Radiographic evaluation of bone formation in the pterygoid region after
maxillary distraction with a rigid external distraction
(RED) device. J Craniofac Surg 12:109-117, 2001; discussion 118
38. Figueroa AA, Polley JW: A rigid adjustable internal distraction (RAID) device to manage maxillary hypoplasia.
Presented at: Program International Society of Craniofacial Surgery, XIth International Congress; September
11-14, 2005; Queensland, Australia
39. Figueroa AA, Polley JW, Figueroa AL: Introduction of a
new adjustable internal maxillary (AIM) distraction system for correction of maxillary hypoplasia. J Craniofac
Surg (in press)
40. Posnick JC, Tiwana PS: Cleft-orthognathic surgery, in
Berkowitz S (ed): Cleft Lip and Palate. Heidelberg, Berlin, Springer, 2006, pp 573-585
41. Posnick JC, Ruiz RL: Discussion: Secondary orofacial
cleft deformities, in Goldwyn RM, Colen MM (eds): The
Unfavorable Result in Plastic Surgery. Philadelphia, PA,
Lippincott Williams and Wilkins, 2001, pp 349-358
42. El-Bialy TH, Royston TJ, Magin RL, et al: The effect of
pulsed ultrasound on mandibular distraction. Ann Biomed
Eng 30:1251-1261, 2002
43. Cheung LK, Zheng LW: Effect of recombinant human
bone morphogenetic protein-2 on mandibular distraction at different rates in an experimental model. J
Craniofac Surg 17:100-108, 2006; discussion 109-110
44. Raschke MJ, Bail H, Windhagen HJ, et al: Recombinant
growth hormone accelerates bone regenerate consolidation in distraction osteogenesis. Bone 24:81-88, 1999
45. Aspenberg P, Jeppsson C, Wang JS, et al: Transforming
growth factor beta and bone morphogenetic protein 2
for bone ingrowth: a comparison using bone chambers
in rats. Bone 19:499-503, 1996
46. Wen-Ching Ko E, Figueroa AA, Polley JW, et al: Soft
tissue profile changes after maxillary advancement with
distraction osteogenesis by use of a rigid external distraction device: a 1-year follow-up. J Oral Maxillofac Surg
58:959-969, 2000; discussion 969-970
47. Guyette TW, Polley JW, Figueroa A, et al: Changes in
speech following maxillary distraction osteogenesis. Cleft
Palate Craniofac J 38:199-205, 2001
48. Ko EW, Figueroa AA, Guyette TW, et al: Velopharyngeal changes after maxillary advancement in cleft
patients with distraction osteogenesis using a rigid external distraction device: a 1-year cephalometric followup. J Craniofac Surg 10:312-320, 1999; discussion
321-322
49. Cheung LK, Loh JS, Ho SM: The early psychological
adjustment of cleft patients after maxillary distraction
osteogenesis and conventional orthognathic surgery: a
preliminary study. J Oral Maxillofac Surg 64:1743-1750,
2006
Intraoral Distraction of Segmental
Osteotomies and Miniscrews in Management
of Alveolar Cleft
Eric J.W. Liou, DDS, MS, and Philip K.T. Chen, MD
Management of a wide alveolar cleft and alveolar bone graft failure is among
the most difficult tasks for both surgeon and orthodontist. This article aims to
introduce the techniques of intraoral distraction of segmental osteotomy for
solving a wide alveolar cleft, and orthodontic management with miniscrews for
solving alveolar bone graft failure; and also to evaluate the feasibility and
clinical results of moving teeth into alveolar clefts. Interdental distraction osteogenesis was performed to minimize the alveolar cleft before alveolar bone
grafting in 21 patients whose alveolar cleft was wider than a maxillary canine.
All clefts were successfully approximated, and the 4- to 5-year results were
shown to be stable. In addition, orthodontic protraction of the buccal teeth by
using miniscrews as a temporary anchorage device was performed in 13 cases
to minimize and/or eliminate the residual bony bridge or alveolar cleft after the
previous failure of an alveolar bone graft. The buccal teeth were protracted with
intermittent light continuous force. The results revealed that the residual
bony bridges or alveolar clefts were minimized and that the space of the
cleft was completely closed. The periodontal apparatus of the teeth that
were moved into the residual bony bridge or alveolar cleft remained
similar before and after the treatment. The orthodontic tooth movement
into a residual alveolar cleft is clinically feasible in certain circumstances.
However, the long-term status of the periodontal apparatus of the teeth
that were moved into the alveolar cleft should be monitored. (Semin
Orthod 2009;15:257-267.) Crown Copyright © 2009 Published by Elsevier
Inc. All rights reserved.
econdary autogenous alveolar bone grafting
is a well-established method with well-documented long-term results in treatment of the
alveolar cleft and oronasal fistula in patients with
clefts.1-6 Several factors, such as a wide alveolar
S
From the Department of Orthodontics and Craniofacial Dentistry, Chang Gung Memorial Hospital and Graduate School of
Craniofacial Medicine, Chang Gung University, Taipei, Taiwan
and Department of Plastic and Reconstructive Surgery, Craniofacial
Center Chang Gung Memorial Hospital, Taipei, Taiwan.
Address correspondence to Eric J.W. Liou, DDS, MS, 199 TungHwa North Road, Taipei, 105, Taiwan; Phone: ⫹886968373022; E-mail: [email protected]
Crown Copyright © 2009 Published by Elsevier Inc. All rights
reserved.
1073-8746/09/1504-0$30.00/0
doi:10.1053/j.sodo.2009.07.002
cleft, inadequate primary wound closure, and postoperative wound dehiscence and infection, have
been attributed to its failure. The closure of a wide
alveolar cleft is challenging because of the difficulty in its complete closure by using local attached gingiva. A problem in the management of
failure of an alveolar bone graft is the even higher
failure rate of the subsequent alveolar bone graft,
which may be due to the scar tissue.
The authors of the present article have set up
a treatment protocol to solve these problems.
For an alveolar cleft that is wider than a maxillary
canine, the technique of interdental distraction
osteogenesis (IDO) is used to minimize the alveolar cleft before alveolar bone grafting or gingivoperiosteoplasty. For an alveolar bone graft failure, the technique of orthodontic protraction of
Seminars in Orthodontics, Vol 15, No 4 (December), 2009: pp 257-267
257
258
Liou and Chen
the buccal teeth by using miniscrews as a temporary anchorage device (TAD) is used to minimize or eliminate the residual bony bridge or
alveolar cleft so that the subsequent alveolar
bone graft or gingivoperiosteoplasty is feasible.
lar bone grafting, creating dental space for relieving dental crowding, and avoiding worsening the
velopharyngeal insufficiency. The timing for IDO
is at the age of 9-10 years,7 which is the same as the
timing for conventional alveolar bone graft.
Interdental Distraction Osteogenesis for
Management of a Wide Alveolar Cleft
Presurgical Orthodontics
IDO is a technique of dentoalveolar lengthening
and gingival histogenesis through intraoral distraction of the segmental osteotomy.7-11 The dentoalveolus is osteotomized and then transported to
approximate the alveolar cleft by growing local
alveolus and attached gingiva at a distant site
from the cleft (Figs. 1 and 2). Its advantages
include eliminating the need for extensive alveo-
The periodontal tissue of the teeth by the alveolar cleft should remain healthy throughout
the treatment. The maxillary dentition is first
aligned and leveled so the labial-and-lingual and
the vertical gingival levels of the teeth by the
alveolar cleft are even. Following this, an interdental space is then opened orthodontically at
the selected distraction site to avoid dental root
injury during the osteotomy. A transpalatal arch
Figure 1. Interdental distraction osteogenesis for the closure of a wide alveolar cleft in an 11-year-old boy with
unilateral cleft lip and palate. (A) The alveolar cleft was 11 mm before distraction. A transpalatal arch and fixed
orthodontic appliances were placed for the presurgical orthodontic preparation. (B) The 11-mm alveolar cleft
was successfully approximated after the interdental distraction osteogenesis and orthodontic treatment. A
lingual bonded retainer was bonded for the post-treatment retention. (C) The width of the alveolar bony defect
of the cleft is shown on the predistraction radiograph. (D) The post-treatment radiograph shows that the alveolar
cleft was successfully approximated and bone grafted. (Color version of figure is available online.)
Management of Alveolar Cleft
259
Figure 2. Interdental distraction osteogenesis for the closure of alveolar clefts on both sides in a 10-year-old boy
with bilateral cleft lip and palate. (A) The premaxilla deviated to the left side, a fistula on the left, and a 9-mm
alveolar cleft on the right before treatment. (B) The fistula on the left and alveolar cleft on the right were closed
and approximated after the distraction and orthodontic treatment. A lingual bonded retainer was used for the
post-treatment retention. (C) The width of the alveolar bony defect of the fistula and alveolar cleft is shown on
the predistraction radiograph. (D) The post-treatment radiograph shows the alveolar cleft and fistula to be
successfully approximated and the bone grafted. (Color version of figure is available online.)
made of 0.032⬙ ␤-titanium wire is then placed for
consolidating the maxillary molars on both sides
as a unit before surgery (Figs. 1A and 2A).
The most frequent distraction site is between
the maxillary first molar and second premolar.7,11 However, the interdental distraction site
may vary. The guidelines for a proper distraction
site are as follows:
1. An interdental distraction site should have
enough healthy attached gingiva and oral mucosa for a primary closure after surgery.
2. The interseptal bone of an interdental distraction site should be as high as possible and
at least 3 mm in thickness. At least 1.0 mm of
alveolar bone should be preserved on each
side of the distraction. Thin alveolar bone is
subjected to be resorption by the postoperative regional accelerated phenomenon,12-15
which leads to root exposure and a reduction
in alveolar bone height. A reduction in alveolar bone height will result in less volume and
height of the regenerate.
3. The distracted segment should contain at
least 2 teeth to ensure adequate blood supply
from the adjacent gingival or oral mucosa.
Single tooth distraction is not recommended.
Surgery and Distraction Procedures
Maxillary interdental and horizontal osteotomies
of the buccal cortical plate and the medial wall of
the maxillary sinus and palate are performed to
completely mobilize the distracted segment.
260
Liou and Chen
Figure 3. Intraoral distraction device and segmental
osteotomy for the interdental distraction osteogenesis. (Color version of figure is available online.)
(Fig. 3). The orthodontic arch wire is used not
only to move teeth but also to prevent medial
and palatal collapse of the osteotomized segment during placement of the distraction device. The soft tissues should be closed carefully
over the osteotomy site to avoid wound dehiscence during the distraction procedure. Softtissue dehiscence during distraction exposes the
soft callus and leads to severe bone resorption,
gingival recession, and dental root exposure.
Therefore, the length of latency period is determined by the normalcy of the soft-tissue
wound healing, and the rhythm of callus distraction must be synchronous with the pace of
the soft-tissue distraction histogenesis.
When a bone-borne distraction device is used,
the upper bony part of the osteotomized segment
is subjected to distraction more than the occlusal
level. In addition to the screw track of the distraction device, heavy nickel–titanium (NiTi) coil
springs or elastics could be applied as an adjunctive distraction force at the occlusal level to ensure
that the osteotomized segment is distracted bodily
and also to mold the regenerate in a linear curvature direction along the orthodontic archwire.
the maturation of the regenerate by replacing
the regenerate with the more mature bone induced by the orthodontic tooth movement.20
Another benefit of this is to use the created
space for relieving dental crowding.7
The timing of moving teeth into the regenerate has been reported experimentally to be from
1 to 12 weeks after distraction.20-23 There is no
agreement on the optimal timing of tooth movement into the regenerate. The general guideline
is that the earlier the orthodontic tooth movement, the faster the tooth movement but the
more the root resorption will occur. The authors’ preference is to move teeth into the regenerate 2-3 weeks after distraction.7 The boneborne distraction device is maintained for 3-4
months for holding the regenerate, while at the
same time it is used as a TAD for the postdistraction orthodontic tooth movement (Fig. 4). Under this circumstance, the postdistraction orthodontic tooth movement could usually be
completed in 3-4 months because the regenerate
is still soft.
Either alveolar bone grafting or gingivoperiosteoplasty can be performed as the final treatment procedure for closing the alveolar cleft.
The alveolar bone grafting is performed when
the alveolar cleft is wider than 2 mm, whereas
gingivoperiosteoplasty is performed when the
cleft is less than 2 mm.
Postdistraction Orthodontic Management
The regenerate matures in approximately 3 months
but is subject to shrinkage in volume during maturation.16-19 The strategy to minimize the shrinkage is to move teeth into the regenerate. To fill
the regenerate with teeth makes the regenerate
less prone to the shrinkage, and also accelerates
Figure 4. The intraoral distraction device was used as
a temporary anchorage device for the postdistraction
orthodontic tooth movement after interdental distraction osteogenesis. A coil spring was applied between
the distracter and first molar for moving posterior
teeth into the regenerate. (Color version of figure is
available online.)
Management of Alveolar Cleft
Evaluation of Treatment Results
A total of 21 patients, including 13 unilateral
and 8 bilateral cleft patients, who had IDO for
approximating the wide alveolar cleft were reviewed for their treatment results.11 The follow-up period was 4-5 years. There were 29 alveolar clefts and the average width was 10 mm. The
distracted segments of the dental arches were
moved almost bodily toward the cleft as revealed on the panoramic and cephalometric
radiographs. The average amount of distraction, as measured on the radiographs, was 12
mm with a range of 10-20 mm. The relapse was
0.5 mm in the first 3 months after removal of
the distraction device. Clinically, 28 of 29 al-
261
veolar clefts were approximated completely by
soft-tissue contact after IDO. Thirteen of the
29 alveolar clefts were successfully bone
grafted and 16 of the 29 alveolar cleft underwent gingivoperiosteoplasty only. The 4- to
5-year follow-up revealed that the treatment
results were stable.
Orthodontic Management of Alveolar
Bone Graft Failure By Using
Orthodontic Miniscrews
An alveolar bone graft failure could range from
a residual bony bridge across the cleft to a complete absence of bone formation in the alveolar
Figure 5. Orthodontic management of the residual bony bridge across an alveolar cleft in a 14-year-old girl with
bilateral cleft lip and palate. (A) The maxillary dentition was well aligned; the orthodontic miniscrews were
inserted in the infrazygomatic crests of the maxilla on both sides; and NiTi coils were used to protract the buccal
teeth into the residual bony bridges. (B) The alveolar bone height of the residual bony bridges ranged from
one-half to one-third of the anterior teeth root length before treatment. (C) The residual bony bridge across the
alveolar clefts was approximated successfully after the treatment. (D) The edentulous space and residual bony
bridges on both sides were successfully eliminated, and the alveolar bone height was resumed on the anterior
teeth. (Color version of figure is available online.)
262
Liou and Chen
Figure 6. Orthodontic management of the residual alveolar cleft and residual bony bridge in a 21-year-old male
patient with bilateral cleft lip and palate. (A, B, and C) At the beginning of the treatment, the buccal teeth on both
sides were well aligned and protracted into the residual alveolar cleft and bony bridges by using miniscrews and NiTi
coil springs. (D) Bony defect of the residual alveolar cleft on the right side and bony defect of nasal floor and residual
bony bridge on the left side. (E, F, and G) The right and left edentulous space had been closed clinically, and a pair
of ␤-titanium extruding cantilever arms were using for extruding the upper anterior teeth. (H) The edentulous space,
residual alveolar cleft on the right, bony defect of the nasal floor, and residual bony bridge on the left side were
successfully eliminated after the treatment. (Color version of figure is available online.)
cleft. To manage the failure, IDO or orthognathic surgery with segmental advancement of
the lesser segment24 could be the surgical treatment modalities. With the introduction of miniscrews as a TAD in orthodontics,25-41 nonsurgical
orthodontic management of a failed alveolar
bone graft has become feasible.
In orthodontic management of alveolar bone
graft failure, the miniscrew is used to protract
the buccal teeth into the alveolar cleft. The protraction of buccal teeth into the alveolar cleft is
to narrow or even eliminate the residual bony
bridge or alveolar cleft, and also to approximate
the soft tissues of the alveolar cleft so that primary closure of the subsequent bone graft or
gingivoperiosteoplasty can be more predictably
performed.
The miniscrew can be inserted in the infrazygomatic crest of the lesser segment of maxilla.42 The
insertion angle is 60° anteroposteriorly to the maxillary occlusal plane, and with the screw head
emerging from the mucogingival junction at the
first premolar area. To insert the miniscrew between the teeth is not appropriate due to the
movement of the buccal teeth, which may hit the
miniscrew, and alternatively the orthodontically
loaded miniscrew might move and hit the
roots.43,44
The advantage of protraction of the buccal
teeth is creating alveolar bone on the buccal,
Management of Alveolar Cleft
263
Figure 6. (continued)
palatal, and distal sides of tooth movement (the
tension side osseous reaction). This is similar
to distraction osteogenesis. Orthodontic tooth
movement has been proposed as orthodontic
periodontal osteogenesis.20,45,46 Another advantage is the pressure (mesial) side soft-tissue reaction of the protraction that replaces the scar
tissue with gingival tissue in the cleft site so that
primary closure of the subsequent bone graft or
gingivoperiosteoplasty is feasible.
Clinical management, as well as the osseous
reaction on the pressure side of the protracted
teeth, differs depending on the presence or absence of a bony bridge.
Orthodontic Management of a Residual Bony
Bridge Across Alveolar Cleft
Teeth should remain within the anatomical
boundaries of the dentoalveolar process to
survive and function, especially the tooth root
apex. The question as to whether tissue changes
on the pressure side of the orthodontic tooth
movement allow these protracted buccal teeth to
move into a residual bony bridge across an alveolar cleft has clinical significance. This latter
circumstance could be similar to those of moving the tooth into an area with reduced alveolar
bone height in patients with partially edentulous
dentitions.
An experimental study in the beagle’s mandible has shown that a tooth with normal periodontal support can be orthodontically moved
into an area of reduced bone height with maintained height of the supporting apparatus.47
The lowest point of the experimentally reduced alveolar bone height was above the level
of the root apex. On the pressure side, supporting alveolar bone was present, extending
far coronal to the surrounding experimentally
created bone level but not reaching the com-
264
Liou and Chen
plete height as the original supporting bone.
The histologic picture of the bone tissue in the
coronal portion of the root showed a large
number of cells in contrast to the compact
appearance of the more apically located bone,
as in the unmoved tooth.
The interesting finding was that the newly
formed bone on the pressure side showed resorption on the surface near the root and apposition on the opposite side of the thin bone
plate. This is the compensatory bone deposition
on the pressure side, which has been interpreted
to be related to piezoelectric effect through
strain-generated potentials,48 arising because of
mechanically induced deformation of collagen
or hydroxyapatite crystals.49
This experimental model revealed that a tooth
can be moved into an area of reduced alveolar
bone height where the bone level is good enough
to cover the root apex. This experimental model
also has been tested in partially edentulous patients with normal periodontal tissue support
located adjacent to an area with reduced bone
volume but good enough to cover the root apex,
as long as bodily tooth movement with light
orthodontic forces are used and proper oral
hygiene is maintained.48
Clinical guidelines for successful orthodontic
management of a residual bony bridge across
alveolar cleft were drawn based on these experimental and clinical studies and the present authors’ clinical experiences:
1. Alveolar bone and gingival height of the
teeth by the cleft are not critical, but the
gingival tissue should be healthy. The bone
height can be re-established after the subsequent alveolar bone graft.
2. The bony bridge across the cleft should be
thick enough, both at the oral cavity and
nasal cavity sides, to cover the root apex of
the teeth by the cleft. This is to ensure that
the root apex of the tooth by the cleft remains inside the bony bridge throughout its
protraction.
3. Light continuous orthodontic force should be
used, and proper oral hygiene should be maintained throughout the treatment period.
Six patients have been treated using this technique (Fig. 5). Clinical and computed tomography scan evaluations revealed that the residual
bony bridge across alveolar cleft had been min-
imized or eliminated and that the space of the
cleft had been closed completely. No prosthesis
or dental implant was needed in these cases for
oral rehabilitation in these patients. The periodontal apparatus of the teeth that were moved
into the residual bony bridge remained similar
and had no obvious periodontal loss before and
after the treatment. The root apex remained
inside the alveolar ridge.
Orthodontic Management of the Residual
Alveolar Cleft
The question of whether alveolar bone traces
tooth movement into a residual cleft where
there is no bony bridge is most significant. The
pressure side osseous reaction of orthodontic
management of the residual alveolar cleft could
be similar to the circumstance of maxillary or
mandibular anterior retraction or lateral expansion.
During maxillary or mandibular anterior retraction, it was shown that the alveolar bone
remodeling occurs at the margin and midroot
levels50 but has a definite limit in remodeling
where the root apex abuts against the cortex.51,52 This means that the root at the margin
and midroot levels could be moved more than
the original thickness of the alveolar bone but
that the root apex could not. However, the
alveolar thickness of the pressure side decreases after retraction,50-53 and excessive retraction of the root apex causes loss of alveolar
bone and exposure of the root.53-55 Similarly,
excessive transverse tooth movement also causes
dehiscence and fenestration on the pressure
side.56,57,61 Clinical studies58-60 and autopsy findings56,57,62 revealed that the fenestration and dehiscence on the pressure side could be re-established by a thin layer of bone; but experimental
studies have indicated that the thin layer of bone
was insufficient to cover the root completely.63-65
Although the biological limits set by the pressure side of tooth movement are thinning of the
alveolus, fenestration, dehiscence, and questionable capability of re-establishing the cortex, to
move teeth into a residual alveolar cleft by using
miniscrews after failure of bone graft is still feasible
in certain circumstances. The following clinical
guidelines were therefore developed for successful
results:
Management of Alveolar Cleft
1. The alveolar bone and gingival height of the
teeth by the cleft is not critical, but the gingival tissue should be healthy and oral hygiene maintained throughout the treatment
period. The bone height can be re-established after the subsequent correction alveolar bone graft.
2. The mesiodistal thickness of the alveolar
bone besides the root apex of the teeth adjacent to the cleft should be thick enough to
cover the range of tooth movement needed
for the closure of the residual cleft, or should
be thicker than the width of residual alveolar
cleft (Fig. 6B).
3. The teeth should be moved intermittently
with light continuous force to avoid compromising the periodontal support of the teeth
that are moving into the residual alveolar
cleft. This is to alternately interpose 1 month
of recess between 2 months of tooth movements, which gives time for the alveolar bone
of the teeth adjacent to the cleft to re-establish through compensatory bone deposition
on the pressure side of the tooth movement.
Seven patients have been treated by this technique (Fig. 6). The clinical and computed tomography scan evaluations revealed that the residual alveolar cleft had been minimized or
eliminated and that the space of the cleft had
been closed completely. No prosthesis or dental
implant was needed in these patients for their
oral rehabilitation. The periodontal apparatus
of the teeth that were moved into the residual
bony bridge remained similar and had no obvious periodontal loss before and after the treatment. The root apex remained contained within
the alveolar ridge.
Conclusion
In conclusion, we note the following; 1) an alveolar cleft wider than a maxillary canine in unilateral or bilateral cleft lip and palate can be
minimized or approximated by the interdental
distraction; 2) the residual bony bridge or alveolar cleft of an alveolar bone graft failure can
be minimized or eliminated through buccal
teeth protraction by using miniscrews; and 3)
the orthodontic tooth movement into a residual alveolar cleft is clinically feasible in certain
circumstances. However, the long-term status
265
of the periodontal apparatus of the teeth that
were moved into the alveolar cleft should be
monitored.
References
1. Boyne PJ: Autogenous cancellous bone and marrow
transplants. Clin Orthop Relat Res 73:199, 1970
2. Troxell JB, Fonseca RJ, Osbon B: A retrospective study of
alveolar cleft grafting. J Oral Maxillofac Surg 40:721,
1982
3. Witsenburg B: The reconstruction of anterior residual
bone defects in patients with cleft lip, alveolus and palate. J Maxillofac Surg 13:1977, 1985
4. Ross RB: Treatment variables affecting facial growth in
complete unilateral cleft lip and palate. Cleft Palate J
24:5-77, 1987
5. Boyne PJ: Use of marrow-cancellous bone grafts in maxillary alveolar and palatal clefts. J Dent Res 53:821, 1974
6. Abyholm FE, Borchgrevink HC, Eskeland G: Cleft lip
and palate in Norway (III). Clinical treatment of CLP
patients in Oslo 1954-75. Scand J Plast Reconstr Surg
15:15, 1981
7. Liou EJ, Chen KT, Chen RY, et al: Interdental distraction
osteogenesis and rapid orthodontic tooth movement: a
novel approach to approximate wide alveolar cleft or
bony defect. Plast Reconstr Surg 105:1262-1272, 2000
8. Yen SL-K, Gross J, Wang P, et al: Closure of a large
alveolar cleft by bony transport of a posterior segment
using orthodontic archwires attached to bone: report of
a case. J Oral Maxillofac Surg 59:688-691, 2001
9. Dolanmaz D, Karaman AI, Durmus E, et al: Management
of alveolar cleft using dento-osseous transport distraction osteogenesis. Angle Orthod 73:723-729, 2003
10. Yen SL, Yamashita DD, Kim TH, et al: Closure of an
unusually large palatal fistula in a cleft patient by bony
transport and corticotomy-assisted expansion. J Oral
Maxillofac Surg 61:1346-1350, 2003
11. Liou EJ, Chen PKT: Management of maxillary deformities in growing cleft patients, in Berkowitz S (ed): Cleft
Lip and Palate: Diagnosis and Management. Berlin Heidelberg, Germany Springer-Verlag, 2006
12. Frost HM: The biology of fracture healing. Clin Orthop
Relat Res 248:283-293, 1989
13. Yaffee A, Fine N, Binderman I: Regional accelerated
phenomenon in the mandible following mucoperiosteal
flap surgery. J Periodontol 65:79-83, 1994
14. Wilcko WM, Wilcko T, Bouquot JE, et al: Rapid orthodontics with alveolar reshaping: two case reports of
decrowding. Int J Periodontics Restorative Dent 21:9-19,
2001
15. Wilcko WM, Ferguson DJ, Boouquot JE, et al: Rapid
orthodontic decrowding with alveolar augmentation:
case report. World J Orthod 4:197-205, 2003
16. Ilizarov GA, Lediov VL, Shitin VP: The course of compact bone reparative regeneration in distraction osteosynthesis under different conditions of bone fragment
fixation and experimental study, in Russian: Exp Khir
Anesteziol 14:3-12, 1969
266
Liou and Chen
17. Aronson J: Experimental assessment of bone regenerate quality during distraction osteogenesis, in Brighton CT, et al (eds): Bone Formation and Repair.
London, UK, American Academy of Orthopedic Surgeons, 1994, pp 405-419
18. McCarthy JG, Schreiber J, Karp N, et al: Lengthening the
human mandible by gradual distraction. Plast Reconstr
Surg 89:1, 1992
19. Polley JW, Figueroa AA: Management of severe maxillary
deficiency in childhood and adolescence through distraction osteogenesis with an external adjustable rigid
distraction device. J Craniofac Surg 8:181, 1997
20. Liou EJW, Polley JW, Figueroa AA: Distraction osteogenesis: the effects of orthodontic tooth movement on distracted mandibular bone. J Craniofac Surg 564-571,
1998
21. Nakamoto N, Nagasaka H, Daimaruya T, et al: Experimental tooth movement through mature and immature
bone regenerates after distraction osteogenesis in dogs.
Am J Orthod Dentofac Orthop 121:385-395, 2002
22. Cope JB, Harper RP, Samchukov ML: Experimental
tooth movement through regenerate alveolar bone: a
pilot study. Am J Orthod Dentofac Orthop 116:501-505,
1999
23. Cope JB, Liou EJ, Figueroa A, et al: Tooth movement
into regenerate alveolar bone: experimental basis and
clinical results, in Samchukov ML, et al (eds): Craniofacial Distraction Osteogenesis. St. Louis, MO, USA,
Mosby, 2001
24. Posnick JC, Tompson B: Cleft-orthognathic surgery:
complications and long-term results. Plast Reconstr Surg
96:255-266, 1995
25. Kanomi R: Mini-implant for orthodontic anchorage.
J Clin Orthod 31:763-767, 1997
26. Costa A, Raffainl M, Melsen B: Miniscrews as orthodontic anchorage: a preliminary report. Int Adult Orthodon
Orthognath Surg 13:201-209, 1998
27. Melsen B, Verna C: A rational approach to orthodontic
anchorage. Prog Orthod 1:10-22, 1999
28. Costa A, Dalstra M, Melsen B, et al: Aarhus anchorage
system. Ortognatod Ital 9:487-496, 2000
29. Melsen B, Costa A: Immediate loading of implants used
for orthodontic anchorage. Clin Orthod Res 3:23-28,
2000
30. Park HS, Bae SM, Kyung HM, et al: Micro-implant anchorage for treatment of skeletal class I bialveolar protrusion. J Clin Orthod 35:417-422, 2001
31. Lee JS, Park HS, Kyung HM: Micro-implant for lingual
treatment of a skeletal class II malocclusion. J Clin
Orthod 35:643-647, 2001
32. Park HS, Kyung HM, Sung JH: A simple method of
molar uprighting with micro-implant anchorage. J Clin
Orthod 36:592-596, 2002
33. Lin JCY, Liou EJ: A new bone screw for orthodontic
anchorage. J Clin Orthod 37:676-682, 2003
34. Park HS, Kwon TG, Sung JH: Non-extraction treatment
with miniscrew implant. Angle Orthod 74:539-549, 2004
35. Lee JS, Kim DH, Park YC, et al: The efficient use of
midpalatal miniscrew implants. Angle Orthod 74:711714, 2004
36. Kuroda S, Katayama A, Takano-Yamamoto T: Severe
anterior open-bite case treated using titanium screw anchorage. Angle Orthod 74:558-567, 2004
37. Lin JC, Liou EJ, Yeh CL: Intrusion of overerupted maxillary molars with miniscrew anchorage. J Clin Orthod
40:378-383, 2006
38. Lin JCY, Liao JJL, Liou EJW, et al: Protrusion treated
with premolar extraction and maximum retraction, in
Cope JB (ed): OrthoTADs: The Clinical Guide and Atlas
(ed 1). Under Dog Media, LP, Dallas, 2007:279-283
39. Liao JJL, Lin JCY, Liou EJW, et al: Protrusion treated by
first premolar extraction and maximum retraction, in
Cope JB (ed): OrthoTADs: The Clinical Guide and Atlas
(ed 1). Under Dog Media, LP, Dallas, 2007:317-321
40. Liao JJL, Lin JCY, Liou EJW: Canted occlusal plane
and anterior open bite treatment, in Cope JB (ed):
OrthoTADs: The Clinical Guide and Atlas (ed 1).
Under Dog Media, LP, Dallas, 2007:327-331
41. Liou EJW, Lin JCY: Adult class II subdivision malocclusion treated with extraction of decayed maxillary second
premolars, in: Cope JB (ed): OrthoTADs: The Clinical
Guide and Atlas (ed 1). Under Dog Media, LP, Dallas,
2007:322-326
42. Liou EJ, Chen PS, Wang YC, et al: A CT scan study on the
thickness of infrazygomatic crest of maxilla and its clinical implications for implant orthodontics. Am J Orthod
Dentofac Orthop 131:352-356, 2007
43. Liou EJ, Pai BC, Lin JC: Do miniscrews remain stationary
under orthodontic force? Am J Orthod Dentofac Orthop 126:42-47, 2004
44. Wang YC, Liou EJ: Comparison of the loading behavior
of the self-drilling and pre-drilling miniscrews throughout orthodontic loading. Am J Orthod Dentofac Orthop
133:38-43, 2008
45. Liou EJ, Huang CS: Rapid canine retraction through
distraction of the periodontal ligament. Am J Orthod
Dentofac Orthop 114:372-382, 1998
46. Liou EJ, Figueroa AA, Polley JW: Rapid orthodontic
tooth movement into distraction osteogenesis in a canine model. Am J Orthod Dentofac Orthop 117:391-398,
2000
47. Lindskog-Stokland B, Wennstrom JL, Nyman S, et al:
Orthodontic tooth movement into edentulous areas
with reduced bone height. An experimental study in the
dog. Eur J Orthod 15:89-96, 1993
48. Thilander B: Infrabony pockets and reduced alveolar
bone height in relation to orthodontic treatment. Semin
Orthod 2:55-61, 1996
49. Zengo A, Pawluk R, Bassett C: Stress-induced bioelectric
potentials in the dentoalveolar complex. Am J Orthod
64:17-27, 1973
50. Sarikaya S, Haydar B, Ciger S, et al: Changes in alveolar
bone thickness due to retraction of anterior teeth. Am J
Orthod Dentofac Orthop 122:15-26, 2002
51. Edward JC: A study of the anterior portion of the palate
as it relates to orthodontic therapy. Am J Orthod 69:249273, 1976
52. Mulie RM, Ten Hoeve A: The limitations of tooth movements within the symphysis studied with laminography
and standardized occlusal films. J Clin Orthod 10:882899, 1976
Management of Alveolar Cleft
53. Vardimon AD, Oren E, Ben-Bassat Y: Cortical bone remodelling/tooth movement ratio during maxillary incisor retraction. Am J Orthod Dentofac Orthop 114:520529, 1998
54. Handelman CS: The anterior alveolus: its importance in
limiting orthodontic treatment. Angle Orthod 2:95-110, 1996
55. Ten Hoeve A, Mulie RM: The effect of antero-postero
incisor repositioning on the palatal cortex as studied
with laminagraphy. J Clin Orthod 10:804-822, 1976
56. Wehrbein H, Bauer W, Diedrich PR, et al: Mandibular
incisors alveolar bone, and symphysis after orthodontic
tooth movement. A retrospective study. Am J Orthod
Dentofac Orthop 110:239-246, 1996
57. Wehrbein H, Fuhrmann RAW, Diedrich PR: Periodontal
conditions after facial root tipping and palatal root
torque of incisors. Am J Orthod Dentofac Orthop 106:
455-462, 1994
58. Batenhorst K, Bower GM, Willaims IE: Tissue changes
resulting from facial tipping and extrusion in monkeys.
L Periodontol 46:660-668, 1974
59. Wainwright WM: Faciolingual tooth movement: its influence on the root and cortical plate. Am J Orthod 64:
278-302, 1973
267
60. Vardimon AD, Graber TM, Voss LR, et al: Determinants
controlling iatrogenic external root resorption and repair during and after palatal expansion. Angle Orthod
61:113-124, 1991
61. Mulie RM, Ten Hoeve A: The limitations of tooth movements within the symphysis studied with laminography
and standardized occlusal films. J Clin Orthod 10:882899, 1976
62. Wehrbein H, Fuhrmann RAW, Diedrich PR: Human
histologic tissue response after long-term orthodontic
tooth movement. Am J Orthod Dentofac Orthop 107:
360-371, 1995
63. Wingard CE, Bowers GM: The effect of facial bone from
facial tipping if incisors in monkeys. J Periodontol 47:
450-454, 1976
64. Engelking C, Die Zachrisson BU: Auswirkung der
schneidezahnretraktion auf das parodontium von Affen
nach vorausgegangener protrusion durch die kortikalis.
Inf Orthod Kieferorthop 2:127-146, 1983
65. Karring T, Nyman S, Thilander B, et al: Bone regeneration in orthodontically produced alveolar bone dehiscence. J Periodontal Res 17:309-315, 1982
Surgical/Orthodontic Treatment of
Mandibular Asymmetries
Pamela R. Hanson, DDS, MS, and Michael B. Melugin, DDS, MS
The management of a mandibular asymmetry requires a combined surgical
and orthodontic approach. Orthodontic and orthopedic management in a
growing patient can sometimes fully correct an emerging minor mandibular
asymmetry. Moderate to severe asymmetries can usually be minimized but
not fully corrected with early orthodontic and orthopedic intervention.
Sometimes the severity of associated dysfunction or the presence of developmental compensations that are occurring with growth require early surgical intervention. Early surgical asymmetry correction (during growth), as
well as surgical treatment at growth cessation, has the same requirements
with respect to selecting the proper treatment approach. Ideally, the selected treatment should optimize symmetry, while minimizing morbidity
and treatment duration and maximizing long-term predictability. (Semin
Orthod 2009;15:268-278.) © 2009 Published by Elsevier Inc.
he timing and method of treatment is determined by the magnitude of mandibular
asymmetry, the skeletal age of the patient, and
the presence of functional deficits.
Minor asymmetries can be corrected with
growth modification through orthopedic and
orthodontic forces. Asymmetric forces delivered
during growth can result in resolution of asymmetry in mild cases. In more moderate to severe
asymmetries, effective growth modification may
only be enough to improve, but not fully correct,
asymmetry.
An assessment of the nature and magnitude
of the mandibular asymmetry must be completed as the first step toward management. Data
gathering for this assessment includes a thorough clinical and radiographic evaluation, pos-
T
From the Division of Oral and Maxillofacial Surgery, Medical
College of Wisconsin, Milwaukee, WI, Cleft and Craniofacial
Teams, Children’s Hospital of Wisconsin, Milwaukee, WI, Department of Orthodontics, School of Dentistry, Marquette University,
Milwaukee, WI, and Department of Dentistry, Children’s Hospital of
Wisconsin, Milwaukee, WI.
Address correspondence to Pamela R. Hanson, DDS, MS, 15855
West National Avenue, New Berlin, WI 53151; Phone: (262)
784-4050, Fax: (262) 784-3189; E-mail: [email protected]
© 2009 Published by Elsevier Inc.
1073-8746/09/1504-0$30.00/0
doi:10.1053/j.sodo.2009.07.006
268
teroanterior and lateral cephalometric studies,
and a dental occlusal evaluation.
The orthodontic and orthopedic management of mandibular asymmetry falls into 2 categories: orthodontic correction of the occlusal
asymmetry, or correction of the underlying skeletal discrepancy by combined orthodontic and
orthopedic means.
The correction of occlusal asymmetry may
include several treatment methods, including
asymmetric extraction therapy, asymmetric functional appliance therapy, asymmetric elastic traction (Fig. 1), asymmetric force delivery using
fixed or removable appliances, and others. A
successful outcome with treatment of this type is
the creation of a more symmetric and functional
occlusion while accepting the underlying skeletal disharmony.
Sometimes, however, the correction of an occlusal asymmetry allows for improvement in skeletal symmetry. In a patient with unilateral Class
II malocclusion and maxillary transverse deficiency, for example, correction of the unilateral
posterior crossbite will allow the mandible to
take a Class I position on the affected side, improving symmetry1 (Fig. 2).
The management of mandibular asymmetry
in the skeletally immature patient may take several courses: (1) fully addressing the asymmetry
Seminars in Orthodontics, Vol 15, No 4 (December), 2009: pp 268-278
Treatment of Mandibular Asymmetries
269
Figure 1. Orthopedic and/or orthodontic management of a young patient with asymmetric malocclusion. (A)
Asymmetric malocclusion in the mixed dentition, Class II (left side) and Class III (right side), midlines are not
coincident, occlusal cant to the mandibular dental arch. (B) Improved symmetry in the permanent dentition
after maxillary expansion, full fixed appliances, and elastic traction. (C) Continued asymmetric elastic traction.
Note that the maxillary and mandibular midlines are coincident, the occlusal cant is corrected, and right-to-left
symmetry of occlusion (Class I bilaterally) and the maxillo-mandibular transverse dimension are in harmony. (D)
Final skeletal and occlusal result with correction of the skeletal and occlusal disharmony. (Color version of figure
is available online.)
by orthopedic and/or orthodontic means, (2)
surgically addressing the asymmetry on skeletal
maturity, (3) orthodontic and/or orthopedic
management during the years of facial growth
followed by definitive surgical and/or orthodontic correction on completion of facial skeletal
growth, or (4) surgical correction of the asymmetry during growth and, if needed, again at
skeletal maturity. If early treatment objectives
are met from the standpoint of function, occlusion, and/or facial symmetry, the patient
must be retained and monitored through the
remainder of growth to ensure that the correction was stable. Reinstitution of orthopedic
and/or orthodontic treatment may be needed
if asymmetry reemerges with growth. A longrange plan that includes surgery at growth
cessation may be elected.
Patients with an asymmetry that is moderate
to severe and with no significant functional limitations may wait until skeletal maturity is
reached for a definitive orthodontic and/or surgical correction. This approach is best used for
patients with reasonable function and cosmesis,
who will not be negatively affected by waiting for
definitive treatment. If the patient is being negatively affected functionally, psychosocially, or cosmetically, the decision to address the asymmetry
early and then possibly again later may be the best
option. The intent of this approach is to optimize
function and cosmesis during growth, providing a
more normal interim status for the patient. Early
interventions will likely decrease the magnitude of
surgical correction that might be necessary at skeletal maturity. An early intervention that results in a
reduction of the severity of skeletal deformity will
result in a definitive surgical procedure that may
be less extensive and more stabile.
In the skeletally immature patient with severe
asymmetry, the option to treat early might be the
most appropriate choice, especially if there are
associated functional, psychosocial, or esthetic
issues that demand early intervention. Again,
later treatment will likely be needed, but the
magnitude of subsequent treatment is diminished by early intervention.
270
Hanson and Melugin
Figure 2. A 9-year-old boy with mandibular occlusal asymmetry and maxillary transverse deficiency. (A, B) Class
II subdivision (right side) malocclusion, mandibular midline (right side) 6 mm, maxillary transverse deficiency.
(C, D) At full permanent eruption following Phase I orthopedics and/or orthodontics which included maxillary
expansion and fixed anterior appliances only. Note that the maxillary and mandibular midlines are coincident,
the maxillo-mandibular transverse relationship is coincident, and the patient has bilateral Class I occlusion.
(Color version of figure is available online.)
Surgical Correction of Mandibular
Asymmetry
4. Alloplastic reconstruction of the ramus and/or
temporomandibular joint.
The surgical correction of mandibular asymmetry can be accomplished with several procedures. The most commonly employed procedures are as follows:
Selection and timing of the appropriate procedure requires that consideration be given to the
following:
1. Osteotomies (sagittal split, vertical ramus, inverted C, segmental osteotomies, others)
2. Autogenous or combined autogenous and/or
allogeneic (cadaveric) grafts
3. Distraction osteogenesis
1. Magnitude of the deformity
2. Nature of the asymmetry (overgrowth, undergrowth of structures, or some combination of
both)
3. Patency of the airway attributable to mandibular skeletal deficiency and retromandibular
airway obstruction.
Figure 3. Bilateral Sagital split ramus osteotomy. (Reprinted with permission from Elsevier.)
Figure 4. Internal vertical ramus osteotomy. (Reprinted with permission from Elsevier.)
Treatment of Mandibular Asymmetries
4. Skeletal age
5. Psychosocial and functional needs of the
growing patient that may require early (nondefinitive) surgical intervention
Mandibular Osteotomies
An osteotomy is a “bone cut” or a sectioning
into 2 or more pieces of the bone (in this case,
the mandible). Bone can then be removed at
the osteotomy site to reduce the mandibular
size, or bone can be grafted interpositionally
into the osteotomy site to lengthen the bone,
or the osteotomy can be structured such that
there is a planar section of overlap that allows
the bone halves to slide over one another to
lengthen the bone (the sagittal osteotomy or
the inverted “C” osteotomy) (Fig. 3). At surgery, with the osteotomy technique, the bone
is made shorter or longer by a specific length
that is planned before surgery, using clinical
and cephalometric evaluation. In general,
the magnitude of mandibular lengthening
through osteotomy techniques is limited by
long-term data that suggest stability for moves
271
less than 8-10 mm. Greater lengthening is possible, but the long-term stability of such advancements diminishes sharply above 10 mm.
Interpositional bone grafting and rigid internal fixation at the osteotomy site will improve
the stability of advancements of large magnitude.2-4
The mandible can be shortened or set back
with osteotomy techniques as well. Bone can be
removed from the ramus osteotomy site and the
body of the mandible slid posteriorly along
the plane of the sagittal osteotomy to reduce the
size of the mandible. A vertical ramus osteotomy
can also be used to set back or reduce the anteroposterior size or projection of the mandible
(Fig. 4). The choice of procedure depends on
multiple factors that include magnitude, lateral
projection of the gonial angle, the surgeon’s confidence in using a sagittal osteotomy for setback,
fixation, and stability among others (Fig. 5).5
Other segmental osteotomies of the mandible
are available for managing asymmetry, including
dentoalveolar segmental osteotomies, midline
osteotomies, and osteotomies of the inferior bor-
Figure 5. A skeletally mature 18-year-old girl with asymmetric prognathism. (A) Pretreatment findings were as
follows: skeletal and facial asymmetries, including chin point is to the right, mandibular morphology is
asymmetric, Class III malocclusion on the left side, Class II malocclusion on the right side, mandibular midline
is 7 mm right of the maxillary and facial midline. (B) Postorthognathic surgery and surgical orthodontics.
Improved facial symmetry, chin point is centered, mandibular right-to-left symmetry, bilateral Class I malocclusion, dental and facial midlines are coincident. (Color version of figure is available online.)
272
Hanson and Melugin
der of the mandible with advancement, setback,
asymmetry correction, or some combination of
the above mentioned osteotomies.6,7
Osteotomies are usually fixated rigidly or semirigidly with plates, screws, mesh, pins, and/or
wires. Rigid fixation can be combined with intermaxillary fixation. After healing of the osteotomies
is completed, the new size and shape of the mandible will change only as a result of relapse, late
and unexpected skeletal growth, or additional
skeletal surgery.
When orthognathic surgery is used to address
mandibular asymmetry, presurgical orthodontic
therapy is used to remove dental compensations,
level, align, and coordinate arches. The orthodontist and surgeon must agree on the final occlusal and skeletal outcome. The orthodontist
must provide a presurgically adjusted dentition
that allows the surgeon to place skeletal segments
in the predetermined position (Figs. 5 and 6).
Bone Grafts
Bone grafts may be used in combination with
osteotomies to improve the stability of large sagittal advancements of the mandibular body. In ad-
dition, allogeneic (cadaveric) bone can be used
interpositionally, or in combination with autogenous (harvested from the hip, calvarium, rib of the
same patient) to reconstruct large deficiencies of
the mandible. Before the advent and widespread use of distraction osteogenesis, large
magnitude deficiencies could be managed
with an allogenic hollowed-out mandibular
form filled with autogenous bone, or alternately, an autogenous rib or hip bone strut
packed with particulate autogenous bone. Allogeneic bone by itself does not transfer bone
cells. Therefore, it has limited applications for
mandibular lengthening. The addition of autogenous bone involves a separate surgical site
for bone harvesting. This involves additional
cost, time, and morbidity. In addition, rib and
clavicle may be used to reconstruct the ramus
of the mandible for large magnitude deficiencies that include absence of a normal articulating condylar surface. These bone grafts are
harvested in continuity with their articulating
cartilage, which then serves as the articulating
surface within the temporomandibular joint.
These costochondral grafts have the potential
for growth when used in a growing patient.
Figure 6. An 18-year-old girl with hemifacial microsomia. (A) After presurgical orthodontic preparation,
immediate presurgery findings were as follows: soft tissue and skeletal left-sided deficiencies, occlusal cant,
discrepancies between the maxillary, mandibular, and facial midlines. (B) Postorthognathic surgery and surgical
orthodontics. Orthognathic surgery included Le Fort I leveling by differential impaction and down grafting and
advancement and bilateral sagittal split ramus osteotomy. Post-treatment findings include soft tissue and skeletal
symmetry, occlusal cant corrected, coincident midlines, and good overall occlusion. (Color version of figure is
available online.)
Treatment of Mandibular Asymmetries
This growth, however, is not predictable and
may exhibit undergrowth or, more rarely,
overgrowth. These grafts may also be rigidly or
semirigidly fixated to the mandible, and are
subject to the volume limitations of the softtissue bed at the site.
Distraction Osteogenesis
The use of distraction osteogenesis (Fig. 7) for
the correction of mandibular growth deficiencies has been described in the published data of
craniofacial surgery. An osteotomy is performed
in the mandible. An expansion screw is attached
to the mandible, across the osteotomy site with
skeletal pin fixation. After a latency period, the
screw is adjusted at a rate of 1 mm per day, which
lengthens the healing bone callus (or regenerate)
and the adjacent soft-tissue envelope (Fig. 8). This
procedure differs from grafting in that the bone
and the surrounding soft tissues are formed where
needed, rather than being harvested from a second remote site. Instead of stretching the softtissue envelope to place a graft, surrounding soft
tissue grows and expands along with the generated
bone, presumably providing superior stability with
273
distraction when compared with grafting (as well
as providing needed soft-tissue contour and/or
bulk). Grafted bone can become infected and/or
fail to integrate at the recipient site, whereas distracted bone is native to the mandible and improves postsurgical stability.
Distraction techniques may be less predictable than orthognathic surgery for correction
of mandibular asymmetry, in that it is challenging to predetermine the precise shape of
the newly formed regenerate. Distraction osteogenesis is a dynamic process that requires
careful and precise planning and surgical
technique to create a regenerate that corrects
the mandibular asymmetry.8-11 In contrast,
grafting and orthognathic surgery, despite
their shortcomings, predictably achieve the
surgical plan, although in some cases with less
stability.
In the mild-to-moderate (ⱕ10 mm) deformities, correction of the asymmetry with conventional orthognathic surgery is desirable. In the
more severe cases in which orthognathic surgery is
less practical, distraction osteogenesis becomes the
treatment of choice. The distraction regenerate
Figure 7. A) distraction device placement at surgery, prior to initiation of distraction, B) Distraction device activation,
creation of the distraction gap by mandibular lengthening. (Reprinted with permission from Elsevier.)
274
Hanson and Melugin
Figure 8. A 10-year-old girl with a diagnosis of craniofacial microsomia with left-sided 3-dimensional soft tissue and
skeletal deficiencies. (A) Pretreatment: chin point to the left, occlusal cant, mandibular asymmetry. (B) Unilateral
distraction osteogenesis with an internal distraction device. (C) Postdistraction facial symmetry: chin point, occlusal
cant, and mandibular soft and skeletal asymmetry corrected. (Color version of figure is available online.)
can be manipulated by adjustment of the distraction device, or with orthopedic forces applied to
the mandibular body. In addition, it is often possible to mold the regenerate while it is still plastic
before consolidation.
Before distraction surgery, fixed orthodontic
and distraction stabilization appliances (Fig. 9)
are placed to decompensate the dentition and to
prepare the arches for the postdistraction occlusion. When distraction is used as a definitive
surgical procedure, the goal is a functional and
esthetic occlusion. In this case, presurgical alignment of the dental arches is similar to preparation
for orthognathic surgery. Fixed orthodontic appliances are placed, all dental compensations
resolved, and arches are coordinated. Progress
dental study models are prepared frequently
during the course of predistraction orthodontics. The maxillary and mandibular dental study
models can be hand-articulated into the predicted postdistraction occlusion and evaluated
for compatibility of the occlusion. If the distraction is not to be the definitive surgical intervention, then the predistraction orthodontic preparation is less demanding.
During the course of distraction activation and
consolidation periods, orthodontic dental movement may be achieved. Efficiency of dental movement and orthopedic changes may, in fact, be
enhanced immediately after this surgical intervention.12 Although fixed orthodontic appliances can
achieve individual tooth movement, distraction
stabilization appliances10 (Figs. 9 and 10) stabilize
the arch for orthopedic manipulation. This appliance consists of 4 orthodontic bands soldered to a
heavy palatal and lingual arch. This appliance provides multiple labial, palatal, and lingual sites for
attachment of intermaxillary elastics. These elastics
are used to manipulate the regenerate during distraction and later to achieve orthopedic and dental corrections.13
In the unilateral mandibular deficiency, the
maxilla on the affected site is vertically deficient.
As the ramus is lengthened on the affected side,
the mandibular dentition moves downward,
away from the maxillary dentition resulting in an
open bite. The postdistraction open bite can be
addressed with a postdistraction orthodontic
bite block that is gradually adjusted to achieve
hypereruption of the dentition and vertical
growth of the alveolar process, hence leveling
the occlusal plane (Figs. 11 and 12).
Alloplastic Reconstruction of the
Ramus and Temporomandibular Joint
Although alloplastic reconstruction (total joint
prosthesis) is usually used for the multiple operated end-stage degenerative joint disease patients, there are applications for their use in
asymmetric patients. Asymmetries that are secondary to ankylosis, severe degenerative joint
disease, or condylar pathology or necrosis might
be best served with an alloplastic reconstruction.
Treatment of Mandibular Asymmetries
275
Figure 9. Distraction stabilization appliances, designed to control the distal segment during distraction and consolidation. (A) Fixed maxillary palatal expansion appliance and mandibular lingual arch. (B) Cross arch elastics to
control distal segment position. Note the buccal headgear tubes and buccal and lingual attachments to support elastic
traction. (Reprinted with permission from Elsevier.) (Color version of figure is available online.)
Total joint prosthesis is an alternative for costochondral or sternoclavicular grafting for patients
who require a replacement of large condyle
and/or ramus segments. Although autogenous
grafts confer the ability to grow, they require a
second surgical site for harvest. In the nongrowing patient, the alloplastic total joint prosthesis
requires no harvest, might better resist reankylosis (heterotopic calcification), and is not as
susceptible to the resorption or failure as can be
a graft at the site of significant soft-tissue envelope stretch that can occur when trying to re-
establish the vertical height of a degenerated or
otherwise vertically deficient ramus. The current
generation of total joint prostheses is computerassisted designed and computer-aided manufactured, and custom fit to the ramus and condyle
of the individual patient based on that individual’s computed tomography scan. Because of this
custom fit and the use of biocompatible materials, these joints are a good long-term solution to
significant volume deficiency of the mandible in
association with the loss of the articulating surface. These asymmetries may be developmental
Figure 10. The biomechanics of distraction stabilization appliances. (A) Laterognathism: mandibular and chin
point shift away from the distraction side, crossbite on the distraction side, buccal crossbite on the contralateral
side, and failure of desired open bite formation on the distraction side. (B) Maxillary expansion to address
crossbites, mandibular midline position restored by interarch elastic wear: cross arch/cross palatal, Class III on
distraction osteogenesis side, Class II on the contralateral side, crossbite on both sides. (Reproduced with
permission from Barry Grayson, Institute of Reconstructive Plastic Surgery, New York University Medical Center.
Reprinted with permission from Elsevier.) (Color version of figure is available online.)
276
Hanson and Melugin
alloplasts include infection and/or failed integration, the potential for long-term eventual device failure, and the fact that the alloplast does
not grow, remodel, or adapt.
Selection of the Proper Surgical
Procedure for the Correction of
Mandibular Asymmetry
Figure 11. An 8-year-old boy with a diagnosis of Goldenhar Syndrome. (A) Pretreatment findings: rightsided 3-dimensional soft tissue and skeletal deficiencies, chin point to the right, mandibular midline right
of maxillary dental and facial midlines. (B) Pretreatment occlusal cant demonstrating right-sided mandibular vertical and anterior–posterior deficiency and
compensatory maxillary vertical and anterior–posterior deficiency. (C) Unilateral right distraction device
positioned perpendicular to the functional occlusal
plane to provide vertical lengthening of the mandibular ramus. Note the correction of the chin point to
the left and correction of the right skeletal and soft
tissue deficiencies and leveling of the mandibular
occlusal plane. There is a unilateral open bite created
by the correction of the mandibular vertical deficiency and the remaining compensatory maxillary
cant and vertical deficiency. (D) Postunilateral distraction to level the mandibular occlusal plane and
correct the vertical deficiency of the mandible and
postorthopedic leveling of the compensatory maxillary occlusal cant by selective eruption and vertical
alveolar development. (Color version of figure is available online.)
or secondary to the failure of prior procedures
(eg, for failed or ankylosed prior rib grafts). In
the skeletally mature or near skeletally mature
asymmetry patient, this form of reconstruction
provides an alternative to distraction and/or
bone reconstruction. Obvious shortcomings of
Conventional orthognathic surgery, with or
without allogeneic or autogenous interpositional bone grafts, may be indicated for correction of mild to moderate anteroposterior
and vertical deficiencies of the mandible (approximately ⬍10 mm). In the more severe
cases, interpositional grafting improves longterm stability. If interpositional grafting is required, bone can be harvested from the symphysis, the contralateral ramus, the maxillary
tuberosity, the tibia, or calvarium, adding minimum additional surgical time or morbidity.
Alternatively, a block of allogeneic material
may be used. Orthognathic surgical correction
of mandibular asymmetry allows immediate intraoperative assessment and modification of
the resulting symmetry and occlusion, whereas
in distraction osteogenesis these modifications
and alterations occur during the activation
and consolidation phases.14 In moderate cases
in which both orthognathic surgery and distraction osteogenesis could be performed, the
former offers several advantages. Orthognathic surgery achieves the clinical objectives
in a 1-step procedure, whereas distraction osteogenesis requires an extended period for
activation, consolidation, and surgical removal
of the devices. In distraction, there may also be
external scars and some degree of imprecision
in the correction of mandibular deformity and
occlusion. Although orthognathic surgery provides certain advantages in these moderate
cases, it may be less stable in the long run.
As mentioned previously, osteotomies are
used to reduce hyperplastic structures that are
contributing to mandibular asymmetry. Vertical ramus osteotomies allow setback of the
body and ramus and may be completed using
an intraoral, extraoral, and/or endoscopic
technique. Sagittal split osteotomies may also
be used for the reduction of a hyperplastic
mandible; however, this procedure for setback
or size reduction exhibits lower long-term sta-
Treatment of Mandibular Asymmetries
277
Figure 12. Post-unilateral mandibular distraction. (A) A desired unilateral posterior open bite is demonstrated
by the distraction, correcting the mandibular occlusal cant and the remaining uncorrected maxillary canted
occlusal plane. (B) (lateral view), C (frontal view). An acrylic splint is placed to maintain the mandibular
corrected plane of occlusion and to allow for sequential adjustment of the splint to allow for super eruption of
the most posterior maxillary tooth and vertical alveolar development, thereby correcting the maxillary occlusal
cant orthopedically. The splint may be stabilized to the maxillary arch with elastic traction as well as augmenting
the supereruption of the teeth sequentially. (D) Final occlusion following occlusal plane leveling and orthodontic finishing. (E) (Reproduced with permission from Dr Barry Grayson, Craniofacial Orthodontist at New York
University describing the biomechanics of maxillary occlusal plane leveling.). (Color version of figure is available
online.)
bility because of factors related to technique
and patient selection.4 There is no distraction
procedure for the reduction in size of a hyperplastic structure.
In addition to ramal osteotomies, segmental
and symphyseal osteotomies may also be used in
the correction of mandibular asymmetry, providing for early rehabilitation and function. In cases
in which there is a borderline airway problem,
one must carefully determine at what level (retromaxillary or retromandibular) the problem
exists. If the airway deficiency is at the retromandibular level, one must be aware that a mandibular set back procedure can potentially create a
worsening of the airway dynamics. The decision
as to whether an asymmetry is due to under-
278
Hanson and Melugin
growth on one side or overgrowth on the other
side is based on careful clinical and cephalometric evaluation. In addition, increased uptake of
radionuclide in the condylar area of the enlarged ramus might be used to corroborate the
diagnosis of condylar hyperplasia (nuclear scintigraphy or bone scan).
For patients with potential concerns related
to sleep-disordered breathing that is at least
partially attributable to decreased airway volume, consideration must be given to preserving airway space.15
In the growing patient, a definitive surgical
correction is recommended on completion of
facial skeletal growth. However, functional
(psychosocial, airway, speech, swallowing) deficits often require early surgical (orthognathic
or distraction osteogenesis) intervention. If
early surgery is indicated, overcorrection of
the deficient mandible might be recommended to compensate for the innate growth
problem, with the awareness that a secondary
surgical procedure might be needed at the
completion of facial growth. If a decision is
made to wait until growth completion, potential dental and alveolar compensations might
occur. These could be managed orthodontically and orthopedically before the definitive
surgical correction. In addition, some surgeons consider the sagittal split osteotomy
more difficult when performed in a young
growing child.
The correction of mandibular asymmetry
sometimes requires a different surgical procedure on each side of the mandible. For example,
a vertical ramus osteotomy setback on one side
and a sagittal split osteotomy advancement on
the other may be indicated. Similarly, a rib graft
might be used to restore length on the deficient
side, combined with a sagittal split osteotomy
advancement on the contralateral side.
The patient’s needs can be fully addressed
only through the effort of a craniofacial orthodontist operating within the context of an
experienced interdisciplinary team. The
craniofacial orthodontist carefully describes
the skeletal and/or dental deformity, facial
esthetics, and the patient’s stage of growth and
development. Other members of the team define critical functional and psychosocial needs.
Taking the team’s critical evaluation and rec-
ommendations into consideration, the skilled
surgeon is best able to select among the various surgical options (conventional orthognathic surgical procedures, distraction osteogenesis) to meet the patient’s needs.
References
1. Chang JY, McNamara JA Jr, Herberger TA: A longitudinal study of skeletal side effects induced by rapid maxillary expansion. Am J Orthod Dentofacial Orthop 112:
330-337, 1997
2. Gassmann CJ, Van Sickels JE, Thrash WJ: Causes, location, and timing of relapse following rigid fixation after
mandibular advancement. J Oral Maxillofac Surg 48:450454, 1990
3. Bays RA, Bouloux GF: Complications of orthognathic
surgery. Oral Maxillofac Surg Clin North Am 15:229-242,
2003
4. Serafin B, Perciaccante VJ, Cunningham LL: Stability of
orthognathic surgery and distraction osteogenesis: options and alternatives. Oral Maxillofac Surg Clin North
Am 19:311-320, 2007
5. Tucker MR: Surgical correction of mandibular excess,
technical considerations for mandibular setbacks. Atlas
Oral Maxillofac Surg Clin North Am 1:29-39, 1993
6. Bloomquist DS: Anterior segmental mandibular osteotomies for the correction of facial-skeletal deformities.
Oral Maxillofac Surg Clin North Am 19:369-379, 2007
7. Alexander CD, Bloomquist DS, Wallen TR: Stability of
mandibular constriction with symphyseal osteotomy.
Am J Orthod Dentofacial Orthop 103:15-23, 1993
8. Grayson B, Santiago P: Treatment planning and biomechanics of distraction osteogenesis from an orthodontic
perspective. Semin Orthod 5:9-24, 1999
9. Grayson BH, Santiago PE: Treatment planning and
vector analysis of mandibular distraction osteogenesis.
Atlas Oral Maxillofac Surg Clin North Am 7:1-13,
1999
10. Hanson PR, Melugin MB: Orthodontic management of
the patient undergoing mandibular distraction osteogenesis. Semin Orthod 5:25-34, 1999
11. Hanson PR: Treatment planning and orthodontic management of patients undergoing mandibular distraction
osteogenesis, in Samchukov ML, Cope JB, Cherkashin
AM (eds): Craniofacial Distraction Osteogenesis. St.
Louis, MO, Mosby, 2001, pp 156-167
12. Frost HM: The regional acceleratory phenomenon: a
review. Henry Ford Hosp Med J 31:3-9, 1983
13. Hanson P, Melugin M: Orthopedic and orthodontic
management of distal segment position during distraction osteogenesis. Atlas Oral Maxillofac Surg Clin North
Am 16:273-286, 2008
14. Chigurupati R: Orthognathic surgery for secondary cleft
and craniofacial deformities. Oral Maxillofac Surg Clin
North Am 17:503-517, 2005
15. Leighton S, Drake A: Airway considerations in craniofacial patients. Oral Maxillofac Surg Clin North Am 16:
555-566, 2005