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. 2011 Jun 1;17(2):138-148.
doi: 10.1053/j.sodo.2011.01.001.

Protocols for Late Maxillary Protraction in Cleft Lip and Palate Patients at Childrens Hospital Los Angeles

Stephen L-K Yen  1
Affiliations

Protocols for Late Maxillary Protraction in Cleft Lip and Palate Patients at Childrens Hospital Los Angeles

Stephen L-K Yen. Semin Orthod. .

Abstract

This paper describes the protocols used at Childrens Hospital Los Angeles (CHLA) to protract the maxilla during early adolescence. It is a modification of techniques introduced by Eric Liou with his Alternate Rapid Maxillary Expansion and Constriction (ALT-RAMEC) technique. The main differences between the CHLA protocol and previous maxillary protraction protocols are the age the protraction is attempted, the sutural loosening by alternating weekly expansion with constriction and the use of Class III elastics to support and redirect the protraction by nightly facemask wear. The CHLA protocol entirely depends on patient compliance and must be carefully taught and monitored. In a cooperative patient, the technique can correct a Class III malocclusion that previously would have been treated with LeFort 1 maxillary advancement surgery. Thus, it is not appropriate for patients requiring 2 jaw surgeries to correct mandibular prognathism, occlusal cants or facial asymmetry. The maxillary protraction appears to work by a combination of skeletal advancement, dental compensation and rotation of the occlusal planes. Microscrew/microimplant/temporary anchorage devices have been used with these maxillary protraction protocols to assist in expanding the maxilla, increasing skeletal anchorage during protraction, limiting dental compensations and reducing skeletal relapse.

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Figures

Figure 1
Figure 1
Pretreatment. 13-year-old female with repaired unilateral cleft lip and palate planned for maxillary protraction. Fixed appliances were used to align premolars in preparation for maxillary protraction. (A) Extraoral frontal view; (B) extraoral profile view; (C) intraoral right lateral view; (D) intraoral frontal view; (E) intraoral left lateral view. (Color version of figure is available online.)
Figure 1
Figure 1
Pretreatment. 13-year-old female with repaired unilateral cleft lip and palate planned for maxillary protraction. Fixed appliances were used to align premolars in preparation for maxillary protraction. (A) Extraoral frontal view; (B) extraoral profile view; (C) intraoral right lateral view; (D) intraoral frontal view; (E) intraoral left lateral view. (Color version of figure is available online.)
Figure 1
Figure 1
Pretreatment. 13-year-old female with repaired unilateral cleft lip and palate planned for maxillary protraction. Fixed appliances were used to align premolars in preparation for maxillary protraction. (A) Extraoral frontal view; (B) extraoral profile view; (C) intraoral right lateral view; (D) intraoral frontal view; (E) intraoral left lateral view. (Color version of figure is available online.)
Figure 1
Figure 1
Pretreatment. 13-year-old female with repaired unilateral cleft lip and palate planned for maxillary protraction. Fixed appliances were used to align premolars in preparation for maxillary protraction. (A) Extraoral frontal view; (B) extraoral profile view; (C) intraoral right lateral view; (D) intraoral frontal view; (E) intraoral left lateral view. (Color version of figure is available online.)
Figure 1
Figure 1
Pretreatment. 13-year-old female with repaired unilateral cleft lip and palate planned for maxillary protraction. Fixed appliances were used to align premolars in preparation for maxillary protraction. (A) Extraoral frontal view; (B) extraoral profile view; (C) intraoral right lateral view; (D) intraoral frontal view; (E) intraoral left lateral view. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 2
Figure 2
Treatment changes in same patient after first three weeks of protraction. (A) Extaroral frontal view; (B) extraoral three-quarter view; (C) extraoral profile view; (D) intraoral right lateral view; (E) intraoral frontal view; (F) intraoral left lateral view; (G) palatal occlusal view; (H) mandibular occlusal view; (I) view of downward direction of elastic pull to facemask. (Color version of figure is available online.)
Figure 3
Figure 3
Post-treatment. (A) Intraoral frontal view patient wearing retainers with artificial tooth; (B) pre-and post treatment tracing; (C) vacuum-form retainers with buttons for Cl III elastics. (Color version of figure is available online.)
Figure 3
Figure 3
Post-treatment. (A) Intraoral frontal view patient wearing retainers with artificial tooth; (B) pre-and post treatment tracing; (C) vacuum-form retainers with buttons for Cl III elastics. (Color version of figure is available online.)
Figure 3
Figure 3
Post-treatment. (A) Intraoral frontal view patient wearing retainers with artificial tooth; (B) pre-and post treatment tracing; (C) vacuum-form retainers with buttons for Cl III elastics. (Color version of figure is available online.)
Figure 4
Figure 4
Lateral cephalometric radiographs of a patient treated by maxillary protraction demonstrating the importance of overcorrection and settling after expander removal. (A) Lateral cephalographs taken before protraction; (B) overcorrection with 9 mm of overjet; (C) settling of occlusion at the end of treatment.
Figure 4
Figure 4
Lateral cephalometric radiographs of a patient treated by maxillary protraction demonstrating the importance of overcorrection and settling after expander removal. (A) Lateral cephalographs taken before protraction; (B) overcorrection with 9 mm of overjet; (C) settling of occlusion at the end of treatment.
Figure 4
Figure 4
Lateral cephalometric radiographs of a patient treated by maxillary protraction demonstrating the importance of overcorrection and settling after expander removal. (A) Lateral cephalographs taken before protraction; (B) overcorrection with 9 mm of overjet; (C) settling of occlusion at the end of treatment.
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
Figure 5
Figure 5
Microimplant-supported maxillary protraction. (A) Extraoral profile view; (B) intraoral frontal view showing lower microimplant position; (C) intraoral frontal view showing treatment changes; (D) palatal occlusal view showing microimplant positions; (E) pre-treatment lateral cephalogram; (F) post-treatment cephalogram after four months of maxillary protraction; (G) post-treatment extraoral profile view. (Color version of figure is available online.)
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