Perpendicular serial maxillary distraction osteogenesis in cleft lip and palate patients

Abstract

Background: Cleft lip and palate patients often have a retruded maxilla with a severely narrowed deficient maxillary arch. This report aims to describe the management of severe maxillary retrusion and constriction in cleft lip and palate patients using distraction osteogenesis applied in serial sequence in two directions perpendicular to each other.

Materials and methods: Two adult male cleft lip and palate patients were treated with maxillary distraction osteogenesis in two stages. In the first stage, surgically assisted rapid palatal expansion with a tooth-borne device was performed to significantly expand the maxillary arch in the transverse dimension. After the teeth were orthodontically aligned, the horizontal distraction of the maxilla was made by two internal maxillary distraction devices.

Results: In the first patient, the maxilla was initially widened by 11 mm and then distracted forward by 20 mm. Despite the breakage of the shaft of one of the two distractors at the end of distraction, a satisfactory occlusion was found at the time of distractor device removal. The maxillary position has remained stable through 8 years of follow-up. In the second patient, the palate was widened by 14 mm and the maxilla was distracted forward by 22 mm. The maxillary position has remained stable through 3 years of follow-up.

Conclusion: Sequential serial distraction of maxilla in two planes perpendicular to each other is a safe and stable approach for the treatment of cleft lip and palate patients with severe transverse and anteroposterior discrepancies.

Keywords: Cleft lip and palate; maxillary distraction osteogenesis; palate expansion.

Figure 1

Preoperative frontal photograph of case 1

Figure 2

Preoperative lateral photograph of patient

Figure 3

Preoperative photograph of severely malaligned and malpositioned teeth with severe transverse maxillary deficiency

Figure 4

Preoperative left lateral buccal segment view of occlusion

Figure 5

Preoperative occlusal view showing severely constricted maxillary arch

Figure 6

Maxillary tooth-borne device being activated to initiate transverse maxillary distraction

Figure 7

Occlusal radiograph taken at the start of maxillary transverse distraction

Figure 8

Occlusal radiograph taken at the end of maxillary transverse distraction. Note the large diastemma that has been produced in the midline

Figure 9

Maxillary occlusal view photograph showing teeth being aligned in the maxilla following its transverse distraction

Figure 10

Photograph showing retrusive maxilla prepared for advancement

Figure 11

Lateral cephalometric radiograph just prior to maxillary anterior distraction

Figure 12

Maxillary distractor footplates are prebent and fitted and secured with screws to stereolithic skull of patient

Figure 13

Alignment rods are attached to the distractors installed on stereolithic skull to check alignment

Figure 14

Maxillary distractors fitted at time of Le Fort I osteotomy

Figure 15

Postoperative lateral cephalometric radiograph showing maxillary distractors at the beginning of distraction

Figure 16

Maxilla distracted into its new occlusal relationship. The distractors are kept in place for 3 months following the attainment of the final maxillary position as retention devices

Figure 17

Lateral cephalometric radiograph taken after distractor removal and replacement by 4 L-shaped internal fixation plates

Figure 18

Broken distractor rod with a crack in its shaft noted at the time of distractor removal. This breakage seemed to have no influence on the distraction outcome

Figure 19

Postoperative frontal photograph of patient

Figure 20

Postoperative anterior view of occlusion with class I molar relationship and no cross-bite

Figure 21

Postoperative right lateral occlusal view

Figure 22

Postoperative left lateral occlusal view

Figure 23

Preoperative frontal photograph of case 2

Figure 24

Preoperative anterior view of occlusion of constricted and retrusive maxilla after preliminary orthodontic alignment

Figure 25

Right lateral view of buccal segment showing severely retrusive maxilla and complete cross-bite

Figure 26

Left lateral view of buccal segment showing severely retrusive maxilla and complete cross-bite

Figure 27

Anterior view of occlusion after transverse distraction of maxilla increasing the palatal width by 14 mm

Figure 28

Predistraction lateral cephalometric radiograph showing severe maxillary retrusion

Figure 29

Lateral cephalometric radiograph showing maxilla with distraction devices and maxilla partway advanced

Figure 30

Dental implant being placed into generously wide anterior maxillary ridge left by the wake of bone produced by maxillary transverse distraction procedure without the need for bone grafting or augmentation of the ridge

Figure 31

Postretention lateral cephalometric radiograph with distractors having been removed 3 months following the completion of distraction. Internal fixation devices have been applied for long-term retention, and dental implants are in place with anterior incisal alignment normalized

Figure 32

Posttreatment panoramic radiograph showing restored dental implants in position

Figure 33

Postoperative frontal facial photograph of case 2 showing improved facial esthetics with new position of anteriorly distracted maxilla with improved subnasal support

Figure 34

Postoperative anterior view of the occlusion and dental implant restorations

Figure 35

Postoperative right lateral buccal segment view of occlusion with no cross-bite

Figure 36

Postoperative left lateral buccal segment view of occlusion with no cross-bite