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Richardson S, Sinai Khandeparker RV, Krishna S, Diwaker M. Cleft Maxillary Hypoplasia: Comparison of Techniques and Proposal of a Novel Treatment Protocol for Management. J Craniofac Surg 2023:00001665-990000000-01201. [PMID: 37973037 DOI: 10.1097/scs.0000000000009844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/30/2023] [Indexed: 11/19/2023] Open
Abstract
This study was designed to compare different techniques of managing cleft maxillary hypoplasia and to propose a treatment protocol taking patient's age of presentation, amount of maxillary hypoplasia, and presence/absence of velopharyngeal insufficiency (VPI) into consideration. Five treatment modalities, viz. facemask therapy (Group I), anterior maxillary distraction (Group II), total maxillary distraction osteogenesis using rigid external distraction devices (Group III) and internal distraction devices (Group IV), and conventional orthognathic surgery (Group V), were assessed retrospectively using lateral cephalograms (taken at 3 intervals) and speech records (studied pre- and post-operatively). The results were subjected to statistical analysis. A P value of less than 0.05 was considered statistically significant. The mean advancement achieved in groups I, II, III, IV, and V was 4.2±1.54, 9.03±2.62, 11.82±1.18, 10.41±1.42, and 7.24±2.44 mm, respectively. The mean horizontal relapse noted in Groups I, II, III, IV, and V was 2.3 mm (n=8), 2.1 mm (n=14), 3.4 mm (n=10), 1.4 mm (n=5), and 2.4 mm (n=24), respectively. Compared to other groups, group II had fewer patients exhibiting relapse, a statistically significant observation. Similarly, statistically significant improvement in speech outcomes was found only in group II compared to other groups. Based on the results, a treatment protocol was proposed. The authors conclude that the proposed protocol would enable surgeons to decide the most appropriate treatment modality paying attention to not only the age of presentation and amount of advancement but also presence/absence of VPI which is instrumental in deciding upon the most appropriate treatment.
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Affiliation(s)
- Sunil Richardson
- Department of Oral and Maxillofacial Surgery Richardson's Dental and Craniofacial Hospital, Parvathipuram, Nagercoil, Tamil Nadu, India
| | - Rakshit Vijay Sinai Khandeparker
- Department of Oral and Maxillofacial Surgery Richardson's Dental and Craniofacial Hospital, Parvathipuram, Nagercoil, Tamil Nadu, India
- Department of Oral and Maxillofacial Surgery, Goa Dental College and Hospital, Bambolim, Calapor, India
| | - Shreya Krishna
- Department of Oral and Maxillofacial Surgery Richardson's Dental and Craniofacial Hospital, Parvathipuram, Nagercoil, Tamil Nadu, India
- Department of Dentistry Vimhans Nayati Super Specialty Hospital, New Delhi, India
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Yamagata K, Mohri T, Watanabe A, Bukawa M, Uchida F, Fukuzawa S, Ishibashi-Kanno N, Bukawa H. Anterior Maxillary Distraction Osteogenesis With Bone-borne Intraoral Buccal Devices for Maxillary Hypoplasia With Cleft Lip and Palate. J Craniofac Surg 2023; 34:1867-1871. [PMID: 37253151 DOI: 10.1097/scs.0000000000009412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/20/2023] [Indexed: 06/01/2023] Open
Abstract
Anterior maxillary distraction osteogenesis (AMDO) surgery for cleft lip and palate involves distraction of a segment of the anterior maxilla and advancement using 2 intraoral buccal bone-borne distraction devices. The anterior part of the maxilla is advanced anteriorly with less relapse which increases maxillary length and does not affect speech. We aimed to evaluate the effects of AMDO, including lateral cephalometric changes. Seventeen patients who had undergone this procedure were included in this retrospective study. The distractors were activated by 0.5 mm twice a day after a 3-day latency period. Lateral cephalometric radiographs were evaluated preoperatively, after distraction and removal of distractors, which were compared using the paired Student's t test. Anterior maxillary advancement was obtained in all patients with a median of 8.0 mm. Complications included nasal bleeding and loosening of distractors; however, there was no tooth damage or abnormal movement. The mean sella-nasion-A point (SNA) angle increased significantly, from 74.91° to 79.66°, the A point-nasion-B point angle from -0.38° to 4.34°, and the perpendicular line from nasion to Frankfort Horizontal (NV)-A point from -5.11 to 0.08 mm. The mean anterior nasal spine-posterior nasal spine length increased significantly from 50.74 to 55.10 mm, and the NV-Nose Tip from 23.59 to 26.27 mm. The mean relapse rate of NV-A was 11.1%. AMDO with bone-borne distractor resulted in less relapse and effectively corrected the maxillary retrusion.
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Affiliation(s)
- Kenji Yamagata
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tamaki Mohri
- Mohri Orthodontic Office, 2-2-7 Kasuga, Tsukuba, Ibaraki, 305-0821, Japan
| | - Atsushi Watanabe
- Mohri Orthodontic Office, 2-2-7 Kasuga, Tsukuba, Ibaraki, 305-0821, Japan
| | - Moeka Bukawa
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Fumihiko Uchida
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Satoshi Fukuzawa
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naomi Ishibashi-Kanno
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hiroki Bukawa
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
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Abstract
ABSTRACT A series of skeletal and dentoalveolar/occlusal criteria were proposed for choosing the treatment modality for the management of midface hypoplasia in cleft lip/palate patients, focusing on functional improvement, aesthetics, and minimizing the risk of recurrence and secondary alterations. For which, 42 patients with nonsyndromic cleft lip/palate, all with previous primary lip/palate surgeries and without previous osteotomies, were analyzed. Orthognathic surgery (OS) (n = 24) and maxillary distraction osteogenesis (n = 18) with anterior segmental osteotomies (segmental distraction osteogenesis [SD]), alveolar transport disc (TD), and midface total distraction osteogenesis (TDO) by modified Le Fort III osteotomy was done.The average of maxillary advancement for OS was 5.58 ± 0.83 mm, for SD 9.4 ± 0.89 mm, for TD 8.00 ± 1.00 mm, and for TDO was 8.13 ± 1.55 mm.In the presence of infraorbital and/or zygomatic hypoplasia, TDO was performed using skeletal anchorage, with the requirement of occlusal stability in dental cast in occlusion. In short maxillary arch without dental cast feasibility in occlusion, hypodontia/agenesis or absence of premaxilla, TD and SD was performed. There was only 1 mm of recurrence in 1 patient of each group. Changes in speech were detected in 2 patients in the OS group (8.3%). Orthognathic surgery can be indicated for advancements ≤7 mm not requiring orbito-zygomatic advancement, whereas distraction osteogenesis can be indicated for advances >8 mm with or without the need for orbito-zygomatic advancement, in addition with other dentoalveolar factors and velopharyngeal function.
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Perera WKL, Jayawardana RADTM, Pathirage SL, Dias DK, Dasanayaka DARK. Occlusal and Functional Improvement of Patients With Midfacial Hypoplasia Corrected Using Intraoral Tooth-Borne Mid-Maxillary Osteodistractors at Teaching Hospital-Karapitiya, Sri Lanka. Cleft Palate Craniofac J 2020; 58:1160-1168. [PMID: 33322923 DOI: 10.1177/1055665620980220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Mid-maxillary osteodistraction (MMOD) is a novel technique. This study seeks to assess the occlusal and functional improvement of patients with midfacial hypoplasia secondary to cleft lip and palate. DESIGN This was done as a retrospective study at the Regional Cleft Centre of the Teaching Hospital-Karapitiya (THK). PARTICIPANTS A total of 81 patient records were accessed on those who underwent MMOD with a tooth-borne intraoral device from January 1, 2007, to December 31, 2016, at THK. METHODS Records of the patients included pre- and post-treatment lateral cephalograms, study models, speech assessments, and photographs. RESULTS An advancement ranging from 5 to 12 mm (mean, 8.14 mm) was achieved in all patients; 80% (n = 63) and 87.65% (n = 71) showed improvement in consonant production and quality of speech. These were statistically significant (P < .05). With regard to the Peer Assessment Rating score assessing the occlusal improvement, 97.6% showed an improvement whereas only 2 patients showed no improvement. There was a significant improvement in sella (S), nasion (N), and point A (SNA) angle; point A, the nasion, and point B (ANB) angle; and the maxillary length over the treatment period (P < .05). The change in the ANB angle and maxillary length significantly differed between genders with males having a comparatively higher improvement. The profile improvements were noteworthy on the profile photographs. CONCLUSION This relatively novel approach to maxillary advancement by maxillary distraction using a combined surgical and modified orthodontic technique has proven to be successful. This protocol and the technique have improved function, occlusion, and the aesthetics.
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Affiliation(s)
| | | | | | - Dayanath Kumara Dias
- Oral and Maxillofacial Surgery Unit, Teaching Hospital-Karapitiya, Galle, Sri Lanka
| | - D A R K Dasanayaka
- Department of Physiotherapy, 365459Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka
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Medeiros-Santana MNLD, Araújo BMAM, Fukushiro AP, Trindade IEK, Yamashita RP. Surgical maxillary advancement and speech resonance: comparison among cleft types. Codas 2020; 32:e20190152. [PMID: 32401996 DOI: 10.1590/2317-1782/20202019152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/09/2019] [Indexed: 11/22/2022] Open
Abstract
Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.
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Affiliation(s)
| | | | - Ana Paula Fukushiro
- Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, SP, Brasil
| | - Inge Elly Kiemle Trindade
- Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, SP, Brasil
| | - Renata Paciello Yamashita
- Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, SP, Brasil
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Richardson S, Sinai Khandeparker RV. A retrospective analysis of complications associated with tooth-borne anterior maxillary distraction for managing cleft maxillary hypoplasia: A 12-year experience. J Craniomaxillofac Surg 2020; 48:365-375. [DOI: 10.1016/j.jcms.2020.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/25/2019] [Accepted: 02/14/2020] [Indexed: 10/24/2022] Open
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Richardson S, Krishna S, Bansal A. Use of repeat anterior maxillary distraction to correct residual midface hypoplasia in cleft patients. J Korean Assoc Oral Maxillofac Surg 2018; 43:407-414. [PMID: 29333371 PMCID: PMC5756798 DOI: 10.5125/jkaoms.2017.43.6.407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 08/08/2017] [Accepted: 08/22/2017] [Indexed: 11/24/2022] Open
Abstract
Objectives The study was designed to evaluate the efficacy of performing a second, repeat anterior maxillary distraction (AMD) to treat residual cleft maxillary hypoplasia. Materials and Methods Five patients between the ages of 12 to 15 years with a history of AMD and with residual cleft maxillary hypoplasia were included in the study. Inclusion was irrespective of gender, type of cleft lip and palate, and the amount of advancement needed. Repeat AMD was executed in these patients 4 to 5 years after the primary AMD procedure to correct the cleft maxillary hypoplasia that had developed since the initial procedure. Orthopantomogram (OPG) and lateral cephalograms were taken for evaluation preoperatively, immediately after distraction, after consolidation, and one year postoperatively. The data obtained was tabulated and a Mann Whitney U-test was used for statistical comparisons. Results At the time of presentation, a residual maxillary hypoplasia was observed with a well maintained distraction gap on the OPG which ruled out the occurrence of a relapse. Favorable movement of the segments without any resistance was seen in all patients. Mean maxillary advancement of 10.56 mm was achieved at repeat AMD. Statistically significant increases in midfacial length, SNA angle, and nasion perpendicular to point A distance was achieved (P=0.012, P=0.011, and P=0.012, respectively). Good profile was achieved for all patients. Minimal transient complications, for example anterior open bite and bleeding episodes, were managed. Conclusion Addressing the problem of cleft maxillary hypoplasia at an early age (12–15 years) is beneficial for the child. Residual hypoplasia may develop in some patients, which may require additional corrective procedures. The results of our study show that AMD can be repeated when residual deformity develops with the previous procedure having no negative impact on the results of the repeat procedure.
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Affiliation(s)
| | - Shreya Krishna
- Richardsons Dental and Craniofacial Hospital, Nagercoil, India
| | - Avi Bansal
- Richardsons Dental and Craniofacial Hospital, Nagercoil, India
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Richardson S, Krishna S, Khandeparker RV. A comprehensive management protocol to treat cleft maxillary hypoplasia. J Craniomaxillofac Surg 2017; 46:356-361. [PMID: 29305090 DOI: 10.1016/j.jcms.2017.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 11/29/2017] [Accepted: 12/05/2017] [Indexed: 11/15/2022] Open
Abstract
AIM To describe a comprehensive management protocol to treat cleft maxillary hypoplasia specific to the patient's age, degree of hypoplasia and presence or absence of velopharyngeal incompetence (VPI). MATERIALS AND METHODS A total of 359 patients suffering from cleft maxillary hypoplasia were retrospectively studied from January 2004 till June 2015. Lateral cephalograms were taken to assess the degree of deformity and advancement achieved at three intervals. Patients were treated by four treatment modalities: Facemask therapy, Anterior maxillary advancement, Total maxillary osteogenesis and LeFort I advancement. RESULTS 359 patients of cleft maxillary hypoplasia were treated and followed up for a mean of 25 ± 3.6 months. Group I had 20 patients, all in the pre-pubertal age group with less than 11 mm discrepancy. 25% of patients in this group had relapse; Group II: 196 patients who were all above 11 years of age and included all grades of hypoplasia, only 6.25% patients had relapse; Group III had 36 patients all with severe form of hypoplasia and were above 5 years of age. Relapse in this group was 16.6%; Group IV had 102 patients who were above 16 years of age and had mildmoderate severity of hypoplasia. Relapse rate was 18.75%. CONCLUSION Extensive literature search and our institutional study has helped us formulate a protocol that delineates the most appropriate treatment modality for a specific age group and degree of hypoplasia also considering the effect of treatment on velopharyngeal incompetence.
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Affiliation(s)
- Sunil Richardson
- Richardson's Dental and Craniofacial Hospital, Nagercoil, Tamil nadu, India.
| | - Shreya Krishna
- Richardson's Dental and Craniofacial Hospital, Nagercoil, Tamil nadu, India.
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