Maxillary Expansion in Cleft Lip and Palate using Quad Helix and Rapid Palatal Expansion Screw

Effect of Slow Maxillary Expansion and Alternative Rapid Maxillary Expansion Protocols on Airway Volume in Cleft Palate Cases: A Cone Beam Computed Tomography Based Study

A total of 22 patients with cleft palate aged 8 to 12 years were selected and categorized into two groups: the first group was treated with alternate rapid maxillary expansion and constriction (Alt-RAMEC) using an expander with differential opening (EDO) and facemask, while the second group was treated using slow maxillary expansion (SME) using an EDO. Finally, the pharyngeal airway volume in the two groups was compared using cone beam computed tomography (CBCT). CBCT scans were performed before expansion and six months following the expansion. Alveolar crest level, maxillary breadth, nasal cavity width, arch width, inclination of the molar teeth, buccal and palatal alveolar bone thickness, and maxillary alveolar width were all assessed. Paired t-tests (p=0.05) were applied to compare interphase data. The two groups showed a non-significant difference in terms of nasopharyngeal volume (cm3), oropharyngeal volume (cm3), and overall pre- and post-treatment results (p>0.005). Results of comparison of pre- and post-treatment periods in the Alt-RAMEC group revealed a significantly higher cleft volume (cm3) (p=0.001). Results of comparison of pre- and post-treatment periods in the SME group revealed a substantial rise in cleft volume (cm3) (p=0.003). Results from a comparison of the cleft volume (cm3) between the two study groups pre- and post-intervention revealed a non-significant difference (p=0.200 and 0.054, respectively).

Orthodontic Retainers and the Stability of the Maxillary Arch in Unilateral Cleft lip and Palate Patients: A Systematic Review

OBJECTIVE

The aim of this systematic review was to elucidate the role of orthodontic retainers on the stability of compensatory orthodontic treatment in patients with unilateral cleft lip and palate.

METHODS

Five electronic databases (PubMed, Scopus, Web of Science, LILACS, and LIVIVO) and the grey literature (OpenGrey and Google Scholar) were investigated, according to the population, exposure, comparator, outcomes and Study design eligibility criterion. The risk of bias assessment was determined based on the Risk of Bias In Nonrandomized Studies of Exposure (ROBINS-E) and the level of evidence with the GRADE tool.

RESULTS

Three studies were included: two presented moderate risk of bias and one high. A moderate level of evidence revealed a mean value of 0.6 mm of intercanine relapse distance, and great variability between the data, regardless of the use or type of retention or rehabilitation. Relapse in the posterior region showed clinical significance, from -1 to -1.7 mm, especially in individuals who did not use retention, except in patients with symmetrical arches with Hawley retainer, where this value varies from -0.2 ± 0.63 mm.

CONCLUSIONS

Orthodontic retainers do not seem essential to prevent relapse at anterior maxillary dimensions after compensatory orthodontic treatment in patients with unilateral cleft lip and palate. Relapse in the posterior region can achieve greater clinical significance, which highlights the need for prolonged use of Hawley retainers and periodic evaluation of the stability of treatment results. Prospective studies with a longer follow-up can improve the certainty of the evidence.

F-quad helix for simultaneous maxillary expansion and tooth alignment in patients with unilateral cleft lip and/or palate

Illustrating F-quad helix with extension arms that simultaneously expand maxillary arch and rotate its central incisor adjacent to the alveolar cleft while aligning palatally ectopic canines. Incisor rotation occurred before alveolar grafting, while canine traction was performed after alveolar grafting. The construction of this appliance is shown in detail.

Effect of Maxillary Expansion on the Maxillary Arch Width in Patients with Bilateral Cleft Palate: A Review

OBJECTIVES

To perform a comprehensive review of the literature to compare the effects of slow maxillary expansion (SME) and rapid maxillary expansion (RME) on maxillary arch width in patients with bilateral cleft palate.

METHODS

The databases include Medline, PubMed, Cochrane (CENTRAL) and (CDSR), OpenGrey, and ClinicalTrials.gov were searched for relevant studies that met the eligibility criteria published before or on 31 October 2022. The search was confined to the English language. The selection of eligible studies and collection of data were performed independently. Risk of bias assessment was conducted using the Cochrane Risk of Bias tool 2.0.

RESULTS

Two randomized controlled trials were available based on the search in the published literature. Both studies compared arch width between SME and RME in cleft palate patients and digitals casts and three-dimensional images used for the evaluation. A moderate risk of bias was evident in the available studies.

CONCLUSIONS

Both SME and RME can achieve similar amounts of maxillary expansion in patients with bilateral cleft palate.

Rapid maxillary expansion vs slow maxillary expansion in patients with cleft lip and/or palate: a systematic review and meta-analysis

OBJECTIVES

To compare the dentoalveolar outcomes of slow maxillary expansion (SME) and rapid maxillary expansion (RME) used for maxillary expansion before secondary alveolar bone grafting in patients with cleft lip and/or palate (CL/P). Secondarily, the advantages and disadvantages of SME vs RME were reviewed.

MATERIALS AND METHODS

A systematic search was conducted up to November 2021, including Medline (via PubMed), Embase (via Ovid), Web of Science, Cochrane Central, and Google Scholar. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Risk-of-bias assessment was performed using the Risk of Bias (RoB 2.0) and Risk Of Bias In Non-randomized Studies of Interventions (ROBINS I) tool. Overall quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation tool.

RESULTS

Of 4007 records, five studies met the inclusion criteria. The randomized control trial (RCT) had a low risk of bias, the non-RCTs presented with a moderate risk of bias. Arch width and perimeter increased significantly with both SME and RME treatments. No difference in the increase in palatal depth was found. The meta-analysis showed a greater anterior-to-posterior expansion ratio for the Quad Helix (QH) appliance. The results for dental tipping were not conclusive.

CONCLUSIONS

SME and RME promote equal posterior expansion in cleft patients. The anterior differential expansion is greater with SME (QH appliance). No clear evidence exists concerning the amount of dental adverse effects of SME and RME in cleft patients.

Reconstruction of Oronasal Fistula with Tongue Flap: A Cleft Palate Report

Oronasal fistula can persist after conventional secondary alveolar bone graft surgery, which may lead to functional issues, such as regurgitation of fluids from the oral to the nasal cavity. This manuscript describes a clinical case of a patient with a bilateral cleft lip and palate that underwent tongue graft surgery for closure of an oronasal fistula after three failed local mucosa flap surgeries. The multidisciplinary treatment was comprised of orthodontic treatment, mucosa and alveolar grafts for palate closure and aesthetic rehabilitation of the anterior maxillary teeth. Smile aesthetics were noticeably improved, enhancing the patient’s self-perception and confidence.

Cleft Orthodontic Care in Europe: A Cross-Sectional Survey

(1) Background: Orthodontists have an important role in cleft care. Over the two decades since the Eurocleft studies, a significant improvement in healthcare systems has been achieved but there has been no critical assessment regarding the establishment of proposed standard protocols. This study aimed to describe the current provider characteristics, orthodontic appliances, services offered, orthodontic complications, and cost analysis of cleft treatment in Europe. (2) Methods: A cross-sectional 22-question online survey, accessible from January 2021 to July 2021, was sent to 214 practitioners, pertaining to provider characteristics, orthodontic appliances, services offered, orthodontic complications, and cost analysis. Descriptive statistics were calculated for each question. Fisher’s exact test was used to assess the association between categorical variables. (3) Results: A total of 79 responses from 23 European countries completed the survey (response rate = 37%), with 69 surveys being assessed after the exclusion of incomplete surveys. Rapid maxillary expansion was the preferred expansion protocol (45%). Distraction osteogenesis was the most reported alternative treatment to secondary bone grafts (19%), with private practitioners being less likely to perform these treatments (Fisher’s exact test, p = 0.001). Orthodontic services offered were, however, rather similar in the various locations of provision (hospital and/or university, private). Compromised oral hygiene (77%) was the most reported orthodontic complication. The National Health Services support the majority of cleft orthodontic care (67%) in Europe. (4) Conclusion: An apparent improvement in orthodontic healthcare provision has been achieved within Europe in the last two decades, but there are several discrepancies, namely regarding treatment timing and the appliances offered.

Intercenter comparison of slow and rapid maxillary expansion in unilateral complete cleft lip and palate

Objective:

The aim of this study was to compare the occlusal changes of rapid maxillary expansion (RME) and slow maxillary expansion (SME) in patients with unilateral complete cleft lip and palate (UCLP), by means of digital dental models.

Methods:

Group RME was composed by 22 patients (13 males and 9 females), with mean age of 9.9 years, treated with rapid maxillary expansion with Hyrax appliance in Center 1. Group SME was composed by 29 patients (14 females and 15 males), with mean age of 10.7 years, treated with slow maxillary expansion with quad-helix appliance in Center 2. Digital dental models of the maxillary dental arch were obtained immediately pre-expansion (T1) and 6-month post-expansion (T2). Transversal distances, arch perimeter, arch length, palatal depth, palatal volume and posterior tooth inclination were digitally measured. Interphase and intergroup comparisons were performed with paired t-test and independent t-test, respectively.

Results:

Intercanine expansion was 4 to 5mm in both groups, and increase in the intercanine distance was similar for both groups. RME group showed a greater increase in arch distances at the region of permanent premolar and molars, compared to SME group. Arch perimeter increase was greater for RME group, compared to SME. No differences were found for arch length, palatal depth, palatal volume and posterior tooth buccal tipping.

Conclusion:

RME and SME produced similar dentoalveolar outcomes, with greater amount of expansion on RME group.

Orthodontics for Unilateral and Bilateral Cleft Deformities

Orthodontic treatment of patients with unilateral and bilateral cleft palate requires an extensive interdisciplinary approach to achieve optimal functional and esthetic rehabilitation. Intervention is divided into 3 main stages: early mixed, late mixed, and permanent dentition. Treatment modalities can vary according to developmental stage, severity of cleft, and presence of other dentofacial abnormalities. This article describes the use and efficacy of different orthodontic, orthopedic, and surgical approaches at each developmental stage of unilateral and bilateral clefts, whereby the orthodontist plays a pivotal role in the different phases of growth and development of the cleft lip and the patient.

Dental arch size and shape after maxillary expansion in bilateral complete cleft palate: A comparison of three expander designs

OBJECTIVE

The objective of this study was to compare the effects on upper dental arch size and shape after maxillary expansion with Hyrax, Quad-helix, and a differential opening expander in bilateral cleft lip and palate (BCLP) patients.

MATERIALS AND METHODS

Seventy-five BCLP patients were divided into three groups: Hyrax (H), Quad-helix (QH), and Expander with differential opening (EDO). Digital models were obtained before (T1) and after 6 months (T2) of maxillary expansion. Twelve landmarks were placed by one investigator on T1 and T2 dental models of each group, and x,y coordinates for each landmark were collected. For dental arch size analysis, centroid size of each dental arch at T1 and T2 was calculated from raw coordinates and was used as the measure of size. Procrustes Analysis was performed for dental arch shape analysis. Analysis of variance was used to compare the groups for size and shape differences (P < .05).

RESULTS

There were no significant dental arch size differences among the expanders at T1 or T2. Differences in arch shape were found between all groups at T2. Intragroup arch shape showed a significant variation for the QH and EDO groups. while it remained stable in the H group.

CONCLUSIONS

Both the QH and the EDO create dental arch shape changes with greater intercanine than intermolar increase. The H does not change the dental arch shape.

Three-Dimensional Displacement of Partial Craniofacial Bones Following Rapid Maxillary Expansion in Young Patients with Angle Class III Malocclusions

OBJECTIVE

The aim of this study was to analyze the displacement in 3D direction of some craniofacial bones with the rapid maxillary expansion in Angle class III malocclusion.

METHOD

Thirteen Angle class III patients (mean age: 12.4 ± 1.7 years; 7 males, 6 females) using rapid maxillary expansion as part of their orthodontic treatment were selected and computed tomography scans were taken before and after expansion. The 3D models were reconstructed using the Mimics software and the maxillary, zygomata, nasal bones were separated. With 3D models correction and registration, the displacements in the 3D directions of partial craniofacial bones were measured. Quantitative variables were analyzed by using SPSS19.0 and a t value less than 0.05 was considered statistically significant.

RESULTS

Measurement results showed that rapid maxillary expansion produced significant displacement in both sides of the maxillary, zygomata, and nasal bones. In the width of the midline palatine suture, the anterior nasal spine point was expanded a mean 4.18 mm (range 2.42 mm-5.68 mm, Pleft = 0.007, Pright = 0.014) and the posterior nasal spine point was expanded a mean 2.14 mm (range 1.96 mm-2.43 mm, Pleft < 0.001, Pright = 0.002). In the width of the maxillary in coronal plane, the Spr point was expanded a mean 4.86 mm (range 3.34 mm-6.22 mm, Pleft = 0.004, Pright = 0.008) followed by the A point expanded a mean 4.47 mm (range 2.87 mm-5.97 mm, Pleft = 0.005, Pright = 0.010). The bilateral maxillary moved to both sides and the points of the front maxillary anterior nasal spine and A moved forwards and downwards. In the width of the zygomata, the Zm point was expanded 2.18 mm (range 1.87 mm-2.41 mm, Pleft = 0.001, Pright = 0.002) on average and moved backwards, the retral and upper points of the zygomata Za and Mz also moved backwards. The points Zm, Za, and O all moved upwards. The external lateral side of the nasal bone expanded to both sides, the Ipa point was expanded a mean 2.04 mm (range 1.11 mm-2.46 mm, Pleft = 0.008, Pright = 0.019) and the centre of the nasal bone moved backwards and downwards.

CONCLUSION

With rapid maxillary expansion, the increasement of width in the maxillary affected the position of the zygomata and nasal bones in the 3D directions, caused changes in facial appearance.

Long-term stability after multidisciplinary treatment involving maxillary distraction osteogenesis, and sagittal split ramus osteotomy for unilateral cleft lip and palate with severe occlusal collapse and gingival recession: A case report

In this report, we describe a case involving a 34-year-old woman who showed good treatment outcomes with long-term stability after multidisciplinary treatment for unilateral cleft lip and palate (CLP), maxillary hypoplasia, severe maxillary arch constriction, severe occlusal collapse, and gingival recession. A comprehensive treatment approach was developed with maximum consideration of strong scar constriction and gingival recession; it included minimum maxillary arch expansion, maxillary advancement by distraction osteogenesis using an internal distraction device, and mandibular setback using sagittal split ramus osteotomy. Her post-treatment records demonstrated a balanced facial profile and occlusion with improved facial symmetry. The patient's profile was dramatically improved, with reduced upper lip retrusion and lower lip protrusion as a result of the maxillary advancement and mandibular setback, respectively. Although gingival recession showed a slight increase, tooth mobility was within the normal physiological range. No tooth hyperesthesia was observed after treatment. There was negligible osseous relapse, and the occlusion remained stable after 5 years of post-treatment retention. Our findings suggest that such multidisciplinary approaches for the treatment of CLP with gingival recession and occlusal collapse help in improving occlusion and facial esthetics without the need for prostheses such as dental implants or bridges; in addition, the results show long-term post-treatment stability.

A Programmable Expander for Patients With Cleft Lip and Palate

This report describes a method to expand cleft segments of patients with cleft lip and palate prior to the secondary alveolar bone graft (ABG) using a reprogrammable nickel titanium expander. The expander can be reprogrammed with electric current to the desired width for each patient and delivers a gradual slow expansive spring force that expands and aligns the segments without further adjustments. Reprogramming the expander eliminates the need for multiple appliances and reduces chair time and patient appointments. The expander can be left in place during the ABG, because it does not interfere with a palatal flap. This alternative approach may be useful for patients who travel long distances to obtain cleft-related care.

Dentoalveolar Effects of Early Orthodontic Treatment in Patients With Cleft Lip and Palate

No agreement exists on the most appropriate timing of orthodontic treatment in patients with cleft lip and palate. The aim of this study is to investigate the effect of early orthodontic treatment on development of the dental arches and alveolar bone.A dental casts analysis was performed on 28 children with cleft lip and palate before orthodontic treatment (T0; mean age, 6.5 ± 1.7) and at the end of active treatment (T1; mean age, 9.2 ± 2.1 years). The considered variables were: intercanine and intermolar distances; dental arch relationships, evaluated according to the modified Huddart/Bodenham system.The study group was divided into 2 samples according to the age at T0: Group A (age < 6 years) and Group B (age ≥ 6 years). A statistical comparison of the treatment effects between the 2 samples was performed.Patients in Group A exhibited a greater increase of intercanine distance (8 mm versus 2.7 mm; P<0.001), intermolar distance (7.2 mm versus 5 mm; P = 0.06), and Huddart/Bodenham score (7.1 versus 3; P < 0.05) when compared with patients in Group B.Early orthodontic treatment strongly improved the dental arch relationship, since subjects starting the therapy before the age of 6 had a better response in terms of anterior maxillary expansion.

Slow versus rapid maxillary expansion in bilateral cleft lip and palate: a CBCT randomized clinical trial

OBJECTIVES

The purpose of this "two-arm parallel" trial was to compare the orthopedic, dental, and alveolar bone plate changes of slow (SME) and rapid (RME) maxillary expansions in patients with complete bilateral cleft lip and palate (BCLP).

MATERIAL AND METHODS

Forty-six patients with BCLP and maxillary arch constriction in the late mixed dentition were randomly and equally allocated into two groups. Computer-generated randomization was used. Allocation was concealed with sequentially, numbered, sealed, opaque envelopes. The SME and RME groups comprised patients treated with quad-helix and Haas/Hyrax-type expanders, respectively. Cone-beam computed tomography (CBCT) exams were performed before expansion and 4 to 6 months post-expansion. Nasal cavity width, maxillary width, alveolar crest width, arch width, palatal cleft width, inclination of posterior teeth, alveolar crest level, and buccal and lingual bone plate thickness were assessed. Blinding was applicable for outcome assessment only. Interphase and intergroup comparisons were performed using paired t tests and t tests, respectively (p < 0.05).

RESULTS

SME and RME similarly promoted significant increase in all the maxillary transverse dimensions at molar and premolar regions with a decreasing expanding effect from the dental arch to the nasal cavity. Palatal cleft width had a significant increase in both groups. Significant buccal inclination of posterior teeth was only observed for RME. Additionally, both expansion procedures promoted a slight reduction of the alveolar crest level and the buccal bone plate thickness.

CONCLUSIONS

No difference was found between the orthopedic, dental, and alveolar bone plate changes of SME and RME in children with BCLP. Both appliances produced significant skeletal transverse gains with negligible periodontal bone changes. Treatment time for SME, however, was longer than the observed for RME.

CLINICAL RELEVANCE

SME and RME can be similarly indicated to correct maxillary arch constriction in patients with BCLP in the mixed dentition.

[Evaluation of the timing of orthodontic arch expansion and graft in cleft lip and palate]

Maxillary transverse growth is inhibited by congenital cleft, early surgical scar strain, and oppression of lipmuscles in patients with cleft lip and palate. Clinical manifestations have shown severely constricted maxilla, insufficientmaxillary width, mismatch of upper and lower dental arches, and crossbite. Alveolar bone graft and arch expansion can effectively correct the deficiency in maxillary width. This paper discusses the timing and success rate of alveolar bone graft, as wellas the relationship between alveolar bone graft and arch expansion. Secondary alveolar bone graft is optimally performed beforepermanent canine eruption, especially when the teeth have formed between half and three quarters of their roots. Rapid maxillaryexpansion prior to alveolar bone graft is beneficial because this process increases the gap of the cleft, expands bone graft, andreduces the difficulty. However, the stability of this process remains controversial. Small-scale studies have reported that rapidmaxillary expansion after alveolar bone graft can open the midpalatal suture without bone graft loss. Slow maxillary expansioncan provide continuous light forces to reconstruct the bone. However, these studies are coordinated with fixed orthodontictreatment. Further research is necessary to determine the effects of maxillary expansion on long-term stability of teeth.

[Evaluation of the timing of orthodontic arch expansion and graft in cleft lip and palate]

Maxillary transverse growth is inhibited by congenital cleft, early surgical scar strain, and oppression of lipmuscles in patients with cleft lip and palate. Clinical manifestations have shown severely constricted maxilla, insufficientmaxillary width, mismatch of upper and lower dental arches, and crossbite. Alveolar bone graft and arch expansion can effectively correct the deficiency in maxillary width. This paper discusses the timing and success rate of alveolar bone graft, as wellas the relationship between alveolar bone graft and arch expansion. Secondary alveolar bone graft is optimally performed beforepermanent canine eruption, especially when the teeth have formed between half and three quarters of their roots. Rapid maxillaryexpansion prior to alveolar bone graft is beneficial because this process increases the gap of the cleft, expands bone graft, andreduces the difficulty. However, the stability of this process remains controversial. Small-scale studies have reported that rapidmaxillary expansion after alveolar bone graft can open the midpalatal suture without bone graft loss. Slow maxillary expansioncan provide continuous light forces to reconstruct the bone. However, these studies are coordinated with fixed orthodontictreatment. Further research is necessary to determine the effects of maxillary expansion on long-term stability of teeth.