Long-term results of maxillary distraction osteogenesis in nongrowing cleft: 5-years experience using internal device
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Patients with cleft lip and palate (CLP) related deformities frequently have maxillary hypoplasia in all dimensions. These patients usually present with class III malocclusions, retruded midfaces and narrow hard palates. The skeletal problems can be treated by means of Le Fort I maxillary procedures. Surgical and orthodontic correction of severe maxillary hypoplasia, as often seen in CLP patients, has however proved to be challenging. The magnitude of the advancement is often hampered and the post operative stability significantly affected by palatal soft tissue scarring. The slow distraction of bone and the histogenic abilities of distraction osteogenesis (DO) have made it an atractive alternative treatment option for the management of maxillary hypoplasia in these patients. This paper presents the treatment results of 15 nongrowing CLP patients with severe maxillary hypoplasia treated by means of intra oral distraction. The mean anterior distraction of the maxillas was 12.7 mm (9-15.0 mm). The long-term cephalometric and clinical evaluation after a minimum of 60 months (mean follow-up 71 months) proved to be stable. The treatment results revealed, that distraction osteogenesis in nongrowing CLP patients with severe maxillary hypoplasia proved to be a predictable and stable option (Tab. 2, Fig. 3, Ref. 26).Keywords:
Maxillary hypoplasia
Cephalometry
To simulate maxillary distraction osteogenesis and evaluate the change of soft and hard tissue before and after treatment, using Computer-Assisted Simulation System for Orthognathic Surgery( CASSOS 2001).A fourteen-year-old boy with severe maxillary hypoplasia, due to unilateral cleft lip and palate, was analysed by cephalometric analysis. The simulations of maxillary distraction osteogenesis (Le Fort I osteotomy and Le Fort II osteotomy) were re-analysed. After the treatment, cephalometric analysis was preformed again. The data were compared.The maxillary hypoplasia was well treated using maxillary distraction osteogenesis; Compared with Le fort I osteotomy, more satisfactory results can be obtained by Le fort I distraction osteogenesis.Maxillary distraction osteogenesis is a better way to treat severe maxillary hypoplasia with operated CLP than maxillary osteotomy. CASSOS 2001 can help surgeons and patients on simulation and evaluation of maxillary distraction osteogenesis, and on decision of treatment plan.
Maxillary hypoplasia
Cephalometric analysis
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Distraction osteogenesis (DO) is a mechanobiological process of producing new bone and overlying soft tissues through the gradual and controlled distraction of surgically separated bone segments. The process of bone regeneration during DO is largely affected by distraction parameters. In the present study, a distraction strategy with varying distraction rates (i.e., “rate-varying distraction”) is proposed, with the aim of shortening the distraction time and improving the efficiency of DO. We hypothesized that faster and better healing can be achieved with rate-varying distractions, as compared with constant-rate distractions. A computational model incorporating the viscoelastic behaviors of the callus tissues and the mechano-regulatory tissue differentiation laws was developed and validated to predict the bone regeneration process during DO. The effect of rate-varying distraction on the healing outcomes (bony bridging time and bone formation) was examined. Compared to the constant low-rate distraction, a low-to-high rate-varying distraction provided a favorable mechanical environment for angiogenesis and bone tissue differentiation, throughout the distraction and consolidation phase, leading to an improved healing outcome with a shortened healing time. These results suggest that a rate-varying clinical strategy could reduce the overall treatment time of DO and decrease the risk of complications related to the external fixator.
Bone Formation
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This study analyzed the outcomes of nongrowing patients with unilateral mandibular hypoplasia treated according to a specific protocol, which combines distraction osteogenesis, orthodontic treatment, and conventional osteotomies.The patients treated were objectively evaluated. Patient's satisfaction was assessed by questionnaire. Surgical changes were analyzed using cephalometry and three-dimensional facial surface data before surgery (T0) and at long-term (T1) follow-up.Four patients were included in this study. The normalization of facial proportion and a high increase in symmetry were evident. Residual defects were documented in the postoperative symmetry of the chin. In the questionnaire, all patients gave favorable responses to their facial changes; for most of the objective parameters, all patients improved.A multistage treatment protocol for the correction of facial deformities in patients with unilateral mandibular hypoplasia is a valid procedure for skeletal and occlusal stability. An evident improvement of the facial appearance is also achieved.
Facial symmetry
Cephalometry
Maxillary hypoplasia
Mandible (arthropod mouthpart)
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Objective To simulate maxillary distraction osteogenesis and evaluate the change of soft and hard tissue before and after treatment,using Computer-Assisted Simulation System for Orthognathic Surgery(CASSOS2001).Methods A fourteen-year-old boy with severe maxillary hypoplasia,due to unilateral cleft lip and palate,was analysed by cephalometric analysis.The simulations of maxillary distraction osteogenesis(Le Fort I osteotomy and Le Fort II osteotomy)were re-analysed.After the treatment,cephalometric analysis was preformed again.The data were compared.Results The maxillary hypoplasia was well treated using maxillary distraction osteogenesis;Compared with Le fort I osteotomy,more satisfactory results can be obtained by Le fort I distraction osteogenesis.Conclusion Maxillary distraction osteogenesis is a better way to treat severe maxillary hypoplasia with operated CLP than maxillary osteotomy.CASSOS2001can help surgeons and patients on simulation and evalution of maxillary distraction osteogenesis,and on decision of treatment plan.
Maxillary hypoplasia
Cephalometric analysis
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Craniofacial surgery
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Background Distraction osteogenesis is now an important clinical tool in craniofacial surgery. However, controlling the distance and vector of distraction in infants with syndromic craniosynostosis with good repeatability is a task that still proves difficult today. We have developed a new facial osteogenesis distraction system that combines the advantages of external and internal distraction devices to enable control of both the distraction distance and vector. This article describes the method and short-term results of this system. Methods Our distraction system uses both a conventional external distraction device and a newly developed internal distraction device. Postoperative control of the distraction vector is performed using the external device, whereas control of distraction distance is done with the adjustable-angle internal device. This system was used for 2 patients with Crouzon syndrome. Results The system enabled control of lengthening distance and vector, and no complications occurred during the procedures. Conclusions We developed a facial distraction system leveraging the advantages of external and internal distraction devices, which we then used to successfully control both lengthening distance and vector. The system would be particularly indicated in patients with severe scarring due to multiple follow-up surgeries and in patients requiring distraction of 20 mm or more. Aligning the periorbital profile at 5 to 6 years old caused the maxilla to rotate counterclockwise, and we consider that a procedure combining Le Fort III osteotomy with Le Fort I and II osteotomies is required to prevent these rotations.
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Although maxillary distraction osteogenesis has been used for early treatment of midfacial hypoplasia, the inevitable osteotomies are still a complicated and invasive procedure for growing patients. Based on the bone-borne trans-sutural distraction osteogenesis, novel improvements to the approach were made to treat midfacial hypoplasia, and the clinical outcomes and skeletal changes were analyzed.Seventy consecutive growing cleft lip and palate patients with midfacial hypoplasia were treated with trans-sutural distraction osteogenesis. The distraction system consists of a rigid external distractor, nickel-titanium shape memory alloy spring, and bone-borne traction hooks. The whole distraction process was recorded in detail clinically. Lateral cephalographs and computed tomographic scans were taken and analyzed by cephalometric measurement and color-map analysis to assess the skeletal changes.All of the patients except one achieved satisfactory appearance and occlusal relationship. The unilateral maximum traction force presented an increased trend with age, but this relationship was not absolute. The whole trans-sutural distraction osteogenesis process was divided into three clinical stages: the startup period, the rapid movement period, and the consolidation period. Cephalometric analysis showed a great increase in SNA, ANB and horizontal movement of the maxillae after distraction, but with marginal relapse at 6 to 18 months postoperatively. Visualized changes of the midfacial skeleton were observed by three-dimensional color mapping. The results showed an unequal advancement in different regions.Trans-sutural distraction osteogenesis process with adaptations offers an alternative method for the early treatment of midfacial hypoplasia in growing patients with cleft lip and palate.Therapeutic, IV.
Maxillary hypoplasia
Cephalometric analysis
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