ORIGINAL ARTICLE Management of severe cleft maxillary deficiency with distraction osteogenesis: Procedure and results

Alvaro A. Figueroa, DDS, MS,a and John W. Polley, MDb Chicago, Ill. Distraction osteogenesis has become an important technique to treat craniofacial skeletal dysplasia. In this study, the technique of maxillary distraction with a rigid external distraction device is presented. Cephalometric results in the first 14 consecutive patients are analyzed. The study sample consisted of 14 patients with various cleft types and maxillary hypoplasia treated with the rigid external distraction technique. Analysis of the predistraction and postdistraction cephalometric radiographs revealed significant skeletal maxillary advancement. All patients had correction of the maxillary hypoplasia with positive skeletal convexity and dental overjet after maxillary distraction. The morbidity for the procedure was minimal. Surgical and orthodontic procedures are thoroughly described. (Am J Orthod Dentofacial Orthop 1999;115:1-12)

istraction osteogenesis is rapidly becoming an alternative technique to treat craniofacial dysplasias. It was initially used successfully to treat unilateral or bilateral mandibular dysplasias.1 The application to other regions of the craniofacial skeleton are currently being explored, and animal and clinical trials have been conducted.2-8 The purpose of this report is to present our technique for maxillary distraction osteogenesis in cleft patients with severe maxillary deficiency, with the use of a rigid external distraction (RED) device (Fig 1), to describe the orthodontic appliance required to deliver the traction force through the dentition to the maxillary bone, and to present the clinical and cephalometric results in our initial series of 14 consecutive patients.
MATERIAL AND METHODS Patient Selection and Evaluation

tographs and video imaging, as well as discussion with other patients and their families who have undergone the procedure. The patient and parents were thoroughly familiarized with the mechanics of the distraction apparatus and distraction protocol before the procedure.
Intraoral Splint

Patients were selected based on cause and severity of the maxillary hypoplasia. Presurgical records were obtained including a comprehensive speech evaluation by the speech and language pathologist. The cephalometric radiographs are obtained at the completion of distraction and at yearly intervals to monitor outcome. Time was spent with the patient and the patients family, explaining in detail the distraction process with phoFrom the Craniofacial Center and Department of Orthodontics, University of Illinois at Chicago. aAssociate Professor, Department of Orthodontics. bDirector, Craniofacial Center; Associate Professor, Department of Surgery. Reprint requests to: Alvaro A. Figueroa, DDS, MS, Craniofacial Center, University of Illinois at Chicago, 811 S. Paulina St., Rm. 161 COD M/C 588, Chicago, IL 60612; E-mail, Afig@uic.edu Copyright 1999 by the American Association of Orthodontists. 0889-5406/99/$8.00 + 0 8/1/91527

In order to apply traction to the maxilla through the dentition, a rigid intraoral splint needs to be fabricated. Orthodontic bands with 0.050 inch headgear tubes are fitted either on the second primary molars (children under 6 years) or first permanent molars and an alginate or compound impression is taken of the maxillary arch. The impression is poured with dental stone. The splint is made on the working model, with 0.045 or 0.050 stainless steel rigid orthodontic wire. If the patient does not have orthodontic brackets, the labial and palatal wires are bent in close contact with most of the maxillary teeth. If the patient has orthodontic brackets, the labial wire has to be bent outward and gingivally to clear the existing appliances. If needed, a transpalatal bar can be added to increase rigidity. Connecting wires between the labial and palatal arches through the embrasures between the lateral and canine teeth bilaterally or in any other area where the wire can be passed without interfering with the occlusion may also be incorporated (Fig 2). The basic design of the splint has been successfully used in patients undergoing protractive face mask therapy. The rigid splint is then tried in the patient, assuring adequate fit, and two markings are done on the labial wire just medial to both commissures. The splint is removed from the patients mouth and two straight pieces of 0.050 or 0.060 inch rigid stainless
1

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Fig 1. A, Disassembled RED device with activating and assembling screwdrivers. B, Patient undergoing RED. Note anterior adjustable outrigger system connected with surgical wires to the hooks from the intraoral appliance. C, Close-up view of the distraction screws linked to the intraoral splint through the external traction hooks with surgical wires.

steel orthodontic wire are soldered perpendicular to the labial wire. These vertical wires have a short end towards the vestibule that eventually will be used as intraoral hooks. The long end of the vertical wire is marked while the device is in the mouth to bend the external traction hooks (Fig 2). The wire is bent under, over and anterior to the lip. The ends of the wire are bent in a circle to

eliminate sharp ends and to have a rigid eyelet from where to apply the traction. This traction eyelet is positioned at the level of the floor of the nose or at any other desired level to control rotational movements of the maxilla (Fig 2). The purpose of this external hook is to avoid any irritation to the lip while applying traction and also to control the direction of the traction forces, relative to the approximate center of resistance of the maxilla.9,10 The completed splint is cemented in the clinical setting and at the time of surgery, circumdental wires are passed through most of the maxillary teeth to increase rigidity and stability (Fig 3). In certain instances, it becomes necessary to do an intraoral splint to an abnormal arch form, knowing that after distraction, the patient will undergo further orthodontic treatment or surgical orthodontic expansion of the arch. If it is determined that the arch will be expanded surgically at the time of the required osteotomy for distraction, the cast has to be cut, aligned, and the splint made to the newly desired maxillary arch form. It is preferable to do arch expansion procedures before or after maxillary distraction to avoid moving the maxillary bone simultaneously in several directions where vector control can become more difficult. If the clinician desires to expand simultaneously with anterior distraction, an expansion screw can be incorporated into the splint, which has to be split into two segments, but the rigidity of the device may be compromised. The intraoral splint can also be made with a commercially available orthodontic headgear facebow with a long external outer bow and an inner bow without loops. The inner bow is bent to the desired arch form, and the loose ends are passed through the headgear tubes for future soldering. The outer bow is bent downward and anteriorly, in order to clear the upper lip. The advantage of using a face bow is that the wires for the traction hooks (outer bow) are strong and rigid and the traction hooks are already soldered (Fig 4). It is difficult to use the face bow in maxillary arches with poor arch form or in young children because it is difficult to adapt the inner bow to the teeth, making circumdental wiring difficult. In younger patients in which cooperation might be a factor, the splint can be cemented after the patient is anesthetized and before surgical preparation in the operating room. In cases in which a splint has been made to a surgically created arch form, the splint has to be cemented after the maxillary osteotomy is completed and the segments have been mobilized. This procedure can be difficult, as the segments are mobile and maintaining a dry field can be difficult. Adequate assistance from the surgeon and assisting personnel are required to hold the segments in place and maintain a dry field.

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Fig 2. A, Intraoral appliance in working model. Note transpalatal bar as well as interdental bars to increase rigidity. B, Vertical wires soldered perpendicular to labial aspect of intraoral splint. Upper portion of wire to be used as intraoral hooks and lower extensions to be used for external traction hooks. C, Facial photograph of patient with cheek markings identifying approximate center of rotation of maxilla to be used as guidelines to bend external traction hooks. D, External traction hooks with eyelets for connecting wire to RED device. Note position of eyelets at the level of the floor of the nose and above approximate center of resistance of maxilla. External traction hooks have been bent to comfortably clear upper lip.

Surgery and Rigid External Distraction Device Placement

The indications, details of surgery, and placement of the cranially fixed rigid external distraction (RED) device have been previously reported.8 A complete Le Fort I osteotomy is performed, including pterygomax-

illary and septal dysjunction, with mobilization. Metallic markers are placed above and below the osteotomy and in the anterior aspect of the maxilla for follow-up, and the soft tissue incision is closed. In young children, a modified high LeFort I osteotomy, with minimal downfracturing, is required to avoid disturbing devel-

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Fig 3. Intraoral appliance used to deliver distraction force to the maxilla. Note circumdental wiring.

Fig 5. Intraoperative view of a modified high LeFort I osteotomy in 6-year-old patient. Note proximity of the osteotomy to the infraorbital nerve (arrow). Three metallic bone markers were utilized for postoperative followup. Traction hook in the foreground.

Table I.

Diagnosis and sex distribution of the sample

Diagnosis N 7 5 2 14 Male 5 4 1 10 Female 2 1 1 4

UCL/P BCL/P Facial cleft and BCL/P Total

Fig 4. A, Intraoral splint made with an orthodontic head gear face bow with long external outer bow. B, Completed intraoral appliance made from a head gear face bow. The outer bow has been bent to form the traction hooks. Note small soldered hooks (arrow) to be used during the facial mask retention phase after distraction.

is completed, the halo portion of the RED device is adjusted for the width of the neurocranium and is rigidly fixed around the head with two or three scalp screws on each side. The vertical bar of the RED is in the center, sufficiently anterior and also parallel to the facial plane. Initially the vertical facial bar is removed as the traction forces are not applied until 3 to 5 days after surgery, facilitating postoperative management and feeding.
Distraction Protocol

oping tooth buds (Fig 5). Every effort is made at the time of surgery to make an osteotomy cut that will direct the maxillary segment with the appropriate horizontal and vertical vectors to prevent the creation of an anterior open bite or elongation of the lower face. In younger patients, the presence of tooth buds may not allow placement of the osteotomy in the desired direction, making the placement of the traction hooks extremely important to control maxillary vertical and horizontal movements. Once the maxillary osteotomy

A sample of 14 patients with various cleft types (Table I) underwent distraction with the RED device (Fig 1). The vertical bar was connected to the halo and the horizontal bar with the distraction screws and was placed at the appropriate vertical level based on the vector needed to obtain the desired maxillary movement 4 days (with children) or 5 days (with teenagers and adults) after surgery. The force vector is determined by clinical evaluation and through cephalometric prediction tracings (Fig 2). A 25 gauge surgical wire was used to connect the traction hook to the traction screws (Fig 1). Distraction was performed at home by turning the activating screw at a rate of 1 mm per day (2 turns).

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Fig 7. Anatomic landmarks: sella (S), center of sella turcica; nasion (N), most anterior point of nasal frontal suture; anterior nasal spine (ANS), most anterior point of the spine; A point (A), most anterior limit of the maxillary alveolar bone at the level of the incisor root apex; posterior nasal spine (PNS), intersection between the nasal floor and the posterior contour of the maxilla; apex of maxillary incisor root (U1A), uppermost point of the incisor root; tip of maxillary incisor crown (U1T), maxillary incisor edge; tip of mandibular incisor (L1T), mandibular incisor edge; apex of mandibular incisor root (L1A), lowermost point of the mandibular incisor root; B point (B), most anterior limit of the mandibular alveolar bone at the level of the incisor root apex; pogonion (PG), most anterior limit of the mandibular symphysis; menton (ME), most anterior point of the mandibular symphysis; gonion (GO), the point at the greater convexity of the mandibular gonial region. Reference planes: sella-nasion plane (SN); palatal plane (PPL), line through ANS and PNS; maxillary incisor axis (U1), line passing through U1A and U1T); mandibular plane (Mand Pl), tangent to the lower border of the mandible through ME and GO.

Fig 6. Six-year-old female with left unilateral cleft lip and palate and maxillary hypoplasia treated with maxillary distraction with RED. Predistraction (A) and postdistraction (B) photographs. Note improvement in facial convexity, cheek projection, and balance of face. C, Patient underwent 6 to 8 weeks of retention with a removable face mask with elastic traction.

The patients were followed weekly to assess bone consolidation and to make adjustments in the vertical position of the horizontal traction bar and screws, to maintain control over the maxillary position. Once the appropriate amount of distraction was achieved, the RED system was left in place for 2 to 3 weeks to permit bone consolidation. The RED device was removed in the clinic. After the RED device was

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Fig 9. Predistraction (solid line) and postdistraction (broken line) average tracings of the maxilla for all patients. Note minimal changes in incisor position relative to the maxillary palatal plane.

Fig 8. Predistraction (solid line) and postdistraction (broken line) average cephalometric tracings for all patients. Note maxillary advancement with correction of negative overjet and improvement of skeletal convexity, upper lip and nose advancement, and minimal changes in mandibular position.

the horizontal was used. Linear horizontal changes were measured relative to a line perpendicular to the SN plane, passing through sella, and vertical changes were measured perpendicular to the S-N plane. The preoperative and postoperative cephalometric values were statistically analyzed by means of a paired t test.
RESULTS

removed, the labial hooks were cut. Positive traction was continued by means of elastic traction through an orthodontic face mask, using the intraoral hooks (Fig 6). For this purpose, one or two 6 oz elastics were used on each side. The retention period after active distraction was between 6 and 8 weeks. Although not done in this series of patients, if orthodontic appliances are in place, interarch elastics can be used to further improve occlusal relations.
CEPHALOMETRIC EVALUATION

The preoperative and postretention lateral cephalometric radiographs were used for analysis. The postretention radiographs were obtained 3 to 4 months after distraction. The radiographs were traced, and 13 anatomic landmarks were recorded (Fig 7). All tracings were done by a single investigator (AAF). Availability of serial radiographs in all patients permitted landmark verification. All x-rays were corrected to 0% magnification. We looked at the recorded anatomic landmarks and calculated 14 measurements, 7 angular and 7 linear (4 horizontal and 3 vertical). For the linear measurements, an x-y coordinate system with the S-N plane as

All of the surgery and RED device placement in this series was performed by a single surgeon (JWP). Perioperative antibiotics were routinely used. All patients began routine oral hygiene and an unrestricted soft diet 24 hours postoperatively. No intermaxillary fixation nor bone grafts were used. There was no surgical morbidity in any of the 14 patients in this series. There were no problems with bleeding or infection. None of the patients required a blood transfusion; there were no problems of dental injury, avascular necrosis, or gingival injury. There were no complications with wearing the external device, including pain, discomfort, or loosening during the distraction process. The intraoral splint remained intact in all patients through the active and retention phases. None of the families had difficulty following the distraction instructions. The predistraction and postdistraction angular and linear cephalometric measurements are given in Tables II and III. The average predistraction SNA angle was 77.6 and the postdistraction SNA angle was 85.3, for an average increase of 7.7. The average predistraction ANB was -1.2 and postdistraction was 7.3, with an increase of 8.6. The skeletal angle of convexity increased postdistraction by 17.2. All of these three measurements were statistically significant. The horizontal ANS change between predistraction and post-

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Table II.

Angular changes after RED (n = 14)

Table III. Horizontal

(x) and vertical (y) linear changes

Change (mm) 7.1 + 3.9** 0.4 + 3.0 8.3 + 3.3** 1.3 + 3.4 11.6 + 4.6** 1.8 + 3.5 12.7 3.0**

Measurements Postdistraction (degrees) Predistraction (4 months) Difference Significance SNA SNB ANB Convexity (NAPg) Mand Pl/SN angle U1 -PPL angle 77.6 5.6 78.8 4.0 1.2 3.5 3.5 7.5 39.2 6.7 100. 7 15.7 85.3 5.6 77.9 4.1 7.3 3.0 13.7 6.0 41.4 5.9 7.7 2.9 0.8 1.8 8.6 3.6 17.2 7.3 2.2 2.4 ** NS ** ** * NS

after RED (n = 14)

Landmark-axis ANS-x ANS-y A Point-x A Point-y U1-x Ul-y Overjet **P < .001.

98.8 14.4 1.2 11.3

*P < .01, **P < .001.

distraction cephalometric radiographs was 7.1 mm, and the average horizontal advancement of the A point after distraction was 8.3 mm. The horizontal advancement at the upper incisal edge averaged 11.6 mm, and all patients had a positive correction of their overjet with an average 12.7 mm change. All of the linear horizontal changes were significant (P < .001) between predistraction and postdistraction measurements. The desired treatment goals were obtained in all patients. The vertical changes in the position of ANS, A point, and upper incisor edge were small and not significant. None of the patients resulted with an open bite. The mandibular plane angle changed 2.2. The average skeletal changes after RED are shown in Fig 8. The predistraction and postdistraction dental changes are also given in Tables II and III and Fig 9. The change in the angle of the upper incisor edge to the palatal plane averaged -1.2 for all patients, and it was not statistically significant. None of the patients in this series resulted with interdental spaces created posterior to the most distal point of anchorage of the intraoral splint.
DISCUSSION

It has been estimated that 25% to 60% of all patients born with complete unilateral cleft lip and palate will require maxillary advancement to correct the maxillary hypoplasia and improve aesthetic facial proportions.11,12 Patients with severe cleft maxillary deficiency are difficult to treat with standard surgical/orthodontic approaches. These patients have maxillary hypoplasia (vertical, horizontal, and transverse dimensions) and often thin or structurally weak bone. The hypoplasia in cleft patients is also compounded by residual palatal and alveolar fistulas, absent and aberrant dentition, pharyngeal flaps, and scarring of the palatal and pharyngeal soft tissues. The physical deformities associated with maxillary hypoplasia contribute to multiple functional deficiencies. These include severe malocclusions that result in

compromised mastication and speech and nasal pharyngeal airway patency. The severe concave facial profile has negative psychosocial ramifications. Current protocols for the treatment of maxillary hypoplasia in cleft patients rely on a surgical/orthodontic approach, including a LeFort I maxillary advancement with concomitant fistula closure, and maxillary and alveolar bone grafting. This surgery includes rigid internal fixation hardware for stabilization of the repositioned maxilla in the postoperative period. The long-term results of cleft patients with maxillary deficiency treated in such fashion have been reported and allude to increased relapse tendency (greater than 20%) after maxillary advancement.13-16 All of the patients in our series, if they had undergone correction of the deformity with a standard orthognathic approach, would have also required mandibular setback surgery because of the severity of the maxillary hypoplasia. The main disadvantage to this two-jaw approach for cleft patients is that the majority of them have a mandible that is normal in both size and position or even small and retrognathic,17-24 Setback of the mandible in an effort to reduce the amount of maxillary advancement compromises final lower facial form and esthetics. Expansion of the soft tissue facial mask yields the most pleasing long-term aesthetic facial balance and harmony. This concept is extremely important in cleft patients.25 The concept of gradually advancing the maxilla after LeFort I corticotomy was originally presented by Molina and Ortiz-Monasterio.26 In their technique, an orthodontic face mask with elastics was used to deliver the traction force to the maxilla. This technique has several shortcomings, such as not delivering controlled forces, pressure sores on the chin and forehead, compliance, and most importantly the inability to advance the maxilla sufficiently to correct severe cleft maxillary hypoplasia. We have used this face mask approach after complete maxillary osteotomy with disappointing

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A C

Fig 10. Profile photographs and cephalometric radiographs of a 10-year-old patient with bilateral cleft lip and palate and severe maxillary hypoplasia before (A and B) and after (C and D) distraction. Note dramatic improvement in facial, skeletal, and dental relations after a 16 mm total maxillary advancement with correction of anterior crossbite. (Printed with permission, J Craniofacial Surg 1997;8:181-5.

results.27 The patients were undercorrected with residual anterior crossbites. This limited maxillary skeletal response has also been observed by others.28-30 These unfavorable experiences prompted us to modify the technique and use a RED device. RED uses a skeletally (cranial) fixed distraction device that allows for predictable control over the distraction process. The RED device is adjustable, offering the ability to change the vertical and horizontal vector of distraction, at any time, without discomfort to the patient during the distraction process. The difference between the two systems is evidenced by the greater maxillary advancement obtained in those patients who underwent RED, compared with those reported in patients who underwent face mask distraction.27-30

In the past, it has been virtually impossible using maxillary advancement alone to treat patients with severe maxillary deficiency. With the use of RED, a severely hypoplastic maxilla can be repositioned and maintained to the desired horizontal and vertical position without the use of bone grafting and fixation hardware (Fig 10). Contrary to the use of protraction face mask,31,32 with or without osteotomy, maxillary advancement with distraction using the RED system can be done with minimal alterations on mandibular position (Fig 8). Maxillary advancement at the LeFort I level with the RED device allows for complete versatility in both the amount and direction of the distraction process. This control on maxillary movement is feasible

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Fig 11. Preoperative (A and B) facial profile view and intraoral view of a 512 year old boy with right unilateral cleft lip and palate and bilateral crossbites. Facial and intraoral views 3 months after distraction (C and D). Note improvement in facial convexity and lip and nose relations, as well as correction of the crossbites. The intraoral splint is still secured with circumdental wires and is being used for the retention period after distraction.

because of the design of the RED device system. The external distraction system allows complete vertical adjustability of the distraction screws mounted on the horizontal bar. The design of the intraoral splint, with placement of the external traction hooks located at the level or above the palatal plane, assures the clinician that the vector of the distraction force can be controlled relative to the position of the center of mass of the maxilla. It is believed that the center of resistance, of the not osteotomized maxillary bone, is located approximately at the apex of the maxillary premolars in the lateral view.9,10 With the RED system, one can control and change as needed, the force vector that passes through (straight advancement) or above (downward advancement) the center of resistance of the maxilla (Figs 1 and 2). This is one of the main advantages of RED over internal devices that inherently have limited vector control. Before bending the traction hooks, the clinician can

transfer the approximate center of resistance of the maxilla from the cephalometric radiographs and from the clinical examination to the face of the patient. The skin is marked, corresponding to the center of resistance, and the external traction hooks are bent to the desired position (Fig 2). After connecting the distraction screw with the traction hook, the clinician can evaluate the direction of the distraction force and can adjust it, relative to the center of mass or resistance of the maxilla (Fig 1). Because the intraoral splint is made rigid enough, preventing permanent deformation of the traction hooks, the use of casted full coverage rigid splints is not necessary. The slight flexibility present in the traction hooks allows for energy storage that may result in continuous force to the maxilla between activations. This continuous tension is believed to be conducive to osteogenesis,33,34 a favorable event during the distraction process. Our current experience indicates that the

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Fig 12. Preoperative facial profile view and intraoral view in a 12-year-old female with right cleft lip and palate with maxillary hypoplasia, anterior crossbite, and open bite (A and B). Postoperative views (C and D) after maxillary distraction with RED demonstrating improvement in facial convexity, fullness of the infraorbital region, and improved lip and nose relations. The intraoral view demonstrates correction of anterior crossbite and open bite. Degree of maxillary advancement is shown by the position of the second maxillary premolar in full Class II relation after distraction (arrows).

use of a commercially available face bow facilitates the fabrication of the intraoral splint. The outer face bow wire has significant diameter to allow for the necessary rigidity. The amount of necessary soldering is also minimized as the outer bows are used as the traction hooks. Care must be taken to bend the traction hook while the outer bow arms are long; working with short segments of wire of heavy diameters is difficult. The commercially available face bow is indicated for those patients with a dental alveolar arch of sufficient size and form to facilitate contouring the inner bow. If the dental alveolar arch is irregular or too small, it will be difficult to obtain close adaptation to the teeth, which makes placement of the required circumdental wires a difficult and unstable process. For small or irregular arches, we

prefer to bend our own splint with appropriate gauge wire. The advantages of the described intraoral splint are various and include the following:
It is custom designed, which is imperative, especially in patients with clefts that present with severe dental malpositions and collapsed cleft arch segments. The device is inexpensive and easily constructed by the orthodontist. It is hygienic, comfortable, and nontraumatic. It does not interfere with speech and eating. Simultaneous orthodontic movement, such as correction of dental rotations, as well as expansion, can be performed. The active and retention intraoral devices are the same. The vectors of distraction can be changed at any time during the distraction process without discomfort to the patient, thus allowing for force vector changes as needed.

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The use of the cranium as an anchorage base for the stabilization after maxillofacial surgery is not a new concept.35 Not even the youngest patients had complaints or problems with wearing the device throughout the distraction process. No special scalp pin care is required and the use of ointments and creams at the scalp pin interface is discouraged. The patients simply shampoo and wash their hair with the device in place. The RED device is removed in the clinic after the rigid retention phase usually without the use of local anesthesia. Contemporary surgical/orthodontic approaches for the treatment of maxillary deficiency in cleft patients is usually dependent on the patient having reached skeletal maturity before the reconstructive surgery can be performed. The RED technique for maxillary distraction osteogenesis eliminates the negative technical factors associated with traditional orthognathic surgery in patients in transitional dental development. An osteotomy with complete mobilization is required with no repositioning or placement of bone grafts. Rigid internal fixation hardware is not used, eliminating the risk of dental injury during plate stabilization; thus this technique can be used throughout childhood. The only limitations in the application of this technique for patients with severe skeletal hypoplasia include adequate dentition (primary or permanent) for fixation of the intraoral splint and patient tolerance to the external distraction device. Because the RED system uses dental support, the presence of a healthy dentition is required. Skeletal anchorage for maxillary traction hooks or osseointegrated implants may need to be considered for patients with inadequate dentition. Rigid external distraction has allowed us to effectively treat patients with severe maxillary skeletal hypoplasia from the age of 5 years and up (Figs 11 and 12). No longer is it necessary to wait years for the patient to reach maturity before their severe maxillary facial deformity is corrected with the associated functional, esthetic, and psychosocial benefits. All patients treated with RED are cautioned that a percentage will require a final finishing LeFort procedure at skeletal maturity. It is anticipated that this procedure will not require a major movement, thus enhancing stability. This technique provides an excellent modality for correcting severe maxillary deficiency in patients with facial clefting and other anomalies with structurally thin bone in the maxilla (ectodermal dysplasia, Johansson Blizzard syndrome, etc.). Modifications of this technique are undergoing clinical trials to advance not only the maxilla at the LeFort I level but also advancement at the LeFort II, III, monoblock, and fronto-orbital levels. This article reports our preliminary experience with this technique.

We will prospectively follow these patients to evaluate the stability of maxillary distraction, and its effects on facial, dental, and velopharyngeal development.
CONCLUSIONS

Maxillary distraction osteogenesis after complete osteotomy with the RED technique is a highly effective treatment modality to manage cleft-related maxillary hypoplasia. The technique allows for vector control of the osteotomized maxilla throughout the distraction process. It has been used, with minimal morbidity, in children as young as 5 years of age, adolescents, and adults. In all patients treated with RED the initial negative skeletal convexity and dental overjet were satisfactorily corrected with the associated favorable soft tissue changes. We thank Dr. Eric Jein-Wein Liou for computer and statistical assistance.
REFERENCES 1. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1-8. 2. Rachmiel A, Pottaric Z, Jackson IT, Sugihara T, Clayman L, Tops JS, et al. Midface advancement by gradual distraction. Br J Plast Surg 1993;46:201-7. 3. Altuna G, Walker DA, Freeman E. Surgically assisted rapid orthodontic lengthening of the maxilla in primates: a pilot study. Am J Orthod Dentofacial Orthoped 1995;107:531-6. 4. Block MS, Cervini D, Chang A, Gottsegen GB. Anterior maxillary advancement using tooth-supported distraction osteogenesis. J Oral Maxfac Surg 1995;53:561-5. 5. Polley JW, Figueroa AA, Charbel FB, Berkowitz R, Reisberg D, Cohen M. Monobloc craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: a preliminary report. J Craniofac Surg 1995;6:421-3. 6. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices: review of 5 cases. J Oral Maxfac Surg 1996;54:45-53. 7. Cohen SR, Burstein FD, Stewart MB, Rathburn MA. Maxillary-midface distraction in children with cleft lip and palate: a preliminary report. Plast Reconstr Surg 1997;99:1421-6. 8. Polley JW, Figueroa AA. Management of severe maxillary deficiency in childhood and adolescence through distraction osteogenesis with an external adjustable rigid distraction device. J Craniofac Surg 1997;8:181-5. 9. Nanda R. Biomechanical and clinical considerations of a modified protraction headgear. Am J Orthod 1980;76:125-39. 10. Nanda R, Kuhlberg A. Principles of biomechanics. In: Nanda R, editor. Biomechanics in Clinical Orthodontics. Philadelphia: W.B. Saunders Co; 1997. p. 1-22. 11. Ross RB. Treatment variables affecting facial growth in complete unilateral cleft lip and palate: 7, an overview of treatment and facial growth. Cleft Palate J 1987;24:71-7. 12. Panula K, Lorius BBJ, Pospisil OA. The need for orthognathic surgery in patients born with complete cleft palate or complete unilateral cleft lip and palate. Oral Surg Oral Diag 1993;4:23-8. 13. Hochban W, Gans C, Austermann KH. Long-term results after maxillary advancement in patients with cleft. Cleft Palate Craniofac J 1993;30:237-43. 14. Cheung LK, Sammam N, Hiu E, Tiderman H. The 3-dimensional stability of maxillary osteotomies in cleft patients with residual alveolar clefts. Br J Oral Maxillofac Surg 1994;32:6-12. 15. Posnick JC, Dagys AP. Skeletal stability and relapse patterns after LeFort I maxillary osteotomy fixed with miniplates: the unilateral cleft lip and palate deformity. Plast Reconstr Surg 1994;94:924-32. 16. Erbe N, Stoelinga P, JW, Leenen RJ. Long-term results of segmental repositioning of the maxilla in cleft palate patients without previously grafted alveolo-palatal clefts. J Craniomaxillofac Surg 1996;24:109-17. 17. Aduss H. Craniofacial growth in complete unilateral cleft lip and palate. Angle Ortho 1971;41:202-13. 18. Bishara SE, Krause CJ, Olin WH, Weston D, Tan Ness J, Felling C. Facial and dental relationships of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J 1976;13:238-52. 19. Smahel Z, Brejcha M. Differences in craniofacial morphology between complete and incomplete unilateral cleft lip and palate in adults. Cleft Palate J 1983;20:113-27. 20. Bishara SE, Jakobsen JR, Krause JC, Sosa-Martinez R. Cephalometric comparisons of individuals from India and Mexico with unoperated cleft lip and palate. Cleft Palate J 1986;23:116-25.

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