Introduction: Distraction Osteogenesis (DO) in patients with lower facial clefts is rarely reported. Standard osteotomies are difficult and prone to significant relapse in such patients.

Aim: This presentation introduces novel techniques in the management of severe malocclusion in a patient with bilateral Tessier meridian 7 facial clefts requiring DO.

Methods: A 15-year old male with severe mandibular retrognathia due to amniotic bands with necessary macrostomia repair was treated with DO of the mandible at two ages. The first attempted DO at another centre at 6 years of age failed totally because of a lack of patient and family compliance. At age 14 the mandible was distracted in three planes of space using two SYNTHES multiplanar extraoral mandibular distraction devices at a rate of 1 mm per day guided by intraoral splints. The distractors were maintained for 9 months following distraction for consolidation purposes.

Results: The mandible was lengthened by 35 mm using DO. The external pins retaining the distractors loosened just before their planned removal. The occlusal plane discrepancies were treated with vertical elastics. The downward and forward vectors of the Herbst Appliance and Activator provided active retention in complementary directions.

Conclusions: Significant distraction of the mandible is a safe approach for the treatment for a patient with facial clefting and severe antero-posterior discrepancies. A unique role for Herbst Appliances and Activator in the retention of such cases is introduced. Parental and patient co-operation is an important key to the success of labour intensive procedures such as DO.

Conflict of interest: None declared.