Armamentarium

History of the Procedure

Three-dimensional (3D) maxillary deficiency may be present in a variety of craniofacial syndromes, clefts, and some idiopathic clinical situations. The deficiency may be present at different maxillary levels and must be treated accordingly. These levels may include Le Fort I level, either low or high (see Figures 40-1 and 40-2 ); quadrangular Le Fort I level. This chapter covers only intraoral devices; it does not address the problem of total midface or frontofacial deficiency.

A to N, A 30-year-old patient after unilateral cleft lip and palate repair and maxillary hypoplasia. The patient was treated with intraoral maxillary advancement, mandibular subapical osteotomy, and orthodontics. Radiographs show intraoral distractors, the advancement vector, and anterior suspension wire to control vertical movement. A unilateral or bilateral cleft maxilla was converted into a single unit by fixing the two or three segments into an acrylic-metal palatal splint out of the model surgery with multiple interdental wires. The cleft maxilla is converted into one single unit by the use of a long, 2-mm-thick plate across the cleft, fixed with multiple screws above the tooth level; the plate had been pre-bent, pre-adapted, and pre-measured in the 3D model. An orthodontic surgical arch is fixated to the braces. The alveolar cleft could be grafted with bone grafts, into a three-layered flap chamber, simultaneously. The distractors were installed, and an anterior suspension wire controlled the vertical movement as the maxilla was advanced. A maxillary Le Fort I level was performed, and the single-unit maxilla was advanced into occlusion progressively after a latency period of 7 days activation 1 mm once a day and the consolidation period of 6 months. To avoid velopharyngeal incompetence, a mandibular subapical osteotomy was performed, dividing the major discrepancy between the two jaws. In addition, a right posterior maxillary osteotomy was used to close the edentulous space. The patient was referred to the orthodontist for finishing and dental implant insertion in the alveolar bone graft site.

Long-term follow-up of 20 years in a patient with a unilateral cleft lip and palate. Treatment involved Millard’s rotation and advancement cheiloplasty, followed by Veau’s push-back palatoplasty. At the end of growth, the patient presented with a severe maxillary deficiency and occlusal compensations. She was then treated with a mandibular subapical osteotomy to level the occlusal plane and close the temporary tooth extraction spaces, allowing partial Class III correction. In addition, maxillary advancement via internal distraction osteogenesis and widening were performed, followed by finishing orthodontics and lateral incisor dental implants. The rhinoplasty was performed when the internal distractors were removed. Note that the distractors were carefully fixated with the ideal vector; however, for postoperative control, a pyramidal vertical suspension 0.024-gauge wire was used to control the vertical final maxillary positioning. A, Four months of age. B, End of growth. C, After rhinoplasty. D, E, The osteotomy design included a high LeFort I to project the perinasal areas, and the lower lip was improved by a posterior repositioning subapical osteotomy. Cephalic radiographic views. Preoperatively (F) and after the distractors were removed (6 months after surgery) (G) . Panoramic views. Preoperatively (H), during distraction protocol (I) and 6 months after surgery with dental implants in position (J) . Intraoral views. Frontal views: before surgery (K), during orthodontic alignment (L), and final photograph after 20-year follow-up (M) . Occlusal view: unilateral cleft lip and palate (N) . After the end of growth, the patient presented severe transverse maxillary deficiency (O) . After distraction osteogenesis and widening surgery (P) .

Traditional surgery has some limitations in terms of the amount of movement, the need for iliac crest bone grafts, and the stability and quality of bone. The soft tissues also can be a limitation, especially clefts and scar tissue from multiple surgeries. Intraoral distraction osteogenesis may be a better choice as an alternative method; it provides better stability and easier surgery (based on performing the osteotomies and fixing the appliances); no bone grafts are needed, and costs are reduced because the patient is discharged from the hospital earlier and is able to resume activities in a week’s time. Through the years, two different approaches have been published for distraction osteogenesis in the craniofacial region: extraoral distractors or intraoral distractors. Extraoral distractors involve a semicircular metal structure fixed to the skull with multiple screws with a vertical bar connected to facial plates by wires and coils to exert the anteroposterior pressure and advance the midface. There have been modifications and improvements to ensure skull stability and vector control, and attachments and connectors are available from various companies. The common problems are social inconvenience, facial scars and, more important, all patients have the distractors removed before completing the distraction consolidation phase (in large movements this would require up to a year); consequently, the stability is jeopardized.

Internal maxillary distractors are based on a solid body with a barrel to be activated between anterior and posterior plates for bony fixation. Different designs had been published to improve bone anchorage, easier activation, and vector control and to facilitate removal. An understanding of biology and biomechanics is fundamental to predictably correct facial anomalies. The distraction protocol is based on the amount of movement, the age of the patient, and the quality and quantity of bone; minor or standard deformities are corrected with traditional surgery.

To obtain optimal results, ideally ortho­dontics will be used in the correction of facial and occlusal discrepancies. The surgery must be planned in 3D models to perform the model surgery; the distractors are prebent, preshaped, and activated to full movement; and the vector is planned to the objective movement. Once the appliances have been activated and perfect occlusion has been obtained in the model, the actual surgery is performed with proper vectors; the size of the distractors (e.g., 15, 20, 25 mm) and the length of the screws are measured and will be ready for surgery. All this work is done before the surgical intervention and must be supervised by the group expert and discussed with the orthodontist. The surgeon ensures that the final positioning of the midface is occlusally stable and must be maintained until bone rigidity occurs, after the distraction’s consolidation phase. This may take 3 to 12 months, depending on the variables of amount of movement, age of the patient, and quantity and quality of bone. The distractor appliances are easy for the patient to use and can remain in place comfortably for a long time, with the patient resuming regular activities a few days after surgery.

Some patients show divergences from the treatment plan, even though the appliances were prepared to obtain the best occlusion possible. In such cases the surgeon needs to install a secondary method to make postoperative changes in the vector, such as circumferential vertical anterior suspension wires, or he or she must change the position of the anterior plate by changing the screws under intravenous sedation. Under no circumstances should the surgeon remove the distraction appliances and expect guiding elastics to improve or maintain the occlusion. The collagen fibers in the distraction chamber are under tension, awaiting mineralization in the consolidation stage; if the appliance’s rigidity collapses or it is removed, the fibers contract, the segments become unstable, and complete recurrence results.

Chin, Guerrero, Salyer, Wangerin, and Kessler were pioneers in developing internal devices or in using existing mandibular technology to advance the maxilla at different levels, following the true indications for distraction osteogenesis.

History of the Procedure

Three-dimensional (3D) maxillary deficiency may be present in a variety of craniofacial syndromes, clefts, and some idiopathic clinical situations. The deficiency may be present at different maxillary levels and must be treated accordingly. These levels may include Le Fort I level, either low or high (see Figures 40-1