All patients underwent a thorough history and clinical examination as well as a complete dental and orthodontic examination. Preoperative and postoperative photographic and cephalometric records were obtained as reported previously. Time was spent with the patient and the patient’s family, explaining the distraction process in detail utilizing photographs, video imaging, as well as discussions with other patients and their families who have undergone the procedure. The patient and parents were thoroughly familiarized with the distraction apparatus and its mechanics prior to the procedure.

For this group of patients, a custom-made intraoral orthodontic splint, which acts as the link between the maxillary skeleton and distraction apparatus, was inserted in each patient (Fig. 28.1). This intraoral splint was constructed with rigid 0.045 or 0.050 stainless steel orthodontic wire. The splint was cemented to the first permanent molars or second primary molars and was further secured at the time of surgery with circumdental stainless steel surgical wire. For older children and adults, the splint was inserted in the clinic prior to the surgical procedure. For young children, the splint was placed in the operating room after anesthetic induction and prior to the osteotomy. External traction hooks were bent under and in front of the upper lip with the end of the hook ending at the level of the palatal plane. The splint also included intraoral hooks that were utilized for the required retention phase at the completion of active maxillary distraction. Certain orthodontic tooth movements as well as orthodontic expansion of the upper arch can be performed at the time of maxillary distraction by incorporation of an expansion screw and segmentalizing the intraoral splint into two units. In order to improve rigidity, the splint can be manufactured by using an orthodontic cervical face bow. The external bow is bent to create the external traction hooks. Currently, the intraoral part of the splint utilized at our center is made of heavy 0.045 or 0.050 stainless steel orthodontic wire. In the anterior region, two square tubes are soldered just medial to the oral commissures (Fig. 28.1e). These tubes are used to house removable traction hooks made of heavy rectangular wire (Fig. 28.1f). This design offers the advantage of not having the external traction hooks present at the time of surgery facilitating anesthesia management and intraoral surgical manipulation.

All 18 patients in this series underwent a LeFort I osteotomy with the height of the transverse osteotomy varying depending on the dental age and aesthetic requirements of each patient. In patients with transitional dentition, a high transverse maxillary osteotomy was performed, just below the level of the inferior orbital rim. The osteotomy circumvents the infraorbital foramen to prevent injury to the infraorbital neurovascular bundle and avoids all permanent tooth buds. Mobilization of the maxillary segments is achieved, including pterygomaxillary and septal disjunction. No intraoperative repositioning of the maxillary segments is performed, and no autogenous or alloplastic bone grafting or internal skeletal fixation hardware is utilized. For the patients in this series who underwent rigid external distraction, the halo portion of the distraction device was placed immediately after closure of the intraoral incision. In the first four consecutive patients with severe cleft maxillary hypoplasia that we elected to treat with maxillary distraction, we performed the distraction with elastic traction as described below. After four consecutive treatment failures in these patients, we abandoned elastic distraction for rigid external distraction.

Fourteen patients underwent rigid external maxillary distraction (Fig. 28.1, Table 28.2) (Polley and Figueroa 1997). These patients had the rigid device placed at the time of surgery and had their distraction performed through mechanical activation of the distraction device. Four patients in this series underwent face mask elastic distraction osteogenesis (Table 28.2). An orthodontic face mask was utilized with elastics placed on the intraoral hooks. Up to 2 lb of elastic force was utilized for each patient through a combination of 8-oz elastics. Patients were instructed to wear the face mask 24 h a day for a period of 3 months. All patients underwent a latency period of 4–5 days following the osteotomy and then began distraction. For the rigid external distraction group, distraction was performed at the rate of 1 mm/day. In this group, the distraction device was kept in place 3–4 weeks following completion of the distraction process for rigid retention. An additional 4–6 weeks of face mask elastic retention at night time only was utilized in this group. For the rigid external distraction group following the period of rigid retention, the external distraction device was removed in an office setting. For the very young patients in this series, the distraction device was removed with mild sedation.