Midmaxillary internal distraction osteogenesis: ideal surgery for the mature cleft patient

Distraction osteogenesis is a recent technique often used for maxillary advancement to correct skeletofacial deformities in cleft patients. Conventional orthognathics falls short of achieving adequate stable results. Osteodistraction with Le Fort I osteotomy may create velopharyngeal incompetence. The authors propose a new technique for distracting only the anterior maxilla to improve aesthetics and occlusion while preserving existing speech patterns, using skeletally fixated intraoral devices.

Seven patients with cleft lip and palate aged 15 years 11 months to 26 years 5 months were selected. All osteotomies included horizontal anterior maxillary osteotomies created to the first molar and vertical osteotomies created between the second premolar and the first molars. Patients were evaluated preoperatively and postoperatively by a speech pathologist by means of fiberoptic video nasoendoscopy.

Absolute bony anteroposterior movement ranged from 8 to 18.0 mm (average, 11.29 mm). Changes in skeletal facial profile (N- A-Pg) demonstrated approximately 18.61 degrees of correction in the conversion toward convex profiles. Patients were advanced to stable class I or mild class II relationships, and open bites were closed without development of hypernasal speech.

This novel technique permits significant anterior movements, allowing dramatic improvements in functional and facial aesthetic outcomes. Furthermore, intraoral appliances allowed greater acceptance in this age group. Disadvantages include complicated orthodontic setup and surgical procedure, as well as the cost of occasionally necessary dental implants. No postoperative relapse was seen at an average follow-up of 33 months. This approach renders comfortable yet effective patient care, yielding optimum results while circumventing shortcomings of conventional techniques.