YIJOM-4705; No of Pages 7

Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx

https://doi.org/10.1016/j.ijom.2021.04.012, available online at https://www.sciencedirect.com

Clinical Paper
Cleft lip and palate

Non-surgical treatment of M. C. Meazzini1, N. Cohen1,

L. Autelitano2, J. Radojicic3
1
Smile House, Orthodontic Service, Regional

vertical excess of the premaxilla Centre for CLP, Department of Maxillofacial

Surgery, Santi Paolo and Carlo Hospital,
Milan, Italy; 2Smile House, Regional Centre
for CLP, Department of Maxillofacial Surgery,

in growing bilateral cleft lip and Santi Paolo and Carlo Hospital, Milan, Italy;
3
Department of Orthodontics, University
Clinical Centre of Ni, Ni, Serbia

palate patients
M.C. Meazzini, N. Cohen, L. Autelitano, J. Radojicic: Non-surgical treatment of
vertical excess of the premaxilla in growing bilateral cleft lip and palate patients. Int.
J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2021 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Abstract. Patients with bilateral complete cleft lip and palate (BCLP) may present a
vertical excess of the premaxilla in childhood. This is a severe functional and
aesthetic problem, where bone grafting is more challenging. The aim of this study
was to describe a simple and reproducible non-surgical orthopaedic treatment for
vertical excess of the premaxilla in the deciduous/early mixed dentition phase in
BCLP patients. Six growing patients with complete BCLP with a severe vertical
excess of the premaxilla were included. An intrusion device associated with a
bonded rapid palatal expander was applied to intrude the premaxilla. Radiographic
and photographic records obtained before and at the end of the orthodontic
intrusion, at short- and long-term follow-up, were available. A flattening of the
occlusal plane was achieved in all patients. Normalization of the position of the
maxillary incisors and gingival display in relation to the upper lip was obtained, and
an improvement in anterior nasal spine position was also observed in all cases. The
novel technique described might be of assistance in treating BCLP children with Key words: Cleft Palate; Maxillary Bone; over-
vertical excess of the premaxilla during the deciduous/early mixed dentition phase. bite; orthodontics; osteotomy.
This simplified, easily reproducible method may allow the burden of care of this rare
but complex problem affecting BCLP patients to be reduced significantly. Accepted for publication 26 April 2021

Vertical excess of the premaxilla in bilat-
eral cleft lip and palate (BCLP) patients is
a major challenge for both orthodontists
and maxillofacial surgeons. Both vertical
and sagittal excess are induced by an
overgrowth at the premaxillary-vomerine
suture1,2.
Sagittal dental and skeletal maxillary
protrusion is physiological and desirable
in BCLP during childhood and typically
does not need any correction, because
there is a progressive and spontaneous
reduction of maxillary projection during
growth, and a significant number of
patients with BCLP will require midface
advancement at skeletal maturity3–5.
Therefore, it is generally not prudent to
reduce sagittal protrusion during growth.
Vertical excess of the premaxilla in
BCLP, on the other hand, usually does
not improve spontaneously with growth.

0901-5027/000001+07 ã 2021 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Please cite this article in press as: Meazzini MC, et al. Non-surgical treatment of vertical excess of the premaxilla in growing bilateral
cleft lip and palate patients, Int J Oral Maxillofac Surg (2021), https://doi.org/10.1016/j.ijom.2021.04.012
YIJOM-4705; No of Pages 7

2 Meazzini et al.

Table 1. Case series with skeletal and dental measurements, before the orthodontic intrusion (T0) and at the end of the orthodontic intrusion (T1).
Patient number 1 2 3 4 5 6 Average Paired t-test
Sex F F M M M F difference (T0 vs T1)
Age at T0 (years) 4.9 5.1 4 7 5.3 5.4 T1–T0 (mm)
T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1
Vertical excess of the 9 0 8 1 10 2 8 0 8 1 12 3 8.3 0.000002
premaxilla (mm)
Vertical intrusion of 62 54 60 55 61 59 63 61 55 52 60 52 4.7 0.01
incisors (mm)
Vertical intrusion ANS (mm) 41 37 38 36 39 36 38 37 34 31 33 27 3.2 0.006
Occlusal plane ( ) 28 5 20 10 20 10 17 10 20 9 27 11 12.8 0.003
Overjet (mm) 6 1 5 2 7 2 5 2 6 2 18 5 5.5 0.02
Overbite (mm) 11 0 8 1 10 2 8 0 8 1 12 3 8.7 0.00002
SNA change T0–T1 ( ) 1 2 0 2 0 5 1.7
Rotation of the premaxilla No No No No Yes No No No No No Yes No
Posterior crossbite Yes No Yes No Yes No Yes No Yes No Yes No
Type of surgery pre/post ESGAP ESGAP SBG SBG Waiting Waiting
intrusion (age, years) (2) (5.9) (5.4) (11.9) for SBG for SBG
Follow-up time (years) 13.6 13.2 5.3 7.2 3.3 1.1
Age at longest follow-up 19.8 19.1 10.1 15.3 8.1 7.2
*(T0) initial records; (T1) records at the end of the orthodontic intrusion; Vertical excess of the premaxilla(mm): distance between the incisal edge
of the upper incisor (U1) and an occlusal plane obtained between the molar and the canine occlusal point; Vertical Intrusion of incisors(mm):
distance between U1 and a horizontal reference line constructed down anteriorly 7 degrees to the Sella-Nasion plane(S-N); Vertical intrusion of
Anterior nasal Spine(mm): distance between Anterior nasal Spine (ANS) and a horizontal reference line constructed down anteriorly 7 degrees to
the Sella-Nasion plane(S-N); occlusal plane( ):angle between the occlusal plane and the Frankfurt plane; ESGAP: Early Secondary Gingivo
Alveolo Plasty; SBG: Secondary autogenous bone grafting.

It represents a severe aesthetic and psy-
chosocial problem. Bone grafting in these
patients is also more challenging. There-
fore, correction of the vertical premaxil-
lary excess during childhood is highly
recommended.
In the 1960s and 1970s, premaxillary
osteotomies were often performed to in-
trude and set back the premaxilla. How-
ever, severe growth impairment induced
by premaxillary osteotomy was repor-
ted3,6. Padwa et al. in 1999 suggested that
premaxillary osteotomies performed be-
tween 6 and 8 years of age do not harm
subsequent growth8. Regrettably, the lon-
gest follow-up in that study only reached
age 11 years, which is too far from the end
of growth to draw any conclusions regard-
ing growth in BCLP9.
The current evidence in the literature
does not recommend a surgical approach
with premaxillary osteotomy in patients
younger than 9–11 years of age2,11. Nev-
ertheless, there are no clear guidelines
regarding the treatment of vertical pre-
maxillary excess in the literature. Based
on the age of the patient and the severity
of the vertical premaxillary protrusion,
Meazzini at al. proposed a protocol with
three different treatment approaches that
included orthopaedic, orthodontic, and
surgical intrusion. The rigid orthopaedic
intrusion described for very young
patients (deciduous/early mixed denti-
tion), though effective, raised various pro-
blems in terms of patient compliance and
orthodontic management12.
The aim of this study was to describe a
simple and reproducible non-surgical or-
thopaedic approach for the treatment of
vertical excess of the premaxilla in BCLP
patients in the deciduous/early mixed den-
tition phase. A description of the various
steps in the protocol is provided.
Patients and methods
Patients
Six growing patients with complete BCLP
(three female and three male) presenting a
severe vertical protrusion of the premax-
illa were included in this study. The study
was approved by the internal ethics com-
mittee of the hospital (N.0001191/2019).
The study followed the current national
and international laws and regulations
governing the use of human subjects (Dec-
laration of Helsinki II). Informed consent
was obtained from all of the participants
included in the study.
As only one of the patients had undergone
primary surgery at the study centre, there
was a high heterogeneity in surgical proto-
cols. All patients had undergone cheilo-
plasty at a younger age. The patient
treated at the study centre had been sub-
jected to lip and soft palate closure at 6
months and an early secondary gingivoal-
veoloplasty (ESGAP) together with hard
palate closure at 20 months of age13. Two
patients had had cheiloplasty and soft palate
closure only. Three patients had already
received soft and hard palate closure as well
as lip closure at the time of intrusion. The
case series with skeletal and dental data is
reported in Table 1. Five patients were in
full deciduous dentition between 4 and 5
years of age before intrusion (T0). One
patient was 7 years old at T0.
All patients presented a severe aesthetic
disharmony at rest and during smile, with
a prominent and downward displaced pre-
maxilla, interposed between the upper and
lower lip, with excessive premaxillary
gingival display (Fig. 1a–f). The overbite
ranged from 8 mm to 12 mm and the
overjet ranged from 5 mm to 18 mm at
T0 (Table 1). None of the patients treated
with the technique described in this report
were excluded from the sample.
Photographic records were obtained im-
mediately before the orthodontic intrusion
(T0) and at the end of the orthodontic
intrusion (T1) and, when available, at
the longest follow-up.
Premaxillary intrusion device
An efficient, but relatively complex device
was developed by Liou et al.14 and modi-
fied by Meazzini et al.12. These authors
used an intraoral tooth-borne appliance,
which delivered heavy intermittent intru-
sive forces to the premaxilla through two
lateral rigid lever arms. The orthodontic
techniques applied are typical intrusion
mechanics15. In the present study, instead
of using a rigid system, which many ortho-
dontists find complex and which is not
easily accepted by the young patients, a

Please cite this article in press as: Meazzini MC, et al. Non-surgical treatment of vertical excess of the premaxilla in growing bilateral
cleft lip and palate patients, Int J Oral Maxillofac Surg (2021), https://doi.org/10.1016/j.ijom.2021.04.012
YIJOM-4705; No of Pages 7

Non-surgical treatment of vertical excess in BCLP 3

Fig. 1. Female BCLP patient with a severe vertical and horizontal excess of the premaxilla (case 6). Images a–f: initial lateral X-ray, extraoral and
intraoral frontal, lateral, and palatal photographs before the orthodontic intrusion (T0). Images g–l: lateral X-ray, extraoral and intraoral frontal,
lateral, and palatal photographs at the end of the orthodontic intrusion (T1).

bonded expander was applied. This appli-
ance exerts a double effect that includes an
expansion of the lesser segments that are
usually constricted in these patients and a
solid anchorage for the orthodontic intru-
sion wires. The orthodontic wires deliver
low and continuous forces to gradually
intrude the premaxilla. Intrusion was
started directly with rectangular wires. A
titanium molybdenum steel (TMA) 0.017
 0.025 inch wire was initially applied,
with active bends added between the pre-
maxilla and the lesser segments in cases of
rotation and asymmetry of the premaxilla.
The TMA was subsequently substituted
with pre-formed wires, in sequence,
straight 0.017  0.025 nickel–titanium
(NiTi) and then reverse curve 0.017 
0.025 NiTi rectangular wires. In the five
patients in deciduous dentition, an acrylic
cap with brackets was applied instead of

Please cite this article in press as: Meazzini MC, et al. Non-surgical treatment of vertical excess of the premaxilla in growing bilateral
cleft lip and palate patients, Int J Oral Maxillofac Surg (2021), https://doi.org/10.1016/j.ijom.2021.04.012
YIJOM-4705; No of Pages 7

4 Meazzini et al.

Fig. 2. Female BCLP patient with a severe vertical and horizontal excess of the premaxilla (case 6). Images a–d: photographs of the intrusion
device and intraoral frontal, lateral, and palatal photographs with the intrusion device in situ.

Fig. 3. Cephalometric landmarks and measurements.

brackets directly bonded on the teeth, in
order to reduce the risk of debonding,
emergency visits, and total chair time
(Fig. 2).
Patients were checked after 2 months
and every 3–4 months subsequently, for a
total treatment time of 10–16 months.
Cephalometric analysis
Lateral cephalometric radiographs tak-
en at T0 and at T1 were obtained for all
patients. Lateral cephalometric tracings Results
at T0 and T1 were superimposed on
The rotation and asymmetry of the pre-
the anterior cranial base, orienting on
maxilla observed at T0 in two patients
the sella–nasion line. For linear mea-
(cases 3 and 6) were normalized at T1.
surements, a horizontal reference line
A flattening of the occlusal plane was
constructed 7 down and anteriorly to
obtained in all patients (below 11 at T1).
the sella–nasion plane (SN) was
Superimposition of the lateral cephalo-
depicted, as described previously
metric X-rays showed that the premaxil-
(Fig. 3)16. The differences between
lary dentoalveolar height was significantly
T0 and T1 values were analysed with
decreased and within the normal range at
a paired t-test (P-value for significance
T1 (from 1 mm to 3 mm). One patient
set at 0.05).

Please cite this article in press as: Meazzini MC, et al. Non-surgical treatment of vertical excess of the premaxilla in growing bilateral
cleft lip and palate patients, Int J Oral Maxillofac Surg (2021), https://doi.org/10.1016/j.ijom.2021.04.012
YIJOM-4705; No of Pages 7

Non-surgical treatment of vertical excess in BCLP 5

Fig. 4. Female BCLP patient with a severe vertical excess of the premaxilla (case 2). Images a–c: initial lateral X-ray and intraoral frontal and
lateral photographs before the orthodontic intrusion (T0). Images d–f: lateral X-ray and intraoral frontal and lateral photographs at the end of the
orthodontic intrusion (T1). Images g–i: lateral X-ray and intraoral frontal and lateral photographs after 13 years of follow-up (at 19 years of age).

(case 5) showed an overcorrection of 1 mm
above the occlusal plane between the molar
and canine occlusal points. The anterior
nasal spine was slightly lifted in all patients,
by an average value of 3.2 mm, ranging
from 1 mm to 6 mm (P = 0.006). The
nasolabial morphology was mildly im-
proved as a consequence of the raising of
the anterior nasal spine. There was also
extrusion of the posterior segments in all
patients, which is usually desirable because
of the vertical maxillary defect, as noted in
T0 and T1 lateral X-rays (Fig. 1a vs g, and
Fig. 4a vs d).
The patient who had ESGAP at 2 years
of age did not need further alveolar
surgery after intrusion. One patient
underwent hard palate closure together
with ESGAP immediately after intrusion.
Two patients had a secondary autogenous
bone grafting (SBG) immediately after the
orthodontic intrusion and two patients are
still waiting for SBG, using a night-time
acrylic appliance to aid retention of the
newly positioned premaxilla during the
first year post-intrusion. Only two out of
six patients were followed-up in the long-
term post intrusion, until 19.8 years and
19.1 years of age, at the completion of
growth. These patients showed a stable
occlusal result, with no further need for
orthodontic intrusion or any surgical treat-
ment (Fig. 4). The results are shown in
Table 1.
Discussion
Sagittal maxillary protrusion in BCLP
during childhood typically does not
need any correction, because there is
a progressive and spontaneous reduc-
tion of maxillary protrusion (SNA an-
gle) during growth in BCLP patients, as
demonstrated by Vargervik3 , Smahel4
and Trotman and Ross 5. Therefore, it
is not prudent to correct a sagittal pro-
trusion during growth, unless there are
severe psychological problems17. In
those cases where the premaxillary sag-
ittal protrusion does not allow for a
bone graft, it is possible to orthodonti-
cally protract the posterior segments
instead of surgically retracting the
premaxilla18. In contrast, vertical dis-
placement of the premaxilla needs to be
corrected during growth, since no spon-
taneous improvement occurs2 .
The origin of premaxillary vertical
outgrowth is not precisely known. Given
the fact that we had a very heterogeneous

Please cite this article in press as: Meazzini MC, et al. Non-surgical treatment of vertical excess of the premaxilla in growing bilateral
cleft lip and palate patients, Int J Oral Maxillofac Surg (2021), https://doi.org/10.1016/j.ijom.2021.04.012
YIJOM-4705; No of Pages 7
6 Meazzini et al.
group from a surgical standpoint, we
have tried to find a common denomina-
tor. The only common factor between
these six patients, even considering the
patients treated in the past with the pre-
vious intrusion technique12, was the con-
stant interposition of the premaxilla
between the upper and lower lip since
early infancy. Poor lip repair did not
seem to be the main factor in this group,
although it cannot be excluded as a
cofactor.
Furthermore, premaxillary sagittal and
vertical protrusion are often combined,
and a moderate amount of premaxillary
orthopaedic retraction is required to allow
lip competence (Fig. 1).
Although rigid orthopaedic intrusion,
as described previously, has been demon-
strated to be very effective in correcting
the severe aesthetic and functional pro-
blems without harming subsequent
growth12,14, this requires a technically
complicated appliance, increased chair
time, and high compliance, and there is
a high risk of emergencies; therefore,
there is a higher burden of orthodontic
care. The aim of this paper was to de-
scribe a simple, approachable, and easily
reproducible orthodontic method for the
treatment of premaxillary vertical excess
in patients in the deciduous/early mixed
dentition phase, which the orthodontist in
the team may propose as an alternative to
a surgical premaxillary intrusion. The
authors are not aware of any previous
publications on the same simple ap-
proach. The method was well tolerated
by all patients during early childhood.
The use of a bonded expander and bonded
anterior acrylic cap reduced the initial
total visits for appliance delivery from
three to two and reduced the risk of
debonding, emergency visits, and total
chair time.
The technique of non-surgical intru-
sion with orthodontic wires during
growth described in this study utilizes
low forces that allow the relationship
between the anterior teeth and upper
lip to be improved, by both contracting
the overgrowth that has occurred
at the vomero-premaxillary suture and
controlling the vertical premaxillary
growth, while allowing a posterior max-
illary growth, often deficient in BCLP
patients. The biological effect obtained
seems to be, in part, an actual bony
contraction19.
This approach normalized the position of
the maxillary incisors in relation to the
occlusal plane and to the upper lip, as shown
in Figures 1 and 4 and in Table 1. Lateral
cephalometric superimposition confirmed
Please cite this article in press as: Meazzini MC, et al. Non-surgical treatment of vertical excess of the premaxilla in growing bilateral
cleft lip and palate patients, Int J Oral Maxillofac Surg (2021), https://doi.org/10.1016/j.ijom.2021.04.012
this observation. The significant decrease
in the premaxillary dentoalveolar height
might be related to a sutural contraction/
osteolysis in the vomero-premaxillary su-
ture, combined with a slight vertical dis-
placement of the vomero-nasal complex
and of the nasal bones and a mild lifting
of the anterior nasal spine.
The results of this study are based on a
small series of heterogeneous patients,
since this anomaly is fortunately rarely
observed. Therefore, this study has no
presumption of giving any scientific ev-
idence: it is the suggestion of an ex-
tremely simple and repeatable non-
surgical approach that may be an addi-
tional tool for the orthodontist in order to
help the surgeon in the treatment of these
rare, but psycho-socially handicapping
deformities.
In conclusion, a multidisciplinary
approach allows the cleft team to select
the most appropriate method of treat-
ment, depending on the age of the patient
and the severity of the disharmony and
the surgical treatment previously per-
formed. The technique described in this
study might be of benefit in treating
BCLP children with vertical excess of
the premaxilla during the deciduous den-
tition or the early mixed dentition phase.
It is a simple, reproducible method, with
a low need for compliance. This simpli-
fied method may allow the burden of
care of this rare but complex and
psychologically distressing problem af-
fecting BCLP patients to be reduced
significantly.
Funding
This research did not receive any specific
grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Competing interests
The authors declare no potential conflicts
of interest with respect to the research,
authorship, and publication of this article.
Ethical approval
The study was approved by the internal
ethics committee of the hospital
(N.0001191/2019).
Patient consent
Informed consent was obtained from all of
the participants included in the study.
Acknowledgements. We wish to thank
Fabio Carta, specialized orthodontic tech-
nician, for the construction and donation
of two of the appliances used in the
sample.
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