ORIGINAL ARTICLE
Effect of Bone-Borne Trans-Sutural Distraction
Osteogenesis Therapy on the Cranial Base
of Children With Midfacial Hypoplasia Due to Cleft
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Lip and Palate
Peiyang Zhang, MD,* Haizhou Tong, MD,† Yujie Chen, BS,* Binyi Zhou, BS,*
Lin Fang, MD,‡ and Zhenmin Zhao, MD*
Abstract: Bone-borne trans-sutural distraction osteogenesis
(TSDO) is widely used to treat midfacial hypoplasia in children
with cleft lip and palate; however, its effects on the cranial base
are still poorly understood. The authors aimed to study mor-
phological changes in the cranial base after TSDO. Pre and
postoperative computed tomography (CT) images of cleft lip
and palate children with midfacial skeleton dysplasia who un-
derwent TSDO were collected retrospectively, and their corre-
sponding 3-dimensional models were measured. Results showed
no significant change in the length of the anterior or posterior
cranial fossa, but the length of the middle cranial fossa in-
creased significantly. The anterior cranial base rotated upward
with the sella turcica at the center, whereas the cranial base
angle increased. The sphenoid bone exhibited morphological
changes. Post-TSDO, the lateral plate of the pterygoid process
increased in length. The angle of the 2 lateral plates of the
pterygoid process, the greater wings of the sphenoid bone, and
From the *Department of Plastic Surgery, Peking University Third
Hospital; †Department of Cleft Lip and Palate, Plastic Surgery
Hospital, Peking Union Medical College and Chinese Academy of
Medical Sciences; and ‡Department of Noninvasive Surgery, Plastic
Surgery Hospital, Peking Union Medical College and Chinese
Academy of Medical Sciences, Beijing, China.
Received May 23, 2022.
Accepted for publication September 5, 2022.
Address correspondence and reprint requests to Zhenmin Zhao, MD,
Department of Plastic Surgery, Peking University Third Hospital,
Haidian, Beijing 100191, China; E-mail: zhaozhenmin0098@163.
com
This project was supported by the National Nature Science Foundation
of China (grant 81571925) and Beijing Municipal Science and
Technology Commission (No. Z171100001017212).
P.Z. and H.T. contributed equally to this work.
This retrospective study was performed according to the principles of
the Declaration of Helsinki. It was approved by the Ethics Com-
mittee of Peking University Third Hospital (Beijing, China), Chinese
Academy of Medical Science. Informed consent was obtained from
the parents or legal guardians of patients for both study partic-
ipation and publication of identifying information/images in an
online open access publication.
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal's website, www.jcraniofacialsurgery.
com.
Copyright © 2022 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000009101
The Journal of Craniofacial Surgery  Volume 34, Number 2, March/April 2023
Copyright © 2022 Mutaz B. Habal, MD. All rights reserved.
the smaller wings of the sphenoid bone decreased. Posterior
inclination of the pterygoid process increased. Mean volume of
the sphenoidal sinus increased postoperatively compared with
the preoperative volume. Apparent changes in the cranial base
after TSDO are primarily in the middle cranial fossa, mani-
festing as an increase in the sphenoid bone body length, ex-
pansion of the sphenoidal sinus volume, growth of the pterygoid
process forward and downward, a decrease in the angle of both
the greater and smaller wings of the sphenoid bone, and an
increase in the posterior inclination of the pterygoid process.
Key Words: cleft lip and palate, cranial base, midfacial hypoplasia,
sphenoid bone, trans-sutural distraction osteogenesis (TSDO)
(J Craniofac Surg 2023;34: 551–555)
M idfacial hypoplasia, defined as restricted growth of the
nasomaxillary and zygomatic bones, can manifest as
craniomaxillofacial skeletal deformities associated with genetic
disorders such as Apert syndrome,1 Crouzon syndrome,2 or
secondary to congenital cleft lip and palate (CLP).3
The growth of the midfacial skeleton mainly depends on 2
mechanisms. First, it relies on the growth remodeling of the skel-
eton itself; second, it is promoted by cranial base growth.4,5 Dis-
ruption of these mechanisms, resulting from environmental or
genetic factors at an early age, can lead to midfacial hypoplasia.3
Some children with CLP exhibit significant maxillary retrusion
deformity and maxillofacial dysfunction owing to endogenous de-
velopmental deficits and sequential treatments (surgical and non-
surgical).6–10 This deformity mainly manifests as a retrusion
deformity of the infraorbital, zygomatic, nasal regions, and
maxilla.11–14 In addition to affecting appearance, it can also affect
children’s masticatory and speech functions, and even cause respi-
ratory problems, such as obstructive sleep apnea syndrome.15,16
Thus, this deformity requires early correction. > 25% of children
with CLP have severe deformities and require comprehensive sur-
gical treatment to improve form and function.11,17,18
Three main surgical procedures are commonly used in the
clinical treatment of midfacial hypoplasia: traditional orthog-
nathic surgical techniques, maxillary distraction with osteot-
omy, and trans-sutural distraction osteogenesis (TSDO). The
first 2 techniques require osteotomy, which can result in
complications such as severe postoperative bleeding, inferior
alveolar nerve damage, velopharyngeal incompetence, and
postsurgical relapse, among others.19–22
The TSDO technique applies an external force to the
naturally existing cranial and facial sutures. This induces bone
551
 Zhang et al The Journal of Craniofacial Surgery
reconstruction and new bone formation around the sutures,
which can effectively adjust the shape and position of the cra-
niomaxillofacial skeleton to a certain extent without osteotomy.
Trans-sutural distraction osteogenesis avoids the risks of enor-
mous trauma, heavy bleeding, and other complications caused
by osteotomy. It is particularly suitable for pediatric patients
during the growth period;3,23 accordingly, children can undergo
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surgery at an early age without carrying a deformed appearance
and dysfunction into older age or adulthood.
Many studies have conducted cephalometric analysis on
2-dimensional (2D) or 3-dimensional (3D) images to describe
the craniomaxillofacial skeleton after distraction osteogenesis
therapy.24–33 However, few reports have investigated the
changes in the cranial base, which may play an essential role in
midfacial skeleton growth. The cranial base is the bony con-
nection between the cranial and facial bones. It consists of the
ethmoid, sphenoid, and occipital bones. Three growth plate-like
structures are located between these bones, which are called the
cranial base synchondroses (CBS); these are the growth centers
of the cranial base.34 The CBS consists of 3 cartilage unions
called spheno-ethmoidal synchondrosis (SES), intersphenoid
synchondrosis, and spheno-occipital synchondrosis (SOS). The
anterior cranial base is closely related to the maxilla below it,
and together, they form the ethmoid-maxilla complex.35 This
demonstrates that the cranial base is closely related to midfacial
growth and development.
To reveal the morphological changes of the cranial base after
TSDO, we built and analyzed 3D models based on computed
tomography (CT) images of 29 children with midfacial hypo-
plasia due to CLP who have undergone bone-borne TSDO
therapy.
METHODS
Participants
This study is a retrospective analysis of pediatric cases with
skeletal midfacial hypoplasia secondary to CLP who underwent
TSDO performed by our medical team at the Plastic Surgery
Hospital, Chinese Academy of Medical Science, and the De-
partment of Plastic and Cosmetic Surgery, Peking University
Third Hospital, from January 2005 to June 2020.
The inclusion criteria were as follows: (1) Children (under 18
y of age) with midfacial hypoplasia due to CLP; (2) complete
medical records of the traction procedure; (3) complete cranial
computed tomography (CT) imaging data collected pre-
operatively (T0) and within 1 week after the removal of rigid
external distractor (RED) (T1); and (4) the TSDO procedure
must be performed by the same surgeon.
The exclusion criteria were as follows: (1) severe complica-
tions during traction, including titanium nail fixation site in-
fection, severe titanium nail maladjustment, loosening of the
RED, and traction hook dislodgement; (2) early withdrawal of
the traction device for any reason; and (3) incomplete data re-
cords.
According to our surgical data, 85 consecutive children with
midfacial hypoplasia due to CLP underwent TSDO. Eight of
the 85 children were excluded because of complications and 48
lacked complete clinical records. Finally, 29 children met the
inclusion criteria, including 25 males (86.2%) and 4 females
(13.8%). Before traction, the mean age was 11.1 ± 2.3 years old
(5–15 y old). Nine children had bilateral CLP, and 20 had
unilateral CLP (8 on the right and 12 on the left). The maximum
unilateral traction force ranged from 3 to 6 kg, with a mean of
552
Copyright © 2022 Mutaz B. Habal, MD. All rights reserved.
 Volume 34, Number 2, March/April 2023
4.34 ± 0.79 kg, and the duration of the traction period ranged
from 24 to 60 days, with a mean of 40.7 ± 8.1 days.
Distraction Device
The distraction device consisted of a RED (Cibei Medical
Treatment Appliance Co.), nickel-titanium springs (GEE Co.),
and traction hooks (GEE Co.). The traction spring can produce
a stable and continuous traction force of 250 g per 1 mm stretch
within the deformation range.
Surgical Procedure
While the patient was under general anesthesia, an incision
was made in the mucosa at the top of the oral vestibular sulcus
in the position of the maxillary cuspid on each side and sepa-
rated to reveal the piriform aperture margins. A bone hole was
dilated obliquely, ~10 mm outside the lateral pyriform rim and
5 mm above the root of the cusp, to connect with the nasal
cavity. A traction hook was installed through the perforation,
with the caudal end passing through the base of the corre-
sponding nostril. The RED was fixed to the skull with titanium
nails 4 to 5 cm above the superior point of the auricle. Care was
taken to prevent the titanium nail from entering the skull. Then,
traction hooks on both sides were attached to the RED through
nickel-titanium springs. Finally, the traction force direction was
adjusted to ~20 to 30 degrees downward and horizontally
(Fig. 1).
Distraction Procedure
The starting traction force at the end of the surgery was 750
g per side, which was maintained for 3 to 5 days to allow the
patient to adapt. Then, the length of the spring was adjusted at a
rate of 1 to 2 mm every 2 to 3 days to gradually increase the
traction force until the desired maxillary advancement was
achieved. This was followed by a maintenance and con-
solidation period of 1 to 3 months. Subsequently, the traction
force was gradually decreased, and the whole distraction device
was removed.
Three-Dimensional Measurement and
Statistical Analysis
Computed tomography images of the whole skull were col-
lected at T0 and T1. The CT images were stored in the digital
imaging and communications in medicine (DICOM) file format,
and 3D models were created and measured using Mimics Re-
search software (version 20.0; Materialize). Craniometric anal-
yses were performed after segmentation. The definition of
landmarks is listed in Supplemental Table 1 (Supplemental
Digital Content 1, http://links.lww.com/SCS/E661). The defi-
nition of distances, angles, and volume are listed in Supple-
mental Table 2 (Supplemental Digital Content 2, http://links.
lww.com/SCS/E662). Two physicians independently calibrated
the measurement points and the results were averaged from the
2 measurements.
We used a 2-tailed t test in the Statistical Package for the
Social Sciences software (SPSS version 23.0; IBM Corp) to
perform the statistical analysis (P ≤ 0.05, level of significance).
RESULTS
Morphological Analysis of the Cranial Base
We performed linear and angular measurements of the cra-
nial base on a 3D model at T0 and T1, and the data is shown in
Supplemental Table 3 (Supplemental Digital Content 3, http://
links.lww.com/SCS/E663). The length of the cranial base in the
anteroposterior direction increased significantly after TSDO,
Copyright © 2022 by Mutaz B. Habal, MD
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FIGURE 1. A patient with a distraction device.
with a 2.4% increase in the total cranial base length (N-Ba)
(P < 0.001). The length of the anterior cranial base (N-S) in-
creased by 3.0% (P < 0.001), whereas the length of the posterior
cranial base (S-Ba) did not change significantly. In the anterior
cranial base, the length of the middle cranial fossa increased; Es-
S and Es-So increased by 9.6% and 4.9%, respectively
(P < 0.001), whereas that of the ethmoid bone (Fe-Es) in the
anterior cranial fossa decreased by 3.7% (P = 0.004), and N-Es
did not change significantly (P = 0.074). In the sagittal plane,
the sphenoid sinus was enlarged in the anteroposterior and
vertical directions (Figs. 2A, B).
The skull base angle (N-S-Ba) was 133.41 ± 5.11 degrees
preoperatively and increased by 1.1% after TSDO (P = 0.001),
suggesting a slight blunting of the anterior skull base relative to
the basilar clivus.
Changes in the Sphenoid Bone and Sphenoidal
Sinus in the Middle Cranial Fossa
Linear, angular, and volumetric measurements of the sphe-
noid bone and sphenoidal sinus on the 3D model were per-
formed at T0 and T1, and the data is shown in Supplemental
Table 4 (Supplemental Digital Content 4, http://links.lww.com/
SCS/E664). During TSDO, the pterygoid morphology of the
middle cranial fossa changed most significantly. After TSDO,
the posterior tilt of the middle cranial fossa increased, whereas
the mid-cranial basal angle (Ba-Es-Ptm) increased by 21.7%
(left side, P < 0.001) and 18.3% (right side, P < 0.001).
The length of the lateral plate of the pterygoid process
(Lppa-Lpp) increased by 80.1% (left side, P < 0.001) and 85.0%
(right side, P < 0.001) after TSDO, with no significant difference
between the left and right sides. Lppr-S-Lppl decreased by 1.7%
(P = 0.002) after TSDO, and the angle of the bilateral LPPA
processes decreased by 41.8% (P < 0.001) (Figs. 2C, D). The
angle of the bilateral greater wings of pterygoids was reduced by
4.3% after traction (P < 0.001) (Figs. 2E, F), and the angle of
the bilateral smaller wings of pterygoids was reduced by 1.3%
(P = 0.012) compared with that before TSDO.
The mean volume of the sphenoid sinus cavity (Vs) was
5205 ± 3242 mm3 before the operation and increased by 34.5%
after TSDO (P < 0.001). The CT value of the bilateral pter-
ygomaxillary sutures decreased significantly (P < 0.001) after
TSDO (Supplemental Table 4, Supplemental Digital Content 4,
http://links.lww.com/SCS/E664).
DISCUSSION
Among the surgical treatments for skeletal midfacial dysplasia,
TSDO is the most advantageous in terms of avoiding the risks
and complications of severe trauma and bleeding caused by
osteotomy.31,32,36 Trans-sutural distraction osteogenesis also
Copyright © 2022 by Mutaz B. Habal, MD
Copyright © 2022 Mutaz B. Habal, MD. All rights reserved.
Effect of Bone-Borne TSDO Therapy
allows for an earlier age of intervention, as it is indicated for
pediatric and adolescent patients during the growth period.
Thus, patients will not experience a deformed appearance and
dysfunction into older age or adulthood. In recent years, the
bone-borne TSDO technique has been widely used in clinical
practice. Although the short-term effectiveness of TSDO has
been discussed,3,15,24,25 long-term stability for 5 or 10 years has
not been examined. In addition, the effects of TSDO on the
cranial base have not yet been reported.
Some domestic and international scholars have used cranial
3D models based on CT images to measure and study the
morphological characteristics of the cranial base in children
with midfacial hypoplasia. However, these studies were mainly
conducted in children with congenital craniomaxillofacial skel-
etal anomalies such as Crouzon syndrome37,38 and metopic
synostosis;39 to date, no studies have been conducted specifically
on the cranial base of children with midfacial hypoplasia
secondary to CLP.
The growth of the midfacial skeleton consists of 2 main
types: passive growth driven by the cartilage growth center of
the cranial base and active growth driven by the growth of the
facial suture and bone surface. The combined action of the 2
growth centers results in the forward and downward growth of
the midfacial skeleton. In children younger than 6 to 7 years,
when the central nervous system is developing rapidly and
cranial bone volume is increasing significantly, the growth and
movement of the midface are mainly driven by the growth
center of the cranial base, which is known as cranial base
synchondrosis.3 Around the age of 7 to 12 years, as the
development of the central nervous system in children ap-
proaches that of adults, changes in cranial volume gradually
slow down, and the growth and developmental activity of CBS
diminish progressively. Therefore, during the growth period of
children, the midfacial skeleton and cranial base can be affected
by external or internal factors, which can lead to skeletal mid-
facial hypoplasia.
Current clinical studies suggest that skeletal midfacial hypo-
plasia secondary to CLP is mainly due to the interference of repair
surgery, periosteal injury, and postoperative scar formation.17,40,41
However, there are no reports on whether CLP repair affects the
growth and development of the cranial base.
The scar tissue after CLP surgery inhibits the growth of the
maxillary-associated sutures and the midfacial bones them-
selves. However, in pediatric patients with CLP, their growth
potential can be stimulated by external traction. Based on this
mechanism, bone-borne TSDO was developed.3
This study showed that the significant increase in cranial
base length after TSDO was mainly attributed to the middle
cranial fossa length, especially the Es-S. Es-S is a part of the
sphenoid bone consisting of the jugum sphenoidal and tuberc-
ulum sellae, located between the 2 cartilage growth centers (SES
and SOS) of the cranial base. The growth and development of
the cranial base depend mainly on the intrachondral osteo-
genesis of these cartilaginous unions,42 especially the SOS. The
ossification and closure of the SOS transpire relatively late and
play a crucial role in the growth and development of the cranial
base in infants and children.43,44 Normally, the intersphenoid
synchondrosis closes near birth,45 the SES closes at ~6 years of
age,44,46 and the SOS begins to fuse at around 14 to 16 years of
age and completely disappears after ~25 years of age.42 In ad-
dition, the growth of the skull base is associated with an ex-
pansion of the mandible, eruption of teeth, and development of
the masticatory and nasopharyngeal muscles.
To discuss the causes of Es-S growth, 3 hypotheses are
proposed: (1) the bone adjacent to the spheno-ethmoidal suture
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 Zhang et al The Journal of Craniofacial Surgery
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FIGURE 2. Sagittal view of cranial base length changes. (A) Before trans-sutural
distraction osteogenesis (TSDO); (B): after TSDO; yellow dotted lines: increase
after distraction; white dotted line: no significant change before and after
distraction; see Supplemental Table 1 for the definition of landmarks. Changes
in the lengths and angles associated with the lateral plate of the pterygoid
process. (C) Before TSDO; (D) after TSDO; solid line: Lpp/R-S-Lpp/L; dotted
line: LPPA. Changes in the angle of bilateral greater wings of pterygoids. (E)
Before TSDO; (F) after TSDO.
increases significantly after TSDO, suggesting that there may
still be osteogenic potential in the closed suture, as it regains
osteogenic ability under traction force; (2) the jugum sphenoidal
and tuberculum sellae undergo skeletal remodeling and growth
through subperiosteal osteogenesis; and (3) both modalities may
coexist in this process. Therefore, further animal experiments
are required to investigate the mode and characteristics of
osteogenesis in the middle cranial fossa under traction force.
The cranial base angle in children with midfacial hypoplasia
enrolled in this study remained within the normal range of 115 to
145 degrees before TSDO.42 During the traction process, the
anterior cranial base rotated upward, with the sella turcica as the
center, thus causing an increase in N-S-Ba. Ba-Es-Ptm increases
after TSDO, reflecting an overall increase in the posterior tilt of
the middle cranial fossa.
During TSDO, the most apparent morphological changes
occur in the sphenoid bone of the middle cranial fossa. The sella
turcica is the center of the cranial base and the anterior margin
of the sphenoid bone is the bridge connecting the middle facial
bones to the cranial base; at the bottom of the cranial base, the
anterolateral aspect of the pterygoid process is connected to the
zygomatic bone through the pterygomaxillary suture, the an-
teromedial part of the pterygoid process is connected to the
maxillary bone through the palatine bone, and the medial plate
of pterygoid process is connected to the edge of the vomer,
which all together form a close connection between the sphe-
noid bone and the middle facial bones. In the anterior part of
the cranial base, the large wing of the pterygoid bone is con-
nected to the zygomatic and frontal bones, and the small wing
of the pterygoid bone forms an extensive connection with the
frontal bone. In the central part of the cranial base, the jugum
sphenoidal, the anterior and inferior walls of the sphenoid sinus
are connected to the ethmoid bone and vomer, respectively, and
all are ultimately connected to the maxilla.42 These are the
possible pathways for the transmission of traction force from
the maxilla to the cranial base during TSDO.
In this study, we found significant growth and lengthening of
the anterior pterygoid process. The CT values in the area where
the pterygoid process joined the zygomatic and palatal bones were
significantly reduced. LPPA, greater wings of pterygoids, and
smaller wings of pterygoids were substantially smaller, which is
consistent with the forward growth of the pterygoid bone under
the effect of traction. Simultaneously, the anteroposterior dia-
meter of the pterygoid body increased with skeletal remodeling,
and the volume of the pterygoid sinus increased significantly.
This study is the first to measure and study the morpho-
logical changes of the cranial base in growing children with
midfacial hypoplasia due to CLP who underwent bone-borne
554
Copyright © 2022 Mutaz B. Habal, MD. All rights reserved.
 Volume 34, Number 2, March/April 2023
TSDO. The main limitation of this study was the lack of normal
controls, and the difficulty of excluding the effect of normal
growth and development on the cranial base, which will be
explored in our subsequent studies. Further studies analyzing
the impact of different CLP repair methods, orthodontic sur-
geries, time of CLP repair surgery, and other related factors on
the growth and development of the cranial base are needed to
determine how exogenous stimuli modulate the growth and
development of the cranial base.
CONCLUSIONS
The most apparent changes in the cranial base after TSDO
happen mainly in the middle cranial fossa, which is manifested
as an increase in the length of the body of the sphenoid bone,
expansion of the sphenoidal sinus volume, growth of the pter-
ygoid process in the forward and downward directions, a de-
crease in the angle of both the greater and smaller wings of the
sphenoid bone, and an increase in the posterior inclination of
the pterygoid process. These changes, which may affect the
patient head shape and brain volume, need to be considered in
bone-borne TSDO procedures.
ACKNOWLEDGMENTS
The authors thank Editage (https://www.editage.cn) for English
language editing.
REFERENCES
1. Lu X, Forte AJ, Sawh-Martinez R, et al. Spatial and temporal
changes of midface in apert’s syndrome. J Plast Surg Hand Surg
2019;53:130–137
2. Forte AJ, Lu X, Hashim PW, et al. Analysis of airway and midface
in crouzon syndromes. Ann Plast Surg 2019;82:686–691
3. Tong H, Song T, Sun X, et al. Imaging study of midface growth
with bone-borne trans-sutural distraction osteogenesis therapy in
growing cleft lip and palate patients. Sci Rep 2019;9:871
4. Goldstein JA, Paliga JT, Wink JD, et al. Earlier evidence of spheno-
occipital synchondrosis fusion correlates with severity of midface
hypoplasia in patients with syndromic craniosynostosis. Plast
Reconstr Surg 2014;134:504–510
5. Marulanda J, Murshed M. Role of matrix gla protein in midface
development: Recent advances. Oral Dis 2018;24:78–83
6. Lee JC, Slack GC, Walker R, et al. Maxillary hypoplasia in the cleft
patient: contribution of orthodontic dental space closure to
orthognathic surgery. Plast Reconstr Surg 2014;133:355–361
7. Lai LH, Hui BK, Nguyen PD, et al. Lateral incisor agenesis
predicts maxillary hypoplasia and le fort i advancement surgery in
cleft patients. Plast Reconstr Surg 2015;135:142e–148e
8. Wu T-T, Chen PKT, Lo L-J, et al. The characteristics and
distribution of dental anomalies in patients with cleft. Chang Gung
Med J 2011;34:306–314
9. Delestan C, Montoya P, Doucet J-C, et al. New neonatal
classification of unilateral cleft lip and palate-part 1: to predict
primary lateral incisor agenesis and inherent tissue hypoplasia. Cleft
Palate Craniofac J 2014;51:392–399
10. Doucet J-C, Delestan C, Montoya P, et al. New neonatal
classification of unilateral cleft lip and palate part 2: to predict
permanent lateral incisor agenesis and maxillary growth. Cleft
Palate Craniofac J 2014;51:533–539
11. Cohen SR, Corrigan M, Wilmot J, et al. Cumulative operative
procedures in patients aged 14 years and older with unilateral or
bilateral cleft lip and palate. Plast Reconstr Surg 1995;96:267–271
12. Molina F, Ortiz Monasterio F, De La Paz Aguilar M, et al.
Maxillary distraction: aesthetic and functional benefits in cleft lip-
palate and prognathic patients during mixed dentition. Plast
Reconstr Surg 1998;101:951–963
13. Swennen G, Colle F, De May A, et al. Maxillary distraction in cleft
lip palate patients: a review of six cases. J Craniofac Surg 1999;10:
117–122
Copyright © 2022 by Mutaz B. Habal, MD
 The Journal of Craniofacial Surgery  Volume 34, Number 2, March/April 2023
14. Swennen GRJ, Treutlein C, Brachvogel P, et al. Segmental
unilateral transpalatal distraction in cleft patients. J Craniofac Surg
2003;14:786–790
15. Zheng Y, Tong H, Yin N, et al. Rigid external distraction with
intranasal bone-borne traction hooks for midfacial hypoplasia. Sci
Rep 2018;8:9948
16. Neelapu BC, Kharbanda OP, Sardana HK, et al. Craniofacial and
Downloaded from http://journals.lww.com/jcraniofacialsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI
upper airway morphology in adult obstructive sleep apnea patients:
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/12/2023
a systematic review and meta-analysis of cephalometric studies.
Sleep Med Rev 2017;31:79–90
17. Deluke DM, Marchand A, Robles EC, et al. Facial growth and the
need for orthognathic surgery after cleft palate repair: literature
review and report of 28 cases. J oral Maxillofac Surg 1997;55:694–697
18. Rosenstein S, Kernahan D, Dado D, et al. Orthognathic surgery in
cleft patients treated by early bone grafting. Plast Reconstr Surg
1991;87:835–892
19. Roy A-A, Rtshiladze MA, Stevens K, et al. Orthognathic surgery
for patients with cleft lip and palate. Clin Plast Surg 2019;46:
157–171
20. Garg S, Kaur S. Evaluation of post-operative complication rate of
le fort i osteotomy: a retrospective and prospective study.
J Maxillofac Oral Surg 2014;13:120–127
21. Eshghpour M, Mianbandi V, Samieirad S. Intra and postoperative
complications of le fort i maxillary osteotomy. J Craniofac Surg
2018;29:e797–e803
22. Watanabe M, Watanabe A, Takano N, et al. Morphologic
evaluation for safe le fort i osteotomy in cleft lip and palate. Cleft
Palate Craniofac J 2018;55:728–735
23. Tong H, Liu L, Tang X, et al. Midface distraction osteogenesis
using a modified external device with elastic distraction for crouzon
syndrome. J Craniofac Surg 2017;28:1573–1577
24. Yatabe M, Garib DG, Faco RAS, et al. Bone-anchored maxillary
protraction therapy in patients with unilateral complete cleft lip and
palate: 3-dimensional assessment of maxillary effects. Am J Orthod
Dentofacial Orthop 2017;152:327–335
25. Garib D, Yatabe M, De Souza Faco RA, et al. Bone-anchored
maxillary protraction in a patient with complete cleft lip and palate:
a case report. Am J Orthod Dentofacial Orthop 2018;153:290–297
26. Jahanbin A, Kazemian M, Eslami N, et al. Maxillary protraction
with intermaxillary elastics to miniplates versus bone-anchored
face-mask therapy in cleft lip and palate patients. J Craniofac Surg
2016;27:1247–1252
27. Ahn H-W, Kim K-W, Yang I-H, et al. Comparison of the effects of
maxillary protraction using facemask and miniplate anchorage
between unilateral and bilateral cleft lip and palate patients. Angle
Orthod 2012;82:935–941
28. Meazzini MC, Zappia LB, Tortora C, et al. Short and long-term
effects of late maxillary advancement with the liou-alt-ramec
protocol in unilateral cleft lip and palate. Cleft Palate Craniofac J
2019;56:159–167
29. On SW, Baek S-H, Choi J-Y. Effect of long-term use of facemask
with miniplate on maxillary protraction in patients with cleft lip and
palate. J Craniofac Surg 2018;29:309–314
Copyright © 2022 by Mutaz B. Habal, MD
Copyright © 2022 Mutaz B. Habal, MD. All rights reserved.
Effect of Bone-Borne TSDO Therapy
30. Morales-Fernández M, Iglesias-Linares A, Yañez-Vico RM, et al.
Bone- and dentoalveolar-anchored dentofacial orthopedics for class
iii malocclusion: new approaches, similar objectives?: a systematic
review. Angle Orthod 2013;83:540–552
31. Tong H, Gao F, Yin J, et al. Three-dimensional quantitative
evaluation of midfacial skeletal changes after trans-sutural
distraction osteogenesis for midfacial hypoplasia in growing
patients with cleft lip and palate. J Craniomaxillofac Surg 2015;43:
1749–1757
32. Tong H, Wang X, Song T, et al. Trans-sutural distraction
osteogenesis for midfacial hypoplasia in growing patients with cleft
lip and palate: clinical outcomes and analysis of skeletal changes.
Plast Reconstr Surg 2015;136:144–155
33. Heymann GC, Cevidanes L, Cornelis M, et al. Three-dimensional
analysis of maxillary protraction with intermaxillary elastics to
miniplates. Am J Orthod Dentofacial Orthop 2010;137:274–284
34. Cha BK, Choi DS, Jang IS, et al. Aberrant growth of the anterior
cranial base relevant to severe midface hypoplasia of apert
syndrome. Maxillofac Plast Reconstr Surg 2018;40:40
35. Chitguppi C, Rimmer RA, Garcia HG, et al. Evaluation of cranial
base repair techniques utilizing a novel cadaveric cpap model. Int
Forum Allergy Rhinol 2019;9:795–803
36. Liu C, Hou M, Liang L, et al. Sutural distraction osteogenesis (sdo)
versus osteotomy distraction osteogenesis (odo) for midfacial
advancement: a new technique and primary clinical report.
J Craniofac Surg 2005;16:537–548
37. Lu X, Jorge Forte A, Sawh-Martinez R, et al. Association of
regional cranial base deformity and ultimate structure in crouzon
syndrome. Plast Reconstr Surg 2019;143:1233e–1243e
38. Lu X, Forte AJ, Steinbacher DM, et al. Enlarged anterior cranial
fossa and restricted posterior cranial fossa, the disproportionate
growth of basicranium in crouzon syndrome. J Craniomaxillofac
Surg 2019;47:1426–1435
39. Cabrejo R, Lu X, Persing J. The endocranial bifrontal angle: a
longitudinal evaluation in two patients with metopic synostosis.
J Craniofac Surg 2019;30:1644–1646
40. Oberoi S, Chigurupati R, Vargervik K. Morphologic and
management characteristics of individuals with unilateral cleft lip
and palate who required maxillary advancement. Cleft Palate
Craniofac J 2008;45:42–49
41. Hsieh CH-Y, Ko EW-C, Chen PK-T, et al. The effect of
gingivoperiosteoplasty on facial growth in patients with complete unilateral
cleft lip and palate. Cleft Palate Craniofac J 2010;47:439–446
42. Gray H. The skull. In: Susan S, ed. Gray’s anatomy: The anatomical
basis of clinical practice, 42nd edn. Elsevier Health Sciences; 2020;
Chapter 34:558–572
43. Bjork A. Cranial base development. Am J Orthod 1955;41:199–255.
44. Ford E. Growth of the human cranial base. Am J Orthod 1958;44:
498–506
45. Hayashi I. Morphological relationship between the cranial base and
dentofacial complex obtained by reconstructive computer
tomographic images. Eur J Orthod 2003;25:385–391
46. Scott J. The cranial base. Am J Phys Antropol 1958;16:319–348
555