Treatment of Maxillary Hypoplasia in

Cleft Lip and Palate Patients:

Keeping The Total Burden of Care as
Low as Possible
Presented by:
Siwi Bagus.A

Supervised by:
Dewi Haryanti, dr, Sp.BP-RE

Program Studi Ilmu Bedah

Fakultas Kedokteran UNS
JOURNAL READING
 ABSTRACT
Maxillary hypoplasia is a common problem in cleft patients. The literature has
shown that early treatment is unstable. On the other hand, long‑term results of
Introduction the application of the Alternate Rapid Maxillary Expansion and Constriction
(Alt‑RAMEC) technique have been shown to be stable. Therefore, a later approach
might be considered if the objective is purely occlusal/esthetic.
To describe the rationale behind a protocol for the treatment of maxillary
Objective hypoplasia in cleft lip and palate (CLP) patients where timing is guided by the
different indications.
We subdivided this study into two groups.
(1) Early treatment group (preliminary study): 30 unilateral CLP (UCLP) and
bilateral CLP patients were treated early with expansion and face mask with
Materials two specific functional indications. The objective of early treatment thus, was
and purely functional.
Methods (2) Late adolescence treatment group (follow‑up study): a different group of older
patients was treated at a later stage with an esthetic‑occlusal aim. 39 UCLP
patients were consecutively treated with the Alt‑RAMEC technique at an
average age of 13.2 years (11.3–14.2 years) before protraction.
 ABSTRACT
1) Early treatment group (preliminary results): the sagittal advancement of
A‑point, after the application of the face mask and expander, was 2.6 ± 1.2 mm.
About 65% of the OM patients had a net improvement of all audiological
symptoms, and 100% of OSAS patients had a significant improvement of
Results
obstructive parameters (apnea‑hypopnea index).
2) Late treatment group (follow‑up study): the sagittal advancement of A‑point,
after the application of the Alt‑RAMEC technique, was 5.6 ± 2.7 mm. The
position of the maxilla was stable in the long term.
 Even though skeletal relapse is expected after early correction of maxillary
hypoplasia, there might be an indication in patients with functional problems,
to avoid more complex treatments.
 To correct the occlusal esthetic problem related to maxillary hypoplasia, it is
Conclusions
advisable to wait till after growth peak and apply a modified Alt‑RAMEC
technique, with a double‑hinged expander and to obtain more stable long‑term
results. This technique seems to significantly reduce, especially in female
patients, the need for final orthognathic surgery.
INTRODUCTION
INTRODUCTION
 The incidence of maxillary hypoplasia in
UCLP patients needing osteotomies at the
completion of growth : 25%; 26%; and
48%.
 Developing midfacial retrusion in CLP
children has been conventionally treated
with protraction face mask at an early age.
 Maxillary skeletal base protraction with
face mask in UCLP is reported to range
between 0.95 and 1.68 mm, or up to 2.5
mm. 6
INTRODUCTION
 A face mask is more efficient when applied early
(after the age of 9–10 years), its effect is
generally more dentoalveolar than skeletal.
 In most cases, the original skeletal pattern of
growth gradually reappears within 3 years after
the completion of active treatment.
 In a 10‑year follow‑up study shown, that most
patients ended either with dental compensations
or needed surgical correction

7
INTRODUCTION
 Rapid maxillary expansion (RME) loosens the
articulations of the maxillary complex from the rest of the
skull, whereby rendering more effective maxillary
protraction.
 Alt‑RAMEC technique is a protocol which allows to
disarticulate all circummaxillary sutures in patients who
are close to the end of craniofacial growth; the technique
does not use a traditional expander, but a two‑hinged
rapid palatal expander, in its biomechanics, expanding
and rotating each half of the maxilla outward, while
buttressing against the pterygoids posteriorly.
 Timing of treatment seems fundamental for the success 8

of the technique in the long term.

MATERIALS AND METHODS
Early Treatment Patients (4–9 Years)

The inclusion criteria :

• Unilateral, bilateral CLP patients affected by maxillary hypoplasia, and skeletal Class III
malocclusion with no CO‑CR shift
• Deciduous dentition or early mixed dentition
• Associated problems:
 Audiometric test depicting hearing loss and Type B or C tympanograms
 Obstructive sleep apnea (OSAS) with Apnea Hypopnea Index (AHI) >4.
• Full cooperation of the patients.

30 patients were treated early with expansion and face mask with two specific functional indications:
― 22 were affected by middle ear infection, otitis media (OM), with subsequent hearing
impairment
― 8 by OSAS
The objective of early treatment, thus, was purely functional.
Late treatment patients (11–14 years)

The inclusion criteria :

• Complete UCLP patients consecutively treated with Alt‑RAMEC
• Vertebral stage of maturation V3 at the beginning of treatment (usually corresponding to late
deciduous or permanent dentition)
• Skeletal Class III malocclusion with no CO‑CR shift
• Full cooperation of the patients.

 A modification of the original Liou Alt‑RAMEC technique has been applied since 2005 by the
authors in 106 patients: of these patients, 48 where noncleft, nonsyndromic, Class III patients.
 The results of the first 29 patients affected by UCLP, consecutively treated with this technique,
were reported in a previous study. 10 additional patients were included in this study. Therefore,
the actual total study sample was 39.
 The average age of the patients in the sample was 13.2 years (11.3–14.2 years) before protraction.
 The average age at long‑term follow‑up was 18.3 years (17.4–24.7).
 Rapid Palatal Expander (RPE) and Face Mask Protocol
A traditional RPE was cemented to which a face mask was applied at least 14 h/day.
All patients had at least 8 mm expansion, as the objective of the treatment was functional
and not occlusal.
 Unilateral cleft lip and palate female patient,
protracted early for hearing disorder :

a) Profile of a female unilateral cleft lip and palate

patient at 7 years of age pre-treatment.
b) Profile at the end of maxillary protraction.
c) Lateral occlusal photograph pretreatment.
d) Lateral occlusal photograph post-treatment.
e) Audiometric test pre-treatment.
f) Audiometric test post-protraction.
g) Otoscopy pre-treatment (Tympanogram Type B).
h) Otoscopy post-treatment (Tympanogram Type A)
 Alternate Rapid Maxillary Expansion and Constriction protocol
(Alt-RAMEC)

• The double‑hinged maxillary expander (DHME) consisted of a

jackscrew in the center, and two hinges of rotation posteriorly.
• In the lower arch, a double lingual arch with anterior hooks was
soldered on molar and premolar bands.

The treatment protocol : 7 cycles with 7 days of expansion and 7 days of

constriction, 1 mm/day, alternatively.
After 7 weeks of alternate expansion‑constriction, a mild mobility of the whole
maxilla was felt clinically and a mild discomfort was reported by the patient,
especially at the paranasal area.
 Alternate Rapid Maxillary Expansion and Constriction protocol
(Alt-RAMEC)

• When no dental movement was desired, the original protocol

was modified adding temporary skeletal anchorage devices
(TADs) provided by two maxillary and two mandibular
titanium miniscrews.
• After the completion of the expansion/constriction cycles,
the technique included 5–7 months of active maxillary
protraction. The maxillary protraction was delivered by a pair
of tooth‑borne, intraoral maxillary protraction springs,
which produced a force of 300 gr per side.
• Given the relatively frequent breakage of the β‑titanium
springs, all patients continued protraction with intraoral
elastics (300 gr), to be used 24 h per day, also during
mealtimes.
 Cephalometric Analysis

• A lateral cephalometric radiograph was taken before (T0) and after maxillary protraction
(T1), and at long term (Tlt).
• Lateral cephalometric tracings were superimposed on the anterior cranial base, orienting
on the Sella‑Nasion (SN) line.
Example of a patient, protracted late (during
adolescence) to treat the progressive Class III:

a) A female UCLP Van der Woude patient at

11.9 years of age pre-treatment.
b) Lateral occlusal photograph pre-treatment.
c) Lateral X_ray pre-treatment.
d) Patient at the end of maxillary protraction.
e) Lateral occlusal photograph post-
treatment.
f) Lateral X_ray post-treatment. In this patient
TADs were used in the mandibular arch.
g) Profile at smile 7 years post-treatment.
h) Lateral X_ray 7 years post-treatment.
i) Lateral occlusal photograph 7 years post-
treatment
ENT Evaluation
Tympanometry : to test the condition of the middle ear, mobility of the tympanic
membrane, and the conduction bones by creating variations of air pressure in
the ear canal.

Respiratory Evaluation
Polysomnography was carried out in patients with respiratory distress. In this
preliminary report, only AHI will be reported as parameter to evaluate
improvement in breathing.
 RESULTS
The ICC used to assess the consistency of the single rater was 0.982, thus providing an
indication of good intrarater reliability.
Early Treatment Patients
Skeletal results
The average advancement of point A in these patients was 2.6 ± 1.2 mm.

ENT results
• 35% of the patients had no ENT improvement, and 8% needed, even
after protraction, T tubes placement to improve hearing loss.
• 65% of the patients had an average improvement of hearing in both
ears.
• Hearing threshold decreased significantly of 21 db (range 11–26 db).
• Tympanograms went from Type C and Type B to Type A bilaterally in
60% of the patients

Obstructive sleep apnea results

Average initial AHI was 13.1 ± 3. After over‑expansion and protraction
average AHI was 3.3 ± 2.
20
Late Treatment Patients
 At T1 (immediate postprotraction) the maxilla was advanced at A point
on an average 5.6 mm (P < 0.001).
 The mandibular posterior rotation was not significant.
 Two patients developed reciprocal TMJ click, which were addressed with
physical therapy.
 In the long term (at least 6 years postprotraction), the maxilla remained
stable, with no significant relapse, in all patients followed long‑term
posttreatment.
 The mandible grew, after the completion of treatment, at B point on an
average 3 mm.
 Clinically, none of the patients presented periodontal problems or loss of
vitality of teeth.
 None of the patients had a permanent TMJ dysfunction in the long term.
 One of the female patients (16% of the females) and two male patients
(32% of the males) at the completion of growth required a le Fort I
21
osteotomy.
DISCUSSION
 Early Treatment (Functional) Sample

 Eventhough the skeletal recurrence of early treatment, the results both in the ENT
sample and in the OSAS sample justify the additional burden of care.
 Skeletal and soft‑tissue expansion induced by the palatal separation forces,
transversally and sagitally, affected the nasomaxillary complex, tubal dilator muscles,
and Eustachian tube dysfunction.
 The results in the OSAS group justify the early treatment as well, as all patients had a
final AHI lower than 4–5. This result is superior to that reported after treatment with
RPE only, as significant protraction was added to the skeletal modification.
 All patients needed overcorrection of the Class III to obtain full improvement of
OSAS. Therefore, treatment time was relatively long (average time 19 months ± 4).
 Early Treatment (Functional) Sample

List of possible main indications for early protraction, consider:

1. Hypoacousia and tympanic membrane distortions
2. OSAS (more common in cleft children with pharyngeal flaps)

Also,
1. Large soft‑tissue gaps, which do not allow the surgeon to perform bone graft
and soft‑tissue closure. Protraction of the posterior segments allows to avoid
flaps such as lingual flaps or buccal flaps
2. Seldom indication is given by the speech pathologist for difficulties in
articulation
3. Severe incisal trauma
 Late Treatment Sample
This study confirmed that a repetitive weekly protocol of Alt‑RAMEC, using a two‑hinged
expander with skeletal anchorage and intraoral traction, allows to obtain significant
advancement of the maxilla in cleft patients and that the maxillary results remain stable
in the long term.

• The total amount of maxillary advancement was almost 6 mm in 6 months; the long‑term
evaluation revealed that the maxillary advancement was stable.
• Kaya et al. reported an average maxillary advancement of 2 mm adding miniplates and a
face mask
• Canturk reported over 3 mm maxillary advancement applying night‑time face mask and
daytime Class III elastics.
 Late Treatment Sample

The reasons which may have allowed a greater advancement in the present study may be :

1. The two‑hinged expander has a specific geometry which allows a better loosening of all
circumaxillary sutures. Histologically, the circumaxillary sutures, is not a simple
deposition of osteoid, as found in RPE, but a process of sutural stretching and
protraction osteogenesis.
2. Springs or intraoral elastics are used 24 h/day, even during eating time, and this is a
fundamental advantage over face mask, which is usually only worn during night‑time.
3. The skeletal anchorage allows distributing the forces of traction directly to the bones,
with greater maxillary advancement and significant reduction of dentoalveolar
compensation.
 Late Treatment Sample
• Another reason of the success in the long term of this technique is the timing of
treatment.
• Other methods for maxillary advancement involving zygomatic and mandibular plates,
seem to allow for a much lower advancement of the maxilla in UCLP patients (1.6 mm–
2.2 mm) and until now have provided no long‑term data.
• The maxillary advancement obtained with our late protraction technique is lower than
that reported in patients treated later with orthognathic surgery at the completion of
growth (6.8 ± 1.7 mm). This suggests that some of the patients treated with Alt‑RAMEC
will not avoid surgery.
• The advantage from the psychological aspect : the appearance of the patient improves
significantly during adolescence.
CONCLUSION
 Conclusions
1. Early correction of maxillary hypoplasia, even though skeletal
relapse is expected, might be indicated in patients with
functional problems, such as hearing or breathing disorders, to
avoid more complex treatments.
2. To correct the occlusal esthetic problem, it is advisable to wait
till after growth peak and apply a modified Alt‑RAMEC
technique, with a double‑hinged expander, to obtain more
stable maxillary long‑term results. This technique seems to
significantly reduce, especially in female patients, the need for
final orthognathic surgery.
THANK YOU