Tooth-Borne Anterior Maxillary Distraction for Cleft Maxillary Hypoplasia: Our Experience With 147 Patients.
OBJECTIVE
To evaluate the results of anterior maxillary distraction for its efficacy and long-term stability in the management of cleft maxillary hypoplasia in a large series of patients with a long-term follow-up extending to 4 years.


METHODS
One hundred sixty-four patients at least 10 years old with cleft maxillary hypoplasia who presented to the authors' unit from January 2009 through October 2014 were evaluated retrospectively, irrespective of gender, type of cleft lip and palate, and amount of advancement needed. Anterior maxillary distraction using a tooth-borne distractor appliance was carried out in all patients and all patients were followed up to 4 years (range, 1 to 4 yr) to evaluate the stability of the procedure and to document any relapse using digitalized lateral cephalograms taken before distraction, immediately after distraction (T2), and at the last follow-up visit (T3; range, 1 to 4 yr). Seventeen patients were subsequently lost to follow-up; therefore, a complete set of records was available for 147 patients. In a subset of 50 patients, perceptual speech assessment was carried out preoperatively and 6 months postoperatively by 2 speech pathologists using the Perkins scoring system that allowed the evaluation of 5 parameters (velopharyngeal insufficiency, resonance, nasal air emission, articulation, and intelligibility). None of these patients underwent speech therapy during the course of evaluation. The development of complications intra- or postoperatively was noted. The data were tabulated and analyzed.


RESULTS
An advancement ranging from 4.0 to 13.1 mm (mean, 9.42 mm) was achieved in all patients. One hundred forty patients (95.23%) showed stable results on lateral cephalograms and when T2 values were compared with T3 values. Seven patients (4.76%) exhibited skeletal relapse in various linear and angular measurements assessed on lateral cephalograms. At 6-month follow-up, improvements of 62% (n = 31), 64% (n = 32), 50% (n = 25), 68% (n = 34), and 70% (n = 35) in velopharyngeal insufficiency, resonance, nasal air emission, articulation, and intelligibility, respectively, were observed, with worsening of all parameters in 1 patient (2%). An overall complication rate of 25.17% (n = 37) was noted, with bleeding being the most common intra- and postoperative complication noted in 15 patients (10.2%). No serious consequences related to any complication were noted.


CONCLUSIONS
Anterior maxillary distraction can be considered a suitable treatment option for the management of mild to moderate cleft maxillary hypoplasia because the anteroposterior deficiency can be addressed at a young age, immediately after the eruption of the maxillary second premolars. Stable long-term results with negligible skeletal relapse are possible with this technique, with an added advantage of unhampered or even improved velopharyngeal function.
Project Director, Dr Jeyashekaran Centre for Cleft Care, Dr Jeyashekaran Hospital; Director, Richardson's Dental and Craniofacial Hospital, Nagercoil, Tamilnadu, India. Electronic address: sunilrichardson145@gmail.com.
Sunil
S
Richardson
Professor, Department of Orthodontics, Rajas Dental College and Hospital, Thirunelveli, Tamilnadu, India.
Dhivakar
D
Selvaraj
Surgical Fellow, Richardson's Dental and Craniofacial Hospital, Nagercoil, Tamilnadu, India.
Rakshit V
RV
Khandeparker
Speech Language Pathologist, Department of Speech Language Pathology, Richardson's Dental and Craniofacial Hospital, Nagercoil, Tamilnadu, India.
Nikkie S
NS
Seelan
Consulting General Dentist, Richardson's Dental and Craniofacial Hospital, Nagercoil, Tamilnadu, India.
Shweta
S
Richardson
D000293:Adolescent; D000328:Adult; D002648:Child; D002972:Cleft Palate / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008437:Maxilla / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D019857:Osteogenesis, Distraction / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult