Cleft lip and palate (CLP) patients suffer from maxillary hypoplasia. The 3 surgical options for these patients are LFI osteotomy, RED, and AMDO. Lefort I can be problematic in CLCP patients due to increased scar tissue which limits maxillary advancement and increases the chances of relapse along with poor velopharyngeal functions. Distraction Osteogenesis with RED is another treatment modality with good advancement results, though some studies have reported the velopharyngeal efficacy to be same as in Lefort I patients. Other studies had applied anterior maxillary distraction osteogenesis (AMDO) for the CLP patients and obtained favorable forward movement of the anterior segment. Thus, the purpose of this study was to investigate the changes and stability of the maxilla and midfacial soft tissue throughout the application of AMDO in unilateral cleft lip and palate (UCLP) and isolated cleft palate patients. The author compared 3 treatment methods in the management of maxillary hypoplasia: LFI osteotomy, RED, and AMDO.

1. Midfacial Changes Through Anterior Maxillary
Distraction Osteogenesis in Patients With Cleft Lip
and Palate
Hiroyuki Kanzaki, DDS, PhD,!yz Yoshimichi Imai, MD, PhD,§ Tetsu Nakajo, DDS,
PhD,!z Takayoshi Daimaruya, DDS, PhD,jj Akimitsu Sato, MD,§ Masahiro Tachi, MD,
PhD,§ Youhei Nunomura, DDS,z Yusuke Itagaki, DDS,z Kazuaki Nishimura, DDS,
PhD,! Shoko Kochi, DDS, PhD,z§ and Kaoru Igarashi, DDS, PhD.
The Journal of Craniofacial Surgery 2017

2. INTRODUCTION
 Cleft lip and palate (CLP) patients suffer from maxillary hypoplasia.
 The 3 surgical options for these patients are LFI osteotomy, RED, and AMDO.
 Lefort I can be problematic in CLCP patients due to increased scar tissue which limits
maxillary advancement and increases the chances of relapse along with poor
velopharyngeal functions.
 Distraction Osteogenesis with RED is another treatment modality with good advancement
results, though some studies have reported the velopharyngeal efficacy to be same as in
Lefort I patients.
 Other studies had applied anterior maxillary distraction osteogenesis (AMDO) for the CLP
patients and obtained favorable forward movement of the anterior segment.
 Thus, the purpose of this study was to investigate the changes and stability of the maxilla
and midfacial soft tissue throughout the application of AMDO in unilateral cleft lip and
palate (UCLP) and isolated cleft palate patients.
 The author compared 3 treatment methods in the management of maxillary hypoplasia:
LFI osteotomy, RED, and AMDO.

3. MATERIALS AND METHODS
 AMDO – 10 patients ( UCLP + isolated palate)
 6 males + 4 females ( Mean Age – 16.75 years).
 RED – 6 patients (UCLP)
 4 males + 2 females ( Mean Age - 21.3 years).
 LFI – 7 patients ( UCLP)
 4 males + 3 females ( Mean age, 21.1 years).

4.  PROCEDURE
 AMDO – AMDO was performed with interdental
osteotomy between the teeth at premolar region, and
the osteotomy continued to the palate and maxilla.
The distractor was attached to the maxillary teeth
across the osteotomy line.
 This distractor was a rapid palatal expansion
appliance (Hyrax Maxi-12, Dentaurum, Germany),
which was customized by their orthodontist to distract
the anterior portion of the maxilla.
 Distractor was a rapid palatal expansion appliance.
The distraction appliance was activated 4 to 5 days
after the surgery at a rate of 0.45mm twice a day.
During the distraction, intermaxillary elastic bands
were applied to the anterior dental arch to prevent the
cranial dislocation of the distracted segment.

5.  RED - The RED II system (Martin) was chosen as the
extraoral device, and the Leipzig retention plate system
(Martin) was used to anchor the maxillary segment.
 Osteotomy involved cutting of the lateral, medial, and
anterior antral walls of the maxilla, as well as the
pterygomaxillary disjunction.
 The plate was then applied to the midface by means of
microscrews (diameter, 1.5 mm) on each side.
 A square metal rod, 1.8 * 1.8 mm, was then bent and
inserted into the rider.
 The rod left the oral cavity through the incision line in
the vestibulum and were arranged around the upper lip.
 Finally, the Leipzig plate was connected to the halo-
borne distractor with a 0.35-mm wire, and the device
was adjusted to reproduce the required vector of
distraction.
 Distraction rate was 1mm/ day.

6.  CEPHALOMETRIC EVALUATION: -
 Eight angular and 5 linear measurements were performed.
 Briefly, lateral cephalograms were taken before the surgery (T1), immediately after the
removal of the distraction device (T2), and 1 year after distraction (T3) with the teeth in
occlusion and the lips in a relaxed position.
 The nasolabial angle (columella point–subnasale [Sn]–lip superior [Ls]) and facial height
(glabella–Sn, Sn–bottom, Sn–stomion [St], and St–bottom) were measured under the
soft tissue profile.

7. RESULTS
Cephalometric tracings in the
Anterior Maxillary distraction
osteogenesis group before
treatment (T1: black line),
immediately after distraction
(T2: red line), and 1 year after
distraction (T3: blue
line)

8.  Representative Superimposed Cephalometric
Tracings: -
 Successful advancement in the anterior bone
fragment with stable posterior bone fragment was
achieved.
 The distance of molar to incisor was increased
during the distraction process from T1 to T2. This
distance was reduced during the postoperative
orthodontic treatment (T2 to T3) for aligning dental
crowding and advancement of molars.

9.  Mean Changes in Cephalometric Values During
Surgery (T1 to T2).
 The mean advancement of point A was 6.6mm in
the AMDO group, 9.8mm in the RED group, and
5.8mm in the LFI group.
 The RED group exhibited clockwise rotation of the
mandible as compared to the AMDO group, with
the significant decrease of SNB.
 RED gave rise to a downward movement of the
posterior part of the maxilla-complex, resulting in
the wedge effect of the maxilla. These differences
resulted in the dramatic improvement of convexity
and ANB in the RED group.
 AMDO group showed increase of the upper incisor
edge to the palatal plane and counterclockwise
rotation of the palatal plane as compared to the LFI
group

10.  Mean Changes in Cephalometric Values During
Postoperative Period (T2 to T3)
 In postoperative period the palatal plane was
stable in AMDO group.
 Counter-clockwise rotation was observed in
the RED and LFI groups.
 There was no significant difference in the
change of point A among the groups.
 Overjet was reduced in the AMDO group
during the postoperative period.
 The relapse rate of the maxilla was 21.2% in
the AMDO group,
 13.4% in the RED group, and 25.5% in the LFI
group, with no statistical difference between
AMDO and RED groups, and between AMDO
and LFI groups.

11.  Mean Changes in Cephalometric Values From Before
Surgery (T1) to 1 Year After Surgery (T3)
 Advancement of point A was similar between the
AMDO and RED groups.
 Advancement of Sn in the RED group (8.1 mm)
was the largest among all groups, and the AMDO
group (4.6 mm) significantly larger advance as
compared to the LFI group (2.6 mm).
 There was no significant statistical difference in
x-axis movement of pronasale between the
AMDO (2.7mm) and RED (4.2 mm) groups,
signifying that the apex of the nose could be
advanced to the same extent in both the groups,
and they were significantly larger than in LFI (1.3
mm).
 The same trend was also observed in the
advancement of Ls (5.2mm in AMDO, 8.4mm in
RED, and 2.0mm in LFI).

12.  Mean Soft Tissue Changes in Cephalograms: -
 The value of pronasale/point A was similar in the
AMDO and RED groups, signifying that the DO
had an advantage in the expansion of soft tissue
and reduction of soft tissue tension.
 Both Sn/point A and Ls/point A showed largest
value in the AMDO group as compared to that in
the other groups, signifying that AMDO would
improve not only skeletal but also soft tissue
points.
 In the midface, the Sn–St was larger in the
AMDO group than in other groups,
postoperatively at 1 year follow up i.e from T1 to
T3.

13. DISCUSSION
 AMDO provides favourable skeletal and soft tissue changes in the midface to the same
extent as RED, which was better than LFI.
 The postoperative stability of AMDO was similar to that of RED and was better than that of
LFI.
 The possible disadvantage of AMDO would be the requirement of extensive orthodontic
effort and difficulty in the correction of the height of the maxilla.
 In addition, a counterclockwise rotation of the palatal plane in the AMDO group was also
seen.
 LFI osteotomy failed in correcting the hypoplastic maxilla and was able to correct only the
position of the maxilla.
 Velopharyngeal function was deteriorated in some patients by LFI maxillary advancement
due to the advancement of the posterior part of the maxilla-complex which was also
reported in RED with LFI patients by O’Gara and Wilson.
 RED can be selected for the patients who need a large amount of maxillary advancement;
LFI would be selected for the patients who do not need a large amount of maxillary
advancement.

14.  MERITS : -
 Three treatment parameters were compared For CLCP.
 Benefit to risk of complication was well discussed.
 A less invasive modality as compared to other extensive procedures was mentioned.
 DEMERITS: -
 Sample size was too small
 No method of randomization.
 No inclusion or exclusion criteria.
 Poor representation of Data (Charts/Bar diagrams).

15. CONCLUSION
 AMDO can improve the midfacial skeletal and soft tissue profile similar to RED,
which is significantly better than LFI. Anterior maxillary DO can also be applied to
the CLP patients as a less invasive surgical alternative with similar soft tissue
improvement and no negative impact on the velopharyngeal function.

16. REFERENCES
 Kanzaki H, Imai ÃY, Nakajo T, Daimaruya T, Sato A, Tachi M. Midfacial Changes
Through Anterior Maxillary Distraction Osteogenesis in Patients With Cleft Lip and
Palate. 2017;00(00):1–6.
 Rao Janardhan S, Kotrashetti SM, Lingaraj JB, et al. Anterior segmental distraction
osteogenesis in the hypoplastic cleft maxilla: report of five cases. Sultan Qaboos
Univ Med J 2013;13:454.
 Daimaruya T, Imai Y, Kochi S, et al. Midfacial changes through distraction
osteogenesis using a rigid external distraction system with retention plates in cleft
lip and palate patients. J Oral Maxillofac Surg 2010;68:1480.
 O’Gara M,Wilson K. The effects of maxillofacial surgery on speech and
velopharyngeal function. Clin Plast Surg 2007;34:395
 Imai Y, Satoh A, Tachi M, et al. Anterior maxillary distraction osteogenesis for
patients with cleft palate: velopharyngeal function and skeletal stability. In: Long
RE, ed. 12th international congress on cleft lip/palate and related craniofacial
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