This case report describes the treatment of a 22-year-old female patient with a unilateral cleft lip and palate using distraction osteogenesis (DO) followed by orthognathic surgery. The patient had midface deficiency, a class III malocclusion, and a retrognathic maxilla. Treatment involved using a RED device to perform DO for 7mm of maxillary advancement. This was followed by Lefort I osteotomy, mandibular setback, and genioplasty. Post-treatment, the patient's profile and occlusion were improved with good stability after 2 years. The report concludes that DO is an effective treatment for severe cleft-related maxillary deficiency.

1. DR.SABA BASIT
MCPS RESIDENT
ORTHODONTICS
AFID
Case Report
By: Ji Hyun Kim and Coworkers
From: AJO-DO March 2015

3. 12/17/2016 3Medscape
“A process in which
increased amount of
both bone and soft
tissue are created as a
result of the gradual
displacement of
surgically created bony
fractures.”
“A process used in
orthopedic surgery and
oral and maxillofacial
surgery to repair
skeletal deformities
and in reconstructive
surgery.”
Also called
‘callus distraction’
‘callotasis’
‘Osteodistraction’
DO

4. “Distraction osteogenesis is a way to make a
longer bone out of a shorter one.”
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7.  22yrs old female
 Korean woman
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8.  Depressed upper lip
 Protruded lower jaw
 Midline deviation
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9.  Born with a complete unilateral CLP
 Received a cheilorrhaphy and a palatorrhaphy
when she was 10 years old
 No history of orofacial congenital anomalies or
deformities in her family
 No other relevant medical history
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10.  Midface deficiency
 Increased mandibular body length
 Lower facial height comparatively longer than midfacial
height
 The length of the mental region was much
greater than that of the upper lip
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12.  Angle class III molar
 Anterior crossbite
 Maxillary jaw deviated to the right
 Missing maxillary second premolars
 Palatally ectopic maxillary right first premolar
 Maxillary dental midline deviated by 3mm
 Peg laterals
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13.  Reverse overjet
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14.  Original cleft defect in the maxillary left lateral
incisor area
 Potentially impacted 3rd molars
 Multiple restorations
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15.  Skeletal class III relationship with a retrognathic
maxilla.
 Hyperdivergent skeletal pattern.
 Retrusive upper lip shows high value of z-angle
 Bimax retroclinations
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17. The midface anteroposterior deficiency
The maxillary Jaw deviation to the right
The skeletal class III relationship
and improve the facial profile
The class III molar relationship and the anterior
crossbite
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TOCORRECT

18. 1. Orthodontic and Surgical treatment
(Maxillary advancement with posterior impaction and mandibular setback)
2. Orthodontic with Distraction Osteogenesis and Orthognathic
Surgery.
(The maxillary advancement with DO followed by orthognathic surgery to
posteriorly impact the maxilla and set back the mandible.)
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Considering the severity of the skeletal discrepancy,
the second option was chosen as a potentially more stable
treatment method.The RED device was planned to
be used to accomplish the maxillary DO.

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Disadvantages of Orthognathic Surgery in severe
maxillary deficiency
•Relapse rates of 25% to 40%
•Instability
•Limited amount of advancement
•Highly invasive surgical technique

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Distraction
Osteogenesis
Predistraction
phase
Distraction and
consolidation
phase
Post distraction
phase
Preoperative
Orthodontics
Orthognathic
Surgery

21.  Intraoral appliance fabricated
 Orthodontic bands
 Vertical wires with hooks soldered perpendicular to the labial
wire
 Two additional short vertical wires with hooks were also
soldered to the labial wire at the position of the canines.
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 Complete maxillary osteotomy
 A RED system with 3 screws on each side of cranium.
 The extraoral hooks were tied to the vertical pin of the RED device.
 Latency period of 8 days
 Distraction at the rate of 0.5 mm twice per day for 10 days
 Intraoral device maintained till 8 weeks

24.  The extra-oral portion was cut
 Facemask for an additional 2 months to minimize
relapse
 Force approximately 340 g (12 oz) with 2 heavy elastics
5/16 inc per side.
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25.  Preadjusted fixed appliances
 Preoperative orthodontics
 #14 was extracted.
 Aligning and leveling
 Decompensation
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27.  Lefort I Osteotomy
1. 5 mm of advancement,
2. 3 mm of posterior impaction,
3. Horizontal rotation for midline correction
 Mandible set back 6mm bilateral sagittal split
ramus osteotomy
 Genioplasty
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29.  Appliances were removed
 Lingual fixed retainers
 Mandibular right second molar was splinted
with adjacent tooth
 Removable wraparound retainers
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31.  The total maxillary advancement with DO was
10 mm
 Since 2-jaw surgery with mandibular setback
was planned from the beginning, no further
maxillary advancement through DO was
performed.
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Total 7 mm of maxillary advancement

34.  The posttreatment extraoral photographs
showed a balanced profile.
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35.  The intraoral photographs demonstrated good
alignment with acceptable overjet and overbite.
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36.  Midline discrepancy was corrected.
 The molar relationship on the right side, class III.
 The molar relationship on the left side, class I.
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37. The final cephalometric analysis:
 Improved profile
 Reduced mandibular body length
 Long mental region reduced
 Maxillary incisors remained retroclined
 Improved madibular incisor
incliniation
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38.  Total treatment time 36 months
 2-year posttreatment photographs and the
cephalometric analysis showed good
stability.
 Pt. was satisfied
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40.  Patient’s strong concern
1. Midline coincidence
2. Improvement of lateral facial profile
 She decided to have:
2-jaw surgery
 Of 10 mm, the true amount of distraction
achieved was 7 mm.
 The 10-mm distraction with the RED device
used in this patient was insufficient.
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41.  Severe retrusion of the maxilla
 Dental midline deviation of 3 mm
 Lack of maxillary incisal exposure and upper lip
support
 Depression of the nasolabial folds
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42.  RED appliance allows 3-plane guidance.
 Considering the occlusal plane angle and the
maxillary incisal exposure ,it is intended to
induce the force vector of the DO to be forward
and downward by adjusting the length of the
vertical hook.
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43.  The distraction vector can be controlled by both
the external device and the intraoral device of
the RED system
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In this patient, the amount of advancement
needed was more than 10 mm; therefore, orthognathic
surgery alone was considered insufficient and unstable.
10mm

45.  Suggested retention period for DO 6 to 8 weeks.
 Red device 8 weeks of consolidation and 8
weeks of retention with the facemask to prevent
relapse as much as possible.
 The 2.4 mm of relapse occurred during the
preoperative orthodontic treatment
1. There was no supplementary appliance for
retention
2. Soft tissue factors and muscle stretch
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46.  Patient had secondary caries on all 4 maxillary
molars.
 To strengthen the anchorage, banding of all 4
molars was planned.
 For a patient with multiple missing teeth or not
enough bone in the cranial vault, mini implants
or plates could be considered for the skeletal
anchorage.
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47.  Louis et al says that relapse rate of OGS increases as the amount of
maxillary advancement increase.
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48. According to some studies, the maximum maxillary advancement
achieved by conventional OGS techniques varies, ranging from 5mm -
10mm,depending upon scar contracture.
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In our patient, 2.4 mm of relapse, which is about
34% of the total amount of advancement, occurred
during the preoperative orthodontic treatment
According to Hochban et al, Cheung et al, Erbe et al reported that
relapse rate after maxillary advancement of 7.8mm,3.3mm and 4.6mm
was 25%,27% and 40% respectively.

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Overcorrection during DO is suggested
Cho and Kyung et al. recommended overcorrection is
of 20% to 30% to minimize relapse.

51.  DO is an efficient treatment modality in
severe cleft-related maxillary hypoplasia.
 It promotes correction of bone and soft
tissues simultaneously.
 Reduces the amount of maxillary movement
during the surgery.
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TITLE Distraction osteogenesis and orthographic surgery
for a patient with unilateral cleft lip and palate
STUDY DESIGN Case report
STATISTICS USED Not Applicable
DATA ANALYSIS Not Applicable
LEVEL OF EVIDENCE 5
CONCLUSION DO is an efficient treatment modality in cleft-related
maxillary hypoplasia.
LIMITATIONS Single case
RCT’s are not there
Experimental study
INFERENCE Such type of studies are already being conducted in
our setup, they need to be continued.

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