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Growth Characteristics of the Premaxilla and Orthodontic Treatment Principles in Bilateral Cleft Lip and Palate

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Growth Characteristics of the Premaxilla and Orthodontic Treatment Principles in Bilateral Cleft Lip and Palate Growth Characteristics of the Premaxilla and Orthodontic Treatment Principles in Bilateral Cleft Lip and Palate KARIN VARGERVIK, D.D.S. San Francisco, California Sixty-three individuals with complete bilateral cleft lip and palate (BCLP) were studied. In 51 of these subjects no surgical set-back or early bone grafting procedures were done. In the other 12 subjects early surgical procedures to reduce the prominence of the premaxilla had been done. In the larger group the premaxilla was, on the average, protrusive until age 12, after which it gradually became more retrusive. By the end of the growth period the premaxilla was not excessively protrusive in any of these subjects. It was concluded that it is advantageous for the premaxilla in individuals with BCLP to be protrusive during most of the growth period, since the premaxilla grows forward at a slower rate than the mandible. In the 12 subjects with premaxillary surgery, midface retrusion was demonstrated at an early age. The forward growth of the _ premaxilla in these individuals was slower than in the BCLP without premaxillary surgery and all 12 subjects developed rather severe midface retrusion. Orthodontic treatment principles for four different stages of craniofacial and dental development have been outlined. The growth pattern of the premaxilla in if the clefts are complete. Under normal bilateral clefts differs significantly from conditions, growth of the premaxilla is con- normal premaxillary growth. Excessive trolled by forward growth of the midline growth and a horizontal direction of structures and the lateral processes which growth are manifest in utero, and the pre- come forward to entirely enclose the pre- maxilla is generally protrusive at birth. It maxilla. has been carried forward on the mid-struc- The position of the premaxilla in BCLP tures of the nose, which consists of the is further influenced by excessive bone ap- cartilagenous nasal septum normally en- position at the vomero-premaxillary junc- - closed in the vomer, the ethmoid plate, and tion (Pruzansky, 1971; Latham, 1973; the anterior nasal cartilages. These struc- Friede and Morgan, 1976). Its size is also tures are derivatives of the frontal process increased by alveolar bone apposition, as- and are not attached to or influenced by sociated with development and eruption of structures from the lateral nasal processes the incisors, which usually grow in a hori- zontal rather than a vertical direction (Har- Dr. Vargervik is affiliated with the Graniofacial vold, 1954; Atherton, 1974; King et al., Center, School of Dentistry, University of California, 1979). San Francisco. Address editorial correspondence to Dr. Vargervik, Craniofacial Center, Room 747-8, Uni- There is general agreement that the pre- versity of California, San Francisco, CA 94143. Tel- maxilla is protrusive at birth and remains ephone: 415-666-2271. protrusive during the first years of life if 289 290 Cleft Palate Journal, Octobef 1983, Vol. 20 No. 4 surgical intervention in this area is limited group, except the oldest age group, which to lip closure. The subsequent growth and consisted of individuals from age 17 and development of the premaxilla is not as older. The distribution of the subjects in uniformly agreed upon. Since the predic- the age groups is shown in Table 1. tions of growth and development of the In a second group of 12 subjects the involved structures vary, the treatment ra- premaxilla had been set back surgically by tionale and approaches vary accordingly. one of several surgical methods at ages For example, if one assumes that the pro- varying from infancy to 5 years. Adequate trusive premaxilla at age 6 will grow at a data to evaluate the reason or rationale for normal rate and be relatively as protrusive the set back were not available. at ages 12 or 18, it would be logical to All patients had had surgical closure of recommend surgical reduction of its prom- the lip and palate, by a variety of techniques inence. On the other hand, if the premax- performed by different surgeons. Twenty- illa has reached its maximum forward po- five of the subjects received orthodontic sition by age 6, this structure will become treatment at the Center. The other 38 less protrusive as the other facial compo- subjects were treated in their local com- nents continue to grow, and will eventually munities. There was great variation in the become relatively retruded. Therefore, orthodontic treatment procedures ren- surgical set-back would be contraindicated dered outside the Center, with respect to if the goal is the best possible result in the timing of treatment and the type of appli- adult. It is essential to distinguish between ance that was used. The patients were re- a premaxilla that is "too large" and one ferred at various ages to the Center because that is fully developed "too early". they were considered to have developed In this study the position of the basal special treatment problems. The main rea- premaxillary bone and of the alveolar proc- sons for the referrals were speech, second- _ ess have been assessed at differed age levels, ary surgical considerations, and orthodon- ranging from age 4 to adulthood. The dis- tic treatment problems related to either tinction between the position of the basal excessive retrusion or protrusion of the bone and that of the alveolar process is premaxilla. This sample may therefore rep- essential for treatment purposes, because resent a wider than average range in cer- the position of the alveolar bone is much tain of the measured dimensions. more influenced by environmental factors, The control data were made available including orthodontic treatment, than the from the Burlington Growth Centre, cour- basal bone. tesy of Dr. Frank Popovich. Sample Method Sixty-three males with complete bilateral Linear and angular measurements were cleft lip and palate (C-BCLP) were studied obtained on tracings of lateral cephalomet- in two groups. The first group consisted of ric radiographs. The cephalometric land- 51 subjects with no history of surgery to marks and planes are shown in Figure 1. retroposition the premaxilla. They were Due to the difficulties in identifying point divided into eight age groups with a maxi- A in BCLP, point Pr has been used. The mum range of + 11 months within each corresponding mandibular point Id has TABLE 1. Age Distribution of BCLP Subjects Without Premaxillary Surgery Age Group 4 6 8 10 12 14 16 18+ No 11 19 17 16 15 16 5 12 Mean age 4-4 5-9 7-9 10-0 11-9 13-7 5-6 20-3 4-0 5-0 7-1 9-2 11-3 13-0 15-4 17-3 Range to to to to » to to to to 4-9 6-9 8-11 10-10 12-7 14-8 16-3 33-4 Vargervik, PREMAXILLARY GROWTH IN BILATERAL CLEFTS 291 6 to 14 years in six subjects from the larger group. Findings The mean values and standard deviations of the 10 variables for each age group of patients without surgical set-back of the premaxilla are presented in Table 2. The mean distance from the condyle to the an- terior nasal spine (TM-ANS) was 84 mm in the four-year-old group and increased to 97 mm in the 18+-year-old group, an av- erage yearly increase of .9 mm. The mean mandibular length (TM-Pgn) in the four- year-old group was 96 mm and increased to 128 mm in the adults, an average yearly increase of 2.3 mm. The unit difference which represents the anteroposterior rela- tionship between the anterior portions of the maxilla and the mandible changed from 12 mm in the youngest group to 31 mm in FIGURE 1. The following linear measurements were obtained from the lateral headfilms: Maxillary the adults. The lower anterior face height unit length (TM-ANS); mandibular unit length (TM- (ANS-Me) increased from a mean of 63 Pgn); anterior face height (ANS-Me); and the follow- mm at age 4 to 81 mm in the 18+-year-old ing angles: SN-ANS, SN-Pr, SN-Id, PR-N-Id, SN-MP, group, representing an average 1.3 mm and the gonial angle measured as the angle between a tangent to the ramus and a line from the mandibular annual increment. The mean values symphysis to gonion on the image of the left side of showed a decrease in the angle SN-ANS of the mandible. 7° from the youngest to the oldest group and a decrease in the angle SN-Pr of 4°. been used rather than point B. The desig- The angle SN-Id remained unchanged and nation "anterior nasal spine" is used to the angle Pr-N-Id which indicates the an- indicate the most prominent bony structure teroposterior relationship between the on the premaxilla. This landmark has also maxillary and mandibular incisors de- been named point alpha (Handleman and creased. The mean values showed no Pruzansky, 1968). For vertical measure- change in the mandibular plane angle (SN- ments a point on the horizontal contour of MP), but a decrease in the gonial angle. the floor of the nose, 3 mm posterior to Corresponding control data from the Bur- the most prominent point was used as seen lington Growth Centre are shown in Table in Figure 1 (Harvold, 1974). 3. Assessment of the data was based on the The values for the distance from the analysis developed by Harvold on data condyle to the anterior nasal spine (TM- from the Burlington Research Centre ANS) for the 12 subjects who had premax- (Harvold, 1968, 1974). Control standards illary surgery and from the six subjects for boys and girls from age 6 to 16 were whose longitudinal records were examined available.
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