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 premaxilla 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 horizontal 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 anterior 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 average 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 relationship 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. Sample size was 298 at age 6 and at ages 6 and 14 are shown in Figure 2, 190 at 16. The records were taken on or along with the corresponding values from very close to the birthdates. the main BCLP group and from the Bur- The statistical method was a cross-sec- lington Growth Centre's control standards. tional analysis of the measured variables at The mean values and standard deviations each of the eight age levels. In addition, for mandibular length are shown in Figure the change in the position of the premaxilla 3, and for maxillary and mandibular unit has been examined longitudinally from age difference in Figure 4. 292 Cleft Palate Journal, October'11983, Vol. 20 No. 4

Discussion

I- b= 6") < En & U m . iC) o ~ NA

F 6C) < oC) so A\ on iC) w S.D.

GROWTH CHARACTERISTICS 18

These data indicate that the prominence

81 97 81 78 76 39

128 130

Mean of the premaxilla becomes less pronounced

during the growth period. Similar findings

have been presented by other investigators

1.1 1.3 1.8 2.2

7.0 5.2 3.1

6.5 7.9

10.9 S.D.

(Pruzansky, 1955; Harvold, 1961; Narula 16

and Ross, 1970; Friede and Pruzansky,

29 79

94 79 76 81

42 1972). In this sample the mean values for

123

132 Mean

the variables which represent the relative

position of the premaxilla show that at age 3.9

6.6 6.1 3.2 7.1 4.6 4.4 4.6 4.3 6.7 12 its position is similar to that of a noncleft S.D.

individual and after that age may become 14

relatively retrusive. The mean value for

26 77 93 38 73 83 80

120 130 maxillary and mandibular unit difference

Mean

_ (TM-Pgn minus TM-ANS) which measures

the prominence of the anterior nasal spine

7.1

6.6 5.8 5.7 2.4

8.1 4.9 6.4 6.8 8.0 S.D.

area relative to the chin, was 22 mm at age 12 12 in the control group. The distribution Surgery

19 of unit differences in the BLCP sample was:

70 93 85 81 76 39

113 130 Mean 11 mm (1), 13 mm (1), 15 mm (2), 17 mm

(2), 19 mm (1), 20 mm (1), 21 mm (2), 22

mm (2), 23 mm (1), 25 mm (2). This dem- 5.6 5.3 5.5 5.5 3.9

5.0 2.3 7.5 8.2

6.0 S.D. Premaxillary

onstrates a range from protrusion, indi- 10

cated by a small unit difference to slight

70 85 76

91 82

40 retrusion (large unit difference) of the pre-

109 132 Mean Without

maxilla at this age. In the 18-year-plus

group three individuals had a unit differ-

2.9 5.0 5.3 5.4

2.2 7.6 6.5

6.9 4.9 4.1

S.D. ence smaller than the control mean of 28 Subjects

mm: 22 mm (1), 26 mm (2) whereas seven

were higher than the control mean, indi- 14

88 39

65 85 82 BCLP

103 132 cating premaxillary retrusion, 31 mm (1), Mean

the 34 mm (4), 36 mm (1) and 37 mm (1), and

two were the same as the control. for

5.7 5.0 5.7 3.6

5.0 5.8 4.1 6.1 6.7 6.1 S.D. The relationship between the upper and

lower anterior alveolar processes was meas-

ured as the angle Pr-N-Id. This angle de-

87 76 37

98 63 88 84 132 Mean Deviations creased from an average of 7° in the six-

year-old group to a mean value of 2° at

ages 14, 16 and 18+. The angles SN-ANS

3.3

5.1 5.0 3.3 3.1 5.6 7.2

4.5 4.5 S.D. 3.7

and SN-Pr decreased significantly. During Standard

normal growth, these angles increase (Ja- and

12 39

84 63 88 82 77 96 mison et al, 1982).

Mean 136

The data from the six subjects who were

Values followed from age 6-14 demonstrated the

same growth pattern as the cross-sectional Max Unit Mean

Mand Unit data from the main sample discussed above

angle Groups:

2. (Figures 2, 3, and 4). Diff. Variables

The number of patients with premaxil-

Age Unit

Pr-N-Id

SN-MP TM-Pgn TN-ANS SN-ANS SN-Pr SN-Id Gonial ANS-Me lary surgery was small in each age group.

However, there was a clear trend toward

TABLE

Vargervik, PREMAXILLARY GROWTH IN BILATERAL CLEFTS 293

TABLE 3. Mean Values and Standard Deviations From the Burlington Growth Centre's Control Standards (Boys) (Harvold, 1974)

Age Group 6 9 12 14 16

Variables Mean S.D. Mean S.D. Mean S. D. Mean S. D. Mean S. D.

TM-ANS 82 3.2 87 3.4 92 3.7 96 4.5 100 4.1 TM-P 99 3.9 107 4.4 114 4.9 121 6.1 127 5.3 Unit Diff. 17 20 22 25 27 ANS-Me 59 3.6 62 4.3 64 4.6 68 5.2 71 5.7

mm TM-ANS 100 - FIGURE 2. Mean values . and standard deviations of 95- s maxillary unit length (TM- ° ANS) in four groups: Contr. P =-- contr. = Control Standards from the g, _ tree belp Burlington Growth Centre: c - ra = - beip(6) beip = complete bilateral cleft , 9000 &}, """ zap + lip and palate without premax- g5_ 9° illary surgery (n = 51); belp (6) represents the six bilateral f /\ cleft patients with premaxil- go. \\/ lary surgery (n = 12). ?

* §"\/ -/- T I 1 | | T I 4 6 8 10 12 14 16 18 yrs.

mm TM- PGN 135 7

125 - eC CONntr. FIGURE 3. Mean values p15 ++ belp and standard deviations of - = beip (6) mandibular unit length (TM- PGN). 105 -

95 - e

premaxillary retrusion at every age level, than lip closure, the premaxilla continued increasing in severity with increasing age. to grow forward to the end of the growth

With one exception, all individuals dem- period, but at an average rate equal to half onstrated midface retrusion beyond age 12 of that in noncleft individuals. As the av-

(Figures 2 and 4). This finding agrees with erage increase in mandibular length was data from other publications (Bishara and the same in the BCLP subjects as in the

Olin, 1972; Friede and Pruzansky, 1972; control group, the result was a gradual

Friede and Johanson, 1974). reduction of the premaxillary prominence

The data demonstrate than in the BCLP and after age 12, an increased occurrence subjects with no surgical intervention other of maxillary retrusion.

Cleft Palate Journal, October 1983, Vol. 20 No. 4 mm MAX. and MAND. UNIT DIFFERENCES /

354 '

30 - FIGURE 4. Mean values contr. of the changing difference be- 25 - bel tween the mandibular and P maxillary units. Small unit dif- - - belPp (6) ference indicates premaxillary 20 - <=« beip + prominence; large unit differ- surg. ence indicates premaxillary retrusion or mandibular promi- is- nence.

hs Cf -- T T T T T T T 4 6 8 10 12 14 16 18 yrs.

TABLE 4. Comparison of Certain Variables from ficiently to allow lip closure. This treatment the Oldest Age Group in this Study With should be done during the first weeks of Corresponding Data From the Study of Dahl (1970) life while the structures are pliable and on Young Adult Males With C-BCLP bending is possible. If treatment is done Variables Dahl This Study later, the changes which take place at the

SN-ANS (s-n-sp) 82.5 81 vomero-premaxillary junction occur more SN-Pr (s-n-pr) 76.2 78 slowly. The appliance must fit well over the SN-Id (s-n-id) 76.4 76 alveolar process and lip philtrum and the ANS-Me (Sp-Gn) 78.1 81 direction of pull must be controlled in or- SN/MP (NSL /ML) 39.2 39 der to prevent excessive tipping of the pre- Gonial Angle (ML /RL) 131.3 130 maxillary segment (Figure 5). If tipping or rotation is allowed to occur, as may happen under the pull of an elastic strap, one side Some of our measured variables were of the alveolar process may rotate up and also used by Dahl (1970) and the corre- back so far after lip surgery that it pro- sponding data from the two studies are trudes through one nostril (Figure 6). This shown in Table 4. The comparison dem- creates a subsequent difficult treatment onstrates the remarkable similarity of these problem and should be avoided. variables in the two samples of young adults Surgical closure of the lip clefts results in with BCLP. a molding effect and retraction of the al- In the subjects who had early surgery to veolar portion of the premaxilla (Harvold, reduce the prominence of the premaxilla, 1954; Pruzansky, 1955; Harding and Ma- forward growth of this structure took place zaheri, 1972). The degree to which this at a very slow rate and it was progressively occurs depends on the tightness of the lip more retrusive in the older age groups. All and the size and position of the premaxil- of the older subjects with premaxillary sur- lary and lateral segments. The size of the gery demonstrated rather severe midface alveolar process of the premaxilla is deter- retrusion. mined by the number, size, and position of GROWTH CHARACTERISTICS AND MaAN- the developing incisors (Figure 7). AGEMENT OF THE PREMAXILLA FROM IN- By age 3-4 years, the primary incisors in FANCY TO THE ERUPTION OF THE PERMA- the premaxilla usually contact the mandib- NENT INCISORS. In many BCLP infants the ular incisors (Harvold, 1947). From then clefts of the lip can be closed in one or two on, the maxillary anterior teeth and the stages without presurgical retraction of the alveolar process will come forward along premaxilla. When lip closure is not possible with the growth of the mandible. because of extreme premaxillary protru- In some instances, the alveolar portion sion, an extraoral retraction appliance can of the premaxilla may become retracted so be used to deflect the premaxilla back suf- far that an anterior crossbite results. This Vargervik, PREMAXILLARY GROWTH IN BILATERAL CLEFTS 295

FIGURE 5. A:; The premaxilla in this four-week-old baby was too protrusive for surgical lip closure. B: An extra-oral traction appliance was made to fit over the premaxilla and attached with four rubber bands to a bonnet or headgear. C: The forces on the appliance were adjusted to retract the premaxilla symmetrically. D: The position of the premaxilla was adequate for bilateral lip closure at age 12 weeks.

occurs most frequently in patients who ments of the maxilla are severely collapsed have had surgical procedures performed and prevent retraction of the protruding on the premaxilla. In some individuals, a premaxilla by the surgically closed lip, protrusive position of the primary incisors treatment to reposition the segments lat- may be retained by the lower lip posturing erally should be started early, before the and functioning behind the premaxilla. transitional dentition. Generally, ortho- This usually results in excessive vertical dontic treatment to reposition maxillary development of the premaxillary alveolar segments can be delayed until 6-7 years of process and appearance becomes aestheti- age without irreversible growth inhibition cally unacceptable. In order to improve (Ross and Johnston, 1967). appearance and to temporarily reduce the ORTHODONTIC TREATMENT IN THE size of the alveolar process, the primary TRANSITIONAL DENTITION. The perma- incisors can be removed prematurely. This nent incisors in a protrusive premaxilla may results in some resorption of the alveolar also erupt outside the lower lip. Immediate crest and usually allows the lower lip to treatment is indicated at this time to tip function over the process rather than be- back, consolidate and if necessary intrude hind it (Figure 8a). When the lateral seg- the incisors (Figure 8 b,c). If the vertical 296 Cleft Palate Journal, October 1983, Vol. 20 No. 4

FIGURE 6. The premaxilla had been retracted with an elastic strap before lip surgery and it rotated and protruded through the right nostril. A: The right primary central incisor erupted outside the nostril and was removed at age six months. B: When the primary molars had erupted, an appliance was placed and the premaxilla retracted using the left central incisor. C: The medially collapsed lateral segments were moved laterally and the premaxilla held in place after retraction in contact with the lateral segments. D: The right permanent central incisor also erupted through the nostril and was banded from the outside. E: This tooth was moved down into position during a four-month period. Vargervik, PREMAXILLARY GROWTH IN BILATERAL certs 297

FIGURE 7. The size of the alveolar portion of the premaxilla depends on the number of teeth present. A: Only one tooth present. Premaxillary surgery was done at age 3 months. B: The presence of three teeth results in a wide premaxilla. '

FIGURE 8. A: Reduction of the alveolar process has occurred after removal of the primary incisors. B: The left permanent incisor has erupted labially outside of the lower lip. Note also the excessive vertical development. C: The incisors have been tipped lingually and are being held up and back by a heavy labial wire as the lateral segments and the mandible continue to grow forward. D: The incisors are being held with an intrusive force, but have been tipped labially as mandibular growth continues. 298 Cleft Palate Journal, October 1983, Vol. 20 No. 4 development of the premaxilla is not con- ORTHODONTIC TREATMENT IN THE PER- trolled a severe disproportion between the MANENT DENTITION. The path of eruption occlusal plane of the posterior teeth and of the canines must be observed. Enough the incisors can develop (Figure 9). The space must be available for these teeth to maxillary incisors should subsequently be erupt through attached gingiva rather than allowed to come forward along with the the mucosa. This can usually be achieved growth of the mandible. Their position will by proper positioning of the segments. gradually become upright first and subse- Early removal of the primary cuspids may quently labially inclined, depending on the also be indicated to facilitate the best path amount of mandibular growth and the po- of eruption for the permanent cuspids. It sition of the basal bone of the premaxilla is generally not necessary for these teeth to (Figure 8, 10). have bone on the cleft margin through There usually is some medial collapse of which to erupt, because alveolar bone will the lateral segments, and crossbite of the develop with the erupting teeth if adequate cuspids with or without molar crossbite. space is available. The treatment to reposition the segments During this stage, the decision must be laterally should be started at the same time made whether to bring the maxillary cus- as the orthodontic control of the incisors is pids and posterior teeth forward to obviate initiated. The appliance used in the Center the need for prosthetic replacement of for segment repositioning has been de- missing lateral incisors, or to develop space scribed previously (Harvold, 1954; John- for fixed prosthetic replacements at the ston, 1958; Ross and Johnston, 1972; Var- appropriate time. The decision depends on gervik, 1978, 1981). Following segment many factors, including: 1) number of miss- rotation a lingual wire can be placed for ing teeth, 2) position of the premaxillary retention. Further widening of the maxilla and lateral segments, 3) jaw relationship, usually becomes necessary as the mandible 4) position and shape of the cuspids and 5) continues to grow forward. The potential position and condition of the central inci- for adapting the size of the maxilla by seg- sors. ment rotation should not be compromised If the spaces can be closed by natural by prematurely performing alveolar bone teeth, the width of the alveolar clefts will grafting procedures, with the resulting be narrow and the process of creating bone bony bridges across the alveolar clefts. across the clefts will be rather uncompli-

rma

FIGURE 9. A: The maxillary incisors have been allowed to overerupt and the posterior alveolar height is deficient and allows overclosure. The step between the posterior occlusal plane and the incisors has become a difficult orthodontic treatment problem. B: The step has been eliminated by active extrusion of posterior teeth and a slight amount of intrusion of the incisors.

Vargervik, PREMAXILLARY GROWTH IN BILATERAL CLEFTS

A wan *** * vea ase FIGURE 10. A: At age six years-three months, this boy with C-BCLP has a protrusive premaxilla with a steep incisor inclination and excessive overbite. From 6-13 years of age, the mandible increased 9 mm while ANS came forward 3 mm relative to the condylar fossa. The maxillary incisors tipped slightly labially and came forward more than the anterior nasal spine area. B: From 13 years to 17 years and 3 months the mandible continued to grow forward at 3-4 times the rate of the premaxilla. The position of the maxillary incisors changed and became more labially inclined. cated and generally successful (Abyholm et Head films should also be taken with the al., 1981). If spaces are maintained for the mandible in rest position rather than in missing lateral incisors, the alveolar clefts occlusion for the same reasons. If the max- will be wider and bone grafting surgery illary arch is just widened and the increased may be followed by a special post-surgical freeway space and overclosure is not cor- treatment procedure to consistently estab- rected by extrusion of maxillary teeth, lish bony bridges across the clefts (Chierici, there will be a very strong tendency for 1977; Vargervik, 1978). medial collapse of the maxillary segments If the lateral segments in the maxilla have due to their position relative to the tongue remained medially collapsed throughout and buccal musculature. the transitional dentition, vertical height is Final orthodontic alignment of the teeth very often reduced. This can result in ex- should be done when the premolars and cessive freeway space and overclosure, canines have erupted. In order to stabilize which brings the mandible too far forward. the position of the three maxillary seg- Therefore, relative dental arch width and ments, alveolar bone grafting procedures the amount of maxillary expansion neces- should be performed toward the end of the sary cannot be assessed on dental casts with growth period and upon completion of the the teeth in occlusion. A wax bite for relat- orthodontic treatment. The rationale for ing the upper and lower dental casts should the timing of this procedure and the sub- be taken with the mandible closed slightly sequent post-surgical treatment has been from the estimated rest position. When this described previously (Chierici, 1977; Var- method is used, it is possible to determine gervik, 1978, 1981). how much the maxillary teeth should be The necessary prosthetic replacements extruded and moved laterally or labially. are generally made at 18-19 years of age. 300 Cleft Palate Journal, October 1983, Vol. 20 No. 4

elongation, A.M. (21 advancement and nose surgery Pre- op-

E FIGURE 11. A and B: Severe maxillary deficiency with complete lingual crossbite in 21-year-old male with C-BLCP. C: The midface was advanced by a LeFort III procedure combined with a Le Fort I procedure. D: The missing teeth have been replaced with a fixed prostheses. E: Tracing of lateral head film before surgical advancement. F: After surgical advancement, and nose surgery. G: Superimposition indicating the downward and slightly forward movement of the midface.

Vargervik, PREMAXILLARY GROWTH IN BILATERAL CLEFTS 301

Before that time the missing teeth, usually? prominence and forward growth of the the lateral incisors, can be replaced on a premaxilla (surgical setback, early alveolar lingual wire or on a retainer. bonegrafting, vomerplasties) are very Surgical advancement of the maxilla (Le rarely indicated and often result in severe Fort I procedure) or of the entire midface midface underdevelopment, which then re- (Le Fort III procedure) is rarely necessary quires surgical advancement of the maxilla if the treatment procedures outlined above or the entire midface. are followed. It may be indicated, however, Treatment must be tailored to each in- if the premaxilla is severely retruded when dividual patient. The growth data from the growth is completed due to one or more relatively large samples can only serve as a of the following factors: inherent tissue de- general guideline in treatment planning for ficiency, early surgical setback procedures, patients with craniofacial anomalies. other aggressive surgery, early alveolar bone grafting, or inadequate orthodontic References treatment (Figure 11). ABYHOLM, F. E., BERGLAND, O., AND SEMB, G., Sec- ondary bone grafting of alveolar clefts, Scand. J. Summary and Conclusion Plast. Reconstr. Surg. 15: 127-140, 1981. The premaxilla in BCLP may be protru- ATHERTON, J. D., The natural history of the bilateral cleft, Angle Orthod., 42: 269-278, 1974. sive at birth due to primary as well as BISHARA, S. E. anD OLIN, W. H., Surgical reposition- secondary or environmental factors. To fa- ing of the premaxilla in complete bilateral cleft lip cilitate surgical lip closure, excessive pre- and palate, Angle Orthod., 42: 139-147, 1972. maxillary protrusion may require presurg- CHIERICI, G., Experiments on the influence of ori- ical retraction by bending the midline ented stress on bone formation replacing bone grafts, Cleft Palate J. 14: 114-123, 1977. structures. Continued excessive forward DAHL, E., Craniofacial morphology in congenital clefts development of the premaxilla may be of the lip and palate, Acta Odont. Scand. Vol. 28, caused by a lower lip position behind the Suppl. 57: 1970. premaxilla. This can result in further ex- FRIEDE, H. AnD MORGAN, P., Growth of the vomero- permaxillary suture in children with bilateral cleft cessive bone apposition at the vomero-pre- lip and palate, Scand. J. Plast. Reconstr. Surg. 10: 45- maxillary junction as well as a horizontal 55, 1976. development of the alveolar process. Early FRIEDE, H. AnD JOHANSON, B., A follow-up study of removal of the primary incisors will usually cleft children treated with primary bone grafting, improve the lower lip position and also Scand. J. Plast. Reconstr. Surg. 8: 88-103, 1974. FRIEDE, H. AND PRUZANSKY, S., Longitudinal study of result in a temporary reduction of the al- growth in bilateral cleft lip and palate from infancy veolar prominence. To reduce alveolar to adolescence, Plast. Reconstr. Surg., 49: 392-403, prominence after eruption of the perma- 1972. nent incisors in a protrusive premaxilla, HANDELMAN, C. S. AND PRUZANsKY, S., Occlusion and dental profile with complete bilateral cleft lip and these teeth should be held by retrusive and palate, Angle Orthod. 38: 185-198, 1968. intrusive forces until mandibular growth HArpNG, R. L. AnD MAzAHERI, M., Growth and catches up. spatial changes in the arch form in bilateral cleft lip The rate of forward growth of the pre- and palate patients, Plast. Reconstr. Surg. 50: 591- maxilla from age 4 to adulthood in individ- 599, 1972. HARvOLD, E. P., Observations on the development of uals with bilateral clefts is approximately the upper jaw in harelip and cleft palate, Odont. one half of the rate in noncleft controls, Tidskr., 55:3, 289-305, 1947. while the average mandibular growth rate HARvOLD, E. P., Cleft lip and palate, Am. J. Orthod., is the same. Therefore, prominence of the 40: 493-506, 1954. HARvOLD, E. P., Cephalometric roentgenography in premaxilla is desirable in the primary and the study of cleft lip and palate. In: Pruzansky, S transitional stages of the dentition. Pre- (ed), Congenital Anomalies of the Face and Associated maxillary protrusion gradually disappears. Structures, Springfield: Charles C. Thomas, 329- In the young adult male with BCLP, a 336, 1961. retrusion of the midface is a more common HARVOLD, E. P., The Activator in Interceptive Orthodon- tics. St. Louis: The C.V. Mosby Co., 1974. finding than residual protrusion. JamIsoN, J. E., BISHARA, S. E., PETERSON, L. C., Surgical procedures that reduce the DrEKock, W. H., AND KREMENAK, C. R., Longitu- 302 Cleft Palate Journal, October 1983, Vol. 20 No. 4

dinal changes in the maxilla and the maxillary- dlegebladet, 75: 1157, 1971. mandibular relationship between 8 and 17 years of ROBERTSON, N., SHAW, W., AND VOLP, C., The age, Am. J. Orthod., 82: 217-239, 1982. changes produced by presurgical orthopedic treat- JounstoN, M. C., Orthodontic treatment for the cleft ment of bilateral cleft lip and palate, Plast. Reconstr. palate patients, Am. J. Orthod., 44: 750-763, 1958. Surg. 59: 86-93, 1977. KING, B. V., WORKMAN III, C. H. AND LATHAM, R. Ross, R. B., anD JOHNSTON, M. C., The effect of early A., An anatomical study of the columella and the orthodontic treatment on facial growth in cleft lip protruding premaxilla in a bilateral cleft lip and and palate. Cleft Palate J. 4: 157-164, 1967. palate infant, Cleft Palate J. 16: 223-229, 1979. Ross, R. B., AnD JOHNSTON, M. C., Cleft Lip and Palate. LATHAM, R. A., Development and structure of the Baltimore: The Williams and Wilkins Co., 1972. premaxillary deformity in bilateral cleft lip and pal- SUBTELNY, J. D., Orthodontic treatment of cleft lip ate, Brit. J. Plast. Reconstr. Surg., 26: 1-11, 1973. and palate, birth to adulthood, Angle Orthod., 26: NARULA, J. D., AnD Ross, R. B., Facial growth in 273-293, 1966. children with complete bilateral cleft lip and palate, VARGERVIK, K., New bone formation secured by ori- Cleft Palate J. 7: 239-248, 1970. ented stress in maxillary clefts, Cleft Palate J. 15: PRUZANSKY, S., Factors determining arch form in 132-140, 1978. clefts of the lip and palate. Am. J. Orthod., 41: 827- VARGERVIK, K., Orthodontic management of unilat- 851, 1955. eral cleft lip and palate, Cleft Palate J., 18: 256-270, PRUZANSKY, S., The growth of the premaxillary-vom- 1981. erine complex in bilateral cleft lip and palate. Tan-