Orthognathic Surgery in the Young Cleft Patient: Preliminary Study on Subsequent Facial Growth

Purpose: This study evaluated the long-term effects of orthognathic surgery on subsequent growth of the maxillomandibular complex in the young cleft patient. Patients and Methods: We evaluated 12 young cleft patients (9 male and 3 female patients), with a mean age of 12 years 6 months (range, 9 years 8 months to 15 years 4 months), who underwent Le Fort I osteotomies, with maxillary advancement, expansion, and/or downgrafting, by use of autogenous bone or hydroxyapatite grafts, when indicated, for maxillary stabilization. Five patients had concomitant osteotomies of the mandibular ramus. All patients had presurgical and postsurgical orthodontic treatment to control the occlusion. Radiographs taken at initial evaluation (T1) and presurgery (T2) were compared to establish the facial growth vector before surgery, whereas radiographs taken immediately postsurgery (T3) and at longest follow-up (T4) were used to determine postsurgical growth. Each patient's lateral cephalograms were traced, and 16 landmarks were identified and used to compute 11 measurements describing presurgical and postsurgical growth. Results: Before surgery, all patients had relatively normal growth. After surgery, cephalograms showed statistically significant growth changes from T3 to T4, with the maxillary depth decreasing by -3.3° ± 1.8°, Sella-nasion-point A by -3.3° ± 1.8°, and point A-nasion-point B by -3.6° ± 2.8°. The angulation of the maxillary incisors increased by 9.2° ± 11.7°. Of 12 patients, 11 showed disproportionate postsurgical jaw growth. Maxillary growth occurred predominantly in a vertical vector with no anteroposterior growth, even though most patients had shown anteroposterior growth before surgery. The distance increased in the linear measurement from nasion to gnathion by 10.3 ± 7.9 mm. Four of 5 patients operated on during the mixed dentition phase had teeth that erupted through the cleft area. A variable impairment of postoperative growth was seen with the 2 types of grafting material used. No significant difference was noted in the effect on growth in patients with unilateral clefts versus those with bilateral clefts. The presence of a pharyngeal flap was noted to adversely affect growth, whereas simultaneous mandibular surgery did not. After surgery, 11 of 12 patients tended toward a Class III end-on occlusal relation. Conclusions: Orthognathic surgery may be performed on growing cleft patients when mandated by psychological and/or functional concerns. The surgeon must be cognizant of the adverse postsurgical growth outcomes when performing orthognathic surgery on growing cleft patients with the possibility for further surgery requirements. Performing maxillary osteotomies on cleft patients would be more predictable after completion of facial growth. © 2008 American Association of Oral and Maxillofacial Surgeons.

Facial growth evaluation of complete unilateral cleft lip and palate operated patients: a cleft reference center in Paraíba, Brazil, using the GOSLON yardstick

Objectives: To evaluate the surgical outcomes of patients with complete unilateral cleft lip and palate (CUCLP) operated on by a single surgeon of the cleft reference center of the Lauro Wanderley University Hospital at the Federal University of Paraiba. Methods: Forty-four individuals' dental casts diagnosed with CUCLP, born between 1995 and 2002, mean age of 11 years, were evaluated by three calibrated orthodontic specialists and scored by the Great Ormond Street, London and Oslo (GOSLON) yardstick on two occasions. The scores were compared with those observed in other centers around the world. The Kappa test was applied to evaluate the intra- and inter-examiner agreement. Descriptive statistics was applied for the GOSLON yardsticks core. Results: The mean GOSLON score was 2.75. For the GOSLON yardstick, 43.2 % of the sample presented scores 1 and 2, 31.8 % had score 3, and 25 % were with scores 4 and 5. There was very good intra- and inter-examiner Kappa agreement in the application of the GOSLON yardstick. Conclusions: The data suggest favorable outcomes, with 75 % of cases with no need of orthognathic surgery. The Kappa values confirmed the high reproducibility of the GOSLON yardstick. © 2013 Springer-Verlag Berlin Heidelberg.

Changes on facial profile in the mixed dentition, from natural growth and induced by Balters' bionator appliance

Objective: The purpose of this study was to evaluate the facial profile changes induced by Balters' bionator appliance in Class II division 1 patients, at mixed dentition stage. Methods: The sample consisted of 28 prepubertal individuals at stages 1 and 2 of skeletal maturation (CVM), which were divided in two groups. The experimental group consisted of 14 individuals (7 boys and 7 girls, initial mean age of 8y12m) which were treated with Balters' bionator appliance for 14.7 months. The effects of treatment were compared to a control group of 14 subjects (7 boys and 7 girls, initial mean age of 8y5m) with Class II malocclusion, division 1, not orthodontically treated, which were followed up for 15.4 months. The statistical analysis was performed using Student's t test, at a significance level of 5%. Results: The results showed that the Balters' bionator appliance promoted a significant increase on the mentolabial angle, in addition to demonstrating a tendency to reduce the facial skeletal convexity, to restrict the maxillary growth and to increase the nasolabial angle and the lower anterior facial height. Conclusion: It can be concluded that the Balters' bionator appliance improved the facial profile of children treated at mixed dentition stage. © 2013 Dental Press Journal of Orthodontics.

Accelerated wound closure in vitro by fibroblasts from a subgroup of cleft lip/palate patients: role of transforming growth factor-α.

In a fraction of patients surgically treated for cleft lip/palate, excessive scarring disturbs maxillary growth and dento-alveolar development. Since certain genes are involved in craniofacial morphogenesis as well as tissue repair, a primary defect causing cleft lip/palate could lead to altered wound healing. We performed in vitro wound healing assays with primary lip fibroblasts from 16 cleft lip/palate patients. Nine foreskin fibroblast strains were included for comparison. Cells were grown to confluency and scratch wounds were applied; wound closure was monitored morphometrically over time. Wound closure rate showed highly significant differences between fibroblast strains. Statistically, fibroblast strains from the 25 individuals could be divided into three migratory groups, namely "fast", "intermediate", and "slow". Most cleft lip/palate fibroblasts were distributed between the "fast" (5 strains) and the "intermediate" group (10 strains). These phenotypes were stable over different cell passages from the same individual. Expression of genes involved in cleft lip/palate and wound repair was determined by quantitative PCR. Transforming growth factor-α mRNA was significantly up-regulated in the "fast" group. 5 ng/ml transforming growth factor-α added to the culture medium increased the wound closure rate of cleft lip/palate strains from the "intermediate" migratory group to the level of the "fast", but had no effect on the latter group. Conversely, antibody to transforming growth factor-α or a specific inhibitor of its receptor most effectively reduced the wound closure rate of "fast" cleft lip/palate strains. Thus, fibroblasts from a distinct subgroup of cleft lip/palate patients exhibit an increased migration rate into wounds in vitro, which is linked to higher transforming growth factor-α expression and attenuated by interfering with its signaling.

Comparaison des effets sur la croissance des maxillaires de l'utilisation du Forsus® versus celle des élastiques de classe II

Objectif : Évaluer les effets sur la croissance des maxillaires, ainsi que les effets dentaires, de l'utilisation du Forsus versus celle des élastiques de classe II. Matériel et méthode : Un échantillon de 30 patients a été traité sans extraction et a eu une phase d'alignement préliminaire avec appareillage orthodontique fixe complet. Vingt-trois (23) patients (14 filles, 9 garçons) ont été traités à l'aide de Forsus (âge moyen : 13,4 ans) et 7 patients (4 filles, 3 garçons) ont été traités avec des élastiques de classe II (âge moyen : 14,3 ans). Une radiographie céphalométrique a été prise à la fin de la phase d'alignement, juste avant la mise en place de l'appareil myofonctionnel choisi, et une autre au moment de l'enlèvement de l'appareil (temps de port moyen : 0,5 an). Les radiographies ont ensuite été tracées à l'aveugle et 17 mesures ont été sélectionnées pour évaluer l'effet des appareils sur les maxillaires (ANS-PNS, SNA, SNB, ANB, Go-Pg, Ar-Go, Co-Gn, axe Y, Ar-Gn, Ar-Go-Me, FMA, POF/FH, PP/FH, B-Pg(PM), 1/-FH, 1/-/1, /1-PM). Un questionnaire pour évaluer le confort face à leur appareil a été remis aux patients à environ la moitié du temps de port estimé. Résultats : Il n'y a aucune différence statistiquement significative entre les deux traitements sur la croissance du maxillaire (ANS-PNS p = 0,93, SNA p = 0,12). De façon générale, il n'y a pas non plus de différence significative entre les deux traitements sur la croissance de la mandibule (Ar-Gn p = 0,03, SNB p = 0,02 et pour les 6 autres mesures p > 0,05). Pour la composante dento-alvéolaire, les deux traitements proclinent les incisives inférieures et rétroclinent les incisives supérieures, le Forsus causant une plus forte rétroclinaison des incisives supérieures (1/-FH p = 0,007, /1-PM p = 0,10). Pour les changements angulaires des plans, le Forsus cause de manière significative une augmentation de l’inclinaison du plan occlusal (POF/FH p = 0,001). Pour le questionnaire sur l'évaluation du confort, il n'y a pas de différence entre les deux traitements en ce qui concerne la gêne face aux activités quotidiennes (p = 0,19). L'hygiène est plus facile avec les élastiques (p = 0,03). Le sommeil n’est perturbé par aucun des appareils (p =0,76). La différence entre le groupe «élastiques» et le groupe «Forsus» pour le confort en général n'est pas significative (p = 0,08). Conclusions : Le but de l’étude étant de vérifier l’efficacité des élastiques de classe II bien portés versus celle des Forsus, on peut conclure que leurs effets sont relativement similaires sur les maxillaires. Cependant, le Forsus cause de manière statistiquement significative une augmentation de l'angle du plan occlusal et une rétroclinaison plus importante des incisives supérieures.

Comparative study of the Frankel (FR-2) and bionator appliances in the treatment of Class II malocclusion

The purpose of this investigation was to compare the dentoalveolar and skeletal cephalometric changes produced by the Frankel (FR-2) and bionator appliances in persons with Class 11 malocclusion. Lateral cephalograms were available for 66 patients of both sexes, who were divided into 3 groups of 22. The control group included untreated Class 11 children, with an initial mean age of 8 years 7 months; they were followed without treatment for 13 months. The FR-2 appliance group had an initial mean age of 9 years; those children were treated for a mean period of 17 months. The bionator group initially had a mean age of 10 years 8 months; on average, they were treated for 16 months. The results demonstrated no significant changes in maxillary growth during the evaluation period. Both appliances showed statistically significant increases in mandibular growth and mandibular protrusion, with greater increases in patients treated in the bionator group. Both experimental groups showed an improvement in the maxillomandibular relationship. There were no significant changes in growth direction, while the bionator group had a greater increase in posterior facial height. Both appliances produced similar labial tipping and protrusion of the lower incisors, lingual inclination, retrusion of the upper incisors, and a significant increase in mandibular posterior dentoalveolar height. The major treatment effects of bionator and FR-2 appliances were dentoalveolar, with a smaller, but significant, skeletal effect.

Effects of cervical headgear and edgewise appliances on growing patients

Maxillary basal bone, dentoalveolar, and dental changes in Class II Division 1 patients treated to normal occlusion by using cervical headgear and edgewise appliances were retrospectively evaluated. A sample of 45 treated patients was compared with a group of 30 untreated patients. Subjects were drawn from the Department of Orthodontics, Araraquara School of Dentistry, Brazil, and ranged in age from 7.5 to 13.5 years. The groups were matched based on age, gender, and malocclusion. Roughly 87% of the treated group had a mesocephalic or brachicephalic pattern, and 13% had a dolicocephalic pattern. Cervical headgear was used until a Class I dental relationship was achieved. Our results demonstrated that the malocclusions were probably corrected by maintaining the maxillary first molars in position during maxillary growth. Maxillary basal bone changes (excluding dentoalveolar changes) did not differ significantly between the treated and the untreated groups. Molar extrusion after the use of cervical headgear was not supported by our data, and this must be considered in the treatment plan of patients who present similar facial types. (Am J Orthod Dentofacial Orthop 2001;119:531-9).

Treatment Effects Produced by Fränkel Appliance in Patients with Class II, Division 1 Malocclusion

The purpose of this investigation was to evaluate the dentoalveolar and skeletal cephalometric changes produced by the Fränkel appliance in individuals with a Class II, division 1 malocclusion. Lateral cephalograms of 44 patients of both sexes were divided in two groups of 22 each. The control group was comprised of untreated Class II children with an initial mean age of eight years and seven months who were followed without treatment for a period of 13 months. The Fränkel group had an initial mean age of nine years and was treated for a mean period of 17 months. Lateral cephalometric headfilms of each patient were obtained at the beginning and end of treatment. The Fränkel appliance produced no significant changes in maxillary growth during the evaluation period, while a statistically significant increase in mandibular length was observed. The maxillomandibular relationship improved mostly because of an increase in mandibular length. In addition, there were no statistically significant differences in the craniofacial growth direction between the Fränkel and the control group, both showing a slight downward rotation of the palatal plane. The Fränkel appliance produced a labial tipping of the lower incisors and a lingual inclination of the upper incisors as well as a significant increase in mandibular posterior dentoalveolar height. It was concluded that the main effects of the Fränkel appliance during this time period were mostly dentoalveolar with a smaller but significant skeletal mandibular effect.

Avaliação cefalométrica das alterações dentárias esqueléticas induzidas pelo uso do aparelho de Herbst no tratamento da má oclusão de classe II, divisão 1ª de Angle - Estudo longitudinal

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

A influência do padrão respiratório no crescimento craniofacial

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Avaliação cefalométrica do comportamento da mandíbula na interceptação da má oclusão classe II divisão 1 de Angle, com aparelho bionator

Pós-graduação em Ciências Odontológicas - FOAR

Tratamento da classe II hiperdivergente com o aparelho extra bucal de Thurow modificado

Objectives: natural dentofacial changes and that induced by the Thurow modified extra oral appliance (TMEOA) were evaluated in this prospective study. Methodology: the data consisted of fifteen Class II division 1 children 7 to 10 years old, with anterior open bite and hiperdivergent facial pattern treated with the Thurow appliance and of fifteen Class II division 1 children followed longitudinally from 6 to 12 years of age without treatment (Burlington Growth Centre, Toronto University, Canada). The analyses were based in traditional measurements obtained in lateral cephalometric radiographs scanned with the aid of the software Radiocef Studio®. Radiographs were taken in the beginning and after 1 year of treatment for the treated group and at the 6, 9 and 12 years of age for the control group. Results: the data analysis showed that the TMEOA significantly reduced the SNA, ANB, AOBO, SNPOc SNPM, SGO/NMe, OJ e OB. On the other hand the appliance did not interfere with the SNB e SNPP. The natural growth promoted significant change in the ANB, AOBO, SNPOc, OJ e OB from 6 to 9 years and in the SNB, SNPOc e SGo/NMe from 9 to 12 years. The restriction of the maxillary growth (SNA), reduction of the skeletal discrepancy (ANB) and the reduction of the overjet (OJ) were significant with the treatment considering the natural growth as verified in the control group. Conclusion: the TMEOA corrected the skeletal Class II malocclusion by maxillary restriction, reducing the overjet, closing the anterior open bite and decreasing both the hyper divergent facial pattern and mandible plane inclination.

Tratamento da má oclusão de classe II com aparelho Jasper Jumper

The Jasper Jumper appliance was developed as a fixed orthopedic device that is connected to the upper and lower leveling arches to promote the Class II correction by restricting the maxillary growth (headgear effect), mandibular growth inducement (activator effect) and dentoalveolar changes.

Angle class II correction with MARA appliance

Objective: To assess the effects produced by the MARA appliance in the treatment of Angle’s Class II, division 1 malocclusion. Methods: The sample consisted of 44 young patients divided into two groups: The MARA Group, with initial mean age of 11.99 years, treated with the MARA appliance for an average period of 1.11 years, and the Control Group, with initial mean age of 11.63 years, monitored for a mean period of 1.18 years with no treatment. Lateral cephalograms were used to compare the groups using cephalometric variables in the initial and final phases. For these comparisons, Student’s t test was employed. Results: MARA appliance produced the following effects: Maxillary growth restriction, no change in mandibular development, improvement in maxillomandibular relationship, increased lower anterior facial height and counterclockwise rotation of the functional occlusal plane. In the upper arch, the incisors moved lingually and retruded, while the molars moved distally and tipped distally. In the lower arch, the incisors proclined and protruded, whereas the molars mesialized and tipped mesially. Finally, there was a significant reduction in overbite and overjet, with an obvious improvement in molar relationship. Conclusions: It was concluded that the MARA appliance proved effective in correcting Angle’s Class II, division 1 malocclusion while inducing skeletal changes and particularly dental changes.

Prospective study of dentoskeletal changes in class II division malocclusion treatment with twin force bite corrector

Objective: To evaluate the dentoskeletal changes of Class II malocclusion treatment with the Twin Force Bite Corrector (TFBC). Materials and Methods: The sample comprised 86 lateral cephalograms obtained from 43 subjects with Class II division 1 malocclusion; the subjects were divided into two groups. The experimental group comprised 23 patients with a mean initial age of 12.11 years who were treated with the TFBC for a mean period of 2.19 years. The control group included 40 lateral cephalograms from 20 Class II nontreated patients, with an initial mean age of 12.55 years and a mean observation period of 2.19 years. The lateral cephalograms were evaluated before and after orthodontic treatment in group 1 and in the beginning and end of the observation period in group 2. t-Tests were used to compare the initial and final cephalometric characteristics of the groups as well as the amount of change. Results: The experimental group presented greater maxillary growth restriction and mandibular retrusion than the control group, as well as greater maxillomandibular relationship improvement and greater labial tipping of the mandibular incisors. The results also showed a greater decrease in overbite and overjet in the experimental group, and there were no statistically significant differences in the craniofacial growth pattern between groups. Conclusions: The TFBC promotes restriction of anterior maxillary displacement without significant changes in mandibular length and position and improvement of maxillomandibular relationship without changes in facial growth and significant buccal tipping of mandibular incisors. Class II correction with the TFBC occurred primarily as a result of dentoalveolar changes.