Reverse quad helix appliance: differential anterior maxillary expansion of the cleft area before bone grafting

ABSTRACT: Cleft-affected cases present a variable degree of transversal constriction of the maxilla. Our aim is to present a new method for differential expansion of the premaxillary area in unilateral cleft lip and palate-affected patients.The reverse quad helix appliance is made of a 0.036-in stainless-steel wire soldered to 2 bands placed on maxillary deciduous canines or first primary molars (or first permanent premolars). It incorporates 4 helical loops forming an inverse W-arch design. The spring is positioned posterior to the banded teeth; thus, the expansion effect is focused in the anterior maxillary region.A reverse quad helix appliance was activated and cemented in 20 patients for premaxillary expansion. Upper arch width was assessed by means of plaster study models in the anterior and posterior maxillary regions. The mean anterior occlusal expansion achieved by the reverse quad helix (9.60 [±5.24] mm) is statistically significantly larger than that achieved in the posterior region (5.50 [±3.07] mm) (P < 0.0001). The reverse quad helix is an efficient appliance for differential expansion of the anterior maxillary region as a preparatory stage for secondary bone graft procedures in unilateral cleft lip and palate-affected patients.     

Sequential palatal expansion and premaxillary retrusion for cleft palate infants.

This article has described a technique to achieve maxillary orthopedics for the infant with a bilateral cleft lip, protruded premaxilla, and intact palate. Both maxillary expansion and retraction of the premaxilla can be accomplished with the same prosthesis.     

The effects of maxillary quad-helix appliance expansion on cephalometric measurements in growing orthodontic patients

This study was conducted to examine the effects of maxillary quad-helix expansion on frontal and lateral cephalometric measurements in growing orthodontic patients. Twenty subjects, nine girls and eleven boys (x age = 10 years 3 months), each exhibiting at least a unilateral posterior lingual cross-bite that had been treated with a maxillary quad-helix appliance, were selected for this study. Posteroanterior and lateral cephalometric radiographs were taken at the beginning of treatment (T1), when the appliance was removed (Tprog, x time = 9 months), and at retention (T2) and subsequently traced. The T1 and T2 dental casts were also measured as supplements to the cephalometric measurements. Significant orthodontic changes, as seen on the frontal radiographs from T1 to Tprog, included a mean increase in maxillary intermolar width of 5.88 mm, a mean increase in average frontal molar relation of 2.95 mm., and a mean increase in maxillary intercanine width of 2.74 mm. The orthopedic changes, as evidenced radiographically, included a mean increase in maxillary width of 0.92 mm. and an increase in average maxillomandibular width of 0.89 mm. From the above data, a 6:1 ratio of orthodontic movement to orthopedic movement was determined. No significant change in mandibular intermolar width was observed from the cephalometric data or from the cast measurements. The most stable cases after expansion had normal nasal widths and narrow maxillary widths. No correlation was shown between the age of the patients and the orthopedic expansion recorded or between the amount of orthodontic/orthopedic expansion and facial type. It was concluded that all expansion changes showed little relapse from Tprog to T2 and that moderate orthopedic expansion is possible with the quad-helix, but only slight orthopedic expansion was consistently demonstrated.     

Two-point rapid palatal expansion: an alternate approach to traditional treatment

Rapid palatal expansion (RPE) causes separation of the lateral halves of the palate and traditionally has used four maxillary teeth as anchorage. The purpose of this study was to introduce a rapid palatal expander that requires only two anchor teeth (two-point RPEe) and to compare the expansion obtained with that from a Hyrax appliance. This study involved two groups of 25 children aged 7 to 15 years who were treated in a private orthodontist's office with either a Hyrax appliance or a two-point RPEe. Dental casts and occlusal radiographs were made before treatment and at least three months after stabilization of the appliance. Paired t-tests were performed to identify significant intragroup changes, and independent t-tests were performed to determine intergroup differences. The findings showed the two-point RPEe was as efficient as the Hyrax in obtaining dental expansion of the maxillary posterior teeth with less effect on the maxillary anterior and mandibular teeth. Therefore, the two-point RPEe may be useful in certain clinical situations.     

Effect of an intraoral retrusion plate on maxillary arch dimensions in complete bilateral cleft lip and palate patients.

OBJECTIVE: The aim of this study was to analyze maxillary arch dimensions in patients with complete bilateral cleft lip and palate treated with an intraoral retrusion plate prior to lip closure. PATIENTS: The effects of the intraoral retrusion plate were evaluated on serially obtained maxillary casts of 14 patients with complete bilateral cleft lip and palate. RESULTS: The Student's t test for dependent observations showed a significant decrease in distance between the premaxilla and the cleft lateral segments during active treatment. This decrease correlated with an increase in deviation of the premaxilla in relation to the vomer. For each millimeter decrease in distance between the premaxilla and the cleft lateral segments, an average increase in deviation of 4.0 degrees was found. Left and right cleft widths decreased significantly, premaxillary width increased significantly, and transverse dimensions did not change significantly. CONCLUSION: From this study it can be concluded that active presurgical treatment with an intraoral retrusion plate induces a significant decrease in distance between the premaxilla and the lateral segments. This decrease is frequently accompanied by an increase in deviation of the premaxilla relative to the vomer.     

种植钉辅助上颌快速扩弓治疗年轻成人上颌牙弓狭窄的CBCT分析

目的 探讨种植钉辅助上颌快速扩弓治疗年轻成人上颌狭窄的效果.方法 样本包括15.5～28.0岁上颌骨性狭窄病例10例(男3例,女7例),平均年龄(20.1±5.4)岁.使用种植钉辅助上颌快速扩弓技术,分别于治疗前、扩弓后和保持3个月后拍摄CBCT,并对资料进行统计分析.结果 扩弓后腭中缝前部和后部分别增加3.49 mm和2.94 mm,后部腭中缝增量占扩弓器扩大量的47.9％,后部腭中缝增量占第一磨牙间宽度增量的52.3％.鼻腔宽度、上颌基骨和牙槽宽度扩弓后增加(P＜0.05),且保持三个月后增加量无明显改变.牙槽骨高度变化无统计学意义(P＞0.05).结论 种植钉辅助上颌快速扩弓能有效开展年轻成人腭中缝,矫正骨性牙弓狭窄,并减少牙支抗扩弓引起的副作用.     

Arch perimeter changes on rapid palatal expansion

Relationships between changes in arch perimeter and arch width resulting from rapid palatal expansion with the Hyrax appliance were analyzed with the use of dental study casts of 21 adolescent patients. Photographs and measurements from the dental casts obtained before treatment and approximately 3 months after stabilization were used. Regression analysis indicated that changes in premolar width were highly predictive of changes in arch perimeter (r2 = 0.69) at approximately 0.7 times the premolar expansion. Without any orthodontic appliances attached to the mandibular teeth in 16 of the 21 patients, buccal uprighting of the posterior teeth was observed because of the redirection of occlusal forces. In addition, posterior movement of the maxillary incisors and buccal tipping of the anchor teeth were quantified. The prediction of arch perimeter change for a given amount of expansion is helpful in the treatment planning of rapid palatal expansion cases and may facilitate nonextraction orthodontic treatment.     

Stability after Le Fort I osteotomy in cleft lip and palate patients

Le Fort I osteotomies were performed in 20 patients with cleft lip and palate as a one-segment movement, and the fragments were fixed with miniplates without bone grafting. Tracings of preoperative and serial postoperative lateral cephalograms were used to determine changes in maxillary position. The posterior nasal spine, not subjected to extensive changes during surgical procedures and remodeling, was found to be the most reliable landmark for measuring maxillary advancement and stability. The mean maxillary advancement was 5.96 mm. Analysis did not reveal significant changes in linear and angular measurements from immediately postoperative to 6 months postoperative. A modest maxillary advancement by Le Fort I osteotomy, along with alleviation of palatal scar tissue tension and miniplate fixation, is a stable surgical method in patients with cleft lip and palate.     

Repair of complete bilateral cleft lip with severely protruding premaxilla performing a premaxillary setback and vomerine ostectomy in one stage surgery

Background

The authors present a technique for selected cases of CBCL. The primary repair of the CBCL with a severely protruding premaxilla in one stage surgery is very difficult, essentially because a good muscular apposition is difficult, forcing synchronously to do a premaxillary setback to facilitate subsequent bilateral lip repair and, thus, achieving satisfactory results. We achieve this by a reductive ostectomy on the vomero-premaxillary suture.

Material and Methods

4 patients with CBCL and severely protruding premaxilla underwent premaxillary setback by vomerine ostectomy at the same time of lip repair in the past 24 months. The extent of premaxillary setback varied between 9 and 16 mm. The required amount of bone was removed anterior to the vomero-premaxillary suture. The authors did an additional simultaneous gingivoperiosteoplasty in all patients, achieving an enough stability of the premaxilla in its new position, to be able to close the alveolar gap bilaterally. The authors have examined the position of premaxilla and dental arch between 6 and 24 months. We did not do the primary nose correction, because this increased the risk of impairment of the already compromised vascularity of the philtrum and premaxilla.

Results

The follow-up period ranged between 6 and 24 months. None of the patients had any major complication. During follow-up, the premaxilla was minimally mobile. We achieved a good lip repair in all cases: adequate muscle repair, symmetry of the lip, prolabium and Cupid’s bow, as well as good scars.

Conclusions

To our knowledge, there are few reports of one stage surgery with vomerine ostectomy to repair CBCL with severely protruding premaxilla. Doing this vomerine ostectomy, we don’t know how it will affect the subsequent growth of the premaxila and restrict the natural maxillary growth. Applying this alternative treatment for children with CBCL and protruded premaxilla without any preoperative orthopedic, we can successfully perform, in a single-stage surgery, a good primary lip repair at our center. Further confirmations of this surgery with follow up and anthropometric studies of these patients during childhood and adolescence are required. Key words: Protruding premaxilla, bilateral cleft lip, vomerine ostectomy, one stage surgery, Millard II technique.     

An intraoral appliance for management of the protrusive premaxilla in bilateral cleft lip

Management of the protruding premaxilla and prolabium in bilateral cleft lip and palate can be a confounding problem. This report introduces an intraoral traction appliance that has been successfully used to move the premaxilla and prolabium to a more favorable position for surgical repair of the bilateral cleft lip. The appliance consists of a palatal baseplate for anchorage and a latex rubber traction strip looped over the prolabium to retract the premaxillary segment. The results in five cases are presented and compared to two cases where no presurgical management was performed and lip repair had been delayed for medical reasons. Advantages and disadvantages of the appliance are discussed.     

Relapse tendency in maxillary arch width in unilateral cleft lip and palate patients with different maxillary arch forms.

OBJECTIVE: The aim of this study was to investigate the relapse tendency in the maxillary dental arch widths in unilateral cleft lip and palate patients with different types of maxillary arch form. SUBJECTS: Thirty-two unilateral cleft lip and palate patients treated by one-stage surgical palatal closure were included. The subjects were divided into three groups according to the types of the maxillary arch forms: group A, symmetrical arch form; group B, collapse of minor segment; group C, collapse of both segments. METHODS: Using dental casts obtained at three different times, relapse in the intercanine, interpremolar, and intermolar widths in each group was assessed and differences between groups were investigated. Results: Patients in group A showed stable results in all measurements. Patients in group B showed posttreatment relapse in the intercanine width only, whereas patients in group C demonstrated significant posttreatment relapses in the interpremolar and intermolar widths. Comparison between groups showed more significant relapse in the interpremolar and intermolar widths of group C than in those of group B. CONCLUSION: The types of the maxillary arch forms in unilateral cleft lip and palate patients might play a stronger role in the stability of the maxillary dental arch widths after orthodontic treatment in patients with collapse of both segments and a severe degree of maxillary narrowness.     

后牙反[牙合]骨性安氏Ⅲ类错[牙合]早期矫治后腭的变化

目的：探讨以乳磨牙为支抗的上腭快速扩大联合前牵引矫治早期骨性Ⅲ类错[牙合]合并后牙反[牙合]畸形患者腭形态的变化。方法：12例替牙早期骨性Ⅲ类错[牙合]合并后牙反[牙合]病例,第一阶段Hyrax支架式上腭快速扩大器扩大2—3周至上颌牙舌尖咬在下颌牙颊尖。第二阶段前牵引至前牙覆盖2～4mm,对矫治前后模型进行腭形态测量。结果：腭底宽增加1．98mm±0．97mm,磨牙距增加5．04mm±1．30mm,腭底宽增加量／磨牙距的增加量为41％,上颌牙槽突夹角增加8．57°±4．05°,左磨牙的倾斜角颊倾8．99°±4．06°,右磨牙的倾斜角颊倾8．34°±3．94°,变化均有显著性差异。腭深度改变无显著性差异。结论：上腭快速扩大联合前牵引是矫治替牙早期骨性Ⅲ类错[牙合]合并后牙反[牙合]畸形的较好方法,腭底宽、磨牙距、上颌牙槽突夹角、磨牙倾斜角的增加均有显著性差异。腭的明显变化使畸形的上腭趋向正常。     

传统与改良Hyrax扩弓器对牙弓、牙槽骨、基骨影响的CBCT对比研究

目的应用CBCT比较传统Hyrax扩弓器与改良Hyrax扩弓器对牙弓、牙槽骨及基骨的影响。方法将30例上颌牙弓狭窄的患者随机分为2组,传统Hyrax扩弓器组15例患者,8男7女,平均年龄(14.1±2.5)岁,改良Hyrax扩弓器组15例患者,9男6女,平均年龄(13.9±2.6)岁。收集2组患者扩弓前及扩弓3个月后的CBCT扫描数据,重建三维影像并测量牙弓、牙槽骨及基骨的相应指标,应用配对样本的t检验分析2组扩弓后测量指标的变化,应用独立样本的t检验分析2组测量指标之间的差异。结果 2组都存在基骨的改变及牙弓宽度的增加,2组之间的比较显示传统Hyrax组的第一、二前磨牙牙弓宽度大于改良Hyrax组,第一磨牙颊侧及腭侧牙槽骨厚度的变化2组并无统计学的差异,而第一前磨牙颊侧及腭侧牙槽骨的厚度变化2组有统计学差异,此外,2组之间绝对牙倾斜度比较也并无统计学差异。结论两种快速扩弓方法对于纠正上颌牙弓狭窄都有较为明显的效果,传统Hyrax扩弓器对第一前磨牙牙弓宽度及颊腭侧牙槽骨厚度的影响更大。     

Arch width changes with a rapid maxillary expansion appliance anchored to the primary teeth

OBJECTIVE: To examine the dimensional changes after rapid maxillary expansion (RME) carried out in the transitional dentition with the primary teeth as anchorage. MATERIALS AND METHODS: Group A was composed of 31 consecutive transitional dentition patients with posterior quadrant crossbites treated with a Haas-type RME appliance anchored on the maxillary primary molars and canines. No treatment was administered after palatal expansion. Study models were made before RME (T1), at appliance removal (T2), and at least 1 year after appliance removal (T3). A control sample of 60 individuals with posterior quadrant crossbites who had had no orthodontic treatment was categorized into group B (30 individuals with an average age comparable with the treated patients at T2) and group C (30 individuals with an average age comparable with the treated patients at T3). RESULTS: Permanent molar crossbites were corrected at T2, and this correction was maintained at T3 in all patients. The mean permanent maxillary intermolar width was 42.6 +/- 2.3 mm at T1, 46.7 +/- 1.9 mm at T2 (P < .01), and 46.3 +/- 1.8 mm at T3 (P < .01) in group A; 42.9 +/- 2.7 mm (P < .01) in group B; and 44.4 +/- 3.0 (P < .01) in group C. Premolar and canine widths were slightly wider than the control at T3. CONCLUSION: To avoid undesirable treatment-induced effects on maxillary permanent molars, a stable transverse correction could be achieved with the RME appliance anchored on the primary teeth.     

Nasoalveolar molding and long-term postsurgical esthetics for unilateral cleft lip/palate: 5-year follow-up

The nasoalveolar molding (NAM) technique has been shown to significantly improve the surgical outcome of the primary repair in cleft lip and palate patients. A 6-day-old female infant was managed with the presurgical NAM technique. Periodic adjustments of the appliance were continued every week to mold the nasoalveolar complex into the desired shape for the next 5 months. The 13 mm of alveolar cleft width was reduced to 1.5 mm. The depressed nostril on the cleft side was molded into the normal anatomy. The nose and upper lip were surgically repaired at the age of 5 months. The second stage surgery of palatal closure was performed at the age of 18 months. The patient was followed up regularly at 6-month intervals for the next 5 years.     

Palate morphology after unilateral and bilateral cleft lip and palate closure

The aim of the present study was to compare the morphology of the hard palate of patients with uni- and bilateral cleft lip and palate after palatoplasty using vomer and palatal pedicled flaps with the palatal morphology of non-cleft individuals. Eighty patients were enrolled into this retrospective study: 40 patients with cleft lip and palate (30 unilateral, 10 bilateral) and 40 non-cleft patients with class I occlusion, who served as controls. Analysis of the development of the maxillary arch and evaluation of palatal morphology were accomplished from reformatted CT scans from plaster casts of the maxilla at the age of 4, 10 and 15 years (cleft patients) and 10 years (controls). Width and symmetry of the maxillary arch and morphology of the hard palate were assessed in the canine and molar region and compared both among the cleft groups and the controls. Maxillary arch width as assessed from plaster casts did not differ significantly between uni- and bilateral cleft patients and was not significantly different from controls at the age of 10. Deviation from symmetry was present in both types of cleft and significant in unilateral clefts when compared to bilateral clefts and non-cleft patients. Palatal morphology did not differ significantly between uni- and bilateral clefts until the age of 15, but was significantly different from control patients in the molar area at the age of 10 presumably due to the medial shift of soft tissue flaps used for palatoplasty. It is concluded that palatoplasty significantly alters hard palate morphology particularly in the posterior area. The relevance of this alteration for speech and articulation remains to be explored.     

Rapid maxillary expansion followed by fixed appliances: a long-term evaluation of changes in arch dimensions

The purpose of this longitudinal study was to evaluate the short- and long-term changes in dental arch dimensions in patients treated with rapid maxillary expansion (RME) followed by fixed edge-wise appliances. The records of 112 patients in the treated group (TG) were compared with those of 41 untreated controls. Serial dental casts were available at three different intervals: pretreatment (T1), after expansion and fixed appliance therapy (T2), and at long-term observation (T3). The mean duration of the T1-T2 and T2-T3 periods for the TG group was three years two months +/- five months and six years one month +/- one year two months, respectively. Treatment by RME followed by fixed appliances produced significantly favorable short- and long-term changes in almost all the maxillary and mandibular arch measurements. In comparison with controls, a net gain of six mm was achieved in the maxillary arch perimeter, whereas a net gain of 4.5 mm was found for the mandibular arch perimeter of treated subjects in the long term. The duration of retention with a fixed lower appliance in the posttreatment period did not appear to affect the long-term outcomes of the treatment protocol significantly. The amount of correction in both maxillary and mandibular intermolar widths equaled two-thirds of the initial discrepancy, whereas treatment eliminated the initial deficiency in maxillary and mandibular intercanine widths. The amount of correction for the deficiency in maxillary arch perimeter was about 80%, whereas in the mandible a full correction was achieved.     

扩弓辅弓与改良横腭杆扩大上颌牙弓的临床效果比较

目的比较扩弓辅弓和改良横腭杆扩大上颌牙弓的效果。方法分别应用扩弓辅弓与改良横腭杆对35例患者上颌牙弓进行扩弓,比较2组矫治前后的牙弓宽度改变。结果使用扩弓辅弓的病例第一前磨牙扩弓宽度变化不明显,增加2 mm左右,第二前磨牙和第一磨牙的磨牙宽度均有明显扩大,增加4 mm左右;使用改良横腭杆的病例第一、二前磨牙及第一磨牙间宽度均增加4 mm左右。结论上颌牙弓轻中度狭窄的病例采用扩弓辅弓和改良横腭杆扩弓均有较好的扩弓效果,可以根据各自的特点选择合适的病例。     

Transversal Palatal Expansion Using a Palatal Distractor

METHOD AND RESULTS: The method and first results of transversal expansion with a palatal distractor in adolescents and adults with transverse maxillary deficiencies are presented. In ten patients with a mean age of 25.8 years, a newly developed distractor was applied for bone-borne expansion of the two halves of the maxilla following osteotomy of the lateral walls of the maxillary sinuses and the midpalatal suture. After a 3-week distraction period, mean changes of 8.8 mm in intercanine distance (ICD), 8.6 mm in anterior dental arch width (ADA), and 8.3 mm in posterior dental arch width (PDA) were registered. 6 months after the subsequent multibracket appliance therapy, these values were found to be largely constant. CONCLUSION: Because of the short treatment period, the absence of relapses, and the handling simplicity for the patient, this method is recommended for clinical application.     

Immediate and six-month space changes after premature loss of a primary maxillary first molar

BACKGROUND: Premature loss of primary maxillary first molars has been associated with a number of consequences (such as tipping of the first permanent molar). The aim of the authors' study was to investigate dental-arch space problems arising as a result of premature loss of a primary maxillary first molar. METHODS: This study was composed of 19 children who experienced unilateral premature loss of a primary maxillary first molar. The authors used each patient's intact contralateral arch segment as a control. The authors obtained maxillary dental study casts two or three days after the tooth was extracted, as well as six months later. RESULTS: The D + E space from the extraction side six months after removal of the tooth (mean +/- standard deviation, 15.62 +/- 1.13 millimeters) was significantly smaller than the space on the control side (16.88 +/- 1.12 mm) and the initial D + E space (16.70 +/- 0.69 mm). The authors found a significantly shorter arch length (25.47 +/- 1.58 mm) and larger intercanine width (31.29 +/- 2.49 mm) six months after the tooth was extracted compared with the initial arch length (25.66 +/- 1.64 mm) and intercanine width (30.42 +/- 2.64 mm). CONCLUSIONS: The early space changes to the maxillary arch subsequent to premature loss of a primary maxillary first molar are primarily distal drift of the primary canines toward the extraction space and palatal migration of the maxillary incisors. Although 1 mm of space was lost, which is statistically significant, this is not likely to be of sufficient clinical significance to warrant use of a space maintainer. If palatal movement appears to be needed, the dentist should consider use of a palatal arch rather than a band-and-loop maintainer. CLINICAL IMPLICATIONS: The effects of space maintainers need to be re-evaluated in cases of unilateral premature loss of a primary maxillary first molar.