Muneo MIYASAKA, Tadashi AKAMATSU, Akihisa Yamazaki, Teruyuki Ochiai Rica Tanaka, Yuko Sakuma, *Noriaki SAKATA, *Ryoichi NIIKIRA

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1 Toki J Exp Clin Med., Vol. 33, No. 1, pp , 2008 new devie for Fixing the Premxill with osteotomy in hild with omplete ilterl left lip nd Plte in the Mixed dentition Period - Preliminry se report- Muneo MIYASAKA, Tdshi AKAMATSU, Akihis Ymzki, Teruyuki Ohii Ri Tnk, Yuko Skum, *Noriki SAKATA, *Ryoihi NIIKIRA Deprtment of Plsti Surgery, Toki University Shool of Mediine *Deprtment of Orl Surgery, Toki University Shool of Mediine (Reeived Otoer 12, 2007; Aepted Deemer 25, 2007) In the tretment of protruded premxill ssoited with omplete ilterl left lip nd plte, some ptients require surgil setk of the premxill with osteotomy s funtionl nd estheti tretment. no stisftory surgil pprohes hve een estlished for the setk euse it is usully diffiult to fix the premxill fter osteotomy in the mixed dentition period. this pper reports the new method for fixing the premxill with osteotomy in hild with severely protruded premxill in the mixed dentition period. to fix the segment, we frited devie onsisting of pltl ite plte nd n nterior try efore surgery. the spe etween the try nd the premxill ws filled with soft resin during surgery so tht the reposition of the premxill ould e djusted. this pproh produed fvorle result. our devie hs severl dvntges. It llows the djustment of repositioning of the premxill during surgery. It n hnge the rnge of the djustment ording to the intended position of the premxill. It llows seure fixtion of the segment. It is removle for tooth rushing nd oservtion of one union. our devie n e pplied to mny hildren similr to our ptient reported in this pper. Key words: Premxill, devie, left lip, left Plte, osteotomy Introdution A protruded premxill ssoited with omplete ilterl left lip nd plte (BCLP) n use vrious prolems during the tretment. In infny, heiloplsty is diffiult to perform nd does not solve osmeti prolems stisftorily. At the preshool to shool ge, protruded premxill my use inomplete lip losure nd dysrthri, omplite orthodonti tretment, nd result in lrge residul oronsl fistul. In the tretment of protruded premxill, orthodonti tretment nd funtionl jw orthopedis re often effetive. However, some ptients require surgil setk of the premxill with osteotomy s olusl nd estheti tretment. The est timing of the setk vries with hildren, ut the surgery is performed typilly in the mixed dentition period in whih the need of ptient s osmeti improvement inreses in soil life. No stisftory surgil pprohes hve een estlished for the setk euse it is usully diffiult to fix the premxill fter osteotomy in the mixed dentition period. This pper reports the use of new devie for fixing the premxill with osteotomy in hild with severely protruded premxill in the mixed dentition period. To fix the segment, we frited devie onsisting of pltl ite plte nd n nterior try efore surgery. The spe etween the try nd the premxill ws filled with soft resin during surgery so tht the reposition of the premxill ould e djusted. This pproh produed fvorle result. Our devie hs severl dvntges. It llows the djustment of repositioning of the premxill during surgery. It n hnge the rnge of the djustment ording to the intended position of the premxill. It llows seure fixtion of the segment. It is removle for tooth rushing nd oservtion of one union. Our devie n e pplied to mny hildren similr to our ptient reported in this pper. Sujets nd Methods The investigtion onforms with the priniples outlined in delrtion of Helsinki. We used our new devie in premxillry setk with osteotomy performed on 6-yer-old oy with omplete BCLP. He ws orn with gesttionl ge of 40 weeks nd 5 dys. The irth weight ws 3200 g. He ws referred to our hospitl t 7 dys of ge for the tretment of omplete BCLP (Figure 1). The initil exmintion showed well-grown ut protruded premxill. The ptient underwent heiloplsty t 3 months of ge with weight of 5.8 kg (Figure 1). After the opertion the premxill ws retrted y the lil pressure ut desended with its lokwise rottion tht used pltl inlintion of inisor teeth, resulting in deep ite. Tdshi Akmtsu, Deprtment of Plsti Surgery, Toki University Shool of Mediine,143 Shimoksuy, Isehr, Kngw , Jpn 21

2 M. MIYASAKA et l. /A New Devie for Fixing the Premxill in the Mixed Dentition Period Fig. 1. ): The photogrph of ptient on 7 dys of ge. The initil exmintion showed well-grown ut protruded premxill. ): The ptient underwent heiloplsty t 3 months of ge, nd pushk pltoplsty t 1.5 yers of ge. The wound ws overed with n rtifiil dermis grft. ): residul oronsl fistul in the site of lveolr left. Fig. 2. ): The mxill ollpsed rpidly nd redued the inter-nine distne. premxill ws shifted forwrd nd downwrd. Surgil setk of the premxill with osteotomy ws plned on the ptient t 6 yers of ge, efore he entered n elementry shool. ): Lip protrusion, mrkedly otuse olumell-lil ngle, nd severe nostril deformity due to n nteroinferior shift of the nsl se. The ptient underwent pushk pltoplsty t 1.5 yers of ge. The wound ws overed with n rtifiil dermis grft. His nsophryngel losure nd rtiultion improved susequently. The mxillry growth ws suffiient for mintin norml molr olusion. The mxill ollpsed rpidly euse of poor lveolr lignment. This ollpse redued the inter-nine distne nd shifted the premxill further forwrd nd downwrd. This used estheti prolem of lip protrusion, mrkedly otuse olumell-lil ngle, nd severe nostril deformity due to n nteroinferior shift of the nsl se (Figure 2). The funtionl prolem lso existed due to the poor olusion. An instility nd mlposition of premxill used diffiulty of tering food off y his nterior teeth. But the mstitory effiy ws still preserved euse of posterior teeth olusion. Liquid nd pste food dishrge from nose nd n inudile nsl emission were oserved from oro-nsl-fistul t the residul lveolr left. He hd no distorted rtiultion ut hypernslity due to residul oronsl fistul in the site of lveolr left (Figure 1). Sine the ptient s prents wished his fil pperne improved efore he entered n elementry shool, we performed surgil setk of the premxill with osteotomy on the ptient t 6 yers of ge (Figure 3). To mintin lood supply from oth the nsl nd 22

3 M. MIYASAKA et l. /A New Devie for Fixing the Premxill in the Mixed Dentition Period Fig. 3. ): To mintin lood supply from oth the nsl nd vestiulr sides of the premxill, ll muous memrnes on the vestiulr side were preserved intt. A pltl inision ws pled to expose lveolr lefts nd the nterior portion of the vomer for osteotomy. ): Reseted vomer frgments were grfted into oth sides of the left to indue one ridge formtion etween lveolr ridges. No ili one grfts were performed ): The elevted prt of the one ws not removed so tht no tooth germs of entrl inisors nd nines were injured. vestiulr sides of the premxill, ll muous memrnes on the vestiulr side were preserved intt. A pltl inision ws pled to expose lveolr lefts nd the nterior portion of the vomer for osteotomy. The vomer ws reseted with one hisel. In the ompletely moilized premxill, suffiient lood supply ws mintined through oth the muoperiosteum on the vestiulr prt of the premxill nd the muoperiosteum ontinuing from the nsl septum nd floor (Figure 3). Although the premxill ws pled in the intended position, the mount of its setk ws not suffiient s plnned. An elevted one t the left edge fing the lveolr left interfered with the premxill. The elevted prt of the one ws not removed so tht no tooth germs of entrl inisors nd nines were injured. The nsl floor ws losed with sorle sutures. Reseted vomer frgments were grfted into oth sides of the left to indue one ridge formtion etween lveolr ridges. No ili one grfts were performed (Figure 3). In order to fix the premxill, we frited new devie onsisting of n nterior try nd pltl ite plte. The ite plte overed the plte nd ll mxillry teeth inluding molrs on dentl st. Model osteotomy ws performed on the st model to determine the position of the premxill (Figure 4). Bsed on this st, the ite plte ws frited to over lveolr ridges nd teeth. To llow for devition of the premxill from its intended position during surgery, we mde the nterior portion of the plte tht overed the premxill lrger thn the segment. No vertil spe ws llowed euse the vertil positioning of the premxill is importnt to hieve fvorle olusion. Horizontl nd sgittl spe ws llowed for potentil rottions (Figure 4). The devie ws frited y pressing nd molding het-reversile polyester sheet of 1.5 mm in thikness (Durn In., Lyme, Conn., USA). Lrge underuts were loked out, nd smll underuts were left under the survey line for retention. After the premxillry set k nd one grft, the wound ws losed with sutures. Following try-in of the devie in the mouth, the spe etween the premxill nd the try ws filled with soft resin (Tissue onditioner Syofoo In.,Kyoto Jpn) to fix the premxill seurely. The try ws pplied into the mouth efore the resin polymerized. To fix the premxill in the est position, the segment ws hold with instruments in the mouth until resin polymerized (Figure 4). Results The ptient mde fvorle progress fter surgery, without omplitions suh s poor lood irultion in the premxill, wound dehisene, wound infetion, nd exposed one grfts. The devie did not ffet orl hygiene ginst expettion. At 6-month post opertive period, The surgery mrkedly improved the premxillry protrusion, fil pperne in oth frontl nd lterl views, nd olusion (Figure 5). When postopertive olusion ws ompred with preopertive olusion, the overite hnged from 9 to 1 mm, nd the overjet hnged from 7 to 2 mm. The premxill ws fixed ompletely fter surgery. Computed tomogrphy showed suffiient one ridge 23

4 M. MIYASAKA et l. /A New Devie for Fixing the Premxill in the Mixed Dentition Period Fig. 4. ): Model osteotomy ws performed on the st model to determine the position of the premxill. Bsed on this st, the ite plte ws frited to over lveolr ridges nd teeth. ): No vertil spe ws llowed euse the vertil positioning of the premxill is importnt to hieve fvorle olusion. Horizontl nd sgittl spe ws llowed for potentil rottions. ): The spe etween the premxill nd the try ws filled with soft resin (Tissue onditioner Syofoo In.,Kyoto Jpn) to fix the premxill seurely. The try ws pplied into the mouth efore the resin polymerized. To fix the premxill in the est position, the segment ws hold with instruments in the mouth until resin polymerized. Fig. 5. ): ): ): Fil pperne in oth frontl nd lterl views, nd olusion. When postopertive olusion ws ompred with preopertive olusion the overite hnged from 9 to 1 mm, nd the overjet hnged from 7 to 2 mm formtion on the nsl floor side, lthough no ontinuity ws found in lveolr ridges. Preopertive nd postopertive omputed tomogrphys, nd the dentl sts re presented (Figure 6). The funtionl evlution t 6-month post opertive period reveled tht the funtionl prolem ws lso improved. A rigid nd properly positioned premxill improved stility of nterior teeth. And idel oerite nd overjet rought good funtion of tering food off. Liquid nd pste food dishrge from nose were resolved y losing oro-nsl-fistul t the residul lveolr left. An inudile nsl emission ws lso resolved. Speeh pthologist omented tht ptient hd no distorted rtiultion nd hypernslity due to residul oronsl fistul fter opertion. 24

5 M. MIYASAKA et l. /A New Devie for Fixing the Premxill in the Mixed Dentition Period Fig. 6. ): ): ): Preopertive dentl sts re presented. Fig. 7. ): ): ): Postopertive dentl sts re presented. Disussion In hildren with omplete BCLP, protruded premxill n use vrious prolems during the tretment 1) 2). In infny, heiloplsty often uses unestheti result due to wide distne etween oth edges of the left. This is likely to widen the philtrum, resulting in poor estheti improvement of the lips. Other prolems in infny inlude upper lip protrusion, philtrl deformity ssoited with wide middle portion of the upper lip, mrkedly otuse olumelllil ngle, nd nostril deformity. At the preshool to shool ge, there re four mjor prolems used y protruded premxill: (1) mxillry protrusion n use inomplete lip losure nd dysrthri; (2) n unstle premxill omplites orthodonti tretment; (3) n oronsl fistul often remins euse of wide lveolr lefts; nd (4) suh lefts re likely to omplite one grfting, require lrge mount of one grfts, nd led to poor tretment outome. To void or solve these prolems, presurgil orthopedi tretment hs een performed. In some ptients, the tretment is not indited or is not stisftorily effetive if performed. We hve treted suh ptients suessfully with the Lthm s elsti hin premxillry repositioning ppline. 1) However, not mny ptients with omplete BCLP hve een treted with the ppline. The ove-mentioned prolems remin signifint linil hllenge. In the mjority of omplete BCLP hildren with no or ineffetive presurgil orthopedi tretment in infny, premxill severely protrudes forwrd nd downwrd due to its onsiderle vertil shift. Orthodonti tretment lone nnot orret the premxill. Orthognthi surgery is usully needed for the orretion. It n improve mlolusion nd inomplete lip losure, stilize the premxill with simultneous one grfting, nd lose n oronsl fistul. Osteotomy nd repositioning of the premxill, however, my use nerosis of the segment nd dmge to tooth germs of entrl inisors due to poor lood supply, omplitions suh s tooth loss nd one grft infetion, nd srs in lveolr lefts efore one grfting. These enefits nd risks should e ssessed thoroughly efore surgery in eh ndidte for the tretment. Some reserhers hve reported ili one grfting of lveolr lefts with osteotomy in omplete BCLP hildren ged 8 to 10 yers, who re older thn our ptient. The grfting t the shool ge n redue the frequeny of surgeries, ut most prents of BCLP hildren strongly wish hildren s fil pperne improved efore the hildren enter n elementry shool, s with our se. The ili one grfting with osteotomy t the preshool ge is lso enefiil to omplete BCLP hildren, s desried in mny reent reports. However, the grfting in preshool hildren hs not een epted widely. Advntges of erly one grfting hve not een estlished. Some preshool hildren re too smll to hrvest dequte ili one grfts. When the grfting is performed simultneously with osteotomy not only to form one ridge for premxillry fixtion ut lso to lign the permnent teeth, it is often diffiult to mintin dequte lood supply to the premxill during surgery. Mishimmki et l. reported the grfting with osteotomy in six hildren with omplete BCLP 3). None of the hildren experiened one grft rejetion or omplitions inluding nerosis nd infetion of the premxill. To prevent poor lood irultion in the premxill, the reserhers propose tht the grfting with osteotomy should e limited to omplete BCLP hildren whose lveolr lefts re not too wide, who do not hve mny srs ssoited with the initil surgery, 25

6 M. MIYASAKA et l. /A New Devie for Fixing the Premxill in the Mixed Dentition Period Fig. 8. ): Preopertive Cephlogrm ): Postopertive Cephlogrm Fig. 9. ): Preopertive 3D omputed tomogrphy ): Postopertive 3D omputed tomogrphy nd whose periosteum is ville for grft eds. In ddition, they emphsize tht multiple lood pthwys to the premxill should e estlished during surgery. Iino M et l. reported premxillry osteotomy with two-stge ili one grfting of lveolr lefts 4). The initil grfting ws performed on one left. Six months lter, the seond grfting ws performed on the other left. This two-stge proedure ould prevent poor lood irultion in the premxill during surgery. Three methods hve een reported for fixing the premxill fter osteotomy: internl fixtion with plte; fixtion to djent the dentl rh with orthodonti rkets nd wire pplied to the teeth; nd fixtion with ite splint tht is frited s n nhorge efore surgery 4) 5). Internl fixtion of the premxill with plte is often effetive in dult ptients with omplete BCLP. Highly fixtive nd strong pltes, suh s minipltes of 2.0 mm in dimeter, n e used. The dult ptients hve no risk of tooth germ dmge. In omplete BCLP hildren, prtiulrly preshool hildren like our ptient, lrge plte nnot e used euse of limited spe vilility. A smll plte nnot fix the premxill s seurely s lrge plte. Regrdless of its size, plte should e removed lter euse it my ffet mxillry growth, resulting in the inresed frequeny of surgeries. In the mixed dentition period, plte my use dmge to tooth germs in the lveolr ones in oth the premxill nd the mxill. Therefore, plte internl fixtion should e voided in the mixed dentition period. The fixtion of the premxill with n orthodonti wire is seldom indited in omplete BCLP hildren in the mixed dentition period. In most ses, nhor teeth nnot e otined euse of loss of deiduous teeth nd inomplete root formtion of permnent teeth. The fixtion of the premxill with ite splint is ommon tehnique s reported in some literture. 4) Before surgery, the est position of the premxill is deided, nd ite splint is frited ording to this position. In some ses, the premxill nnot e guided to the intended position during surgery. The segment usully devites from its intended position in the diretion, distne, or ngle of repositioning. The uses of the devition inlude the limited region for flp elevtion due to poor lood irultion in the premxill, hrd soft-tissue srs round the premxill, nd insuffiient removl of the lveolr one euse of presene of tooth germs. In our se, the vomer ould e osteotomized nd removed suffiiently. However, n elevted one t the left edge fing the lveolr left interfered with the premxill. The degree of setk of the premxill ws not s muh s plnned. The elevted prt of the one ws not removed so tht no tooth germs of impted entrl inisors nd nines were ffeted. The rh expnsion of the lterl segments seemed to e omplished sed on the inter-nine width ut ws unstisftory for voidne of the one interferene with the premxill. This nnot e ntiipted ompletely with preopertive xil or three-dimen- 26

7 M. MIYASAKA et l. /A New Devie for Fixing the Premxill in the Mixed Dentition Period sionl omputed tomogrphy. The perfet simultion of three-dimensionl lignment of premxill fter osteotomy is diffiult. In ddition, deresed soft tissue elstiity due to srs my impede the repositioning. For these resons, devie for fixing the premxill fter osteotomy should hve some flexiility in positioning. We frited devie onsisting of pltl ite plte nd n nterior try efore surgery. The spe etween the try nd the premxill ws filled with soft resin during surgery. This pproh produed fvorle result. Our devie hs severl dvntges over urrently ville devies for fixing the premxill. It n ommodte devition of the premxill from its intended position during surgery. It overs lveolr ridges s well s teeth to llow seure fixtion of the premxill, wheres onventionl ite pltes typilly involve only the inisl prt of inisors in the fixtion. Soft resin used for our devie is not s elsti s to permit premxillry moility. A devie for fixing the premxill should e designed to ple the segment in the intended position s muh s possile. The originl purpose of use of ite splint tht is frited efore surgery is to ple the premxill in the intended position s muh s possile during surgery. To hieve this purpose, our devie llows no vertil ut some horizontl spe. The disdvntge of our devie is n inresed risk of ries euse the devie overs teeth s well s lveolr ridges. A removle devie for fixing the premxill n e designed. Tooth rushing should e egun with the devie removed when the premxill is fixed sustntilly (pproximtely 7 dys fter surgery). Conlusions A new devie for fixing the premxill with osteotomy produed fvorle result in hild with omplete BCLP in the mixed dentition period. Our devie llows the djustment of repositioning of the premxill during surgery. It n hnge the rnge of the djustment ording to the intended position of the premxill. Intropertive polymeriztion of soft resin etween the devie nd the premxill llows seure fixtion of the segment. Our devie n e pplied to mny hildren with omplete BCLP. Referene 1) Georgide N, Lthm R. Mxillry rh lignment in the ilterl left lip nd plte infnt, using pinned oxil srew ppline. Plst Reonstr Surg 1975; 56: ) Gryson B, Mull D. Nsolveolr molding for infnts orn with lefts of the lip, lveolus, nd plte. Clin Plsti Surg. 2004; 31: ) Mishimki T. One stge SBG nd premxill osteotomy in ilterl left lip nd plte. J. Jpn. Crnio-Mx.-F. Surg. 2002; 18: 21 4) Iino M, Sski T. Surgil repositioning of the premxill in omintion with two-stge lveolr one grfting in ilterl left lip nd plte. Cleft Plte-Crniofil J 1998; 35: ) Niizu K, Murkmi N. Dentl rehilittion of ptient with ilterl left lip nd lveolus in omintion with premxillry osteotomy nd lveolr left one grfting. J Kohokushinetu Asso. Orthod. 1999; 7: 73 27