The patient, a white male, was born with a submucous cleft palate, bifid uvula, and a notch of the posterior hard palate. He received speechlanguage

CASE REPORTS Maxillary protraction to intentionally ankylosed deciduous canines in a patient with cleft palate M. Lena Omnell, DDS, MSD,' and Barbara Sheller, DDS, MSD b Seattle, Wash. The patient, a white male, was born with a submucous cleft palate, bifid uvula, and a notch of the posterior hard palate. He received speechlanguage therapy services through a preschool becausespeech and articulation errors were identified at an early age. He was referred to the craniofacial team at Children's Hospital and Medical Center at age 4 years, 9 months. Two problems were identified: hypernasal speech and a retrusive midface that was manifested dentally as a Class III malocclusion in the primary dentition. Speech radiography and videofluoroscopy revealed severe velopharyngeal incompetence (VPI). No lateral pharyngeal wall movement was detected, and velar elevation was rated 2.5 (on a a to 5 point scale) with no contact between the soft palate and posterior pharyngeal wall. Velopharyngeal incompetence (VPI) is managed surgically either by pharyngeal flap or sphincter pharyngoplasty or' prosthetically with palatal lift or bulb-obturator appliances. Prosthetic management of the VPI using a pharyngeal bulb obturator was recommended for this patient because of the absence of lateral pharyngealwall motion. The obturator was made, and the patient adapted well to it. With the obturator to control nasal air escape and speech therapy to improve articulation, the patient's speech improved. The Class III malocclusion worsened, and the negative overjet increased between age 4 years 9 months and 6 years 5 months. Complete orthodon- From the Children's Hospital and Medical Center and the University of Washington. 'Chief of the Orthodontic Program, Department of Dental Medicine; Affiliate Assistant Professor, Department of Orthodontics, School of Dentistry, and Department of Biological Structure, School of Medicine. 'Orthodontist and Pediatric Dentist, Department of Dental Medicine; Affiliate Assistant Professor, Department of Orthodontics and Pediatric Dentistry, School of Dentistry. AM J ORTHOD DENTOFAC ORTHOP 1994;106:201 5. Copyright 1994 by the American Association of Orthodontists. 0889-5406/94/$3.00 + 0 8/4/48049 Fig. 1. Pretreatment profile photograph at age 7 years 4 months. tic records were then obtained, and diagnostic analysis showed a retrusive maxilla (SNA = 75), a normal mandible (SNB = 81), Class III molar relationship, negative overjet of 7 mm, overbite of 4 mm, and almost all teeth in crossbite, anteriorly and posteriorly. Crowding in the permanent dentition was anticipated in the maxilla. The oral hygiene was good, and there were no carious lesions (Figs. 1 through 5). The family was very interested in correction of the anterior crossbite, and this was supported by the speech pathologist who concluded that some persistent articulation errors could be attributed to the severe Class III malocclusion. Because of the severe skeletal discrepancy, the treatment goal was a skeletal improvement of the malocclusion rather than a compensation and camouflage of the malrelationship that would result from a dental correction. 201

202 Omnell and Sheller August 1994 Fig. 2. Pretreatment intraoral photograph of left side. Fig. 5. Pretreatment cephalogram. Fig. 3. Pretreatment occlusal relationship. Fig. 6. Obturator with pharyngeal bulb. Fig. 4. Pretreatment panoramic radiograph. TREATMENT Ankylosed teeth or osseointegrated titanium implants can be used as anchorage for protraction forces to cause sutural changes in the midface without movement of the ankylosed teeth or the implants.':' A phase I treatment was suggested involving ankylosing maxillary deciduous canines and using a protraction facemask. This treatment phase would not address the crowding. The patient needed to wear the obturator throughout any orthodontic treatment (Fig. 6). The ankylose procedure' was performed at age 7 years 4 months and the protraction was started 2 months later, 1 month with light elastics, thereafter, 300 gm was applied to each side and the facemask was used 12 to 14 hours per day (Fig. 7). The facemask was worn in this way for 15 months and then with reduced force and reduced number of hours per day for another 4 months. His VPI was monitored at 4-month intervals throughout protraction treatment. When the protraction was discontinued, records were obtained (Figs. 8 through 11).

Volume 106, No.2 Omnell and Sheller 203 Fig. 9. Posttreatment intraoral photograph of right side at age 8 years, 9 months. Fig. 7. Protraction facemask in place. Fig. 10. Posttreatment occlusal relationship. cephalometric landmarks during the transitional dentition, it was decided not to quantify on the linear changes that occurred. It was verified by clinical measurement between maxillary deciduous canines that these teeth maintained their distance from each other and did not move during treatment. Crowding remained in the maxillary lateral incisor areas. The patient and his family were delighted with the improvement in facial esthetics. Fig. 8. Posttreatment profile photograph. DISCUSSION Analysis showed improved facial esthetics, improved skeletal relationship (SNA = 81, SNB = 80), correction of anterior crossbite (OJ = 1, OB = 2 mm), Class I molar relationship, correction of bilateral crossbite, and some posterior rotation of the mandible (Fig. 12). Because of the instability of points A and B, as well as other commonly used Children with cleft deformity may develop a retrusive midface at an early age. Several approaches are available for correction of early midface deficiency including surgery and conventional orthodontics. Undesirable side effects are usually associated with each. In the young patient where the circummaxillary sutures are still open the pos-

204 Omnell and Sheller August 1994 Fig. 11. Posttreatment cephalogram. Fig. 12. Superimposition on cranial structures of two cephalograms taken at start of treatment, solid line, and at end of protraction, dotted line. It shows forward movement of the maxillary complex and posterior rotation of the mandible. sibility exists for maxillary advancement by using protraction forces to the teeth from a reversed pull headgear. This concept was presented about 100 years ago in the German literature" and reintroduced by Delaire in France in the early 1970s. 5 However, the nonhuman primate study by Jackson et al." showed that the largest part of the correction seen in the occlusion after protraction to a toothborn appliance was attributed to tooth movement. These findings have been verified in human studies.? However, Rygh and Tindlund" showed that dental and also quite consistent skeletal changes did occur when maxillary expansion preceded the protraction in the young child with cleft palate. In this case the child needed to wear the obturator for speech, and subsequently no other intraoral appliance could be placed. In addition, quite severe crowding was already expected in the anterior region of the maxilla with the eruption of permanent incisors. The goal was not to increase the anterior crowding. When a retrusive midface is present, it would be desirable to achieve skeletal movement without compensatory tooth movement. In 1985 Kokich et al. I reported a case in which intentionally ankylosed maxillary deciduous canines were used as anchorage for protraction. Although the patient demonstrated desirable facial changes, the treatment modality was abandoned as impractical and costly. The technique of ankylosing deciduous canines has since been improved and is now a routine clinical procedure with high success rate." Titanium implants can be used for similar purpose as shown by Smalley et al. 2 When ankylosed teeth are used as anchorage for protraction forces, the maxillary complex moves with no apparent tooth movement as the presented case demonstrated. The established treatment goals were reached, but a phase II treatment will be necessary at a later date to address the crowding. In the meantime follow up on the stability of phase I treatment will continue. Nine months after discontinuing the headgear, the patient still has a positive overbite and overjet. Of additional interest in this patient was the behavior of his VPI. During the 15 months of protraction, he needed three posterior additions to the obturator bulb totaling about 3 mm to maintain the velopharyngeal competence during speech. This was interpreted as further evidence that the maxillary complex moved forward during treatment increasing the velopharyngeal space. This patient illustrated the complexity of treatment planning for young children with cleft palate. Patients and their families demand attention to their esthetic concerns when these children reach school age. Any orthodontic treatment performed for such a young patient should be simple, mechanically, and as efficient as possible. Intentional ankylosis of deciduous teeth when performed in a clinic setting is a demanding procedure for the dentist performing the extraction, endodontic treatment and replantation. The follow-up

AmericanJournal of Orthodontics and Dentofacial Orthopedics Volume 106, No.2 Omnell and Sheller 205 mechanics are simple for bothpatientandorthodontist. The results using protraction with such anchorage are dramatic. The alternative of deferring treatment until the teen years is increasingly unacceptableto these patients and their families. REFERENCES 1. Kokich VG, Shapiro PA, Oswald R, Koskinen-Moffett L, Clarren SK. Ankylosed teeth as abutments for maxil1ary protraction. A case report. AM J ORTHOn 1985;88:303-7. 2. SmalleyWM, Shapiro PA, Hohl TH, Kokich VG, Branemark P. Osseointegrated titanium implants for maxillofacial protraction in monkeys. AM J ORTHOn DENTOFAC ORTHOP 1988;94:285-95. 3. Sheller BL, Omnel1 ML. Therapeutic ankylosis of primary teeth. J Clin Orthod 1991;25:499-502. 4. Potpeschnigg: Deutsch viertel Jahrschrift fur Zahn heilkunde 1875. Monthly Rev Dent Surg 1874-1975;3:464-5. 5. Delaire J. Confection du masque orthopedique. Rev Stomat Paris 1971;72:579-84. 6. Jackson GW, Kokich VG, Shapiro PA. Experimental and post experimental response to anteriorly directed extraoral force in young Macaca nemestrina. AM J ORTHon 1979;75:318-33. 7. Sarnas KV, Rune B. Extraoral traction to the maxilla with face mask: a follow up of 17 consecutively treated patients with and without cleft lip and palate. Cleft Palate J 1987;24: 95-103. 8. Rygh P, Tindlund R. Orthopedic expansion and protraction of the maxilla in cleft palate patients-a new treatment rationale. Cleft Palate J 1982;19[2]:104-12. Reprint requests to: Dr. Lena Omnell Department of Dental Medicine Children's Hospital & Medical Center P.O. Box 5371 Seattle, WA 98105-0371 AAO MEETING CALENDAR 1995-San Francisco, Calif., May 13 to 18, Moscone Convention Center (International Orthodontic Congress) 1996-Denver, Colo., May 11 to 15, Colorado Convention Center 1997-Philadelphia, Pa., May 3 to 7, Philadelphia Convention Center 1998-Dallas, Texas, May 16 to 20, Dallas Convention Center 1999-San Diego, Calif., May 15 to 19, San Diego Convention Center 2000-Chicago, III., April 29 to May 3, McCormick Place Convention Center