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Maxillary Hypoplasia In the Cleft Patient: Contribution of Orthodontic Dental Space Closure to Orthognathic Surgery
Justin C. Lee, MD1, Ginger Slack, MD2, Ryann Walker, MD2, Martin G. Martz, MD2, Lindsay Graves, MD2, Sandra Yen, MD2, Jessica Who, MD2, Rishal Ambaram, MD2, Henry K. Kawamoto, Jr., MD2, James P. Bradley, MD3.
1UCLA, Division of Plastic and Reconstructive Surgery, Department of Surgery and Section of Orthodontics, Los Angeles, CA, USA, 2UCLA, Los Angeles, CA, USA, 3Plastic Surgery, UCLA, Los Angeles, CA, USA.

Purpose: Surgical maneuvers for cleft correction in the developing child are known to be associated with maxillary hypoplasia due to disruption of growth centers and scar tissue formation. However, adjunctive orthodontic treatments apply dentally based restrictions in children over long periods of time and the effects of such restrictions on maxillary growth have not been investigated. Orthodontic closure of dental spaces using canine substitution, a common practice for missing lateral incisors, entails a sizable change to half of the maxillary dental arch. In this study, we present the contribution of orthodontic canine substitution to maxillary hypoplasia and need for orthognathic surgery.
Methods: Unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (CP) patients older than 15 years of age evaluated at the UCLA Craniofacial Clinic between 2008-2012 were retrospectively reviewed for dental anomalies, orthodontic canine substitution, and Le Fort I advancement. Sagittal skeletal relationships of the maxilla to the skull base (SNA), mandible (ANB), and facial height were determined on lateral cephalograms. Univariate and multivariate logistic regression analyses were performed to estimate odds ratios (OR).
Results: 95 patients were evaluated at or near skeletal maturity with an average age of 18.1 years (range 15-24). In the presence of congenitally missing teeth (n=65), 55% of patients who had preservation of dental spaces (n=38) required Le Fort I advancement. In contrast, 89% of patients who underwent canine substitution (n=28) required Le Fort I advancement for maxillary hypoplasia (p=0.003). Patients who underwent canine substitution exhibited a statistically significant increase in maxillary retrusion (average SNA 75.3, range 67-78) when compared to patients with patent dental spaces (average SNA 80.5, range 77-84) on lateral cephalograms (p=0.000004). No significant differences existed in the relationship between the maxilla to the mandible or the relative vertical height of the maxilla. Adjusting for the presence of dental agenesis, logistic regression analyses demonstrated that canine substitution is an independent predictor for orthognathic surgery (OR 6.47, 95% confidence interval 1.6-25.2) as well as maxillary retrusion defined by SNA <78 (OR 24.8, 95% confidence interval 2.9-212.2).
Conclusions: The coordination of orthodontia and surgery are essential components of care for the cleft lip and palate patient. We report a strong association for orthodontic closure of cleft-related dental spaces and maxillary retrusion requiring surgical correction. We suggest that a practice change of the current cleft lip and palate treatment algorithm is warranted to prevent the need for orthognathic surgery at maturity.


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