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ORALANDMAXILLOFACIALSURGERYCLINICSOFNORTHAMERICAVolume32,Number2 May2020ISSN1042-3699,ISBN-13:978-0-323-69492-6

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Contributors

CONSULTINGEDITOR

RUIP.FERNANDES,MD,DMD,FACS, FRCS(Ed)

ClinicalProfessorandChief,DivisionofHead andNeckSurgery,ProgramDirector,Head andNeckOncologicSurgeryand MicrovascularReconstructionFellowship, DepartmentsofOralandMaxillofacialSurgery, Neurosurgery,andOrthopaedicSurgeryand Rehabilitation,UniversityofFloridaHealth ScienceCenter,UniversityofFloridaCollegeof Medicine,Jacksonville,Florida,USA

EDITORS

MICHAELR.MARKIEWICZ,DDSMPH,MD, FACS

ProfessorandChair,DepartmentofOraland MaxillofacialSurgery,WilliamM.Feagans EndowedChair,AssociateDeanforHospital Affairs,SchoolofDentalMedicine,Clinical Professor,DepartmentofNeurosurgery, DivisionofPediatricSurgery,Departmentof Surgery,JacobsSchoolofMedicineand BiomedicalSciences,UniversityatBuffalo,CoDirector,CraniofacialCenterofWesternNew York,JohnR.OisheiChildren’sHospital, Buffalo,NewYork

AUTHORS

VEERASATHPURUSHALLAREDDY,BDS, PhD

BrodieCraniofacialEndowedChair,Professor andHead,DepartmentofOrthodontics, CollegeofDentistry,TheUniversityofIllinoisat Chicago,Chicago,Illinois

SHAYNAAZOULAY-AVINOAM,DDS Resident,DepartmentofOrthodontics,College ofDentistry,TheUniversityofIllinoisat Chicago,Chicago,Illinois

VEERASATHPURUSHALLAREDDY,BDS, PhD

BrodieCraniofacialEndowedChair,Professor andHead,DepartmentofOrthodontics, CollegeofDentistry,TheUniversityofIllinoisat Chicago,Chicago,Illinois

MICHAELMILORO,DMD,MD,FACS ProfessorandHead,DepartmentofOraland MaxillofacialSurgery,CollegeofDentistry,The UniversityofIllinoisatChicago,Chicago, Illinois

RICHARDBRUUN,DDS

CraniofacialOrthodontist,BostonChildren’s Hospital,CleftLip/PalateandCraniofacial Teams,AssistantProfessorofDevelopmental Biology,Part-Time,HarvardSchoolofDental Medicine,SeniorAssociate,Departmentof Dentistry,BostonChildren’sHospital,Boston, Massachusetts,USA

JENNIFERCAPLIN,DMD,MS AssociateDirectorofPostGraduate Orthodontics,AssistantProfessor,Department

ofOrthodontics,CollegeofDentistry,The UniversityofIllinoisatChicago,Chicago, Illinois

STEPHANIEJ.DREW,DMD,FACS

AssociateProfessor,DepartmentofSurgery, DivisionofOralandMaxillofacialSurgery, EmoryUniversitySchoolofMedicine,Atlanta, Georgia

SEANP.EDWARDS,DDS,MD

Professor,DepartmentofOraland MaxillofacialSurgery,UniversityofMichigan, MottChildren’sHospital,AnnArbor, Michigan

AUSTINGAAL,DDS

FormerCleftandCraniofacialFellow,The UniversityofOklahoma,CollegeofDentistry, DepartmentofOralandMaxillofacialSurgery, OklahomaUniversityChildren’sHospital,JW KeysCleftandCraniofacialClinic,Oklahoma City,Oklahoma,USA;CascadiaOMS, Kirkland,Washington,USA

GHALIE.GHALI,DDS,MD,FACS,FRCS(Ed)

JackW.GambleProfessorandChairman, DepartmentofOralandMaxillofacialSurgery/ HeadandNeckSurgery,Chancellor,Louisiana StateUniversityHealthSciencesCenter, Shreveport,Louisiana

JEFFREYHAMMOUDEH,DDS,MD

AssociateChiefPlasticandMaxillofacial Surgery,AssociateProfessor,University ofSouthernCalifornia,DivisionofOral andMaxillofacialSurgery,Departmentof PlasticandReconstructiveSurgery, Children’sHospitalLosAngeles,LosAngeles, California

RICHARDA.HOPPER,MD,MS

Chief,PediatricPlasticandCraniofacial Surgery,MarlysC.LarsonProfessorof CraniofacialSurgery,UniversityofWashington SchoolofMedicine,CraniofacialCenter, DivisionofPlasticandCraniofacialSurgery, SeattleChildren’sHospital,Seattle, Washington

HITESHKAPADIA,DDS,PhD

Chief,DivisionofCraniofacialOrthodontics, SeattleChildren’sHospital,Craniofacial Center,Seattle,Washington

JAMESMACLAINE,BDS

ClinicalInstructor,Departmentof DevelopmentalBiology,BostonChildren’s Hospital,HarvardSchoolofDentalMedicine, Boston,Massachusetts

ASHLEYE.MANLOVE,DMD,MD

ClinicalInstructor,ProgramDirector,Director ofCarleCleftandCraniofacialTeam, DepartmentofOralandMaxillofacialSurgery, CarleFoundationHospital,Urbana, Illinois

MICHAELR.MARKIEWICZ,DDSMPH,MD, FACS

ProfessorandChair,DepartmentofOraland MaxillofacialSurgery,WilliamM.Feagans EndowedChair,AssociateDeanforHospital Affairs,SchoolofDentalMedicine,Clinical Professor,DepartmentofNeurosurgery, DivisionofPediatricSurgery,Departmentof Surgery,JacobsSchoolofMedicineand BiomedicalSciences,UniversityatBuffalo, Co-Director,CraniofacialCenterofWestern NewYork,JohnR.OisheiChildren’sHospital, Buffalo,NewYork

MARKA.MILLER,MD,DMD

AssistantProfessor,DepartmentsofOraland MaxillofacialSurgery,Neurosurgery,and Pediatrics,UTHealthSanAntonio,San Antonio,Texas

DOUGLASOLSON,DMD,MS

CraniofacialCenterofWesternNewYork, OisheiChildren’sOutpatientCenter,Buffalo, NewYork

BONNIEL.PADWA,DMD,MD

OralSurgeon-in-Chief,SectionofOraland MaxillofacialSurgery,AssociateProfessor, DepartmentofPlasticandOralSurgery, HarvardMedicalSchool,Boston, Massachusetts

VICTORIAPALERMO,MD,DDS

FloridaCraniofacialInstitute,Tampa, Florida

YASSMINPARSAEI,DMD

OrthodonticResident,Divisionof Orthodontics,DepartmentofCraniofacial Sciences,UniversityofConnecticut, Farmington,Connecticut

STAVANY.PATEL,DDS,MD

AssistantProfessorandResidencyProgram Director,DepartmentofOralandMaxillofacial Surgery/HeadandNeckSurgery,Louisiana StateUniversityHealthSciencesCenter, Shreveport,Louisiana

JEFFREYC.POSNICK,DMD,MD

ProfessorEmeritus,PlasticandReconstructive SurgeryandPediatrics,Georgetown University,Washington,DC;Professorof Orthodontics,UniversityofMaryland, BaltimoreCollegeofDentalSurgery, Baltimore,Maryland;ProfessorofOraland MaxillofacialSurgery,HowardUniversity CollegeofDentistry,Washington,DC

CORYM.RESNICK,DMD,MD

AttendingPhysician,OralandMaxillofacial SurgeryProgram,AssistantProfessor, DepartmentofPlasticandOralSurgery, HarvardMedicalSchool,Boston, Massachusetts

PATRICALDE,MD,DDS

Director,FloridaCraniofacialInstitute,St. Joseph’sCleftandCraniofacialCenter, Tampa,Florida

GERARDOROMEO,DDS,MD,MBA

DivisionChiefandProgramDirector,Oral andMaxillofacialSurgery,Departmentsof DentalMedicine,andPediatrics,Northwell Health,MedicalCo-Director,Hagedorn CleftandCraniofacialTeamatCohen Children’sMedicalCenter,Assistant Professor,DonaldandBarbaraZuckerSchool ofMedicineatHofstra/Northwell,LongIsland JewishMedicalCenter,NewHydePark,New York

ELIZABETHROSS,DDS

ClinicalInstructor,Departmentof DevelopmentalBiology,BostonChildren’s Hospital,HarvardSchoolofDentalMedicine, Boston,Massachusetts

RAMONRUIZ,DMD,MD

ArnoldPalmerHospitalforChildren,Orlando, Florida

CURTISD.SCHMIDT,DDS

CleftandCraniofacialSurgeryFellow, DepartmentofOralandMaxillofacialSurgery/

HeadandNeckSurgery,LouisianaState UniversityHealthSciencesCenter,Shreveport, Louisiana

STEPHENSHUSTERMAN,DMD

ClinicalAssociateProfessor,HarvardSchoolof DentalMedicine,Dentist-in-Chief,Emeritus, BostonChildren’sHospital,Boston, Massachusetts

KEVINS.SMITH,DDS,FACS,FACD ProfessorandResident/FellowshipProgram Director,TheUniversityofOklahoma,College ofDentistry,DepartmentofOraland MaxillofacialSurgery,Director,JWKeysCleft andCraniofacialClinic,Children’sHospitalof Oklahoma,UniversityofTulsa,MKChapman CleftandCraniofacialClinic,ProfilesOral FacialSurgeryExperts,OklahomaCity, Oklahoma,USA

DEREKSTEINBACHER,MD,DMD,FACS ChiefofOralandMaxillofacialSurgery, DirectorofCraniofacialSurgery,Associate Professor,SectionofPlasticand ReconstructiveSurgery,YaleSchoolof Medicine,NewHaven,Connecticut

SRINIVASM.SUSARLA,DMD,MD,MPH AssistantProfessorofSurgery(Plastic), UniversityofWashingtonSchoolofMedicine, AssistantProfessorofOral-Maxillofacial Surgery,UniversityofWashingtonSchoolof Dentistry,CraniofacialCenter,Divisionsof CraniofacialandPlasticSurgeryand Oral-MaxillofacialSurgery,Seattle Children’sHospital,Seattle, Washington

TIMOTHYJ.TREMONT,DMD,MS ProfessorandChairman,Departmentof Orthodontics,MedicalUniversityofSouth Carolina,Charleston,SouthCarolina

RAYMONDTSE,MD

SeattleChildren’sHospital,Craniofacial Center,Seattle,Washington

MARKURATA,DDS,MD,FACS

AudreySkirballKenisEndowedChairand Chief,DivisionofPlasticSurgeryand reconstructiveMaxillofacialSurgery,Chair

DivisionofOralandMaxillofacialSurgery, OstrowSchoolofDentistry,Universityof SouthernCalifornia,Children’sHospitalLos Angeles,LosAngeles,California

FLAVIOURIBE,DDS,MDentSc

CharlesBurstoneProfessor,ProgramDirector andInterimChair,DivisionofOrthodontics, DepartmentofCraniofacialSciences, UniversityofConnecticut,Farmington, Connecticut

SHANKARRENGASAMYVENUGOPALAN, DDS,DMSc,CAGE(Ortho),PhD DepartmentofOrthodontics,Associate Professor,TheUniversityofIowa,Collegeof DentistryandDentalClinics,IowaCity, Iowa

JENNIFERE.WOERNER,DMD,MD,FACS AssistantProfessorandFellowshipDirector, CleftandCraniofacialSurgery,Departmentof OralandMaxillofacialSurgery/HeadandNeck Surgery,LouisianaStateUniversityHealth

SciencesCenter,Shreveport, Louisiana

SUMITYADAV,MDS,PhD AssociateProfessor,Departmentof CraniofacialSciences,Universityof ConnecticutSchoolofDentalMedicine, Farmington,Connecticut

DAVIDYATES,DMD,MD,FACS ProgramDirector,EPCHCleftandCraniofacial Fellowship,DivisionChiefofCranialandFacial Surgery,ElPasoChildren’sHospital,Clinical AssistantProfessorofSurgery,TexasTech UniversityHealthSciencesCenterElPaso,Paul L.FosterSchoolofMedicine,Partner,High DesertOral&FacialSurgery,ElPaso,Texas

STEPHENYEN,DMD,PhD DirectorofFellowshipinCraniofacialand SpecialNeedsOrthodontics,Divisionof Dentistry,Children’sHospitalLosAngeles, CenterforCraniofacialMolecularBiology, UniversityofSouthernCalifornia,LosAngeles, California

Preface:OrthodonticsfortheCraniofacialSurgeryPatient

MichaelR.Markiewicz,VeerasathpurushAllareddy,andMichaelMiloro

CraniofacialGrowth:CurrentTheoriesandInfluenceonManagement

AshleyE.Manlove,GerardoRomeo,andShankarRengasamyVenugopalan

Craniofacialdevelopmentisahighlycoordinatedprocessunderatightgeneticcontrolandenvironmentalinfluence.Understandingthecoreconceptsofgrowthand developmentofthecraniofacialskeletonandtheimpactoftreatmentongrowthpotentialisvitaltosuccessfulpatientmanagement.Tomaximizeoutcomesandminimizeiatrogenicconsequences,propersequencingandtimingofinterventionsare critical.Thedevelopmentofthecraniofacialskeletonoccursasaresultofa sequenceofnormaldevelopmentalevents:braingrowthanddevelopment,optic pathwaydevelopment,speechandswallowingdevelopment,airwayandpharyngealdevelopment,muscledevelopment,andtoothdevelopmentanderuption.

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167

AnOverviewofTimelineofInterventionsintheContinuumofCleftLipandPalateCare177

DavidYates,VeerasathpurushAllareddy,JenniferCaplin,SumitYadav, andMichaelR.Markiewicz

Thisarticleprovidesanoverviewoftimelineofinterventionsandthecriticalrole differentprovidershaveinthecontinuumofcleftlipandpalatecare.Theearliest interventionisthepresurgicalinfantorthopedictreatment,whichisinitiatedinthe firstfewweeksoflife.Thisisfollowedbyseveralinterventionsdoneinaphased manner.Theseinclude:liprepair,palaterepair,velopharyngealsurgery,maxillary expansion,maxillarybonegrafting,limitedphaseoforthodontictreatment,comprehensivephaseoforthodontictreatment(with/withoutorthognathicsurgery),and restorativedentistry.

DentofacialOrthopedicsfortheCleftPatient:TheLathamApproach

VeerasathpurushAllareddy,StephenShusterman,ElizabethRoss,VictoriaPalermo, andPatRicalde

Presurgicalinfantdentofacialorthopedictreatment(PSIOT)isaprocessbywhich cleftmaxillaryandsofttissuesegmentscanbemovedbeforesurgicalrepairof lip.OneofthePSIOTapproachesusedisthefixedPSIOTusingLathamappliances. Inthisarticle,theauthorsprovideanoverviewofthisapproachandthestep-by-step processofplacingtheseappliancesintraorally.Prospectiverandomizedclinical studiesarenecessarytodefinitivelyanswerconcernssurroundingthelong-termeffectsofPSIOT.

NasoalveolarMoldingforUnilateralandBilateralCleftLipRepair

HiteshKapadia,DouglasOlson,RaymondTse,andSrinivasM.Susarla

Nasoalveolarmolding(NAM)isapowerfultoolinthetreatmentofpatientswithunilateralorbilateralcleftlipandpalate.TheprimarygoalofNAMistoimprovealignmentofcriticalanatomicelementsbeforesurgicalrepairoftheunilateralorbilateral cleftlip.Modificationsofthepositionofthealveolarsegmentsandtheirassociated

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lipelements,thelowerlateralcartilages,andthecolumellaachievedwithNAMare helpfulforcreatingasuitableplatformfortension-freeliprepair.

OrthodonticPreparationforSecondaryAlveolarBoneGraftinginPatientswithComplete CleftLipandPalate

VeerasathpurushAllareddy,RichardBruun,JamesMacLaine,MichaelR.Markiewicz, RamonRuiz,andMarkA.Miller

Thisarticleprovidesanoverviewoftheorthodonticpreparationpriortosecondary alveolarbonegraftingofalveolardefectsinthosewithcompletecleftlipandpalate. Useofconebeamcomputedtomographyindiagnosisandtreatmentplanningfor addressingalveolarclefts,therationaleformaxillaryexpansionpriortoalveolar bonegrafting,keystepsindifferentialmaxillaryexpansion,potentialadverseeffects, andoutcomesassociatedwithmaxillaryexpansionareprovidedinthisoverview.

ObturationandTissueTransferforLargeCraniofacialDefects

CurtisD.Schmidt,StavanY.Patel,JenniferE.Woerner,andGhaliE.Ghali

Reconstructionoflargecraniofacialdefectsrequiresseveralfactorstobeconsideredbeforedecidingonthebestreconstructiveoption.Thisarticlediscusses variousfactorstakenintoconsiderationwhendecidingonwhichreconstructiveoptionisidealforagivenpatientanddefect.Forlargecraniofacialdefects,reconstructionusingtissuetransferisconsideredpreferentiallyoverobturation,althoughin selectdefectsobturationusingatraditionaltooth-orimplant-borneprostheticobturatorcanbeconsideredaviableoption.

AnOverviewofCraniosynostosisCraniofacialSyndromesforCombinedOrthodonticand SurgicalManagement

ShaynaAzoulay-Avinoam,RichardBruun,JamesMacLaine,VeerasathpurushAllareddy, CoryM.Resnick,andBonnieL.Padwa

Thisarticleprovidesanoverviewofepidemiology,genetics,andcommonorofacial featuresofthosewithcraniosynostosis.Patientswithcraniosynostosisrequire severalsurgicalproceduresalongwithcontinuumofcare.Theearliestsurgicalinterventionsaredoneduringthefirstfewyearsoflifetorelievethefusedsutures.Midfaceadvancement,limitedphaseoforthodontictreatment,andcombined orthodontics/orthognathicsurgerytreatmentareusuallyrequiredduringlateryears. Thisarticlepresentsseveralexamplesofcaseswithoutcomesassociatedwith theseprocedures.

OrthodonticConsiderationsforCleftOrthognathicSurgery

StephenYen,JeffreyHammoudeh,SeanP.Edwards,andMarkUrata

Preparationandplanningfororthognathicsurgeryinlateadolescencedepends onthecomplexityofunresolvedproblemswithwhichthepatientpresents. Differentstrategiesarepresentedtoaddresstheseunresolvedproblemsinthe adultpatientwithcleftlipandpalate.DifferentsurgicalandorthodontictreatmentsarepresentedtocorrecttheclassIIImalocclusioninpatientswithcleft lipandpalateinrangesthatareanalogoustotheenvelopeofdiscrepancy.For complexcases,theprinciplesofachievability,stability,andestheticsshould guidethedecision-makingprocessforplanningthepreparationfororthognathic surgery.

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249

StephanieJ.DrewandHiteshKapadia

Thecleftpatientmaypresentwithsignificantmaxillarydeficiencyrequiringmaxillaryadvancementtoestablishbalancedfacialformandfunction.Oftenthese skeletaladvancementsrequiremovementofthemaxillaofmorethan10mm. Thecleftpatientposesspecialchallengesbecauseofdifficultyofmobilizingtissuesonamultiplyoperatedmaxilla,aswellaslong-termstability.Distractionosteogenesisisatechniquethatmaybeappliedtohelpmovethemaxillaovera longdistanceandslowlyexpandthesofttissues.Adiscussionoftheorthodontic andsurgicalconsiderationswhenplanningandexecutingthetechniqueis presented.

OrthodonticandSurgicalPrinciplesforDistractionOsteogenesisinChildrenwithPierreRobinSequence

StephenYen,AustinGaal,andKevinSmith

PatientswithPierre-Robinsequencerecalcitranttononsurgicalinterventionhave historicallyrequiredtracheostomy.Mandibulardistractionprovidesapredictable alternativetreatmenttotracheostomyforimprovingairway.Orthodonticperioperativeinterventionsshouldbeconsidered,includingovercorrection,placementoftemporaryanchoragedevices,elastics,andmoldingtheregenerate.Mandibular distractioncanbetechnicallydifficultandmaycausecomplications.Performed correctly,mandibulardistractionprovidespatientswithabetterqualityoflifethan tracheostomy.

OrthodonticsforUnilateralandBilateralCleftDeformities

YassminParsaei,FlavioUribe,andDerekSteinbacher

Orthodontictreatmentofpatientswithunilateralandbilateralcleftpalaterequiresan extensiveinterdisciplinaryapproachtoachieveoptimalfunctionalandestheticrehabilitation.Interventionisdividedinto3mainstages:earlymixed,latemixed,andpermanentdentition.Treatmentmodalitiescanvaryaccordingtodevelopmentalstage, severityofcleft,andpresenceofotherdentofacialabnormalities.Thisarticledescribestheuseandefficacyofdifferentorthodontic,orthopedic,andsurgicalapproachesateachdevelopmentalstageofunilateralandbilateralclefts,whereby theorthodontistplaysapivotalroleinthedifferentphasesofgrowthanddevelopmentofthecleftlipandthepatient.

Surgical-OrthodonticConsiderationsinSubcranialandFrontofacialDistraction

RichardA.Hopper,HiteshKapadia,andSrinivasM.Susarla

Subcranialandfrontofacialdistractionosteogenesishaveemergedaspowerful toolsformanagementofhypoplasiainvo lvingtheuppertwo-thirdsoftheface. Theprimarygoalofsubcranialorfrontofaci aldistractionistoimprovetheorientationoftheupperfaceandmidfacestru ctures(frontalbone,orbitozygomatic complex,maxilla,nasalcomplex)relativetothecranialbase,globes,and mandible.Thevarioustechniquesuseda retailoredformanagementofspecific phenotypicdifferencesinfacialpositi onandmayincludesegmentalosteotomies,differentialvectors,orsynchronousmaxillo mandibularrotation.

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SelectedOrthodonticPrinciplesforManagementofCranio-MaxillofacialDeformities321

TimothyJ.TremontandJeffreyC.Posnick

Anunderstandingoffundamentalorthodonticprinciplesinvolvingdiagnosis,treatmentplanning,andclinicalstrategiesisessentialforachievingsuccessfuloutcomes inthetreatmentofcraniofacialpatients,particularlycleftlip/palate.Thisarticlefocuseson:customizingamandibulardentalarchformusingtheWALAridge;accuratelydiagnosingthemaxillaryskeletaltransversedimension(cusptocusp/fossato fossa);coordinatingtheupperdentalarchwiththelower;usingasmilingprofileand glabellaverticaltoassessanteroposteriorjawposition;andlevelingthemandibular curveofSpeewhileconsideringthelowerone-thirdoftheface.Theseconceptsinfluencetreatmentoutcomestotheextenttheyareused.

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Preface

Orthodonticsforthe CraniofacialSurgeryPatient

MichaelR.Markiewicz,DDS, MPH,MD,FACS

BDS,PhD

Editors

Thisissueofthe OralandMaxillofacialSurgery ClinicsofNorthAmerica servesasthesecondof a2-partseriesthatemphasizesthecriticalroleof theorthodontistinthemanagementofthecraniofacialsurgerypatient(issue2).Thefirstissue,“OrthodonticsfortheOralandMaxillofacialSurgery Patient”(issue1),reviewed,indetail,common collaborativeproceduresperformedbytheorthodontistandoralandmaxillofacialsurgeonas viewedfromthejointandintegratedperspectives ofbothspecialties.Thisissue,“Orthodonticsfor theCraniofacialSurgeryPatient,”highlightsthe criticalrolethattheorthodontistplaysinthesurgicalproceduresperformedforthecraniofacial patient.

Theimpetusforthisworkwasinitiatedwiththe goalofdevelopingacomprehensivereference textdescribingthemostcommonlyperformed proceduresinvolvingcraniofacialsurgeonsand craniofacialorthodontistsbyexperiencedauthors inbothspecialties.Theeditorsfeelthatthiswas anoften-overlookedareaintheexistingliterature. Toaddressthisgoal,asinthefirstissueinthisseries,weagainfeelthatwehavebeensofortunate torecruitsomeofthemostnotablecraniofacial surgeonsandcraniofacialorthodontistsinthe worldtowriteontopicsandsharetheir

experiencesforwhichtheyareconsideredauthoritativeexperts.Weareveryproudofthistextand sogratefultothosewhohavecontributedtomakingthisauniquecollaborationofpractitioners.

Asinthefirstissueofthisseries,wechargedauthors(oralandmaxillofacialsurgeonsandorthodontists)withthetaskofcollaborationbased upontheirexpertise,regardlessoftheirinstitution orpriorinteractionsorbiases.Asignificantchallengeinachievingthisgoal,andmajordifficulty fortheseauthors,isthattheymaynothaveever meteachother.Yettheywerestillabletowork togetherandproducequalityarticlesforthistext. Alltheauthors,regardlessofinstitutionalandpreconceivedbiases,agreedtojoinusonthismonumentalendeavor.Eachoftheauthorsproduceda thoughtfulandauthoritativearticleforthetopicfor whichtheywereassigned,andwe,theeditors,are sothankfulforthis.

Finally,thesepatientsdescribedinthisissueare sospecialtous,andwearefortunateenoughto beabletotreatthemandmakemeaningful changesintheirlives.Theyareunique,complex, challenging,andperplexing,oftenrequiringusto “thinkoutsidethebox.”Perhapsmostimportantly, treatingthesepatientsistrulyrewardingandan honorforusall.Wehopethistextwillhelpto

VeerasathpurushAllareddy,

MichaelMiloro,DMD,MD,FACS

contributepositivelytotheircarebyreinforcingthe criticalrelationshipsbetweenspecialistsin achievingsuccessfuloutcomes.

MichaelR.Markiewicz,DDS,MPH,MD,FACS DepartmentofOralandMaxillofacialSurgery SchoolofDentalMedicine

UniversityatBuffalo 3435MainStreet,112SquireHall Buffalo,NY14214,USA

DepartmentofNeurosurgery DivisionofPediatricSurgery DepartmentofSurgery JacobsSchoolofMedicineandBiomedical Sciences

CraniofacialCenterofWesternNewYork JohnR.OisheiChildren’sHospital Buffalo,NY,USA

VeerasathpurushAllareddy,BDS,PhD DepartmentofOrthodontics CollegeofDentistry

UniversityofIllinoisatChicago 801SouthPaulinaStreet 138AD(MC841) Chicago,IL60612-7211,USA

MichaelMiloro,DMD,MD,FACS DepartmentofOralandMaxillofacialSurgery CollegeofDentistry

UniversityofIllinoisatChicago 801SouthPaulinaStreet M/C835 Chicago,IL60612-7211,USA

E-mailaddresses: mrm25@buffalo.edu (M.R.Markiewicz) sath@uic.edu (V.Allareddy) mmiloro@uic.edu (M.Miloro)

CraniofacialGrowth: CurrentTheoriesand InfluenceonManagement

AshleyE.Manlove, DMD,MDa,GerardoRomeo, DDS,MD,MBAb,c, ShankarRengasamyVenugopalan, DDS,DMSc,CAGE(Ortho),PhDd,*

KEYWORDS

Craniofacialgrowth Maxillofacialgrowth/development Facialgrowth/development

Dentofacialgrowth/development Craniofacialdevelopment Craniomaxillofacialsurgery

Orthodontics

KEYPOINTS

Tomaximizeoutcomesandminimizeiatrogenicconsequencestogrowth,astrongfoundational knowledgeofcraniofacialgrowthisarequirementofanypractitioner. Thereisacephalo-caudalgradientofgrowthpotentialduringcraniofacialgrowth. Thedevelopmentofthecraniofacialskeletonoccursasaresultofasequenceofnormaldevelopmentalevents.

INTRODUCTION

Themanagementofcraniofacialabnormalities andassociatedmalocclusionrequireswellcoordinatedcollaborativeeffortsfromseveral specialists.Theimpactofgrowthofthecraniofacialskeletononsuccessfultreatmentcannotbe understated.Tomaximizeoutcomesandminimize iatrogenicconsequencestogrowth,astrongfoundationalknowledgeofcraniofacialgrowthisa requirementofanypractitioner.Proper sequencingandtimingofinterventionsarecritical inoptimizingoutcomes.Attimes,interventions thatareharmfulareavoideduntilthepreservation ofgrowthallowsforit(ie,secondaryalveolarcleft bonegraftingincontrasttoprimary)andother times,interventionsareusedtomanipulategrowth toeitherincreaseorlimitit(ie,orthodontichead gearandcranialorthotics).

Despitealonghistoryofstudyandstrongsupportiveevidenceforcertaintheories,nosingletheory,todate,appearstocompletelycaptureall aspectsofcraniofacialgrowth.Withvarioustheories inexistence,geneticcontroltheoryandfunctional matrixtheoryarethe2mostpopularandwidely accepted.Itishighlylikelythatsomeamalgamation ofvarioustheorieswouldbeclosetotruedescription oftheconceptsofcraniofacialgrowth.Thisarticle reviewssomebasicterminologiesofgrowthand development,coreconceptsofnormalgrowth, componentsofcraniofacialgrowth,growthby tissuetypesandanatomicsubunits,andgrowth modificationbyorthodonticintervention.

BASICTERMINOLOGY

Theterms“development”and“growth”are relatedtooneanotherandtypicallydiscussedin

a DepartmentofOralandMaxillofacialSurgery,CarleCleftandCraniofacialTeam,CarleFoundationHospital, 611W.ParkStreet,Urbana,IL61801,USA; b OralandMaxillofacialSurgery,DepartmentofDentalMedicine, NorthwellHealth,HagedornCleftandCraniofacialTeamatCohenChildren’sMedicalCenter,HofstraNorthwellSchoolofMedicine,LongIslandJewishMedicalCenter,270–0576thAvenue,NewHydePark,NY 11040,USA; c DepartmentofPediatrics,NorthwellHealth,HagedornCleftandCraniofacialTeamatCohen Children’sMedicalCenter,HofstraNorthwellSchoolofMedicine,NewHydePark,NY,USA; d Department ofOrthodontics,TheUniversityofIowa,CollegeofDentistryandDentalClinics,801NewtonRoad,DSB, S232,IowaCity,IA52242,USA

*Correspondingauthor.

E-mailaddress: Shankar-Venugopalan@uiowa.edu

OralMaxillofacialSurgClinNAm - (2020) -–https://doi.org/10.1016/j.coms.2020.01.007 1042-3699/20/ 2020ElsevierInc.Allrightsreserved.

tandemoreveninterchangeably.Conceptually, however,theyaredistinct.Theterm“development”describesformation,differentiation,or specializationoftissues/subunits,usuallybytransitioninginanatomicform.Onthecontrary,the term“growth”referstoincreaseinsizeofanytissue,subunit,orunit.

Craniofacialdevelopmentandgrowthbeginin uteroandcontinuevariablyintoadulthood.Three mainparametersaretypicallyusedtodescribe “growth”intheliterature: magnitude, direction, and velocity.The“magnitude”isusedtocategorizegrowthintermsofsome“relativeamount” foragivendimension(transverse,sagittal,and vertical).The“direction,”however,istypically simplifiedintoavectorrepresentingthe“net” directionalgrowth.Theterm“velocity”refersto therateofgrowthperunittime.

Itiscommontoheartheterm“skeletalmaturity” usedwhenplanninginterventionsamongpractitioners.Oftentimes,skeletalmaturitydetermines whetherornotaninterventionisdeemedtobe indicatedorcontraindicated.Althoughsome wouldmistakenlyassumethat“maturity”iscessationofgrowth,amoreaccurateinterpretationof “maturity”wouldconnotemostofthemagnitude andpeakvelocityofgrowthhasoccurred.

CORECONCEPTSOFNORMALGROWTHAND DEVELOPMENT

Concept1

Allindividualsgothroughsimilarstagesofdevelopmentandgrowth,albeitnotalwaystothe sameextentorattheexactsametime.1 Thechronologicage,skeletalage,anddentalagedonotalwayscorrelateinanindividual.Conceptiontobirth averages40weeksandistermedthe“prenatal” period.Developmentandgrowthintermsof magnitudeandvelocityarehighestintheprenatal period.Frombirthto2years(infancy),themagnitudeandvelocityofgrowthanddevelopmentdecreasesuntilitplateausinchildhood.During puberty,themagnitudeandvelocityofgrowthincreasesagain.Followingpubertalgrowth,the magnitudeandvelocityofgrowthsteadily decreases.

Concept2

Notalltissuetypesorpartsofthebodygrowatthe sametimeorthesamerate.Inthecraniofacial subunits,notonlyarevarioustissue typespresent,butthosetissuesarepresentinvariableproportionsatdifferenttimesduringgrowth anddevelopment.Forexample,inagiventime point,thegrowthforneuralorlymphoidtissues

aredifferentinmagnitudeandvelocitythan,say, anysingleboneofthefacialskeleton.

Concept3

Growthpotentialisdrivenbygeneticsandinfluencedbyenvironmentalfactors.“Normalgrowth” occursonaspectrumofwhatwouldbeconsidered“normal.”Therearevaryingdegreesofdeviationfromwhatwouldbeconsideredanormal craniofacialanddentofacialrelationship,which aredeterminedbytheinherentgeneticmakeup. Thosegeneticpredispositions,however,aresubjecttoenvironmentalinfluences.Atthemacro level,growthpotentialofalltissuesandsubunits canonlyberealizedifphysiologyisunimpeded bypathology(ie,propernutritionandabsenceof disease).Atthemicrolevel,introductionofanunfavorablevariable(ie,surgicalscarring)ona growingtissuetypeorsubunitcanalsonegatively impacttheachievementofthegeneticallyprogrammedgrowthpotential.Sometissuesare moresusceptibletoenvironmentalinfluencethan others.

CRANIOFACIALGROWTHBYTISSUETYPE

Inthecraniofacialregion,growthofdifferenttissue types,anatomicunits,andfunctionalspaces occurinacoordinatedrelationshiptooneanother atdifferentratesandtimepoints(Fig.1).Itis widelyacceptedthatcomplexsignalingbetween thesetissuetypesandanatomicunitsmustoccur inaprecisefashiontoachievenormalgrowth bothinuteroandthroughoutlife.Themajor componentsofthecraniofacialgrowthareneural tissue,muscle,tonsils/adenoids,cartilage,bone, sutures,andfunctioningspaces.

NeuralTissue

Neuraltissuecompletesmuchofitsgrowthearlyin development.Atbirth,theneuraltissueshave achievedapproximately60%to70%ofadult size.Byearlychildhood,neuraltissuesreach 95%ofadultdimensions.Thegrowthofneuraltissues(brainandglobes)drivesthegrowthofthe surroundingboneandmusculoskeletaltissues aroundthem.Functionalmatrixhypothesis,as describedbyMossandSalentijn,2 postulates thatitisthesofttissuegrowth(thebrainandsoft tissueenvelope)thatinducesboneandsutural growthofthecranium.

Muscle

Themuscletissueofthecraniofacialregionisless than50%ofadultsizeatbirth.Bythetimeneural tissueshavereachedmaturity,muscletissuehas

reachedonlyapproximately70%ofadultdimensionsinthecraniofacialregion.Muscledimensionsdeveloplaterinchildhoodandadolescence tosupporttheadultdentition,skeletalframe, phonation,anddeglutition.Themusclesare consideredadaptiveinnatureandgrowtosupport function.2

Tonsils/Adenoids

Lymphoidtissuesactuallyexceedadultsizein childhood.Thedimensionsofthetonsilsandadenoidsareapproximately125%ofadultsizebyage 5.Thelymphoidtissuesregressinsizeafter5years ofageandareinpartresponsibleforfurtherdevelopmentofthefunctionalpharyngealspace.This involutionoflymphoidtissuemustbetakeninto consideration,particularly,inpatientswithcleft palate,asitcanresultinworseningofvelopharyngealdysfunctionasthechildgetsolder.3

CartilageandChondrogenesis

Duringearlydevelopment,thereare2kindsof cartilage:(1)primaryand(2)secondary.Theprimarycartilageisuniqueinthatitgrowsinterstitially,itispressuretolerant(ascomparedwith bone,forexample),andisnonvascularinnature. WorkbyScott4 postulatesthatprimarycartilage isgeneticallydrivenandactsasagrowthcenter drivingmuchofthenetchangeincraniofacial formduringdevelopment.Thecranialbaseand

Fig.1. Multipleviewsofskullsfrominfancythroughadolescenceshowthe progressionofcraniofacialbone growth.Thegeneralprogressionis fromsuperiortoinferiorwithadownwardandforwardgrowthvector. (From CostelloBJ,MooneyMP,Shand JM.Craniomaxillofacialsurgeryinthe pediatricpatient:growthanddevelopmentconsiderations.In:FonsecaRJ, editor.Oralandmaxillofacialsurgery. 3rded.St.Louis:Elsevier;2018.p. 627-44;withpermission.)

nasalseptumarederivedfromprimarycartilage. Thegrowthofthenasomaxillarycomplexis dictatedbythegrowthofthecranialbaseand nasalseptalcartilage.Mostprimarycartilageof thecranialbaseisreplacedbyboneviaendochondralossificationearlyinchildhoodthusprimarycartilageasa“driverofgrowth”ends relativelyearly.4 Onthecontrary,thesecondary cartilageisnotundergeneticcontrolinthesame wayasprimarycartilage.Itisconsideredmore “adaptiveinnature”inthatitdoesgrowandultimatelyossify,butitdoessoinresponsetofunctionandisundersignificantenvironmental influence.Inthecraniofacialskeleton,secondary cartilageisfoundinthecondylarhead,coronoid process,angleofthemandible,andmental protuberance.

BoneandOsteogenesis

Boneisacalcifiedtissue,whichishighlyvascular, sensitivetopressure,andissubjectedtoenvironmentalinfluences.5 Theboneformationduring developmentoccursbyeitherintramembranous orendochondralossification.Duringintramembranousossification,themesenchymalcellsdifferentiatedirectlytoosteogeniccells,whereasin endochondralossification,cartilageservesasa template,whichisthenreplacedbybone.Overall bonegrowthdoesnotoccurduetosurfaceappositionofbone.Rather,thebonegrowthoccursby

2majormechanisms:(1)corticaldrift:periosteal depositionofboneandendostealresorptionof bone;and(2)displacement:physicalmovement ofboneduetogrowthoftheadjacentstructure.5 Itmustberememberedthatbonegrowthisnot static,ratherdynamic.Evenafterreachingadult dimensions,boneundergoesnearconstant remodeling.Furthermore,theperiosteumthatsurroundsthebonehasapowerfulinfluenceoverits growthanddevelopment.Therefore,interruption ofthatperiosteumhasthepotentialtoaffectthe growthpotentialofthebone.3

Sutures

Thecranialsuturesarefibrousarticulationsformed betweentheapproximatingosteogenicfrontsof thebonesofcranialvault.Ontheexternalsurface ofthesutureliesthefibrouslayerofperiosteum andontheinternalsurfaceliesthefibrouslayer ofduramater.In-betweentheapproximatingosteogenicfrontsofthesutureliesthemesenchyme, whichprovidesasourcefornewosteogeniccells.6 Thesuturesareimportantsitesofcompensatory growthandplayanimportantroleincraniofacial growth.7 Thegrowthatsuturesoccursasanadaptationtothegrowthoftheneuraltissueandsurroundingtissuessuchasprimarycartilageorsoft tissue.Newboneisdepositedincrementally acrossthosesutureswithremodelingand displacementoccurringinaharmoniousphysiologicbalanceundernormalcircumstances8

FunctioningSpaces

AsdescribedbyMossandSalentijn,2 thecraniofacialregioncontainsvariousspacesthatsupport function,forexample,respiration,deglutition, vision,olfaction,andcognition/neuralintegration. Thedifferenttissuetypesgrowinsupportofsaid functionsresultingin“functioningspaces.”An examplewouldbethatalthoughneuralintegration isthemostessentialofcraniofacialfunctions, growthofthebrainoccursearlyandquickly.The growthofthebraininturndrivesgrowthofthe cranium.Anotherexamplewouldbethatafter birth,alimentationbecomesahigher-orderfunction,thereforeswallowingandjawmovementdrive thedevelopmentofthefunctioningoralcavityand growthofbone,teeth,andmuscletosupportthat function.Enlowandcolleagues5,9 described2 mainmorphologiceventsthatdirectcraniofacial growth,including(1)growthofthebasalcranium, and(2)developmentofpharyngealandfacial airwaystructures.Accordingtohistheory,remodelingoccursascompensatorychangesoftissueto adapttofunction,asdescribedbythefunctional matrixhypothesisofMossandSalentijn.2

CRANIOFACIALGROWTHBYANATOMIC SUBUNIT

Cranium

Thecranialvaultandthecranialbasemakeup theentirecranium.Thecranialvaultis composedofintramembranouslyformedbones, wherebonegrowthoccursatthefibroussuture articulations.Thecranialvaultgrowsexponentiallyduringthefirstyearoflife,reachingapproximately86%ofitsadultsizeby1yearofageand 94%ofadultsizeby5yearsofage. 10 Thisreflectsthesignificantneurodevelopmentthatoccursduringthistimeframe.Apractical applicationofthisknowledgeistheorthotic treatmentofpositionalplagiocephalyhas becomemoreprevalentwiththe“backtosleep” campaign.Asparentsareinstructedtoplace theirinfantsontheirbackwhensleeping,this cancauseflatteningoftheocciputandcompensatoryfrontalbossing.Newbornslacktheneuromuscularstrengthandcontrolofneckmuscles duringthisexponentialneurodevelopmentand rapidgrowthoftheircranialvault,whichcan leadtosignificantflatt eninganddysmorphiccranialvaultgrowth.Giventhatmostcranialvault growthoccursduringthefirstyearoflife,cranial orthotictherapyismosteffectivefrom4months ofageuntil1yearofage.

Contrarytothecranialvault,thecranialbaseis composedofbonesthatformbyendochondral ossification.By5yearsofagetheanteriorcranial baseismorematured(w90%ofadultsize) comparedwiththeposteriorcranialbase(80% ofadultsize).Thecranialbasegrowthoccurs interstitiallyatarticulationscalledsynchondroses, amajorgrowthcenterinthecraniofacialskeleton. Thereare3synchondrosesatthecranialbase:(1) intersphenoidalsynchondroses,whichfuseatthe timeofbirth;(2)sphenoethmoidalsynchondroses, whichfuseat w7to8yearsofage;and(3)sphenooccipitalsynchondroses,whichfuseshortlyafterpuberty.Cranialgrowthdiscrepancyalsocan occurfromcraniosynostosis,whichistheprematurefusionofcranialvaultsutures.Single-suture craniosynostosisismostcommonandusually nonsyndromic.11 Multisuturecraniosynostosis canoccurandismorecommoninconditions suchasApert,Pfeiffer,Crouzon,andSaethreChotzensyndromes.Treatmentofcranialgrowth discrepancyfromprematurefusionofcranialsuturesisusuallyperformedatapproximately 10monthsofageascranialgrowthisslowing down,butsurgerywillstillallowforappropriate volumeforbraingrowthtooccur.Cessationofcranialgrowthoccursat14yearsofageforgirlsand 15yearsofageforboys.

Orbits

Theorbitiscomposedofbonesfromthenasomaxillarycomplex(palatine,maxillary,zygomatic bones),aswellasfromthecranialvault(frontal, ethmoid,sphenoid,lacrimalbones).Thegrowth inthisregionoccursatthesuturesbetweenthese bones.Orbitalgrowthoccursrapidlyinthefirst yearoflifeinassociationwiththegrowthofthe cranialbase,vault,andglobes.Mostorbital bonegrowthiscompleteatapproximately5years ofage.12,13 Intercanthalwidthiscompleteat 8yearsofageingirlsand11yearsofagein boys.Orbitalheightgrowthismoregradual whencomparedwithorbitalvolume,whichultimatelycontributestomidfacialheight.Disruption ofnormalorbitalgrowthisseeninunicoronalcraniosynostosis(Fig.2),aswellasinTessierclefts (Fig.3)thatinvolveanyofthebonesthat constructtheorbit.

Nose

Aninfant’snosehasmorecartilagethanbone whencomparedwithanadultnose.Thereare2 mainperiodsofgrowthofthenose:2to5years ofageandthenduringpuberty.Theseptalcartilageisthoughttobeamajorgrowthcenterand drivingforceinmidfacegrowthearlyindevelopment.Theperpendicularplatearisesfromendochondralossificationalongtheskullbaseand eventuallymeetswiththevomeratapproximately 6to8yearsofagethroughcartilagegrowthand ossification.14 Inaddition,wherethevomerand premaxillameetisanimportantgrowthcenter. Thissuturelineisabnormalincleftpatientsand maycontributetoasymmetricnasalgrowthin thecleftpopulation.15

Zygoma

Thezygomaticbonesalsogrowquicklyduringthe firstyearoflifewithcessationofgrowthatapproximately5to7yearsofage.By5yearsofagethe bizygomaticwidthis83%ofadultwidthandthe widthofthefaceismatureat13yearsofagein girlsand15yearsofageinboys.12,13 Zygomatic deformitiescanbeseenfollowingtraumaaswell asincongenitaldisorderssuchasTreacherCollins andcraniofacialdysostosis.

Maxilla

Themaxilladevelopsbyintramembranousossification.Thegrowthatthecranialbaseexertsamajorinfluenceonmaxillarygrowth,resultingina downwardandforwarddisplacement.Ina compensatoryfashiontothisdisplacement,bone isdepositedatthecircumaxillaryandintermaxillarysutures,andresorbedfromtheanteriorsurfaceofthemaxilla.Inaddition,maxillarygrowth isalsodependentonearlynasalseptalgrowth. Intheantero-posteriordirection,boneisdepositedinthemaxillarytuberosityregion,whichcontributestothelengtheningofthemaxillato accommodatedevelopingdentition.Furthermore, asthemaxilladescendsduringgrowth,boneis resorbedfromthenasalflooranddepositedin thepalatalvault.

Thepremaxillary/maxillarysuturefusesat approximately3to5yearsofage,themidpalatal suturefusesatapproximately15to18yearsof age,andthetranspalatalsuturefusesatapproximately20to25yearsofage.16–18 Thevertical heightofthemaxillareachesitsmaximumgrowth atapproximately12yearsofageingirlsand 15yearsofageinboys.12,13 Theanteriorprojectionofthemaxillareachesskeletalmaturityat

Fig.2. Leftunicoronalcraniosynostosiscausingfacialandorbitalasymmetry.

13yearsofageingirlsand14yearsofageinboys. Growthanddevelopmentofthemaxillaparallels growthandpneumatizationofthemaxillarysinus. Midfacehypoplasiaisaclinicalphenotypeinpatientswithachondroplasia,craniofacialdysostosis syndromes,asaniatrogeniceffectinpatientswith cleftlip/palate,andasaresultoftraumainmidface andnasalfractures.19

Mandible

Thebodyofthemandibledevelopsbyintramembranousossificationandthecondyleby endochondralossification.Inthecraniofacial complex,themandiblehas thegreatestpostnatal growthpotential.Withreferencetothecranial base,themandibleisdisplaceddownwardand forward;however,thedirectionofgrowthatthe condyle,amajorcontributorofpostnatalgrowth, isupwardandbackward.Duringgrowth,increaseinthecorpuslengthisachievedby resorptionalongtheanteriorsurfaceoftheramus anddepositionalongtheposteriorsurfaceofthe ramus.Furthermore,themandibularwidth increasesbybonedepositionalongthebuccal surface.Therefore,growthofthemandibleoccursinallregions,includingthecondyles,rami, andbodythroughdisplacementand remodeling.5 , 20

Mandibularwidthisnearlycompleteat5years ofage.Mandibularheightreachesmaturityat 12yearsingirlsand15yearsinboys.Mandibular anteriorprojectiongrowthiscompleteat13years ofageingirlsand15yearsofageinboys.12,13 Mandibularhypoplasiaiscommonlyseen inPierreRobinsequence,craniofacial microsomia,TreacherCollinssyndrome,Nager syndrome,condylartrauma,andidiopathic condylarresorption,amongothercauses. Mandibularhyperplasiacanbegeneticandis alsoseeninacromegaly.

Fig.3. Tessierorbitalcleft9to10in conjunctionwithleftunicoronalcraniosynostosiscausingsignificantdysmorphiaandfacialasymmetry.

ToothFormationandEruption

Theprocessoftoothformationisundertightgeneticcontrolandtakesplacebyreciprocalinteractionbetweenthedentalepitheliumandneural crestderivedmesenchyme.21 Thedevelopment anderuptionofthedentitioniscloselyintertwined withgrowthanddevelopmentofthemaxillaand mandible.Developmentoftheprimarydentition isinitiatedbythesixthweekofgestation,and thepermanentdentitionisinitiatedatapproximatelythe10thto13thweek.21 Inanormalgrowingpatient,allprimaryteethareeruptedin themaxillaandmandibleby2to2.5yearsof age.Allpermanentteethexceptthirdmolarserupt by12to13yearsofage.Thisisroutinelydelayed inpatientswithcleft.Forteethtoerupt,dentalfolliclesinitiateresorptionofbonealongthepathof eruptionandboneisdepositedontheopposite end.22 Mostteethemergewhenhalftotwothirdsofrootisformedandtherootformationis fullycompleteby2to4yearsaftereruption.There isthereforeanetincreaseinthebonethatsupportsteeththatisassociatedwitheruption.

Tootheruptionisratheradynamicprocessand therateoferuptionparallelstherateofjawgrowth. Duringadolescence,themaxillaryandmandibular molarsdriftmesiallyby w0.6mmperyearand w0.5mmperyear,respectively,23 whereasthe maxillaryandmandibularincisors,duringadolescence,driftmesiallyby w0.3mmperyear.23 In theverticaldimension,themaxillarymolars (w1.2mm/y)andincisors(w1mm/y)eruptslightly morethanthemandibularmolars(w0.9mm/y)and incisors(w0.9mm/y).23 Therefore,asthejawsare displaceddownwardandforwardduringgrowth, teetherupttofillthespaceandtomaintainthe functionalocclusion.Thiseruptionofteethcontributesgreatlytotheverticaldentoalveolar growthinthemaxillaandmandible.23 Thefinalpositionofteethwithinthejawsareinfluencedbythe

balanceestablishedbythepressurefromthe tongue,lips,andcheekmusculature.

GROWTHMODIFICATION

Thedentofacialorthopedicintervention,byan orthodontist,isanattempttomodifygrowthto correctthedevelopingskeletaldiscrepancies.In routineorthodonticdiagnosis,thediscrepancies ingrowthareanalyzedin3dimensions:(1)transverse,(2)sagittal,and(3)verticalplanesofspace. Thewidespreadconsensus,albeitthereareindividualvariations,isthattransversegrowthis completedfirst,thenthesagittalgrowth,and finally,theverticalgrowth.

TransverseDimension

Skeletaldiscrepanciesinthetransversedimension manifestas(1)constrictedorwidemaxilla,and/or (2)constrictedorwidemandible.Thegrowth modificationofconstrictedmaxillaisoften achievedwithpalatalexpansion.Inchildrenat theagegroupof8or9yearsofage,expansion ofthemidpalatalsutureiseasilyachievedwithlittleforceusingtooth-supportedappliances,such asW-archorQuadHelix.24 However,children whoare10yearsorolderrequireheavierforces toopentheinterdigitatedmidpalatalsuture. Therefore,correctionofmaxillaryconstrictionat w10yearsofageoftenrequiresjackscrewdevicestocreatemicro-fracturestoopenthemidpalatalsuture.24 Althoughthegoalofexpansionisto produceskeletalchanges,itisnotalwaysthe case.Thetooth-supportedpalatalexpansiondevicesproduceapproximately50%dentaland 50%skeletalexpansion.24

Theuncorrectedmaxillaryconstrictionat adolescentagegrouppresentsamajorchallenge inopeningthemidpalatalsuturewithtoothsupportedjackscrewdevices.Thisisbecause theheavierforcesdeliveredwithsuchdevices oftenfailtoopenthesutureandwillcausedental tippingandinsomecasesmaycausebuccal bonefracture.Theadventofminiscrewsinorthodontictreatmentallowsdeliveringforcesdirectly tothemidpalatalsutureinachievingtruesutural split.25 Theminiscrew-assistedrapidpalatal expanderisausefulmodalitytocorrectmaxillary constrictioninyoungadultswhomightotherwise requiresurgery.

Unlikethemaxilla,expansionoftheconstricted mandibleispossibleonlywithsurgicalapproach, suchasdistractionosteogenesisduetoearlyossificationofthemidlinemandibularcartilage.24 Currently,therearenoviablegrowthmodification modalitiestocorrectexcessivetransverse

maxillaryormandibulargrowth,andsurgeryis theonlytreatmentofchoice.

SagittalDimension

Inthesagittaldimension,theskeletaldiscrepanciesmanifestas(1)ClassIIskeletalrelationship duetoprognathicmaxillaand/orretrognathic mandible,and(2)ClassIIIskeletalrelationship duetoretrognathicmaxillaand/orprognathic mandible.The2majorgrowthmodificationmodalitiesforClassIIgrowthpatternare(1)tractionwith extraoralforces,suchasheadgear;and(2)functionalappliances,suchasTwinBlock,Bionator, andHerbstappliances.InClassIIskeletaldiscrepancyduetoexcessivemaxillarygrowth,orinsome situationswithnormalmaxillaandretrognathic mandible,extraoraltractionwithheadgearisa reasonabletreatmentmodality.24 Theheadgear therapybeforeorduringadolescencedelivers compressiveforcestothecircumaxillarysutures inrestrainingtheforwardmaxillarygrowthandallowsthemandibletocatchuptoitsinherent geneticallydeterminedgrowthpotential.Thesecondtreatmentmodalityoffunctionalappliance therapyhasbeensurroundedwithmuchcontroversyintheorthodonticliterature.Increasingevidencesupportsthenotionthat,onashort-term basis,functionalappliancetherapybeforeorduringadolescenceacceleratesforwardmandibular growth,but not anymorethantheinherentlydeterminedgeneticpotential.Generally,thefunctional appliancestendtohavesomerestrainingeffect onthemaxilla,withasignificantpartoftheClass IIcorrectionachievedthroughdentoalveolarrather thanskeletalchanges.24,26,27 Thecurrent consensus,basedonmultipleclinicaltrials,with regardtoClassIIgrowthmodificationisthat2phasetreatmentduringadolescenceisnotany moreeffectivethan1-phasetreatmentduring adolescence.24 Therefore,earlytreatmentisindicatedwhenpsycho-socialburdenisamajor concern.

Thecurrentlyavailabletreatmentapproaches forgrowthmodificationinClassIIIgrowthpattern arefacemask(ReversePullHeadgear),chin-cup, andClassIIIelasticsaffixedtoskeletalanchorage. Inpatientswithdeficientmaxillarygrowth,facemasktherapyisindicated,andthegoalofthe interventionistobringthemaxillaforwardand downward.Duringfacemasktherapy,protraction forcesareappliedtothemaxillawithelastics attachedfromafixedintraoralappliancetoan extraoralfacemask.Thefacemasktherapyis effectivebefore8to10yearsofageinproducing improvedskeletalanddentalchanges.24,28 During facemasktherapy,inadditiontomaxillary

protraction,itisnotuncommontofindbackward rotationofmandible.

InthecontinuumofClassIIIskeletaldiscrepancy,excessivemandibulargrowthisontheother endofthespectrum.Inthesepatients,thegoalis toattempttorestrainmandibulargrowthwithchincuptherapy.Thistherapyinvolvesacuporcapon thechinwithanattachmenttothebackofthe head.TheClassIIIpatientswithashortface benefitthemostbychin-cuptherapy.24 Although thegoalofthistherapyistorestrainmandibular growth,italmostalwaysresultsinreductionof chinprojectionbyredirectionofcondylargrowth; backwardrotationofthemandiblewithminimal ornorestraintintheactuallengthofthemandible. Therefore,chin-cuptherapymayactuallyworsen theprofileinindividualswithalong-faceClassIII growthpattern.Chin-cuptherapyiseffectiveat anearlyage;however,thecircumpubertalgrowth ofthemandiblemayreversetheeffectsofearly chin-cuptherapy.28

Theusageofelasticstoboneanchorplatesis growinginpopularity.Theminiplatesareinserted intheinfrazygomaticcrestandinthemandibular canineregion,andClassIIIelasticsareworn fromthemaxillarytothemandibularminiplates tocorrecttheClassIIIskeletalgrowth.Thesuitabletimingofinterventionforthismodalityis w11yearsorolder,asthiswouldallowforstable anchorageintheinfrazygomaticcrestandavoidanceoftoothbuds.Thistherapyappearseffective inproducingmaxillaryprotractionwhileminimizing sideeffectslikedentoalveolarchangesandbackwardrotationofthemandible.24

VerticalDimension

Themanifestationofskeletaldiscrepanciesinthe verticaldimensionare(1)short-faceand(2)longfaceproblems.Oftentimes,theseproblemsmay manifestalongwithskeletalClassIIorIIIgrowth pattern.Inindividualswithshort-faceproblems, typicallythelowerfacialthirdissmallerthanthe upperandthemiddlefacialthirds.Theshort-face individualswillpresentwithlongramus,acute gonialangle,andhypodivergentmandibularplane angle.24 Theaimofgrowthmodificationinthese individualsistoallowfortheverticaldentoalveolar changesbyeruptionofposteriorteeth.Appliances suchasactivatororbionatorwithpalatalacrylic contactingthemandibularincisorsandinterocclusalclearanceintheposteriorregionwould alloweruptionofmaxillaryandmandibularmolars. Suchverticaldentoalveolarchangescould improvetheshortfaceheight.

Contrarytotheshort-facephenotype,isindividualswithlargelowerfacialthird,shortramus,

obtusegonialangle,andsteepmandibularplane angle.Thegrowthmodificationinlong-faceindividualsisratherchallenginganddifficult.Theoretically,growthmodificationingrowinglong-face individualscouldbeachievedwithhigh-pullhead geartorestraindownwardmaxillarygrowthwith posteriorbiteblocktoimpedetheeruptionofteeth andauto-rotatethemandibleintheforwarddirection.24 However,suchagrowthmodification approachnotalwaysproducesthedesiredskeletalchangespredictablyinthelong-faceindividuals.Interestingly,miniscrewimplantsprovidea uniqueopportunityforinterventioninadolescents withlongface.Availablelimiteddatasuggest that,ingrowinghyperdivergentpatients,miniscrewimplantsinthepalateandmandiblewithrigid attachmenttointrudetheupperandlowerposteriorteethcouldpreventtheeruptionofteeth, improvechinprojection,decreasemandibular planeangle,andimprovefacialconvexity.29

SUMMARY

Thedevelopmentofthecraniofacialskeleton occursasaresultofasequenceofnormaldevelopmentalevents:(1)braingrowthanddevelopment,(2)opticpathwaydevelopment,(3)speech andswallowingdevelopment,(4)airwayand pharyngealdevelopment,(5)muscledevelopment,and(6)toothdevelopmentanderuption. Asanorthodontistorsurgeon,itisimportanttounderstandthegrowthanddevelopmentofeach subunitofthefacesotreatmentcaneitherharness andmanipulategrowthoristimedappropriately soastominimizenegativeimpact.Orthopedicappliancescanoftenbeusedduringgrowthphases toattempttomanipulategrowthfavorably.In contrast,itisoftenidealifelectivesurgicalinterventionsaretimedwhenmostgrowthanddevelopmentiscompletesoastonotinterferewith growthpotential.

DISCLOSURE

Theauthorshavenothingtodisclose.

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AnOverviewofTimelineof Interventionsinthe ContinuumofCleftLipand PalateCare

DavidYates, DMD,MDa,VeerasathpurushAllareddy, BDS,PhDb,*, JenniferCaplin, DMD,MSb,SumitYadav, MDS,PhDc, MichaelR.Markiewicz, DDS,MPH,MDd,e,f,g

KEYWORDS

Cleftlipandpalate Timelineofinterventions Orthognathicsurgery Liprepair Palaterepair Alveolarbonegrafting Cleftmaxilla

KEYPOINTS

Manyhealthcareprovidersareinvolvedinthecontinuumofcleftlipandpalatecare. Communicationbetweenprovidersispivotaltorealizegoodend-of-treatmentoutcomes. Treatmentphilosophiesvaryacrosscraniofacialteams.

BACKGROUND

Cleftlipand/orpalate(CL/P)isthemostcommon congenitalcraniofacialanomaly,withaprevalence of1in700livebirths.1–3 AccordingtotheUSCentersforDiseaseControlandPrevention,eachyear 2650babiesarebornwithacleftpalate,and4440 babiesarebornwithacleftlipwithorwithoutacleft palateintheUnitedStates.2,3 Cleftscanbeunilateralorbilateral,completeorincompleteandinvolve thealveolus,lip,and/orpalateinvarious combinations.ThehighestratesofCL/ParereportedinAsianpopulations(0.8–3.7casesper 1000individuals),whilethelowestratesarereported

inAfricans(0.2–1.7casesper1000individuals).4,5 Bothgeneticandenvironmentalfactorshavebeen associatedwiththedevelopmentofCL/P.Some oftheenvironmentalfactorsimplicatedinclude maternalsmokingandalcoholconsumption,poor nutrition,andviralinfections.6 Over350genesand 300syndromeshavebeenassociatedwithCL/P.7 GenesassociatedwithnonsyndromicCL/Pinclude IRF6,8q24,WNT3,10q25,andRFC1.8–11 Inadditiontotraditionalpolymorphisms,certainmethylationpatternshavealsobeenassociatedwithan increaseriskinCL/.12,13 AchildbornwithCL/Pis typicallyfollowedatacleft/craniofacialcenterwhere

a EPCHCleftandCraniofacialFellowship,ElPasoChildren’sHospital,TTUHSC,ElPaso–PaulFosterSchoolof Medicine,HighDesertOral&FacialSurgery,601SunlandParkDrive,bldg2,suite2,ElPaso,TX79912,USA; b DepartmentofOrthodontics,CollegeofDentistry,UniversityofIllinoisatChicago,801SouthPaulinaStreet, 138AD(MC841),Chicago,IL60612-7211,USA; c DepartmentofCraniofacialSciences,UniversityofConnecticut SchoolofDentalMedicine,263FarmingtonAvenue,Farmington,CT06030,USA; d DepartmentofOraland MaxillofacialSurgery,SchoolofDentalMedicine,UniversityatBuffalo,3435MainStreet119SquireHallBuffalo,NY14214,USA; e DepartmentofNeurosurgery,JacobsSchoolofMedicineandBiomedicalSciences,Buffalo,NY,USA; f DivisonofPediatricSurgery,DepartmentofSurgery,JacobsSchoolofMedicineandBiomedical Sciences,Buffalo,NY,USA; g CraniofacialCenterofWesternNewYork,JohnOisheiChildren’sHospital,Buffalo,NY,USA

*Correspondingauthor. E-mailaddress: sath@uic.edu

OralMaxillofacialSurgClinNAm - (2020) -–https://doi.org/10.1016/j.coms.2020.01.001 1042-3699/20/ 2020ElsevierInc.Allrightsreserved.

manyspecialistsareinvolvedinthecontinuumof care.Theobjectiveofthisarticleistoprovidean overviewofmajordentalandsurgicalinterventions thatareperformedinpatientswithCL/P. Ifnottreatedappropriatelyinatimelymanner, thosewithCL/Pcanexperiencecatastrophic eventssuchasprematuredeathandlife-longdifficultiesinfeeding,speaking,hearing,self-esteem, andpsychosocialrelationships.14–16 Theearliest interventioninthosewithCL/Pstartsduringthe firstfewweeksoflife(infantorthopedictreatment

Table1

performedbyapediatricdentistororthodontist inpreparationforrepairofthelip),andthefinal phaseoftreatmentiscomprehensiveorthodontic treatment(with/withoutorthognathicsurgery)that isusuallyperformedinthelateteenyears.Dentists playacrucialroleinthecontinuumofcleftlipand palatecare(Table1);thereforeitbecomescritical thatdentistsareknowledgeableofthetreatment protocolsandtiming.17 Anoverviewofthe timelineofinterventionsfortheCL/Ppatientispresentedin Table1.

Overviewofthetimelineofinterventionsinpatientswithcleftlip/palateandtheprovidersinvolvedat eachstage

Chronologic Age Dental DevelopmentInterventionsProviders

By6moPredentitionInfantorthopedictreatmentOrthodontistand/orpediatric dentist LiprepairCleftandcraniofacialsurgeon

10–24moPrimarydentitionPalaterepair Cleftandcraniofacialsurgeon

1–2yPrimarydentitionEstablishmentofdentalhome (andfollowevery6mo)

2.5–3yPrimarydentitionSpeechassessmentand velopharyngealsurgery(if indicated)

5–10yPrimarydentition andmixed dentition

9–12yEarlytolate mixeddentition

Assesstimingofmaxillary (alveolar)bonegrafting

Maxillaryexpansiontoestablish archformsandcorrect posteriorcross-bites

Pediatricdentist

Cleft/craniofacialsurgeon

Orthodontist/pediatricdentist/ cleftandcraniofacialsurgeon

Orthodontist

Maxillary(alveolar)bonegraftingCleftandcraniofacialsurgeon

Limitedorthodontictreatment followingmaxillary(alveolar) bonegrafting

Orthopedictreatmentusingface mask/reversepullheadgear

12–14yPermanent dentition

>14yPermanent dentition

Boneplate-supportedclass3 elasticstocorrectmaxillary/ mandibularantero-posterior discrepancies

Maxillarydistraction osteogenesis(ifthereislarge maxillary/mandibularanteroposteriordiscrepancy)

Comprehensivephaseof orthodontictreatment(if determinedthattherewillnot beaneedfororthognathic surgery)

Comprehensiveorthodontic treatment(withorwithout orthognathicsurgery)

Orthognathicsurgery(following completionofgrowth)

Orthodontist

Orthodontistandcleft/ craniofacialsurgeon

Orthodontist

Cleft/craniofacialsurgeon

FinalrestorativetreatmentPeriodontist/prosthodontist/ primarycaredentist

PRESURGICALINFANTORTHOPEDIC TREATMENT

Presurgicalinfantorthopedictreatment(PSIOT)is oftenthefirstmajorclinicalinterventionthatisperformedonpatientswithCL/P.PSIOTisinitiated withinthefirstfewweeksoflife,beforesurgical repairofthelip.PSIOTispurportedtorestorethe skeletal,cartilaginous,andsofttissueanatomic relationshippriortoliprepairandconsequently enhancethesurgicaloutcomes.18,19 Facialtapes, Lathamappliances,andNasoalveolar molding(NAM)techniquehavebeenwidelyused forPSIOT(Figs.1). NasoalveolarMoldingfor UnilateralandBilateralCleftLipRepair byKapadia andcolleaguesinthisissueprovideanoverview oftheNAMapproachand Dentofacial OrthopedicsfortheCleftPatient:TheLatham Approach byAllareddyandcolleaguesinthisissue provideanoverviewofLathamapproachforPSIOT. CertaincraniofacialcenterselecttoperformPSIOT onlyifthereisalargedefect,whileseveralothersdo notperformanytypeofPSIOT.20 Therehasbeen considerablecontroversyregardingthelong-term efficacyofPSIOTanditsandadverseimpacton maxillarygrowth.21 StudiesoriginatingfromEurope haveshownthatPSIOTisnotaneffectiveinterventionandrecommendagainstit.22,23 However, severalcraniofacialcentersintheUnitedStates electtoperformPSIOTwithvaryingdegreesofsuccess.ArecentsurveysuggestedthathalfofcraniofacialteamsreportedofferingPSIOT,withtheNAM techniquebeingthemostpopular.20 Graysonand

colleagues24–26 havedemonstratedthatuseof NAMisassociatedwithimprovementsinnasal angleandincreasesofnostrilwidth,columellar height,andcolumellarwidth.27

LIPREPAIR

Primarycleftliprepairisthefirstsurgicalprocedurethatisundertakenbythesurgicalteam (Fig.2).Therepairisgenerallyperformedbetween theagesof3and6monthswiththepurposeof establishinglipcompetencebytheunificationof theunderlyingorbicularisorismuscle.28 Lip competenceisessentialforfeeding,speech,and controloforalsecretions.Therearemultiple differenttechniquesforclosureoftheunilateral cleftlipdefect,withthemostpopularincluding theMillardtechnique,theFisherunilateralcleft liptechnique,andMohlertechnique.Alltechniquesshareincommontheneedtoincreaselip heightontheaffectedsidebyregionalgeometric flaps;however,eachtechniqueapproachesthis problemdifferently.29 Thesurgicaltechniquefor abilateralcleftliprepairisgenerallyapproached inamorestandardfashionacrossallcenters. Theneedforprimaryrhinoplastyatthetimeoflip surgeryhasbeenfiercelydebatedthroughoutthe years.Mostsurgeonshaveincorporatedatleast aminimalnasaldissectionatthetimeoftheprimarylipsurgery,convincedthatitleadstobetter nasaloutcomesanddoesnotsignificantlyincreasetheriskofnasalstenosis.30 Itisessential thatpriortotakingthechildtotheoperating

Fig.1. NAMperformedbyDrLizbethHolguin.Defectsizepre-NAM24mm;post-NAM4mm.(Courtesyof Lizbeth Holguin,DDS,ElPaso,TX.)