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Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 80–85

Contents lists available at SciVerse ScienceDirect

Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology

journa l homepage: www.e lsev ier .com/ locate / jomsmp

riginal research

ong-term stability of soft-tissue changes following maxillary distractionsteogenesis in adult subjects of cleft lip and palate

shok Kumar Jenaa,∗, Satinder Pal Singha,1, Vidya Rattanb,2, Ashok Kumar Utrejaa,3

Unit of Orthodontics, Oral Health Sciences Centre, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, UT, IndiaUnit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, UT, India

r t i c l e i n f o

rticle history:eceived 27 May 2011eceived in revised form8 September 2011ccepted 9 November 2011vailable online 18 December 2011

eywords:oft-tissuehangesaxillaryistractionsteogenesis

a b s t r a c t

Objective: To test the hypothesis that there is no long-term stability of soft tissue changes followingmaxillary advancement with distraction osteogenesis in adult subjects of cleft lip and palate.Setting and sample: Oral Health Sciences Centre at PGIMER, Chandigarh; 15 consecutively treated adultsubjects in the age range of 17–34 years with cleft lip and palate who underwent advancement of maxillaby distraction osteogenesis.Materials and methods: Lateral cephalograms recorded prior to distraction, at the end of distraction, 6-months after distraction and at least 2-years after maxillary distraction of 15 subjects (M = 8, F = 7) in theage range of 17–34 years with complete cleft lip and palate were used for the evaluation of treatmentoutcome and long-term stability of the soft-tissue changes.Results: The soft tissue profile, total soft tissue profile and nasolabial angle were improved significantlyafter immediate (P < 0.001), 6-months (P < 0.01) and 2-years (P < 0.01) of maxillary distraction. Forwardmovement of the nasal tip and nasal base were increased significantly (P < 0.001). The length and thicknessof the upper lip was improved after various time intervals of maxillary distraction osteogenesis (P < 0.01).Approximately 25% of the changes following maxillary distraction were relapsed during first 6-months

of post-distraction follow-up period.Conclusions: Distraction osteogenesis of the maxilla improved the soft tissue profile by increasing theprominence of nose, moving the upper lip forward and normalizing the nasolabial angle. Approximately75% of the changes were remained stable at the end of 2-years of follow-up of maxillary distractionosteogenesis.

ciati

© 2011 Asian Asso

. Introduction

Maxillary distraction offers a solution for the correction ofaxillary hypoplasia in cleft lip and palate subjects. It is widely

ccepted, predictable and stable technique in cleft lip and palateubjects [1–4]. This procedure is performed both in growing [2,5–8]nd adult [9–12] patients. Distraction of maxilla not only allowsorrection of maxillary retrusion during mixed dentition period

ut also allows improvement in facial esthetics [1]. Althoughany studies are there in the literature mentioning the short-

erm and long-term outcomes of skeletal changes [2,5,8–10,13–15]

∗ Corresponding author. Tel.: +91 9876966717.E-mail addresses: ashokkjena@yahoo.co.in (A.K. Jena),

rspsingh chd@yahoo.com (S.P. Singh), drvidyarattan@gmail.com (V. Rattan),shokutreja@yahoo.com (A.K. Utreja).1 Tel.: +91 9815933748.2 Tel.: +91 9914208718.3 Tel.: +91 9914209831.

212-5558/$ – see front matter © 2011 Asian Association of Oral and Maxillofacial Surgeoi:10.1016/j.ajoms.2011.11.001

on of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rightsreserved.

following maxillary distraction but only few studies are therementioning the soft-tissues changes [6,7,16] following maxillarydistraction in cleft lip and palate subjects. However, there is not asingle study to the best of our knowledge mentioning the long-termstability of soft-tissue changes following maxillary distraction par-ticularly in adult subjects of cleft lip and palate. Thus the presentstudy was designed to evaluate the long-term stability of soft-tissuechanges following maxillary distraction osteogenesis in adult sub-jects of cleft lip and palate.

2. Materials and methods

2.1. Patients

The study was conducted on 15 (M = 8, F = 7) North Indian adultsubjects in the age range of 17–34 years with complete cleft lip

and palate who underwent advancement of maxilla by distractionosteogenesis. Among 15 subjects, 8 were with unilateral cleft lipand palate and 7 with bilateral cleft lip and palate. None of the sub-jects had received alveolar bone grafting. All the subjects had severe

ons. Published by Elsevier Ltd. All rights reserved.

A.K. Jena et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 80–85 81

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Fig. 1. The custom made rigid extraoral distractor device fixed in th

nteroposterior maxillary hypoplasia with Class-III malocclusionnd reverse overjet.

.2. Distraction procedure

In all the subjects’ maxillary arch was prepared by multibondedxed orthodontic appliance prior to distraction. After the prepa-ation of maxillary arch, the multibonded appliance was removednd an alginate impression was made for intraoral splint fabrica-ion. High Le Fort-I osteotomy with septal and pterygomaxillaryisjunction was carried out. The splint was cemented to the maxil-

ary arch with glass ionomer cement and the customized distractoras fixed. The design of the customized distractor is described in

ig. 1. After a latency period of 4–6 days, distraction was started athe rate of 1 mm/day by adjusting the screws attached to the trac-ion wires of the intraoral splint. The distraction vector was alongnd parallel to the occlusal plane. All the subjects were followedp weekly and active distraction was continued until 5–8 mm ofositive overjet was achieved. After the consolidation period ofpproximately 6–8 weeks, the distractor and occlusal splints wereemoved. The fixed orthodontic appliance was again bonded andhe correction was retained by Class-III elastic traction (¼”, 6 ozorce). The average duration of orthodontic treatment after maxil-ary distraction was approximately 1 year. The same oral surgeonVR) carried out the procedures in all the subjects. The study waspproved by the Institute Review Board (IRB).

.3. Recording of lateral cephalograms

The lateral cephalograms were recorded at the beginning ofreatment, before distraction procedure (T0), at the end of active

ient. (A) Front view, (B) lateral view and (C) intraoral acrylic splint.

distraction (T1), 6-months after the end of active distraction (T2)and at least 24-months after the end of active distraction osteo-genesis (T3). The mean time interval between the T2 and T3 was25.5 ± 1.94 months. Few cephalograms were recorded in a differentmachine but the magnification was corrected accordingly. For theevaluation of skeletal and soft-tissue changes, lateral cephalogramsrecorded at T0, T1, T2, T3 were traced manually and considered forstatistical analysis. All the cephalograms were traced and analyzedby the same investigator (AKJ). All the linear and angular variableswere measured twice and the mean was considered for statisti-cal analysis. Various cephalometric landmarks, linear and angularvariable for the evaluation of skeletal changes following maxillarydistraction is described in Fig. 2. Various landmarks, linear andangular parameters for the evaluation of soft-tissue changes areshown in Figs. 3 and 4.

2.4. Statistical methods

All the statistical analyses were performed with SPSS software(Version-13). The data were subjected to descriptive analysis formean, range and standard deviation of all variables. ANOVA andpost hoc test were used and probability value (P-value) 0.05 wasconsidered as statistically significant level.

3. Results

The detail results of few important skeletal cephalometric

measurements are described in Table 1. The SNM angle wasincreased significantly (P < 0.001) from predistraction (T0) valueof 65.16◦ to immediate post-distraction (T1) value of 78.50◦. Dur-ing post-distraction follow-up period, the SNM angle was relapsed

82 A.K. Jena et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 80–85

Table 1Treatment changes for few important skeletal measurements before and at various time intervals after distraction osteogenesis of maxilla.

Parameters Pre-distraction (T0) Immediatepost-distraction (T1)

6-monthspost-distraction (T2)

Long-termpost-distraction (T3)

P-value Comparison

Mean ± SD Mean ± SD Mean ± SD Mean ± SD T0–T1 T0–T2 T0–T3 T1–T2 T1–T3 T2–T3

SNM (◦) 65.16 ± 4.26 78.50 ± 6.85 74.41 ± 4.64 73.33 ± 4.88 .000 *** ** ** NS NS NSPtm–M (mm) 37.32 ± 3.47 49.39 ± 2.94 45.84 ± 2.78 43.77 ± 3.07 .000 *** *** *** * ** NSS–N × M–PNS (◦) 11.75 ± 5.75 6.00 ± 5.98 8.16 ± 4.74 9.41 ± 5.08 .084 NS NS NS NS NS NSSNB (◦) 80.58 ± 5.61 79.66 ± 4.71 79.91 ± 5.07 80.16 ± 5.23 .976 NS NS NS NS NS NSFMA (◦) 27.83 ± 5.52 30.66 ± 5.38 29 ± 4.93 28.44 ± 5.65 .609 NS NS NS NS NS NS

NS = non-significant.

mm((awic(o

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marginally from 141.58◦ to 143.16◦ at T2 and then it was remained

* P < 0.05.** P < 0.01.

*** P < 0.001.

arginally and the changes were not significant. The maxillaoved 12.07 mm forward (Ptm–M) by the distraction osteogenesis

T0–T1, P < 0.001). During first 6-months of post-distraction periodT1–T2), the result was relapsed significantly by 3.55 mm (P < 0.05)nd there after the relapse was very minimum. When the maxillaas moved forward during the distraction osteogenesis, it rotated

n the counterclockwise direction and the change was not signifi-ant. The change in the sagittal and vertical positions of mandible

SNB angle and FMA, respectively) following maxillary distractionsteogenesis was very minimum and comparable.

ig. 2. Cephalometric landmarks and various linear and angular parameters for thevaluation of skeletal changes at various time intervals of maxillary distraction.andmarks. S: Sella; N: Nasion; Po: Porion; Or: Orbitale; M: Centre of the pre-maxilla;tm: Pterygomaxillary fissure; PNS: Posterior nasal spine; Go: Gonion; B: Point-B;e: Menton. Reference planes. SN plane: Line joining ‘S’ and ‘N’; FH plane: Line joining

Po’ and ‘Or’. Linear and angular parameters. 1. SNM: The angle between ‘S’, ‘N’ andM’ points; 2. Ptm–M: Linear distance between the perpendiculars drawn from ‘Ptm’nd ‘M’ points on FH plane; 3. S–N × M–PNS: The angle between SN plane and palatallane (M–PNS); 4. SNB: The angle between ‘S’, ‘N’ and ‘B’ points; 5. FMA: The angleetween FH plane and Mandibular plane (Go–Me).

The results of all the soft tissue cephalometric measurementsare described in Table 2. The predistraction (T0) value of soft tissueprofile (n–sn–pg) was improved significantly (P < 0.001) by 19.08◦

at T1 but the improvement was relapsed by 5.34◦ at T2 and in theperiod between T2 and T3, the relapse was only 1.25◦. The total softtissue profile (n–no–pg) was reduced significantly (P < 0.001) frompredistraction (T0) value of 152.75◦ to 141.58◦ at T1 and increased

almost stable. The nasolabial angle (no–sn–ls) was increased signif-icantly (P < 0.001) from the T0 value of 77.58◦ to T1 value of 103.41◦

and during T1 to T2 it was reduced from 103.41◦ to 96.25◦ and

Fig. 3. Cephalometric landmarks and various angular parameters for the evaluationof soft tissue changes at various time intervals of maxillary distraction osteogene-sis. Landmarks: n: soft tissue nasion; no: tip of the nose; sn: subnasal; ls: labralesuperius; li: labrale inferus; si: sulcus inferius; pg: soft tissue pogonion. Angularparameters: 1. n–sn–pg: The angle between ‘n’, ‘sn’ and ‘pg’ points, it represents thesoft tissue profile of the face; 2. n–no–pg: The angle between ‘n’, ‘no’ and ‘pg’ points,it represents the total soft tissue profile of the face; 3. no–sn–ls: The angle between‘no’, ‘sn’ and ‘ls’ points, it represents the nasolabial angle; 4. li–si–pg: The anglebetween ‘li’, ‘si’ and ‘pg’ points, it represents the mentolabial sulcus; 5. n–no × n–pg:The angle between lines joining ‘n’ and ‘no’ points and ‘n’ and ‘pg’ points, it representsthe projection of nose.

A.K. Jena et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 80–85 83

Table 2Treatment changes for all soft tissue measurements before and at various time intervals after distraction osteogenesis of maxilla.

Parameters Pre-distraction(T0)

Immediatepost-distraction (T1)

6-monthspost-distraction (T2)

Long termpost-distraction (T3)

P-value Comparison

Mean ± SD Mean ± SD Mean ± SD Mean ± SD T0–T1 T0–T2 T0–T3 T1–T2 T1–T3 T2–T3

n–sn–pg (◦) −5.58 ± 8.57 13.50 ± 5.82 8.16 ± 7.06 6.91 ± 8.54 .000 *** ** ** NS NS NSn–no–pg (◦) 152.75 ± 5.94 141.58 ± 5.10 143.16 ± 5.78 143.00 ± 5.06 .000 *** ** ** NS NS NSno–sn–ls (◦) 77.58 ± 16.58 103.41 ± 9.62 96.25 ± 8.19 94.83 ± 8.48 .000 *** ** ** NS NS NSli–si–pg (◦) 132.08 ± 14.76 130.08 ± 16.00 130.75 ± 16.12 130.33 ± 15.16 .989 NS NS NS NS NS NSn–no × n–pg (◦) 14.50 ± 3.50 22.50 ± 3.03 19.91 ± 2.96 20.00 ± 2.79 .000 *** ** ** NS NS NSNper–no (mm) 21.02 ± 4.50 27.96 ± 4.00 26.23 ± 3.57 25.71 ± 3.96 .001 ** * NS NS NS NSNper–sn (mm) 3.97 ± 3.84 13.73 ± 4.89 10.78 ± 3.63 9.32 ± 3.95 .000 *** ** * NS NS NSsn–sts (mm) 16.42 ± 3.02 20.64 ± 2.69 19.69 ± 2.46 19.52 ± 2.53 .003 ** * NS NS NS NSls–LUI (mm) 16.22 ± 4.68 10.82 ± 2.22 11.58 ± 2.29 11.36 ± 2.24 .000 ** ** ** NS NS NSsti–me (mm) 52.53 ± 4.58 53.14 ± 4.78 52.68 ± 4.46 52.66 ± 4.62 .989 NS NS NS NS NS NSli–LLI (mm) 17.11 ± 2.65 18.21 ± 2.52 17.79 ± 1.81 17.64 ± 1.80 .692 NS NS NS NS NS NSPog–pg (mm) 11.13 ± 2.14 11.08 ± 2.58 11.27 ± 2.66 11.16 ± 1.74 .998 NS NS NS NS NS NS

NS = Non-significant.* P < 0.05.

** P < 0.01.*** P < 0.001.

Fig. 4. Cephalometric landmarks and various linear parameters for the evaluationof soft tissue changes at various time intervals of maxillary distraction osteogenesis.Landmarks: N: Nasion; Po: Porion; Or: Orbitale; no: tip of the nose; sn: subnasal; ls:labrale superius; sts: stomium superius; sti: stomium inferius; li: labrale inferus; pg:soft tissue pogonion; me: soft tissue menton; LUI: labial surface of upper incisor; LLI:labial surface of lower incisor; Pog: Pogonion. Reference plane. Nasion perpendicular(Nper): It is the perpendicular plane on FH plane at ‘N’ point. Linear parameters: 1.Nper–no: Smallest linear distance from ‘no’ point to Nasion perpendicular plane; 2.Nper–sn: Smallest linear distance from ‘sn’ point to Nasion perpendicular plane; 3.sn–sts: Linear distance between the perpendiculars drawn from ‘sn’ and ‘sts’ pointson Nasion perpendicular plane, it represents the upper lip length; 4. ls–LUI: Lineardistance between ‘ls’ and ‘LUI’ points, it represents the thickness of upper lip; 5.sti–me: Linear distance between the perpendiculars drawn from ‘sti’ and ‘me’ pointson Nasion perpendicular plane, it represents the length of lower lip; 6. li–LLI: Lineardistance between ‘li’ and ‘LLI’ points, it represents the thickness of lower lip; 7.Pog–pg: Linear distance between ‘Pog’ and ‘pg’ points, it represents the thickness ofsoft tissue chin.

during T2 to T3 it was reduced marginally from 98.25◦ to 94.83◦.The value of mentolabial angle (li–si–pg) was comparable at T0,T1, T2 and T3. The T0 value of nasal protrusion (n–no × n–pg) wasincreased significantly at T1 (P < 0.001), at T2 (P < 0.01) and at T3(P < 0.01). The T0 value of Nper–no was increased by 6.94 mm atT1, and the T1 value was decreased by 1.73 mm and 0.52 mm at T2and T3, respectively. However, the T1 and T3 values of Nper–no dis-tance were comparable to each other. The base of the nose (subnasalpoint) was moved 9.76 mm forward from Nasion perpendicular(Nper–sn) at T1 and was relapsed by 2.95 mm at T2. However dur-ing T2 and T3 period, the base of nose was moved only 1.42 mmbackward. The length of upper lip (sn–sts) was increased signifi-cantly at T1 and T2. However the value of upper lip length at T3 wascomparable to that of value at T0. The upper lip thickness (ls–LUI)was reduced by 5.40 mm following immediate maxillary distrac-tion osteogenesis (T1), and the T1 value was increased marginally atT2 and T3. The change in lower lip length (sti–me), lower lip thick-ness (li–LLI) and thickness of soft tissue chin (Pog–pg) at varioustime intervals of maxillary distraction osteogenesis were compa-rable and were not significant statistically.

4. Discussion

As the maxilla advances forward by the distraction osteogenesis,a simultaneous soft tissue expansion is observed and the skin, fatand muscles have more favorable distribution around the mouth[16]. Also the position of the lips, teeth and tongue are in a bet-ter relation [16]. The improvement of the soft tissue profile of themidface in subjects with cleft lip and palate is better following max-illary distraction than advancement of the maxilla by conventionalmaxillary osteotomies [6]. The present study also showed signifi-cant improvement in the soft tissue relationship after immediate,6-months and 2-years of maxillary distraction osteogenesis.

4.1. Soft tissue profile

The soft tissue profile (n–sn–pg) was improved from concavityto the convexity. The total soft tissue profile angle (n–no–pg) wasalso improved from near flat to more convex. The forward move-ment of the tip of nose, base of the nose and upper lip secondaryto advancement of maxilla caused improvements in the soft tissue

profile. Ko et al. reported 15.59◦ reductions in the facial concavityafter 6.99 mm advancement of maxilla in adult cleft patients [7].However in our study we found 19.08◦ improvement in the facialconcavity by 12.07 mm advancement of the maxilla and of total

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4 A.K. Jena et al. / Journal of Oral and Maxillofacia

mprovement, 12.49◦ was remained stable till the end of 2-yearsf maxillary distraction. The relapse in the movement of maxilla5.62 mm) during post distraction period could be responsible foruch relapse.

.2. Nose

The improvements in the positions of the nose and upperip following maxillary distraction osteogenesis in cleft lip andalate subjects have been discussed in the literature [6,7,16]. Theasolabial angle (no–sn–Is) in the present study was increased by5.83◦ after immediate distraction of the maxilla, and was relapsedy 7.16◦ during first 6-months of post-distraction period. Howeverfter 6-months of distraction there was only 1.42◦ relapse in theasolabial angle. The improvement of the nasolabial angle was dueo the forward movement of the base of the nose, downward andorward movement of the upper lip and forward and upward move-

ent of the nasal tip by the maxillary distraction. Previous studieslso reported improvements in the nasolabial angle following max-llary distraction osteogenesis [6,16]. Ko et al. [7] found only 4.96◦

mprovements in the nasolabial angle following 6.99 mm maxil-ary advancement in adult subjects with cleft lip and palate. Theetter improvement of the nasolabial angle in the present studyould be due to more forward movement of the nasomaxillary com-lex. We also observed significant improvement in the projectionf the nose (n–no × n–pg) after maxillary distraction. The forwardovement of the nasal tip caused significant improvement in the

rojection of the nose. The tip of the nose (no) was moved 6.94 mmfter immediate maxillary distraction and remained 5.21 mm and.69 mm forward at the end of 6-months and 2-years of maxil-

ary distraction. The 12.07 mm forward movement of the maxillaPtm–M distance) caused 6.94 mm forward movement of the nasalip. However in contrast to the present study, Ko et al. [7] noted.58 mm forward movement of the nasal tip following 6.96 mmdvancement of the maxilla. The ratio of the forward movementf the nasal tip to the forward movement of the maxilla was lessn our study as compared to the previous study done by Ko et al.7]. The more the maxilla advances, the more the tension of the

id-facial soft tissue overlying the advanced maxilla increases inhe cleft subjects with scar bands in the upper lip. Therefore the

ore the maxilla advances, the more the anterior movement ratioor the mid-facial soft tissue of the maxilla and nose seems to drop.lso the advancement ratio of soft tissue to hard tissue is negativelyorrelated with the age of the patient [7]. The anterior movementatio of the nasal tip to the maxilla was approximately 1:2 in ourtudy. Ko et al. [7] also reported almost similar anterior movementatio of the nasal tip in relation to the maxilla after maxillary dis-raction. However following maxillary advancement by Le Fort-Isteotomy, the movement ratio of nasal tip to maxillary base waseported as 1:3 in cleft patients and 1:4 in non-cleft patients [17].ui et al. [18] reported the ratios of horizontal nasal tip, nasal basend lip movement to underlying hard tissue movement as approx-

mately one fourth, one half and two-third, respectively following

axillary advancement by maxillary osteotomies in cleft lip andalate patients. As marked retrusion and retroclined configurationf the nose are the characteristic in cleft lip and palate patients

able 3nterior movement ratio of the nasal tip and nasal base to the forward movement of thalate.

Year Authors Surgical Technique Anteriornose to m

Present study Distraction 85%2000 Ko et al. [7] Distraction 96%1994 Hui et al. [18] Le Fort-I Osteotomy 50%1977 Freihofer [17] Le Fort-I Osteotomy –

ery, Medicine, and Pathology 24 (2012) 80–85

[19,20], forward movement of the nose following maxillary dis-traction improved the facial esthetics in subjects with cleft lip andpalate. As compared to the tip of nose, the base of the nose wasadvanced more in the present study. As the base of the nose wasfree to move anteriorly then the whole nose, advancement of themaxilla was resulted more forward movement of the nasal base ascomparison to the nasal tip. We found 9.76 mm forward movementof the nasal base after 12.07 mm forward movement of the maxilla.The anterior movement ratio of base of the nose (sn) to the forwardmovement of maxilla was 0.85:1 at immediate after distraction,0.56:1 at 6-months after maxillary distraction and 0.44:1 at after2-years of maxillary distraction. Ko et al. [7] however reported bet-ter movement ratio as 96% after immediate maxillary distractionin growing subjects of cleft lip and palate. The anterior movementratio of the nasal tip and nasal base to the forward movement ofthe maxilla following various surgical procedures as reported bythe various authors is summarized in Table 3.

4.3. Lips

In the present study, we noted 4.22 mm and 3.10 mm lengthen-ing of the upper lip (sn–sts) after immediate and 2-years of max-illary distraction. When the maxilla moved forward, the inelasticlip and nasal base scar prevented the tissue from displacing later-ally and thus resulted lengthening and advancement of the upperlip [17,21]. In growing subjects with cleft lip and palate, maxillarydistraction osteogenesis also resulted large increase in the sub-nasal length (sn–st) [6]. In the present study, the upper lip becamethinner after maxillary distraction. We found significant decreasein the upper lip thickness following immediate and 2-years aftermaxillary distraction osteogenesis in adult subjects with cleft lipand palate. The reduction in the thickness of the upper lip wasexplained by the fact that in cases with large negative overjet anddeep overbite, the lower lip and lower incisors support the upperlip, and might give false image of the thickness of pre-distractionupper lip [21]. Ko et al. [7] reported 1.2 mm decrease of upper lipthickness and the curvature became flattened after 6.99 mm max-illary advancement in growing cleft lip and palate patients. Thepredistraction upper lip thickness has also an effect on the post-distraction change [7]. The thick upper lips shows more changethan the thin lips as the thin lips are compressed less by the surgerythan thick lips [22,23]. Other individual variables such as initial lipstrain, muscle tonicity, lip thickness, racial characteristics, scarringand cleft type also should be considered when analyzing lip formand posture because they may modify the soft tissue response to thechange of the underlying hard tissue. Timing of observation is alsoimportant factor affecting the interpretation of soft tissue response.Several studies have suggested that the soft tissue attain definitiveform after 6th postoperative month [17,21,24]. The present studyshowed no significant change in the thickness and length of thelower lip, chin and change in the mentolabial sulcus following max-

illary distraction osteogenesis in adult cleft lip and palate subjects.This could be because of lack of active tissue growth in the stud-ied subjects. However according to Ko et al. [7] advancement of themaxilla in growing subjects with cleft lip and palate had a secondary

e maxilla following various surgical procedures among subjects with cleft lip and

movement ratio of base of theaxilla

Anterior movement ratio of tip of thenose to maxilla

57.49%65.80%25%33%

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A.K. Jena et al. / Journal of Oral and Maxillofacia

ffect on the lower lip, characterized by protrusion of the lower lipermilion border and increase in lower lip sulcus and curvature.

Thus the present study showed that distraction osteogenesis byustom made distractor was an efficient method for the advance-ent of maxilla and the improvement of midfacial soft tissue in

dult subjects of cleft lip and palate. However during first 6-monthsf post-distraction period large amount of relapse occurred. Over-orrection of 25% and prolonged retention were essential for theong-term stability of changes when the maxillary distraction wasarried out in adult subjects with cleft lip and palate.

. Conclusions

The following conclusions were drawn from the present study:

. Distraction osteogenesis of the maxilla in adult subjects withcleft lip and palate improved the soft tissue profile by increas-ing the prominence of nose, moving the upper lip forward andnormalizing the nasolabial angle.

. Approximately 75% of the changes were remained stable at theend of 2-years of follow-up of maxillary distraction osteogenesis.

. Overcorrection of 25% and prolonged retention were essential forthe long-term stability of changes when the maxillary distractionwas carried out in adult subjects with cleft lip and palate.

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[4] Figueroa AA, Polley JW. Management of severe maxillary deficiency with dis-traction osteogenesis: Procedure and results. Am J Orthod Dentofacial Orthop1999;115:1–12.

[5] Huang CS, Harikrishnan P, Liao YF, Ko EWC, Liou EJW, Chen PKT. Long-termfollow-up after maxillary distraction osteogenesis in growing children withcleft lip and palate. Cleft Palate Craniofac J 2007;44:274–7.

[6] Harada K, Baba Y, Ohyama K, Omura K. Soft tissue profile changes of themidface in patients with cleft lip and palate following maxillary distraction

[

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10] Aksu M, Saglam-Aydinatay B, Akcan CA, El H, Taner T, Kocadereli I, et al. Skeletaland dental stability after maxillary distraction with a rigid external device inadult cleft lip and palate patients. J Oral Maxillofac Surg 2010;68:254–9.

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