Cleft Lip and Palate - part 7 docx

Case 5. A complete bilateral cleft and protruding pre-
maxilla is shown preoperatively (Fig. 22.5). Treatment
consisted of presurgical maxillary orthopedics (Lath-
am), followed by bilateral GPPs and lip and nose cor-
rection at 6months of age. The columellar lengthen-
ing was accomplished by wide dissection of nasal skin
from the alar cartilages, removal of intercrural fat,and
bilateral McComb sutures. Multiple vestibular efface-
ment sutures were passed, and a nasal stent was main-
tained for the first postoperative week. The patient is
shown at 18months of age, before closure of the
palatal cleft.
Case 6. A very wide complete bilateral cleft of the lip
and palate with a projecting premaxilla and very wide
alveolar clefts. Initially treated with presurgical max-
illary orthopedics (Fig. 22.6) in preparation for the
first surgery where the patient underwent a GPP, clo-
sure of the alveolar clefts and closure of the anterior
palate.One year later,the patient underwent closure of
bilateral cleft palate and revision of the lip and nose
using the McComb technique, which is shown. The
patient is shown postoperatively 2 months after the
final procedure.
468
S.A.Wolfe · R. Ghurani · M. Mejia
Fig. 22.5 a–f.
a
d
e
f
bc

Chapter 22
Surgical Treatment of Clefts of the Lip 469
Fig. 22.6 a–k.
a
d
g
hi
ef
bc
Case 7. This patient had primary closure from anoth-
er surgeon of her incomplete bilateral cleft of the lip
using a standard bilateral technique. As the photo-
graphs show (Fig. 22.7), she did not have a Cupid’s
bow, with a fairly tight upper lip and lacking nasal
projection. The patient underwent an iliac bone graft
to the right alveolar cleft, an Abbe flap, and a cleft lip
rhinoplasty which redefined her Cupid’s bow,gave her
more nasal tip projection, and a fuller upper lip.
Case 8. A bilateral cleft lip was corrected in another
country. The preoperative pictures show the patient
following a radial forearm flap performed for a very
large palatal defect following orthodontic alignment
of the premaxilla (Fig. 22.8). The operative pictures
show the fabrication of a complete new alar cartilage
framework overlying the native alar cartilages, with a
columellar strut and spreader grafts (both septal and
conchal cartilage was used). There was no reduction
of the nasal dorsum.A dermal fat graft was also placed
in the central portion of the upper lip.The postopera-
tive pictures were taken at 18months.

Case 9. This patient had previous repair of a bilateral
complete cleft lip by Dr. Millard and had a columellar
elongation with a forked-flap.Patient remained with a
slumping of the nasal tip,and irregularities of the alar
cartilages (Fig. 22.9). Patient underwent a cleft lip
rhinoplasty. This improved his tip projection which
involved reconstruction and augmentation of the alar
cartilages. The patient is shown 7 months postopera-
tively.
Case 10. This 6-year-old child underwent one previ-
ous palatal operation in Cuba, and two subsequent
procedures were performed in this country,leading to
loss of all palatal tissue from the hard-soft palate junc-
tion to the alveolar ridge. A radial forearm flap was
performed along with a lip revision, opening the
poorly repaired lip completely and thereby avoiding
any other cutaneous incision (Fig. 22.10). The proce-
dure was uneventful and the flap had excellent perfu-
sion.
470
S.A.Wolfe · R. Ghurani · M. Mejia
Fig. 22.6 a–k.(continued)
j
k
Chapter 22
Surgical Treatment of Clefts of the Lip 471
Fig. 22.7 a–g.
abc
ed
g

f
472
S.A.Wolfe · R. Ghurani · M. Mejia
Fig. 22.8 a–h.
abc
d
fgh
e
Chapter 22
Surgical Treatment of Clefts of the Lip 473
Fig. 22.9 a–j.
b
e
a
f
i
j
h
g
c
d
474
S.A.Wolfe · R. Ghurani · M. Mejia
Fig. 22.10 a–g.
a
de
bc
fg
References
1. Bromley GS, Rothaus KO, Goulian D Jr. Cleft lip: morbidity

and mortality in early repair. Ann Plast Surg 1983;
10(3):214–217.
2. Latham RA. Orthopedic advancement of the cleft maxil-
lary segment: a preliminary report. Cleft Palate J 1980;
17(3):227–233.
3. Berkowitz S,Mejia M,Bystrik A.A comparison of the effects
of the Latham-Millard procedure with those of a conserva-
tive treatment approach for dental occlusion and facial aes-
thetics in unilateral and bilateral complete cleft lip and
palate: part I. Dental occlusion. Plast Reconstr Surg 2004;
113(1):1–18.
4. Pfeifer TM,Grayson BH, Cutting CB. Nasoalveolar molding
and gingivoperiosteoplasty versus alveolar bone graft: an
outcome analysis of costs in the treatment of unilateral cleft
alveolus. Cleft Palate Craniofac J 2002; 39(1):26–29.
5. Rosenstein SW, Dabo DV. Primary bone grafting. Presented
at the 61st Annual Meeting and Pre-Conference Sympo-
sium of the American Cleft Palate/Craniofacial Association.
Mar.15,2004.
6. McComb H. Primary correction of unilateral cleft lip nasal
deformity: a 10-year review. Plast Reconstr Surg 1985;
75(6):791–799.
7. Millard DR, Jr. Cleft craft.Vol.I.Boston: Little,Brown; 1976.
p.264.
8. Millard DR Jr.Cleft craft.Vol. II.Boston: Little,Brown; 1975.
p.373–374.
9. Berkowitz S. Timing of palatal closure should not be based
on age alone.Cleft Palate J 1986; 23(1):69–70.
10. Bardach J, Salyer K. Surgical techniques in cleft lip and
palate surgery. Chicago: Year Book Medical Publishers;

1986.
11. Furlow LT,Jr.Flaps for cleft lip and palate surgery.Clin Plast
Surg 1990; 17(4):633–644.
12. Cordeiro PG,Wolfe SA. The temporalis muscle flap revisit-
ed on its centennial: advantages,newer uses,and disadvan-
tages. Plast Reconstr Surg 1996; 98(6)980–987.
13. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral
flap: facial artery musculomuccosal (FAMM) flap. Plast
Reconstr Surg 1992; 90(3):421–429.
14. Marshall D, Amjad I,Wolfe SA. The use of a radial forearm
flap for deep central midfacial defects. Plast Reconstr Surg
2003; 111:56–64.
15. Wolfe SA, Berkowitz S. Orthodontic analysis and treatment
planning in patients with craniofacial anomalies. In Plastic
surgery of the facial skeleton. Boston: Little,Brown; 1989.
16. Nylen B, Korlor B, Arnander C, Leanderson R, Barr B,
Nordin KK. Primary early bone grafting in complete clefts
of the lip and palate. Scand J Plast Reconstr Surg 1974; 8:79.
17. Millard DR Jr, McLaughlin CA.Abbe flap on mucosal pedi-
cle.Ann Plast Surg 1979; 3(6):544–548.
18. Polley JW, Figueroa AA. Maxillary distraction osteogenesis
with rigid external distraction. Atlas Oral Maxillofac Surg
Clin North Am 1999; (1):15–28.
19. Limberg, A. Neue Wege in der radikalen Uranoplastik bei
angeborenen Spaltenderformationen: Osteotomia inter-
laminaris und pterygomaxillaris, resectio marginis fora-
minis palatini und neue Plaettchennaht. Fissura ossea oc-
culta und ihre Behandlung. Zentralbl Chir 1927; 54:1745.
Chapter 22
Surgical Treatment of Clefts of the Lip 475

23A.1 Protraction of the Maxilla
Using Orthopedics
Children with complete unilateral and bilateral cleft
of the lip and palate are usually at risk for poor facial
growth. They are prone to developing midfacial retru-
sion related to maxillary hypoplasia or growth retar-
dation secondary to excessive palatal scarring. Usual-
ly, this results in an anterior dental crossbite or
severely rotated maxillary incisors which may occlude
in a tip-to-tip relationship with the mandibular inci-
sors. Depending on the age of the patient and the
extent of midfacial maldevelopment, some of these
early problems can be corrected using midfacial or-
thopedic protraction forces which increase growth at
the circumaxillary sutures as they are repositioned
anteriorly (Fig.23A.1). When all else fails, midfacial
surgery is available.
Some of the earlier work in this field, which en-
couraged a rethinking of the use of orthopedic forces
for the correction of midfacial retrusion, includes
Hass [1], Delaire [2], Delaire et al. [3–5, 9], Irie and
Nakamura [6], Ranta [7], Subtelny [8], Friede and
Lennartsson [10], Sarnas and Rune [11], Berkowitz
[12], Tindlund [13], Nanda [14], and Molstad and
Dahl [15].More recently this area has been influenced
by the work of Tindlund et al. [6–18] and Buschang et
al. [19].
Earlier attempts by Kettle and Burnapp [20] in
which anteriorly directed extraoral forces were de-
rived from chin caps were relatively unsuccessful.

Facial mask therapy seems to offer better control and
a wider range of force application.
In many cases, in the mixed dentition, palatal ex-
pansion using fixed orthodontic appliances was
applied simultaneously with protraction to correct a
bilateral crossbite and create a more favorable condi-
tion for midfacial growth and development.
Prior to the use of orthopedic forces, many stan-
dard orthodontic treatments designed to move the
Protraction Facial Mask
Samuel Berkowitz
23A
Fig. 23A.1 a,b. Protraction of the maxillary complex using
orthopedic forces. The maxilla articulates with nine bones: two
of the cranium, the frontal and ethmoid, and seven of the face,
viz., the nasal zygomatic, lacrimal, inferior and nasal concha,
palatine, vomer and its fellow of the opposite side. Sometimes it
articulates with the orbital surface, and sometimes with the
lateral pterygoid plate of the sphenoid. Illustration showing
how protraction forces applied to the maxilla depend on the
disarticulation and growth at all the dependent sutures.(Cour-
tesy of E.Genevoc)
a
b
dentition to correct a Class III malocclusion due to
midfacial retrusion in the absence of mandibular
prognathism failed. Orthodontic forces applied to the
teeth by Class III elastics would not displace the max-
illa; at best they would flare the maxillary incisors
without creating an adequate incisor overbite and ax-

ial inclination. This treatment was found to be unsat-
isfactory and soon fell out of favor.
Since 1975 Berkowitz has been using a modified
protraction facial mask originally popularized by De-
laire et al. [3] (Figs. 23A.2–23A.4). It has been very
successful in controlling the direction of protruding
forces without causing severe sore spots on the chin or
forehead. He has found that protraction forces do not
modify the direction of mandibular growth as Delaire
et al. [3] claimed, but by increasing midfacial height,
the mandible is repositioned downward and back-
ward with growth to make the patient’s maxillary
retrusion appear less evident.
Protraction forces (350–450gm per side) must be
intermittent (the mask is worn only for 12 h perday),
and directed downward and forward from a hook lo-
cated mesial to the maxillary cuspids. Pulling down-
ward from the molars should be avoided because it
will tilt the palatal plane downward in the back by ex-
truding the molars and thus opening the bite. When
the midfacial height is deficient, protraction forces
need to be modified to increase vertical as well as an-
terior growth. This is done by using more vertically
directed elastic forces.
Berkowitz has found 350–450 gm of force per side
to be adequate in most instances,but there are rare in-
stances when the elastic force needs to be reduced to
prevent sore spots at the chin point. Friede and
Lennartsson [10] have used protraction forces be-
tween 150 to 500gm per side. Ire and Nakamura [6]

have used 400gm per side, Roberts and Subtelny [21]
670 gm, Sarnas and Rune [11] 300–800 gm, and Tind-
480
S. Berkowitz
Fig. 23A.2. a Frontal and b lateral views of a Delaire-style pro-
traction facial mask. Padded chin and forehead rests distribute
reaction forces of 350–400 gm per side equally to both areas.
Elastics are attached to hooks placed on the arch wire between
the cuspids and lateral incisor.
c Intraoral view of edgewise rec-
tangular arch with hooks for protraction elastics.
d, e, f Delaire-
style protraction facial mask used with a fixed labial-palatal
wire framework. Elastic forces of 350–400 gm per side can still
be used with this intraoral framework
a
d
bc
ef
lund et al. [16–18] 350 gm per side. Unfortunately,
when performed in the mixed dentition, treatment
time may extend into years because of the need to
keep pace with mandibular growth. If this is the case,
treatment should be divided into intermittent periods
not to exceed 6months at a time with a break for
1 month between periods. Following this formula, the
patient will usually remain cooperative.
Although Berkowitz has been successful in using
strong elastic forces with labile-lingual appliances
during the deciduous dentition, he recommends

starting treatment at 7–8years of age when all of the
maxillary incisors can be bracketed and a rectangular
edgewise arch with lingual root torque used as Subtel-
ny [8] suggested. The torqued rectangular arch will
carry the incisor roots forward, moving skeletal land-
mark point “A” anteriorly, which prevents stripping of
the alveolar crest with subsequent incisor flaring. The
arch wire needs to be tied back so that it does not slide
anteriorly, tipping the incisor, rather than moving the
entire maxilla forward orthopedically.
Chapter 23A
Protraction Facial Mask 481
Fig. 23A.3 a–x. Case BB (WW-62). Maxillary protraction in a
UCLP.
a Complete unilateral cleft lip and palate. b, c Lip and
nose after surgery.
d Cuspid crossbite of the lateral cleft seg-
ment at 5 years of age due to mesioangular rotation of the
palatal segment.
e Buccal occlusion after expansion using a
quad helix expander.
f, g 6years of age. Note relapse of cuspid
crossbite due to failure of using a palatal arch retainer.
h Palatal
view showing good arch form
a
b
c
fgh
de

482
S. Berkowitz
Fig. 23A.3 a–x. (continued) i, j Facial photographs at 8 years.
k Orthodontic alignment of incisors prior to secondary alveo-
lar bone graft.
l Protraction facial mask with elastics.m, n Class
III elastics used to maintain tension at circumaxillary suture
during the time not wearing protraction forces.
o Occlusion
after orthopedic-orthodontic forces. Lateral incisor space re-
gained.
p Removal retainer with lateral incisor pontic
i
ln
op
m
j
k
Chapter 23A
Protraction Facial Mask 483
Fig. 23A.3 a–x.(continued) q,r Fixed bridge at 18years of age replacing missing lateral incisor and stabilizing maxillary arch form.
s, t, u 17 years prior to nose-lip revision. v, w, x Facial photos at 19 years, showing good facial symmetry after revision
qr
st
w
u
v x
Tindlund et al. [16–18] conclude that early trans-
verse expansion of the maxilla together with protrac-
tion orthodontic treatment is an effective method for

normalizing maxillo-mandibular discrepancies in
cleft lip and palate patients. The average age at the
start of treatment was 6 years, 11 months, and the av-
erage duration of treatment was 13months. Signifi-
cant changes were achieved due to anterior movement
of the upper jaw and a more posterior positioning of
the lower jaw resulting from clockwise mandibular
rotation.
Berkowitz also found that the combined use of
palatal expansion and protraction forces before the
pubertal growth spurt to be a more efficient means of
gaining orthopedic advancement than the use of pro-
traction forces alone.He speculates that the expansion
forces possibly disarticulate the circumaxillary su-
tures, thus allowing the maxillary complex to be car-
ried downward and forward more easily.
Delaire et al. [5] and Subtelny [8] have stated that
orthopedic forces applied to the entire maxillary com-
plex are more likely to be effective in younger chil-
dren.
Berkowitz’s clinical experience supports the rec-
ommendation by Abyholm et al. [22] and Bergland et
al. [23] (1) that a rigid fixation of the advanced maxil-
la should be maintained for at least 3 months after
bone grafting, and (2) the use of protraction forces.
This is necessary to help reduce the tendency to re-
lapse created by the surrounding soft tissue of the lip,
muscles, and skin.
Many patients with a complete bilateral cleft lip
and palate have a protruding premaxilla until 10 years

of age or older, but after the postnatal mandibular
growth spurt, the maxillary incisor teeth may be in
crossbite. Protraction orthopedic forces with anterior
criss-cross elastics upright and reposition the pre-
maxilla forward, perhaps by inducing bone growth at
the premaxillary-vomerine suture. Fixed retention is
always necessary to control the improved incisal over-
bite–overjet relationship at least until secondary alve-
olar bone grafting is done.
484
S. Berkowitz
a
b
Fig. 23A.4.
Case BB (WW-62) a Lateral cephalometric tracings
and superimposed polygons (Basion Horizontal Method) for
Case BB (WW-62) show an excellent facial growth pattern.
b The midfacial growth increment between 15 to 16-4,when the
protraction facial mast was used, increased midfacial protru-
sion to a greater degree than that which would have occurred
normally
References
1. Haas AJ. Palatal expansion: just the beginning of dentofa-
cial orthopedics.Am J Orthod 1970; 57:219–255.
2. Delaire J. Considerations sur la croissance faciale (en parti-
culier du maxillaire superieur): deductions therapeutiques.
Rev Stomatol 1971; 72:57–76.
3. Delaire J, Verdon P, Lumineau J-P, Chierga-Negrea A, Tal-
mant J, Boisson M. Quelques resultats de tractions extra-
orales a appui fronto-mentonnier dans le traitement ortho-

pedique des malformations maxillo-mandibulaires de
classe III et des sequelles osseuses des fentes labio-maxil-
laires. Rev Stomatol 1972; 73:633–642.
4. Delaire J, Verdon P, Kenesi MC. Extraorale Zugkraften mit
Stirn-Kinn-Abstutzung zur Behandlung der Oberkieferde-
formierungen als Folge von Lippen-Kiefer-Gaumenspalten.
Fortschr Kieferorthop 1973; 34:225–237.
5. Delaire J,Verdon P,Flour J.Ziele und Ergebnisse extraoraler
Zuge in postero-anteriorer Richtung in Anwendung einer
orthopädischen Maske bei der Behandlung von Fallen der
Klasse III. Fortschr Kieferorthop 1976; 37:247–262.
6. Irie M,Nakamura S.Orthopedic approach to severe skeletal
Class III malocclusion.Am J Orthod 1974; 67:375–377.
7. Ranta R. Protraction of cleft maxilla. Eur J Orthod 1988;
10:215–222.
8. Subtelny JD. Oral respiration: facial maldevelopment and
corrective dentofacial orthopedics. Angle Orthod 1980;
50:147–164.
9. Delaire J,Verdon P, Flour J. Moglichkeiten und Grenzen ex-
traoraler Krafte in postero-anteriorer Richtung unter Ver-
wendung der orthopädischen Maske. Forttschr Kiefer-
orthop 1978; 39:27–40.
10. Friede H, Lennartsson B. Forward traction of the maxilla in
cleft lip and palate patients. Eur J Orthod 1981; 3:21–39.
11. Sarnas K-V, 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.
12. Berkowitz S. Some questions, a few answers in maxilla-
mandibular surgery.Clin Plast Surg 1982; 9:603–633.

13. Tindlund RS.Orthopaedic protraction of the midface in the
deciduous dentition: results covering 3 years out of treat-
ment. J Craniomaxillofac Surg 1989; 17(Suppl. 1):17–19.
14. Nanda R. Differential response of midfacial sutures and
bones to anteriorly directed extraoral forces in monkeys. J
Dent Res 1978; 57:362.
15. Molstad K,Dahl E.Face mask therapy in children with cleft
lip and palate. Eur J Orthod 1987; 9:3211–3215.
16. Tindlund RS, Rygh P. Maxillary protraction: different ef-
fects on facial morphology in unilateral and bilateral cleft
lip and palate patients. Cleft Palate Crainofac J 1993;
30:208–221.
17. Tindlund RS,Rygh P,Boe OE.Orthopedic protraction of the
upper jaw in cleft lip and palate patents during the decidu-
ous and mixed dentition in comparison with normal
growth and development. Cleft Palate Craniofac J 1993a;
39:182–194.
18. Tindlund RS, Rygh P, Boe OE. Intercanine widening and
sagittal effect of maxillary transverse expansion in patients
with cleft lip and palate during the deciduous and mixed
dentitions. Cleft Palate Craniofac J 1933b; 30:195–207.
19. Buschang PH, Porter C, Genecov E, Genecov D. Face mask
therapy of preadolescents with unilateral cleft lip and
palate.Angle Orthod 1994; 64:145–150.
20. Kettle MA, Burnapp DR. Occipito-mental anchorage in the
orthodontic treatment of dental deformities due to cleft lip
and palate. Br Dent J 1955; 989:11–14.
21. Roberts CA, Subtelny JD. Use of the face mask in the treat-
ment of maxillary skeletal retrusion. Am J Orthod Dento-
facial Orthod 1988; 93:388–394.

22. Abyholm FE,Bergland O, Semb G.Secondary bone grafting
of alveolar clefts: a surgical/orthodontic treatment en-
abling a non-prosthodontic rehabilitation in cleft lip and
palate patients. Scand J Reconstr Surg 1981; 15:127.
23. Bergland O, Semb G, Abydholm F, Borchgrevink H, Eske-
land G. Secondary bone grafting and orthodontic treat-
ment on patients with bilateral complete clefts of the lip
and palate.Ann Plast Surg 1986; 17:460–471.
Chapter 23A
Protraction Facial Mask 485
23B.1 Early Rehabilitation
Optimal rehabilitation of a child with cleft lip and
palate (CLP) involves the achievement of ideal speech,
facial aesthetics, and dental occlusion. Dentofacial ap-
pearance is of major importance for the development
of a child’s self-esteem [1–3]. Early adolescence is a
time of change and uncertainty and a period of spe-
cial importance because negative self-esteem devel-
oped in these years is likely to be retained into adult-
hood [4, 5]. Therefore, early rehabilitation is of major
importance.
Obtaining an optimal treatment result in complete
clefts of the lip and palate is dependent on the prevail-
ing treatment philosophy,clinical skills,and the inter-
action of the Cleft Lip and Palate (CLP)/Craniofacial
Team. The orthodontist is mainly concerned with the
achievement of normal long-term facial growth and
development, based on his or her ability to recognize,
prevent,and treat dentofacial anomalies.
Quality assurance and the cost-effectiveness ratio

are important factors that need to be considered in the
systematic delivery of health care. Quality assurance
focuses on the achievement of the goals and the qual-
ity of overall team management based on the usage of
accepted physiological principles. Treatment results
are not always predictable because patients differ in
their facial growth patterns and the nature of the
palatal defect, requiring individualized orthodontic
treatment plans depending on the developing maloc-
clusion. This philosophy is at variance with the gener-
ally held orthodontic strategy,which is to postpone all
orthodontic intervention until the permanent denti-
tion [6]. The relative low cost of utilizing interceptive
orthopedics at an early age, due to the need for infre-
quent visits with uncomplicated mechanics, is a rea-
sonable option for the early improvement of dentofa-
cial appearance. An additional bonus to performing
treatment at this period is that patients develop a pos-
itive attitude toward themselves and parents to their
child’s future status.
The specific aim of this chapter is to present a CLP
treatment program that incorporates interceptive or-
thopedics in faces with midfacial retrusion and
demonstrate how a fixed orthopedic-orthodontic ap-
pliance system may be used for both transverse
widening as well as the protraction of the maxilla. In-
terceptive orthopedics is discussed with respect to
treatment timing and anticipated clinical results, re-
viewing the limitations, and criteria necessary in case
selection to improve long-term prognosis.

23B.2 Midfacial Retrusion
in CLP Patients
Irrespective of the method used in primary cleft re-
pair and the surgical skill of the operator, a certain
number of patients will show an unfavorable growth
pattern. Even if one plastic surgeon performs all sur-
gery utilizing the same procedures, and the same
treatment protocol, individual outcomes may vary
from excellent to unsatisfactory. The variable results
reflect individual differences in craniofacial type and
growth patterns on which the cleft maxilla is superim-
posed.Also, one needs to consider acquired variables,
such as the degree of prenatal maxillary hypoplasia
and facial asymmetry in cleft embryo-pathogenesis
and detrimental growth deviations related to the sur-
gical procedure and skill of the surgeon.
Midfacial retrusion may be due to underdevelop-
ment and/or relative posterior positioning of the up-
per jaw to the mandible. The maxillary growth defi-
ciency usually is three-dimensional, resulting in a
shortening of maxillary length and a decrease in
width and height. Midfacial retrusion is more often
seen in unilateral cleft lip and palate (UCLP) patients
[7–11] whereas in bilateral cleft lip and palate (BCLP)
Protraction Facial Mask for the Correction
of Midfacial Retrusion: The Bergen Rationale
Rolf S. Tindlund
23B
the initially prominent premaxilla become less pro-
trusive over time, achieving an almost ideal incisor

overjet–overbite relationship by the late teenage years
[12].
Patients with an underdeveloped maxilla,which re-
sults in skeletal and/or dentoalveolar discrepancies,
often show anterior and/or posterior crossbites with a
concave soft-tissue profile. Since 1977 the treatment
protocol of Bergen Cleft Palate–Craniofacial Center
has included an interceptive orthopedic treatment
phase designed to correct anterior and posterior
crossbites during the deciduous and early mixed den-
tition and to obtain optimal alveolar cleft space to en-
hance tooth eruption and alveolar development. This
would ultimately lead to a favorable functional dental
occlusion and create better conditions for attaining
normal midfacial growth and development [9–11,
13–19].
23B.2.1 Anterior Crossbite
Anterior crossbite (incidence about 3%–5% in Scan-
dinavia) may be found in all facial types – prognathic,
orthognathic,and retrognathic – in combination with
varying degrees of hypo- or hyperplasia of the jaws.
Different sagittal skeletal jaw configurations, some
with deep or skeletal open bite may be associated with
excessive dentoalveolar mandibular proclination or
maxillary retroclination along with the lack of suffi-
cient dental space in the upper arch. Guyer et al. [20]
found skeletal maxillary retrusion in two thirds of
noncleft Class III children.This is of great therapeutic
interest since orthopedic influence seems to be more
effective in influencing the sutures of the maxillary

complex than in restraining mandibular growth
[9–11,14–17,21–25].However,the long-term differen-
tial diagnosis between mandibular excess and maxil-
lary retrusion is difficult to determine before puberty
[20, 26–30]. For this reason, children with the appear-
ance of midfacial retrusion and anterior crossbite
may benefit from an early interceptive orthopedic
treatment phase.The need for orthognathic surgery is
usually determined after puberty, taking facial ap-
pearance as well as dental occlusion into considera-
tion. A family anamnesis of anterior and posterior
crossbite is of particular interest in the CLP popula-
tion because maxillary hypoplasia is a common find-
ing in these patients.
23B.2.2 Orofacial Function
Optimal orofacial function with adequate incisor rela-
tionship in the primary dentition are important deter-
minants for normal growth and development of the
anterior part of the maxilla. There is a generally ac-
cepted belief that form and function are mutually de-
pendent. This interaction in facial clefts is important
because malfunction has been shown to negatively in-
fluence facial growth. Thus, the facial characteristics
of a noncleft child who is a mouth-breather may show
some similarities in appearance to the typical CLP pa-
tient [9, 10]. In CLP, midfacial retrusion due to defi-
cient midfacial growth may be aggravated by in-
creased nasal airway resistance, low and forward
posture of the tongue, and lack of sufficient stimuli
from proper masticatory forces.Early widening of the

upper jaw enhances nasal respiration [31–34], while
permitting the tongue to assumes a more normal ele-
vated position within the mouth [35]. Direction of
eruption and the final position of teeth are closely as-
sociated with the development of the alveolar process,
which in turn is dependent upon the number,size,and
location of teeth [36–38]. Early orthopedic treatment
which includes transverse expansion and anterior
protraction of the maxillary complex will improve the
dimensions of the nasal as well as the intraoral space,
permitting the tongue to elevate and assume a normal
posture within the vault space, thus breaking the
vicious circle of poor function leading to poor form
with growth.
23B.3 Principles of Orthopedic/
Orthodontic Treatment
in CLP Patients
The orthopedic/orthodontic CLP treatment protocol
in Bergen utilized since 1977 is based on selective
periods of active, controlled, efficient treatment fol-
lowed by intervals of fixed retention, as recommend-
ed by American Cleft Palate–Craniofacial Association
in 1993 [39]. The easily obtained acceptance of the
need for patient cooperation along with an excellent
cost/effectiveness assessment ratio support the use of
this philosophy of treatment. The following ortho-
dontic treatment phases should be considered as
viable options for the individual patient:
1. Presurgical maxillary orthopedics (0-3months,
used in a few cases only)

2. Interceptive orthopedics (6–7 years, about 20% of
cleft patients) which involves transverse expansion
and protraction (Facial Mask)
3. Alignment of maxillary incisors prior to secondary
alveolar bone grafting
4. Secondary alveolar bone grafting of the cleft alveo-
lar process
5. Conventional orthodontics in the permanent den-
tition is always necessary
6. Dental adjustments dependent on prosthodontic
or orthognathic surgery needs (17–19 years)
488
S. Berkowitz
Individualizing the timing and sequencing of treat-
ment is essential due to the wide range of skeletal mal-
formation associated with dental malocclusions. It is
of utmost importance to individualize each treatment
plan and to revise this plan at different ages of dental
and skeletal development, all of which is conveniently
based on a diagnosis-related checklist.
23B.3.1 Checklist for CLP Orthopedic/
Orthodontic Treatment Objectives
23B.3.1.1 Presurgical Orthopedics
The plastic surgeon seeks to obtain optimal function
and appearance and avoid the need for extensive revi-
sionary surgery by using proven surgical techniques
that result in a minimum of scarring and palatal
growth impairment. In some cases,presurgical ortho-
pedics can help the plastic surgeon unite anatomical
structures with a minimum of force and stress to the

tissue. Individual decisions are made by the plastic
surgeon.
●
Reposition severely displaced maxillary segments.
●
Reduce width of very wide clefts.
●
Improve symmetry of nose and upper jaw.
(Only used in extreme cases, and in some treat-
ment philosophies this stage is not necessary.)
23B.3.1.2 Interceptive Orthopedics
Transverse expansion followed by anterior protrac-
tion of the upper jaw should only be utilized in cases
with anterior and/or posterior crossbite with mid-
facial retrusion. Treatment should be instituted early
enough to allow the permanent incisors to erupt
spontaneously into a normal overjet and overbite
occlusion (Fig. 23B.1).
●
Eliminate anterior crossbite
●
Eliminate posterior crossbite
●
Create optimal space to permit spontaneous erup-
tion of the incisors
●
Improve nasal respiration
●
Improve tongue placement
23B.3.1.3 Alignment of Maxillary Incisors

In spite of achieving optimal dental space after trans-
verse expansion, the permanent incisors often erupt
rotated and retruded, tipped, or retroclined, placing
them in crossbite. After transverse expansion, align-
ment of the permanent incisors is easily performed,
giving the child a nice dental smile equal to that of his
or her classmates (Fig. 23B.2; in Fig. 23B.1 incisor
alignment was not needed)
●
Straightening of malpositioned incisors
●
Creating an optimal aesthetic incisor relationship
to the facial midline
23B.3.1.4 Secondary Alveolar Bone Grafting
The use of primary periosteoplasty at age 3months
was rejected after introduction of secondary bone
grafting [40]. It is usually performed between 8 and
11 years of age with the orthodontist selecting the ap-
propriate age.
●
Eliminate remaining bony clefts and improve bony
support of contiguous teeth
●
Enhance orthodontic closure of the missing incisor
space in the cleft area
●
Stabilize of separated jaw segments
●
Close oronasal fistulas
●

Provide bony support to alar base in cases with
nasal asymmetry
●
Eliminating mucosal recesses
23B.3.1.5 Conventional Orthodontics
in the Permanent Dentition
The orthodontic treatment goals are similar to the
general orthodontic principles utilized for noncleft
patients: To establish ideal dental function, facial aes-
thetics and speech. Extraction of mandibular teeth to
compensate for a hypoplastic upper jaw is usually not
indicated until after the critical mandibular growth
period has passed. In CLP patients, a bonded palatal
fixed retainer is often necessary after treatment in-
volving arch expansion to avoid relapse of the correct-
ed palatal arch form.
●
Improve the relationship of the lips
●
Achieve harmonious balance of the dentition in the
opposing jaws
●
Achieve favorable skeletal maxillomandibular jaw
relationship
●
Achieve normal incisor overjet and overbite
●
Correct dental axial inclinations
●
Avoid the use of artificial teeth

●
Achieve functional dental occlusion
●
Achieve optimal nasal breathing
Chapter 23B
Protraction Facial Mask for the Correction 489
490
S. Berkowitz
Fig. 23B.1. Complete UCLP, category 2A. (1–2) At birth, Janu-
ary 1975, (3–4) after presurgical orthopedics; (5–6) lip closure
at age 3months; (7–12) at 6years moderate anterior and unilat-
eral posterior crossbites with a slight concave profile; (13–27)
interceptive orthopedics from age 6 years includes transverse
expansion for 3months using a quad-helix, (14) followed by
protraction for 6months using a facial mask,(17–18) and reten-
tion using a fixed palatal archwire (15) to encourage spon-
taneous eruption of upper permanent incisors into normal
position.A nice dental smile was achieved without early ortho-
dontic alignment of the upper incisors; (28–33). Alveolar bone
grafting at 10.5years. Two right upper lateral permanent inci-
sors erupted into the cleft area; (34) Facial profile at 12 years
(35–41); conventional orthodontics at 13.5years lasting for
18 months. The two upper second bicuspids were missing and
the supernumerary right upper lateral permanent incisor was
removed; (42–48) dental occlusion at 18.5 years; (49–50)
cephalometric graphic analysis at 6, after interceptive ortho-
pedics, and at 15, and 18years; (51–53) facial appearance at
15 years; (54–59) facial appearance at 18.5 years
1234
5

910
11
678
Chapter 23B
Protraction Facial Mask for the Correction 491
Fig. 23B.1. (continued)
1312
14 15
16 19
21
17
20
23 24 25
18
22
492
S. Berkowitz
Fig. 23B.1. (continued)
27
28 29 30
31 32 33
34
35
36
26
Chapter 23B
Protraction Facial Mask for the Correction 493
Fig. 23B.1. (continued)
37
40

42
45 46 47
43 44
41
38 39
494
S. Berkowitz
Fig. 23B.1. (continued)
48 49
52 5351
50
54 55 56
57 58 59
23B.3.1.6 Dental Adjustments
at Age 16–17 for Girls,
18–19 years for Boys
In cases with major skeletal jaw discrepancies,orthog-
nathic surgery may be needed to normalize the skele-
tal jaw relationship and achieve a well-balanced facial
appearance with stable dental occlusion. If two or
more teeth are absent in the same dental segment, a
small bridge is normally needed. However, dental
implants are likely to become an important aspect of
future prosthetic replacements.
23B.4 Outline of CLP Treatment
Procedures in Bergen
To appreciate our treatment philosophy, a brief sum-
mary of the treatment approach and concepts of the
Bergen Cleft Palate Center will be presented. Along
with the Oslo CP Center, it serves a population of

5 million. Due to demographic distribution, many
patients must travel distances up to 2,000km to either
center. Hardships are compounded by the need to
travel in very cold weather during winter; therefore,
the planning and coordination of health services are
crucial for optimal utilization of available resources.
Treatment costs and travel expenditures are covered
by the government’s social security program. The
Bergen CLP Team treats about 55 newborn babies
yearly. Treatment procedures are coordinated be-
tween the Department of Plastic and Reconstructive
Surgery, University Hospital of Bergen; the CLP Cen-
ter at the Department of Orthodontics and Facial Or-
thopedics, Faculty of Dentistry, University of Bergen;
and the Eikelund Center for Speech Pathology.
23B.4.1 Plastic Surgery
Since 1986, in complete clefts of the lip and palate, a
Millard lip closure is performed at 3 months com-
bined with a single-layer vomerplasty for closure of
the anterior part of the palate.The soft palate and iso-
lated palatal clefts are closed at 12months using a von
Langenbeck technique. Alveolar bone clefts are left
open until secondary bone grafting at 8–11years of
age. Between 1971 and 1986, the lip closure was com-
bined with a periosteoplasty of the cleft alveolar
process [41].
23B.4.2 Interceptive Orthopedics
23B.4.2.1 Protraction Facial Mask
Extraoral heavy forces from a facial mask directed for-
ward and downward from the maxillary cuspid area

have been shown to correct midfacial retrusion at an
early age [9–11,14–17,18, 19,22,23]. Protraction from
the maxillary cuspid area produces an adequate hori-
zontal and vertical force to increase midfacial vertical
height as well as anteroposterior length. In some in-
stances, it also can reduce an anterior open bite by
lowering the palatal plane. For this reason, early cor-
rection of anterior and/or posterior crossbites during
the deciduous and mixed dentition is highly recom-
mended:
Bergen Rationale:
1. Transverse expansion coupled with
2. Protraction of the upper jaw and
3. The use of fixed palatal arch retention after treat-
ment
When considering a treatment plan for young chil-
dren who travel great distances,it is important to con-
sider patient comfort as well as treatment efficiency.
In cases of marked midfacial retrusion, intercep-
tive orthopedics is started at 6years and often lasts
for 15months with an average of six visits (two visits
for a transverse expansion of about 10mm during a
3-month period, and an additional four visits for the
use of protraction forces for 12months).
23B.4.2.2 Quad-helix Spring
(with Four Bands and Hooks)
A fixed palatal expansion appliance can be easily
combined with the use of an extraoral facial mask
(Figs. 23B.1, B.2) [13] providing:
1. Controlled transverse expansion when needed

2. Adequate fixation for anterior protraction by a
facial mask
3. Use with edgewise appliance for the alignment of
incisors
4. Well tolerated by small children without sedation,
causing a minimum of discomfort
5. Minimum of chair time
6. Can be easily kept clean
Chapter 23B
Protraction Facial Mask for the Correction 495
496
S. Berkowitz
a
f
h
g
b
cde
Fig. 23B.2 a–h.
(continued) Interceptive orthopedics (Bergen
rationale).
a, b Transverse maxillary widening using a modi-
fied quad-helix appliance.
c, d Followed by maxillary protrac-
tion with a facial mask (Delaire type).
e, f Correction retained
with a fixed palatal arch with brackets and tubes for early
alignment of the upper incisors. Retention is utilized until
deciduous anchor teeth are shed.
g, h A nice dental smile as

early as possible