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ORIGINAL ARTICLE
Objective: To clarify the differences in the long-term effects of maxillary expansion (ME) and
protraction (MP) in patients with complete unilateral cleft lip, alveolus, and palate (UCLP)
undergoing two types of palatoplasty.
Design: Retrospective longitudinal study.
Setting: Institutional study.
Patients and Interventions: Thirty-eight patients with UCLP treated at Osaka University Dental
Hospital, Japan, were divided into two groups: 19 patients were treated using Wardill-Kilner
push-back palatoplasty (PB), and 19 patients were treated with early two-stage palatoplasty
according to the modified Furlow technique (ETS). All patients exhibited a short maxilla at the
initial orthodontic visit and were treated with ME using a quad helix appliance and MP with a face
mask. Lateral cephalometric data recorded in the initial stage were compared with those
obtained at the end of treatment.
Main Outcome Measurements: The dentoskeletal features and facial soft tissue profile were
evaluated before and after orthodontic treatment. The variation and rate of change during
treatment were also calculated. The Mann-Whitney U test was used for the statistical analyses.
Results: The ETS group showed significantly greater SNA, SNB, and U1-Pp angles and
smaller SN-Mp angles than the PB group after face mask treatment. The variation in the
anteroposterior length of the maxilla during treatment was significantly greater in the ETS group
than in the PB group.
Conclusions: Maxillary protraction was more efficiently accomplished in the patients with
UCLP after early two-stage palatoplasty compared with push-back palatoplasty.
KEY WORDS: early two-stage palatoplasty, Furlow palatoplasty, orthodontic treatment, unilateral
cleft lip and palate, Wardill-Kilner push-back palatoplasty
In patients with cleft lip and palate, various types of ETS method, the soft palate is closed using Furlow double-
palatoplasty have been attempted to prevent postoperative opposing Z-plasty at 12 months of age, and the hard palate
maxillary deciency. The push-back method (PB) has is closed after 6 months.
become widespread; however, apparent maxillary deformi- Some researchers have reported differences in maxil-
ties have been found after surgery (Ross, 1970; Smahel, lary growth and occlusion between patients treated PB
1989; Fujita et al., 2005). In consideration of the effect on and ETS methods (Kitagawa et al., 2004; Yamanishi et
speech and maxillary growth, the early two-stage Furlow al., 2009; Nishio et al., 2010; Yamanishi et al., 2011).
method (ETS; Nishio et al., 2001) has been adopted. In the Signicantly longer anteroposterior palatal lengths and
better crossbite scores are observed in patients at 4 years
of age, on average, among those treated with ETS than
Dr. Tome is Assistant Professor, Department of Orthodontics and those treated with PB. Our previous report (Tome et al.,
Dentofacial Orthopedics, Graduate School of Dentistry, Osaka
University, Osaka, Japan. Dr. Yashiro is Associate Professor, in press) also demonstrated more anteriorly positioned
Department of Orthodontics and Dentofacial Orthopedics, Graduate upper central incisors and lips in the ETS group versus the
School of Dentistry, Osaka University, Osaka, Japan. Dr. Kogo is PB group at 7 years of age.
Professor, Department of Oral and Maxillofacial Surgery, Graduate
School of Dentistry, Osaka University, Osaka, Japan. Dr. Yamashiro At the age of entering elementary school (6 to 7 years of
is Professor, Department of Orthodontics and Dentofacial Orthope- age), when the upper anterior permanent incisors erupt,
dics, Graduate School of Dentistry, Osaka University, Osaka, Japan. patients with complete unilateral cleft lip, alveolus, and
There were no conict of interests or grants for this study.
Submitted March 2015; Revised July 2015; Accepted July 2015. palate (UCLP) and their family members often recognize
Address correspondence to: Dr. Kohtaro Yashiro, Department of the need for orthodontic treatment, complaining of
Orthodontics and Dentofacial Orthopedics, Graduate School of dissatisfaction with their facial/dentoalveolar appearance.
Dentistry, Osaka University, 1-8 Yamada-Oka, Suita, Osaka 565-
0842, Japan. E-mail yashiro@dent.osaka-u.ac.jp. Although maxillary deformities can result from palatoplas-
DOI: 10.1597/15-082 ty, the effects of different protocols of palatoplasty on the
0
0 Cleft PalateCraniofacial Journal, May 2016, Vol. 53 No. 3
Variable Denition
outcomes of maxillary expansion (ME) and protraction All patients exhibited a short maxilla on the initial
(MP) treatment remain unknown. Therefore, the purpose visit to the orthodontic clinic and were treated using
of this study was to investigate whether the outcomes of maxillary expansion with a quad helix appliance and
orthodontic treatment differ after two types of palatoplas- protraction with a face mask. The average treatment
ty. The ndings of this report are expected to provide period using a face mask was 27.3 months in the ETS
insight into the capability of growth modication following group and 29.4 months in the PB group. The
ME and MP in patients with UCLP. orthodontic treatments were performed by experienced
orthodontists who had already completed a university
PATIENTS AND METHODS postgraduate program in orthodontics. This study was
approved by the ethics committee.
Patients
Measurements
The subjects consisted of 38 patients with UCLP who
were divided into two groups: the ETS group (9 boys and Lateral cephalometric radiographs were taken in the
10 girls; mean age, 7 years 2 months; treated with early initial treatment stage (mean age, 7 years 2 months in
two-stage Furlow palatoplasty; Nishio et al., 2001) and the the ETS group and 7 years 5 months in the PB group)
PB group (12 boys and 7 girls; mean age, 7 years 5 months; and at the end of orthodontic treatment (mean age, 11
treated with one-stage PB between 12 and 18 months). In years 6 months in the ETS group and 11 years 5 months
the ETS group, the hard palate was closed by two sets of in the PB group). All cephalometric radiographs were
mucoperiosteal aps on the oral and nasal side. The lateral traced and measured by one examiner. Each cephalo-
relaxing incision was routinely performed. All patients metric radiograph was measured twice, and the mean
received palatoplasty at Osaka University Dental Hospital value was used. A total of 10 randomly selected
First Department of Oral and Maxillofacial Surgery cephalometric radiographs were reexamined to calculate
(Osaka, Japan). To eliminate technical bias, all palatoplas- the intraexaminer error after an interval of 1 day. The
ty procedures were performed by the same senior surgeon. reference points and measurements are shown in Table
Tome et al., MAXILLARY PROTRACTION OUTCOMES AFTER TWO TYPES OF PALATOPLASTY 0
SNA, 8 78.4 3.5 74.7 4.5 4.7 79.2 3.8 77.9 3.4 1.6 .018 5.87 to 0.60
SNB, 8 75.3 3.2 74.1 3.2 1.5 76.3 3.2 76.3 2.9 0.0 .033 4.15 to 0.12
ANB, 8 3.1 2.6 0.6 2.9 69.2 2.9 3.3 0.9 2.9 62.2 .743 2.98 to 0.77
SN-Mp, 8 41.1 5.1 41.8 5.7 2.0 37.5 4.3 37.7 4.8 0.7 .020 0.67 to 7.54
SN-Rp, 8 92.2 5.0 93.2 5.3 1.1 89.6 5.1 91.6 5.6 2.3 .379 2.02 to 5.18
SN-Pp, 8 11.1 4.3 9.3 4.3 11.9 9.4 6.7 7.5 5.2 34.2 .257 1.16 to 5.11
GoA, 8 128.9 6.8 128.2 7.8 0.5 128.1 6.3 126.1 7.2 1.5 .387 2.81 to 7.07
ptm-A/PP, mm 44.0 3.1 42.5 3.7 3.3 43.8 2.8 44.1 3.6 0.3 .196 3.94 to 0.94
ptm-ANS/PP, mm 45.8 3.3 48.1 4.0 4.9 46.3 3.1 49.1 3.5 6.0 .407 3.47 to 1.52
Go-Me, mm 60.7 3.2 68.2 2.6 12.6 60.6 4.2 67.9 4.8 12.3 .835 2.27 to 2.80
Ar-Go, mm 36.7 4.4 41.4 3.6 13.8 38.9 3.6 43.5 3.9 11.4 .514 4.18 to 0.50
Ar-Me, mm 90.1 4.7 100.7 4.6 12.0 91.7 4.5 101.8 5.7 10.9 .101 4.35 to 2.46
U1/PP, 8 89.2 11.5 105.6 8.8 20.1 92.6 10.2 111.7 7.5 22.1 .027 11.51 to 0.75
U1 to NA, mm 5.7 3.7 4.0 2.8 164.8 3.3 4.3 4.3 3.7 259.6 .787 2.45 to 1.87
U1-FH, mm 45.9 5.1 53.2 5.2 16.5 45.9 3.4 52.4 3.4 14.4 .586 2.12 to 3.70
U1-PP, mm 25.2 3.3 27.7 2.9 11.3 25.8 2.4 27.9 2.2 8.7 .755 1.96 to 1.43
U6-FH, mm 36.2 4.8 44.4 4.4 24.2 36.1 5.5 44.4 3.7 24.9 .984 2.70 to 2.65
U6-PP, mm 16.4 3.9 20.1 3.0 31.4 17.4 4.3 20.7 2.0 26.9 .470 2.29 to 1.07
OB, mm 2.1 1.7 1.8 1.8 21.1 2.1 1.6 1.3 2.0 64.4 .456 0.80 to 1.75
OJ, mm 4.6 2.0 0.3 4.1 131.3 3.4 3.4 0.1 3.3 102.5 .894 2.60 to 2.33
Facial contour angle, 8 1.9 5.5 5.0 5.5 164.3 3.8 6.2 3.7 6.1 60.1 .509 2.57 to 5.08
Nasolabial angle, 8 95.4 17.2 86.6 13.8 6.2 94.0 12.9 88.3 13.0 4.7 .688 10.59 to 7.06
Upper lip to E-line, mm 1.5 2.0 1.2 2.3 37.0 0.7 2.4 0.8 2.4 71.7 .541 1.98 to 1.06
Nose prominence, mm 8.2 2.2 10.5 2.5 32.0 7.2 2.9 9.7 2.6 48.2 .356 0.89 to 2.42
1. The details of the denitions are described in our overjet. Moreover, there were no signicant differences
previous report (Tome et al., in press). in the distance from E-line to the upper lip after using a
The variation and rate of change during treatment face mask between the two groups.
were also calculated. The characteristics of the dental,
skeletal, and facial proles after orthodontic treatment Comparison of the Variation and Rate of Change During
were compared using the Mann-Whitney U test. Treatment
The statistical analysis was performed using a
statistical analysis software program (SPSS v17.0, SPSS The variation of SNA was signicantly smaller in the
Inc., Chicago, IL). The signicance of coefcients and ETS group than in the PB group (P .016). The
mean differences was tested at the a .05 level. variation in the length of ptm-A/PP between the pre-
and posttreatment values was signicantly greater in the
RESULTS ETS group than in the PB group (P .031; Table 3).
Meanwhile, there were no signicant differences in the
Comparison of the Measurements After Maxillary variation in the length of ptm-ANS/PP between the two
Protraction Treatment groups (P .440).
The variation in the distance from the E-line to the
According to Students t test for paired samples, there upper lip between the pre- and posttreatment values was
was no statistically signicant intraexaminer error. The signicantly smaller in the ETS group than in the PB
intergroup comparison between the ETS group and PB group (P .011). The distance from the E-line to the
group after treatment using a face mask is shown in upper lip was reduced in the ETS group compared with
Table 2 and Figure 1. The ETS group showed that observed in the PB group.
signicantly greater SNA and SNB angles than the PB
group (P .018 and .033, respectively). A signicant DISCUSSION
difference in the U1-Pp angle was also observed between
the two groups (P .027). A previous report of children with UCLP at 4 years of
There were no signicant differences in the antero- age (Yamanishi et al., 2009; Nishio et al., 2010; Yamanishi
posterior length of the maxilla or the ANB angle et al., 2011) demonstrated longer anteroposterior lengths of
between the ETS and PB groups. The PB group the maxilla and larger overjet in the children treated with
exhibited greater SN-Mp angles than the ETS group ETS than in those treated with PB. In our previous study,
(P .020). Each subject group exhibited reduced we found that ETS results in a favorable facial prole with
0 Cleft PalateCraniofacial Journal, May 2016, Vol. 53 No. 3
PB ETS P
Group Group Value 95% CI
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