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Treatment of maxillary hypoplasia in cleft lip and palate patients: Keeping the total burden of care as low as possible

Introduction: Maxillary hypoplasia is a common problem in cleft patients. The literature has shown that early treatment is unstable; nevertheless, early maxillary protraction may still be taken into consideration, if specific functional problems exist. On the other hand, long-term results of the application of the Alternate Rapid Maxillary Expansion and Constriction (Alt-RAMEC) technique, a maxillary protraction technique applied closer to the peak of growth, have been shown to be stable. Therefore, a later approach might be considered if the objective is purely occlusal/esthetic. Objective: The objective of this study was to describe the rationale behind a protocol for the treatment of maxillary hypoplasia in cleft lip and palate (CLP) patients where timing is guided by the different indications. Materials and Methods: We subdivided this study into two groups. (1) Early treatment group (preliminary study): 30 unilateral CLP (UCLP) and bilateral CLP patients were treated early with expansion and face mask with two specific functional indications: 22 were affected by middle ear infection, otitis media (OM), with subsequent hearing impairment, and 8 by obstructive sleep apnea (OSAS). The objective of early treatment thus, was purely functional. (2) Late adolescence treatment group (follow-up study): a different group of older patients was treated at a later stage with an esthetic-occlusal aim. Thirty-nine UCLP patients were consecutively treated with the Alt-RAMEC technique at an average age of 13.2 years (11.3–14.2 years) before protraction. The average age at long-term follow-up was 18.3 years (17.4–24.7 years). Results: (1) Early treatment group (preliminary results): the sagittal advancement of A-point, after the application of the face mask and expander, was 2.6 ± 1.2 mm. About 65% of the OM patients had a net improvement of all audiological symptoms (audiometric tests and tympanograms), and 100% of OSAS patients had a significant improvement of obstructive parameters (apnea-hypopnea index). (2) Late treatment group (follow-up study): the sagittal advancement of A-point, after the application of the Alt-RAMEC technique, was 5.6 ± 2.7 mm. The position of the maxilla was stable in the long term. Conclusion: Our results suggest that, even though skeletal relapse is expected after early correction of maxillary hypoplasia, there might be an indication in patients with functional problems, such as hearing or breathing disorders, to avoid more complex treatments. On the other hand, to correct the occlusal esthetic problem related to maxillary hypoplasia, it is advisable to wait till after growth peak and apply a modified Alt-RAMEC technique, with a double-hinged expander and to obtain more stable long-term results. This technique seems to significantly reduce, especially in female patients, the need for final orthognathic surgery.