Pacific Coast Society of Orthodontists Bulletin Summer 2023 - 72

Case Report
How would you treat this malocclusion?
Posttreatment
Case L.L., 20 years, 11 months
Treatment Objectives
◾ Correct anteroposterior and transverse
skeletal discrepancy
◾ Improve soft tissue profile
◾ Achieve Class I canine relationship
◾ Achieve normal overjet and overbite
◾ Level and align maxillary and mandibular
dentition
◾ Correct maxillary midline
Treatment Alternatives
The surgical options for 9-mm maxillary
advancement in a patient with cleft lip and
palate include the following:
◾ Option 1: two-jaw surgery-LeFort I and
Bilateral sagittal split osteotomy (BSSO).
◾ Option 2: two stages of treatment-
surgically assisted rapid palatal expansion
(SARPE) followed by a second stage of
orthognathic surgery.
◾ Option 3: maxillary distraction with rigid
external distractor (RED).
◾ Option 4: maxillary distraction with Bollard
plates and facemask-SARPE, LeFort I
followed by maxillary expansion and
distraction osteogenesis.
Treatment Plan
As the transverse expansion was greater than
5 mm, the craniofacial surgeons recommended
a SARPE to correct the transverse
discrepancy. The patient then elected to
combine facemask treatment with SARPE to
correct the Class III malocclusion simultaneously.
In this case, the use of Bollard plates
differs from maxillary protraction as it was
combined with a LeFort I osteotomy to provide
skeletal anchorage for facemask-based
distraction osteogenesis. During the latency
phase, a splint maintained the antero-posterior
position of the Class III malocclusion and
a vertical-pull chin cup was applied to align
the LeFort I cuts to their original positions to
form a distraction callus; otherwise, the maxilla
would be free floating and drop down
from the osteotomy site.
The orthodontic preparation consisted of
a rapid palatal expander in the maxillary
arch and .022-inch edgewise brackets in
the lower dentition. After a four-day latency
period, the maxilla was expanded at 0.5 mm/
day and pulled anteriorly with elastics from
the maxillary Bollard plates to the facemask
(1/2-inch Whale elastics, 14 oz; ORMCO, Brea,
California) and Class III elastics (1/8-inch
medium 3.5 oz) from maxillary Bollard
plates to the mandibular plates mesial to
the canines. The shape of the facemask was
bent outward to create an adjustable rod to
increase the elastic tension. The mandibular
dentition was aligned and leveled during the
maxillary distraction, as the Class III elastics
were not applied to the mandibular archwire
or brackets.
Treatment Progress
Complications of this treatment plan
included loosening and reattachment of a
mandibular Bollard plate, Class III relapse
when the facemask was not worn, and
occasional temporomandibular joint pain.
It took six months of elastic wear to correct
9 mm of anterior crossbite and produce
1 mm of overjet. The rapid palatal expansion
was removed after six months of distraction.
One year later, the Bollard plates were
Figure 6. Progress intraoral radiographs
72
PCSO Bulletin Summer 2023
Pacific Coast Society of Orthodontists Bulletin Summer 2023

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