RU2835468C1 - Method for combined extension of upper jaw in adult patients with narrowing of upper jaw due to cleft lip and palate - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to dentistry, orthodontics and maxillofacial surgery. It involves clinical photographing of the patient, anthropometry of the teeth, dental arches, cone-beam computed tomography of the skull with cephalometry and measurement of the width of apical bases in accordance with the Penn-analysis. After establishing the diagnosis, the clinical-laboratory stages of making the distraction apparatus supported by orthodontic implants are performed using analogue technologies. Orthodontic implants are installed in the area of hard palate, impressions with transfers are made with subsequent production of gypsum working models with analogues of orthodontic implants. Distraction apparatus is made and placed in the patient's mouth. Surgical stage of treatment is carried out in an operating room under combined endotracheal anaesthesia. Two 2-cm-long incisions of the mucous membrane of the upper lip are made on the sides of the cleft of the alveolar process of the upper jaw at distance of 0.5 cm from the upper arch of the vestibule. Mucoperiosteal flap is detached, an anterior surface of the upper jaw is skeletonised, the nasal mucosa is mobilized from the bottom and walls of the piriform opening. Upper jaw osteotomy is performed along Le Fort I lines. The chisel is used to separate maxillary cusps and pterygoid plates on both sides. Screw of the distraction apparatus is unscrewed in order to check the fixation stability and functionality. Edges of the incisional wound are matched and sutured. On 5th postoperative day, the distraction apparatus is activated. After activation, the activation screw is retentioned for 3 months. Further, orthodontic treatment is started. Patient is dynamically observed by an orthodontist and a maxillofacial surgeon. 6 and 12 months after completion of activation of the distraction apparatus, a control cone-beam computed tomography is carried out in order to determine the state of bone tissue after the performed surgical intervention.

EFFECT: method enables higher effectiveness of diagnosis, planning and treatment of adult patients with narrowing of the upper jaw due to cleft lip and palate by creating a single interdisciplinary algorithm of treatment, minimizing the risk of recurrences.

2 cl, 16 dwg, 2 tbl, 2 ex

Description

The invention relates to the field of dentistry, in particular to orthodontics and maxillofacial surgery, and is intended for performing combined orthodontic-surgical treatment of adult patients with narrowing of the upper jaw due to cleft lip and palate.

Underdevelopment of the maxilla is the leading and most common deformity in adult patients with cleft lip and palate. The determining factors of underdevelopment of the maxilla are: reduced internal growth potential of the maxilla due to embryonic developmental disorders; lack of timely and sufficient orthodontic treatment; iatrogenic factor caused by surgical interventions leading to the formation of cicatricial changes (Richardson S., Krishna S., Khandeparker R.V., 2018). In children and growing adolescents, expansion of the maxilla can be successfully performed with the help of orthodontic appliances, without resorting to surgical intervention. In adult patients, due to the completed growth of the skeleton, surgically assisted expansion of the maxilla is the method of choice.

Techniques and methods for performing osteotomy of the upper jaw in case of its narrowing are currently well studied and developed, however, patients with cleft lip and palate have a number of morphofunctional features: violation of the integrity of the maxillary complex, the presence of scar tissue in the area of the defect of the hard palate, as well as communication with the nasal cavity, which often leads to the development of complications. Treatment of adult patients with a narrowing of the upper jaw, who have undergone a number of operations for cleft lip and palate, requires special attention due to the specific morphological features of the structure of the upper jaw, which must be taken into account when performing surgical interventions. At the current stage of development of dentistry, the use of digital technologies in diagnostics and the manufacture of medical devices based on orthodontic implants, the use of surgical navigation templates allow achieving optimal aesthetic and functional results. Segmental osteotomy of the maxilla according to Le Fort I, surgical expansion of the maxilla, the use of orthodontic devices with intraosseous fixation for expansion of the maxilla are the main methods of eliminating the narrowing of the maxilla in patients with clefts. However, segmental osteotomy according to Le Fort I in some cases cannot be performed due to severe cicatricial changes and ischemia of the soft tissues of the palate after primary operations. Surgical expansion of the maxilla is a more predictable method of treatment for such groups of patients. To date, various methods and techniques have been developed for the treatment of children and adolescents with narrowing of the maxilla due to cleft lip and palate, however, there is no single algorithm regulating interdisciplinary interaction between orthodontists and maxillofacial surgeons in the treatment of adult patients who have undergone a number of operations for congenital clefts, in particular, eliminating the narrowing of the maxilla.

There is a method of expanding the upper jaw (patent of the Russian Federation RU 2734053 C1, authors Arsenina O.I. et al.). The method includes expanding the upper jaw in patients with narrowing and deformation of the upper jaw based on the proposed analysis of the CBCT study of the skull, the method of expansion with a combination of laser corticotomy (fractional photothermolysis) and the protocol for activating and deactivating the expansion screw of the orthodontic device. In order to reduce bone density and accelerate the movement of teeth in the transverse direction, a laser corticotomy (fractional photothermolysis) procedure is performed. After fixing the device for expansion of the upper jaw, the patient undergoes a procedure of laser corticotomy (fractional photothermolysis) using the iPlus laser, GoldHanpiace tip, Tip-MX7 (Biolase, USA), then the patient is recommended to activate the expansion screw by 4 turns on the day of the procedure and by 3 turns per day after the intervention for 10 days. After that, the patient must deactivate the narrowing screw by 3 turns per day for 10 days. The essence of this protocol is periodic stretching in combination with compression of the sutures of the upper jaw. The disadvantages of the method include the lack of consideration of all anatomical zones that resist expansion of the upper jaw during corticotomy; the effectiveness in expanding the upper jaw in patients with narrowing of the upper jaw due to cleft lip and palate has not been shown.

Also known is a method for treating skeletal forms of mesial relationship of dental arches in patients with complete facial growth (Patent of the Russian Federation No. 2689027 C1, author Fadeev R.A. et al.). The method includes increasing the dental arch of the upper jaw with its expansion and reducing the length of the dental arch of the lower jaw. For this purpose, the upper dental arch and the entire upper jaw are expanded along the mid-palatine suture by using corticotomy and an expansion device with bone fixation, and to reduce the length of the dental arch of the lower jaw, the lower third molars are removed and the lower dental arch is moved in the distal direction using microimplants installed in the lateral areas of the alveolar part of the lower jaw and using a bracket system. The study includes fixation itself - expansion is performed with an apparatus with bone fixation of its own design after performing corticotomy of the upper jaw in the suture area and along the outer surface. The reduction in the length of the lower dental arch is carried out by its distal movement after preliminary preparation of the site by removing the lower third molars.

Disadvantages of the method:

- all anatomical zones that resist expansion of the upper jaw during corticotomy were not taken into account.

- the impossibility of using the device in case of severe anatomical deformations of the upper jaw due to cleft lip and palate.

A palatal distraction device is known (Patent of the Russian Federation No. 2613089 C2, authors Drobyshev A. Yu. et al.) comprising a housing equipped with a fixing element, inside which a pair of rods with end parts protruding from the ends of the housing are placed along the housing, the rods are mounted inside the housing with the possibility of movement during its rotation relative to each other in the direction of approaching or moving away from each other along the axis of the housing, wherein the end part of each rod is equipped with a plate with spikes made on the side opposite to the side of the plate facing the rod, wherein a through hole is formed in each plate for fixation on the palate (palatine bone) by means of a fixing screw, characterized in that each plate and the corresponding rod are equipped with a detachable connection unit, which contains a protrusion made on the plate on the side opposite to the side with spikes, having a cavity extending outward on the side opposite to the side of the plate with with spikes, the part of the plate body that limits the cavity has a recess of a polyhedral shape, limited by faces with ribs between adjacent faces, and the end part of the corresponding rod has spherical-shaped projections with ribs between adjacent spherical-shaped projections arranged in series along the perimeter, wherein in the assembled position of the spherical shape, the projections of the rod are located in the recess of a polyhedral shape of the cavity of the corresponding plate until they stop in it with the possibility of rocking relative to each other.

Disadvantages of the device:

- massive construction of the device due to the presence of steel plates.

- the design of the device involves the installation of 4 orthodontic implants, which limits its use in patients with a sharp narrowing of the upper jaw due to the lack of sufficient space.

- the impossibility of individualizing the device for each patient.

- the impossibility of using the device in case of severe anatomical deformations of the upper jaw due to cleft lip and palate.

The method we have developed includes a clinical dental examination of the patient, collection of anamnesis, after which, according to the developed algorithm, additional diagnostic methods are carried out, the main diagnosis is made and clinical and laboratory stages of manufacturing a distraction device based on orthodontic implants (OI) are performed using analog or CAD/CAM technologies with a subsequent surgical stage.

The technical objective of the claimed invention is to develop an effective method for combined expansion of the upper jaw in adult patients due to cleft lip and palate, based on strict adherence to an algorithm containing a list of diagnostic measures and clinical and laboratory stages of manufacturing medical devices, eliminating the shortcomings of analogues.

The technical result of the method of combined expansion of the upper jaw in adult patients with narrowing of the upper jaw due to cleft lip and palate is an increase in the efficiency of diagnostics, planning and treatment of patients by creating a single interdisciplinary treatment algorithm. This method is aimed at achieving expansion of the upper jaw at the skeletal level with minimization of the development of relapses, given the high percentage of their occurrence in this group of patients, taking into account the morphofunctional features of the upper jaw.

The technical result is achieved by precisely following the algorithm when performing diagnostic and clinical laboratory stages of manufacturing a distraction device based on orthodontic implants (OI) using analog and CAD/CAM technologies and surgical treatment.

The claimed method of combined expansion of the upper jaw includes two stages: orthodontic and surgical.

The orthodontic stage consists of the sequential implementation of clinical and additional methods of examination of the patient by the orthodontist. First, a clinical dental examination of the patient is performed, anamnesis is collected, clinical photography of the patient is performed, anthropometry of the teeth, dental arches, CBCT of the skull with cephalometry and assessment of the width of the apical bases in accordance with the Penn analysis protocol. To perform the Penn analysis on the cranial CT, the width of the lower jaw is first determined and used as an individual constant. To assess the width of the upper jaw in the multiplanar imaging mode, measurement points - Mx - are determined on axial and coronal sections in accordance with the method of R.M. Ricketts (1969): at the level of the first molars on the right and left in the area of transition of the alveolar process to the zygomatic crest. The deepest point of the base of the upper jaw is point Mx. The size of the upper jaw is measured as the length of the segment between points Mx on the right and left on axial sections. Normally, the width of the upper jaw is 5 mm greater than the width of the lower jaw.

Next, the main diagnosis is established and the design of the device is selected.

To implement the claimed method for manufacturing the device for expanding the upper jaw, there are two manufacturing technologies: CAD/CAM and analog. When manufacturing the device using CAD/CAM technologies, intraoral scanning of the jaws or taking impressions with subsequent manufacturing of plaster models of the jaws is performed, plaster models are scanned with a laboratory scanner to obtain stl files, stl and dicom files are combined, the number of OIs and their position are selected by analyzing CBCT, the distractor design and surgical navigation template are modeled in the program (CAD), the distraction device is manufactured (CAM) using 3D printing on metal (selective laser sintering) and the distractor is fixed in the patient's mouth (Table 1).

When manufacturing the device using analog methods, orthodontic implants are installed in the hard palate area in the amount determined by the orthodontist and dental surgeon, taking into account the anatomical conditions, impressions are taken with transfer caps, plaster models with analogs of orthodontic implants are made, the device is manufactured in a dental laboratory by casting and soldering the components. The finished device is fixed in the patient's mouth. (Table 2).

The next stage is the surgical one, which consists of the following: osteotomy of the upper jaw, activation of the distraction device and postoperative control according to the proposed protocol. In the operating room, under combined endotracheal anesthesia, the skin of the face and neck is treated 3 times with the antiseptic solution "Chisteya" and the oral cavity with the solution "Chlorhexidine" 0.05%. For the purpose of hydropreparation and vasoconstriction, infiltration of soft tissues in the area of the upper fornix of the oral cavity vestibule with Sol.Ultracaini-DS 1:100000 in a total volume of 6.8 ml is performed. 2 incisions of the mucous membrane of the upper lip 2 cm long are made on the sides of the cleft of the alveolar process of the upper jaw, retreating 0.5 cm from the upper fornix of the vestibule. The mucoperiosteal flap is peeled off, the anterior surface of the upper jaw is skeletonized, and the mucous membrane of the nasal cavity is mobilized from the bottom and walls of the pyriform opening. Then, osteotomy of the upper jaw is performed along the Le Fort I lines. Using a chisel, the maxillary tubercles and pterygoid plates are separated on both sides. The distraction device is untwisted to check the stability of fixation and functionality. The edges of the surgical wound are aligned and sutures are applied. On the 5th day after the operation, the distraction device is activated with a special key.

The effectiveness of the method is demonstrated by the following clinical examples.

Clinical example 1

Patient R., 25 years old, came to the hospital orthodontics department of the Federal State Budgetary Institution National Medical Research Center "Central Research Institute of Dentistry and Maxillofacial Surgery" of the Ministry of Health of the Russian Federation with complaints of difficulty chewing food, impaired smile aesthetics, and malposition of teeth (Fig. 11 a, b, c). His medical history includes a number of surgeries for bilateral cleft lip and palate.

On external examination: facial configuration is unchanged, mouth opening is free and complete (up to 40 mm). Nasal breathing is difficult. On en face examination, deformation of the osteochondral part of the nose is noted. The terminal part of the nose is deviated to the right by ~2 mm. Obliquely oriented scars 2 mm wide and 3 mm long are noted from the vestibule of the nasal passages. The scars cross the vermilion border of the upper lip in the central area. The vermilion border of the lips is of a physiological color, the contour is disturbed. Palpation of this area is painless, sensitivity is preserved. Regional lymph nodes are not palpated. Clinical assessment of the teeth, dental arches, occlusal relationships revealed the following: the relationship of the lateral teeth is distal on the right, mesial on the left. Sagittal incisal disocclusion. Vertical incisal disocclusion. Transversal incisal disocclusion. Palatinoocclusion. Saddle-shaped upper dental arch. Crowded position of teeth on the upper and lower jaws. Partial absence of teeth on the upper and lower jaws (Fig. 12 a, b, c, d). Within the framework of the claimed method, the patient underwent clinical photography, anthropometry of teeth, dental arches, radiological examination methods in the volume of CBCT of the skull with cephalometry and Penn analysis. Anthropometry of the dental arches showed a narrowing of the upper dental arch in the molar area by 10 mm.

Cephalometric analysis of the TRG of the head in the lateral projection showed upper and lower retrognathia (∠ SNA=78°, ∠ SNB=76°), retrusion of the lower incisors (angle L1/ML1=82°), vertical pattern of facial skull growth (sum.Bjork=400°). Transverse tomographic analysis according to the Penn protocol showed a narrowing of the upper jaw relative to the lower jaw by 9 mm (Fig. 1 a, b). Based on the primary and additional examination methods, the patient was given the primary diagnosis: combined deformation of the jaws. Upper and lower retrognathia. Skeletal narrowing of the upper jaw by 9 mm. Sagittal incisor disocclusion. Vertical incisor disocclusion. Transversal incisor disocclusion. Palatinoocclusion. Saddle-shaped upper dentition. Crowded position of teeth on the upper and lower jaws. Retrusion of the lower incisors. Partial absence of teeth on the upper and lower jaws. Condition after a series of operations for bilateral cleft lip and palate.

A combined treatment plan was developed: normalization of the upper jaw size using a distraction device supported by orthodontic implants in combination with osteotomy of the upper jaw (surgically assisted expansion); normalization of the shape of the dental arches, position and inclination of the teeth; normalization of interocclusal relationships; retention period. Orthodontic treatment was planned to be carried out using non-removable orthodontic appliances (bracket system) on both dental arches. At the first stage, to manufacture a distraction device in accordance with the proposed method, the patient underwent intraoral scanning to obtain eI files. Then we combined the stl files with the CBCT data, determined the number of orthodontic implants - 2 - taking into account the topographic features of the hard palate, modeled the device design (CAD) (Fig. 2 b, c) and the surgical navigation template, manufactured the device using 3D printing on metal (Fig. 3). We fixed the device in the mouth (Fig. 4), after which, in an outpatient setting, under local anesthesia, we installed orthodontic implants using navigation positioning templates. In the operating room, under combined endotracheal anesthesia, the skin of the face and neck was treated 3 times with the antiseptic solution "Chisteya" and the oral cavity with a solution of "Chlorhexidine" 0.05%. For the purpose of hydropreparation and vasoconstriction, soft tissue infiltration in the area of the upper fornix of the oral cavity vestibule was performed with Sol.Ultracaini-DS 1:100000 in a total volume of 6.8 ml. Two 2-cm-long incisions were made in the mucous membrane of the upper lip on each side of the cleft of the alveolar process of the upper jaw, 0.5 cm from the upper fornix of the vestibule, the mucoperiosteal flap was peeled off, the anterior surface of the upper jaw was skeletonized, and the mucous membrane of the nasal cavity was mobilized from the bottom and walls of the pyriform opening (Fig. 5). Then, osteotomy of the upper jaw was performed along the Le Fort I lines. Using a chisel, the maxillary tubercles and pterygoid plates were separated on both sides. The distraction apparatus was untwisted to check the stability of fixation and functionality. The edges of the surgical wound were aligned and sutures were applied. On the 5th day after the operation, the distraction device was activated. Control was performed at the stages of treatment based on digital models, CBCT: upon completion of the device screw activation, 6 and 12 months after completion of active expansion.

Clinical example 2

Patient S., 22 years old, applied to the hospital orthodontics department of the Federal State Budgetary Institution National Medical Research Center “Central Research Institute of Dentistry and Maxillofacial Surgery” of the Ministry of Health of the Russian Federation with complaints of dissatisfaction with the aesthetics of her smile and incorrect position of her teeth.

During the external examination it was noted: the facial configuration is unchanged, the profile is convex. The mouth opening is free and in full. During the clinical assessment of the teeth, dental arches, occlusal relationships it was established: distal occlusion; transversal incisal occlusion. Crowded position of the frontal group of teeth on the upper and lower jaws. Supra-, vestibuloposition of tooth 1.3. Within the framework of the declared method the patient underwent clinical photography (Fig. 13 a, 6, c, d), anthropometry of the teeth, dental arches, radiographic examination methods in the volume of CBCT of the skull with cephalometry and Penn analysis. Anthropometry of the dental arches showed a narrowing of the upper dental arch in the molar area by 5 mm, a shortening of the length of the anterior segment of the upper dental arch by 5.3 mm. Cephalometric analysis of the TRG of the head in the lateral projection showed retrusion of the lower incisors (angle L1/ML1 = 65.2°), upper prognathism (Z SNA = 87.6°), retroclination of the lower jaw (Z. ML/NSL = 16.6°), horizontal growth pattern of the facial skull (ZN/Go/Me = 63.5°, sum.Bjork = 376°).

Transversal tomographic analysis according to the Penn protocol showed a narrowing of the upper jaw relative to the lower jaw by 8 mm (Fig. 14 a, b). Based on the main and additional examination methods, the patient was given the following primary diagnosis: distal occlusion caused by upper prognathism. Transversal incisor occlusion. Skeletal narrowing of the upper jaw by 8 mm. Shortening of the anterior segment of the dental arch of the upper jaw. Crowded position of the frontal group of teeth on the upper and lower jaws. Retrusion of the lower incisors. Supra-, vestibuloposition of tooth 1.3. Condition after a series of operations for bilateral cleft lip and palate.

A combined treatment plan was developed: normalization of the upper jaw size using a distraction expansion device supported by orthodontic implants in combination with osteotomy of the upper jaw using an apparatus for rapid palatal expansion supported by orthodontic implants in combination with osteotomy of the upper jaw (surgically assisted expansion); normalization of the shape of the dental arches, position and inclination of the teeth; normalization of interocclusal relationships; retention period. Orthodontic treatment was planned to be carried out using fixed orthodontic appliances (bracket system) on both dental arches. At the first stage, in order to manufacture the apparatus for expansion of the upper jaw in accordance with the proposed method, 2 orthodontic implants were installed in the patient's hard palate (Fig. 6). Then, transfer impression caps were installed on the orthodontic implants (Fig. 7), an impression was taken from the upper jaw, analogs of the orthodontic implants were installed in the transfer caps, and a plaster model of the upper jaw was made (Fig. 8). In the dental laboratory, a device for expanding the upper jaw with support on orthodontic implants was made, including orthodontic rings, bars, and a screw (Fig. 9). The device was installed in the mouth. In the hospital, under general anesthesia, an incision was made in the mucous membrane of the upper lip, retreating 0.5 cm from the upper fornix of the vestibule of the oral cavity in the projection of teeth 2.2-2.3, 1.2-1.3. Skeletonization of the anterior surface of the upper jaw, mobilization of the mucous membrane of the nasal cavity from the bottom and walls of the pyriform opening were performed. Then osteotomy of the upper jaw was performed along the Le Fort I lines. Using a chisel, the maxillary tubercles and pterygoid plates were separated on both sides. The device was tested with subsequent compression. The edges of the surgical wound were aligned and sutured layer by layer.

After 6 months of orthodontic treatment after removal of the device for expansion of the upper jaw and installation of the bracket system, normalization of the size of the dental arch of the upper jaw was determined, creation of sufficient space for placing 1.3 in the dental arch. Normalization of occlusion in the transverse direction was achieved, restoration of the coincidence of the interincisal lines (Fig. 15 a, b). When analyzing the situational CBCT according to the Penn analysis protocol, an increase in the width of the upper jaw by 7 mm is noted (Fig. 16).

Advantages of the proposed method:

- taking into account the anatomical features of the hard palate in patients with cleft lip and palate when modeling the structure and positioning the fixing elements of the distraction apparatus;

- unification of an interdisciplinary approach based on the interaction of an orthodontist and a maxillofacial surgeon in the treatment of adult patients with narrowing of the upper jaw due to cleft lip and palate based on strict adherence to the proposed algorithm;

- achieving the predicted expansion, reducing the likelihood of recurrence of transversal deficit in the size of the upper jaw;

- the possibility of using the method for severe anatomical deformations of the upper jaw due to cleft lip and palate in adult patients;

- combining digital patient data and working with them in computer programs with high accuracy allows us to determine the required degree of expansion of the upper jaw and control the amount of expansion;

- the method ensures high predictability of the results of surgical intervention due to precise treatment planning.

This method was used to treat 25 patients aged 18 to 45 years.

Brief description of the drawings Fig. 1

a - measurement of the width of the upper jaw according to the Penn analysis protocol at points Mx-Mx in axial and coronal projections: width of the upper jaw = 57.5 mm.

b - measurement of the width of the lower jaw according to the Penn analysis protocol in axial and coronal projections in the area of the furcation of the roots of the first molars: width of the lower jaw = 60.8 mm.

Fig. 2

a - screenshot from a computer monitor in a technical program: planning the quantity and topography of the installation of orthodontic implants on a digital model of the upper jaw, combined with CBCT.

b - screenshot from a computer monitor in a technical program: a digital model of the device supported by orthodontic implants installed in the area of the hard palate.

in - a screenshot from a computer monitor in a technical program: a digital model of a device supported by teeth and orthodontic implants installed in the area of the hard palate.

Fig. 3 - The upper jaw expansion device is fitted onto a 3D printed upper jaw model.

Fig. 4 - The device for expanding the upper jaw with support on orthodontic implants is fixed in the patient's mouth.

Fig. 5 - Surgical approach.

Fig. 6 - Clinical stage of manufacturing the device for expansion of the upper jaw: orthodontic implants are installed in the area of the hard palate.

Fig. 7 - Clinical stage of manufacturing the device for expanding the upper jaw: transfer caps for taking an impression are installed on the gingival parts of the orthodontic implants.

Fig. 8 - Laboratory stage of manufacturing the device for expanding the upper jaw: plaster model with installed analogues of orthodontic implants.

Fig. 9 - Laboratory stage of manufacturing the device for expanding the upper jaw: the device on a plaster model of the upper jaw.

Fig. 10 - Clinical stage of manufacturing the device for expanding the upper jaw: the device is fixed in the patient's mouth.

Fig. 11 Clinical photographs of the patient's face

a - full face,

b - 3/4,

in - smile.

Fig. 12 - Intraoral photographs of the patient

a - occlusion in the frontal region,

b - occlusion in the lateral section on the left,

in - occlusion in the lateral section on the left,

g - occlusal view of the upper dentition.

Fig. 13 - Intraoral photograph of the patient

a - occlusion in the frontal region,

b - occlusal view of the upper dentition,

in - occlusion in the lateral section on the left,

g - occlusion in the lateral section on the right.

Fig. 14

a - measurement of the width of the upper jaw according to the Penn analysis protocol in axial projection: width of the upper jaw = 53 mm,

b - measurement of the width of the lower jaw according to the Penn analysis protocol in axial projection: width of the lower jaw = 56 mm.

Fig. 15

a - intraoral photograph of patient S. at the stage of orthodontic treatment: occlusion in the frontal section,

b - intraoral photograph of patient S. at the stage of orthodontic treatment: occlusal view of the upper dentition.

Fig. 16 - Measurement of the width of the upper jaw according to the Penn analysis protocol in axial projection after combined expansion: width of the upper jaw = 60 mm.

Claims (2)

1. A method for combined expansion of the upper jaw in adult patients with narrowing of the upper jaw due to cleft lip and palate, consisting of following an algorithm when performing basic and additional diagnostic methods, including clinical photography of the patient, anthropometry of the teeth, dental arches, cone beam computed tomography of the skull with cephalometry and measurement of the width of the apical bases in accordance with Penn analysis, after establishing a diagnosis, clinical and laboratory stages of manufacturing a distraction device with support on orthodontic implants using analog technologies are performed, in accordance with which orthodontic implants are installed in the area of the hard palate, impressions are taken with transfers with subsequent manufacture of plaster working models with analogs of orthodontic implants, a distraction device is manufactured and installed in the patient's mouth, the surgical stage of treatment is carried out in an operating room under combined endotracheal anesthesia, 2 incisions of the mucous membrane of the upper lip 2 cm long are made along on the sides of the cleft of the alveolar process of the upper jaw, retreating 0.5 cm from the upper arch of the vestibule, peel off the mucoperiosteal flap, skeletonize the anterior surface of the upper jaw, mobilize the mucous membrane of the nasal cavity from the bottom and walls of the piriform opening, perform osteotomy of the upper jaw along the Le Fort I lines, separate the maxillary tubercles and pterygoid plates on both sides using a chisel, loosen the screw of the distraction apparatus in order to check the stability of fixation and functionality, match the edges of the surgical wound, apply sutures, activate the distraction apparatus on the 5th day after the operation, retain the activation screw for 3 months after activation is complete, then begin orthodontic treatment, dynamic observation of the patient is carried out by an orthodontist and maxillofacial surgeon, 6 and 12 months after completion of the activation of the distraction apparatus, control cone beam computed tomography to determine the condition of bone tissue after surgery. 2. The method according to item 1, characterized in that the clinical and laboratory stages of manufacturing the device for expanding the upper jaw with support on orthodontic implants are performed using CAD/CAM technologies, including intraoral scanning of the jaws or taking impressions with subsequent manufacturing of plaster models of the jaws, scanning of the plaster models with a laboratory scanner to obtain STL files, combining STL and DICOM files, selecting the number of orthodontic implants and their position by analyzing cone beam computed tomography, modeling the design of the distraction device and modeling the surgical template in the program, manufacturing the distraction device using 3D printing on metal and installing the distraction device in the patient's mouth.