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In 1990 Ralph Millard in conjunction with Dr. Ralph Latham published an initial experience with Dynamic Maxillary Appliances (DMA) and periosteoplasty in cleft lip and palate patients. The goal was to align the alveolar segments, close the oral-nasal fistula and provide better facial balance with tension free closures. Opponents argued that this approach increased the incidence of mid facial retardation and created orthodontic cripples. In 1998, we reported a 13-year longitudinal study on 35 unilateral and 10 bilateral complete clefts with radiographs, cephalometrics, and serial occlusograms with very encouraging results structurally and psychosocially.
METHODS:
Twenty-five patients were assessed for the need and the amount of bone required to consolidate the maxillae, the complexity of orthodontics, the need for orthognathic surgery and the number of interim surgeries performed throughout the growth period. A long-term psychosocial questionnaire was given to parents to evaluate satisfaction with early active intervention and normalization.
RESULTS:
Early intervention with maxillary orthopedics and complete closure of the primary palate at 3 months eliminated the oral-nasal fistula, and provided excellent facial balance. Alignment of the cleft segments allowed for easier closure of the secondary palate and eliminated velo-pharyngeal insufficiency procedures. Bone was demonstrated in the cleft segments, and for those needing additional grafting, the requirements were much less. Because the bone was placed in a healthy recipient bed, consolidation of the maxillae was more successful. Anterior and lateral cross-bites were dental, not skeletal, and were managed with orthodontics. Orthognathic procedures were decreased (0/21 unilateral, 2/4 bilateral) and when performed were easier because of the unification of the upper jaws. Serial photographs and occlusograms, as well as interval cephalometrics demonstrated positive outcomes of this technique. A parental survey further reinforced the psychosocial well being that accompanied early intervention.
CONCLUSION:
Our outcomes support use of this technique and warrant multi-center investigation