Facial growth in a cleft palate patient treated with the Herbst appliance:A long-term profile roentgenographic and roentgen stereometric analysis ofprofile changes and displacement of the jaws

Objective: To monitor facial development in a patient with cleft palate who was treated with the Herbst appliance. Monitoring was in terms of changes in the skeletal profile and growth in the circummaxillary sutures and tempo romandibular joints (TMJs). Design: Prospective profile roentgenography (between the ages of 6 and 20 y ears) and roentgen stereometric analysis (between the ages of 8 and 19 year s). Setting: Center for Craniofacial Anomalies and Department of Plastic and Re constructive Surgery, Malmo University Hospital, Malmo, Sweden. Patient: Boy with cleft of the soft and posterior part of the hard palate a nd marked facial convexity. interventions: Surgical repair of the soft palate at age 9 months, velophar yngeal flap at age 8 years, and insertion of implants under general anesthe sia and treatment with the Herbst appliance at age 11 years. Roentgen exami nations were performed in connection with continued clinical evaluations an d treatment. Main outcome measures: Profile roentgenograms were traced and measured by o ne of the authors using conventional point-based analysis. Stereo roentgeno grams were digitized by the Department of Orthopedic Surgery, Malmo, Univer sity Hospital. Results: The direction of profile changes was partly discordant with the di rection of articular growth in the circummaxillary sutures and TMJs. The su ccessful treatment result was accomplished by a temporary influence on sagi ttal growth direction in the circummaxillary sutures and on rotational grow th direction in the TMJs, combined with a favorable natural remodeling and articular growth pattern. Conclusions: The mode of growth by which treatment aims were reached was pa rtly unexpected, i.e., discordant with the generally accepted principal con cept that treatment with the Herbst appliance positions the mandible forwar d.