The Cleft PalateCraniofacial Journal 00(00) pp.

000000 Month 2015

Copyright 2015 American Cleft PalateCraniofacial Association

ORIGINAL ARTICLE

Cephalometric Outcomes of Maxillary Expansion and Protraction in Patients

With Unilateral Cleft Lip and Palate After Two Types of Palatoplasty
Wakako Tome, D.D.S., Ph.D., M.Orth.R.C.S.(Edin), Kohtaro Yashiro, D.D.S., Ph.D., Mikihiko Kogo, D.D.S., Ph.D.,
Takashi Yamashiro, D.D.S., Ph.D.

Objective: To clarify the differences in the long-term effects of maxillary expansion (ME) and
protraction (MP) in patients with complete unilateral cleft lip, alveolus, and palate (UCLP)
undergoing two types of palatoplasty.
Design: Retrospective longitudinal study.
Setting: Institutional study.
Patients and Interventions: Thirty-eight patients with UCLP treated at Osaka University Dental
Hospital, Japan, were divided into two groups: 19 patients were treated using Wardill-Kilner
push-back palatoplasty (PB), and 19 patients were treated with early two-stage palatoplasty
according to the modified Furlow technique (ETS). All patients exhibited a short maxilla at the
initial orthodontic visit and were treated with ME using a quad helix appliance and MP with a face
mask. Lateral cephalometric data recorded in the initial stage were compared with those
obtained at the end of treatment.
Main Outcome Measurements: The dentoskeletal features and facial soft tissue profile were
evaluated before and after orthodontic treatment. The variation and rate of change during
treatment were also calculated. The Mann-Whitney U test was used for the statistical analyses.
Results: The ETS group showed significantly greater SNA, SNB, and U1-Pp angles and
smaller SN-Mp angles than the PB group after face mask treatment. The variation in the
anteroposterior length of the maxilla during treatment was significantly greater in the ETS group
than in the PB group.
Conclusions: Maxillary protraction was more efficiently accomplished in the patients with
UCLP after early two-stage palatoplasty compared with push-back palatoplasty.

KEY WORDS: early two-stage palatoplasty, Furlow palatoplasty, orthodontic treatment, unilateral
cleft lip and palate, Wardill-Kilner push-back palatoplasty

In patients with cleft lip and palate, various types of
palatoplasty have been attempted to prevent postoperative
maxillary deciency. The push-back method (PB) has
become widespread; however, apparent maxillary deformi-
ties have been found after surgery (Ross, 1970; Smahel,
1989; Fujita et al., 2005). In consideration of the effect on
speech and maxillary growth, the early two-stage Furlow
method (ETS; Nishio et al., 2001) has been adopted. In the
Dr. Tome is Assistant Professor, Department of Orthodontics and
Dentofacial Orthopedics, Graduate School of Dentistry, Osaka
University, Osaka, Japan. Dr. Yashiro is Associate Professor,
Department of Orthodontics and Dentofacial Orthopedics, Graduate
School of Dentistry, Osaka University, Osaka, Japan. Dr. Kogo is
Professor, Department of Oral and Maxillofacial Surgery, Graduate
School of Dentistry, Osaka University, Osaka, Japan. Dr. Yamashiro
is Professor, Department of Orthodontics and Dentofacial Orthope-
dics, Graduate School of Dentistry, Osaka University, Osaka, Japan.
There were no conict of interests or grants for this study.
Submitted March 2015; Revised July 2015; Accepted July 2015.
Address correspondence to: Dr. Kohtaro Yashiro, Department of
Orthodontics and Dentofacial Orthopedics, Graduate School of
Dentistry, Osaka University, 1-8 Yamada-Oka, Suita, Osaka 565-
0842, Japan. E-mail yashiro@dent.osaka-u.ac.jp.
DOI: 10.1597/15-082
ETS method, the soft palate is closed using Furlow double-
opposing Z-plasty at 12 months of age, and the hard palate
is closed after 6 months.
Some researchers have reported differences in maxil-
lary growth and occlusion between patients treated PB
and ETS methods (Kitagawa et al., 2004; Yamanishi et
al., 2009; Nishio et al., 2010; Yamanishi et al., 2011).
Signicantly longer anteroposterior palatal lengths and
better crossbite scores are observed in patients at 4 years
of age, on average, among those treated with ETS than
those treated with PB. Our previous report (Tome et al.,
in press) also demonstrated more anteriorly positioned
upper central incisors and lips in the ETS group versus the
PB group at 7 years of age.
At the age of entering elementary school (6 to 7 years of
age), when the upper anterior permanent incisors erupt,
patients with complete unilateral cleft lip, alveolus, and
palate (UCLP) and their family members often recognize
the need for orthodontic treatment, complaining of
dissatisfaction with their facial/dentoalveolar appearance.
Although maxillary deformities can result from palatoplas-
ty, the effects of different protocols of palatoplasty on the

0
0 Cleft PalateCraniofacial Journal, May 2016, Vol. 53 No. 3

TABLE 1 Denitions of Feature Variables Used in This Study

Variable Denition

Skeletal and dental

Angular measurements
SNA The anteroposterior position of point A relative to the anterior cranial base
SNB The anteroposterior position of point B relative to the anterior cranial base
ANB The anterior-posterior discrepancy between the maxilla and the mandible
SN-Mp The angle between the SN line and Mp (mandibular plane) line
SN-Rp The angle between the SN line and Rp (ramus plane) line
SN-Pp The angle between the SN line and Pp (palatal plane) line
GoA The angle between the Rp line and Mp line
Maxillary length
ptm-A/PP The distance between point A and ptm projected on the palatal plane, respectively
ptm-ANS/PP The distance between ANS and ptm projected on the palatal plane, respectively
Mandibular length
Go-Me The linear between Go and Me
Ar-Go The linear between Ar and Go
Ar-Me The linear between Ar and Me
Dental relations
U1/PP The angle between the upper incisor axis and Pp line
U1 to NA The distance of the most anteriorly placed point of upper incisor to NA line
U1-FH The distance between U1 to the FH plane
U1-PP The distance between U1 to the palatal plane
U6-FH The distance between U6 to the FH plane
U6-PP The distance between U6 to the palatal plane
Overbite The vertical projection of upper incisor beyond the lower incisor, measured perpendicular to the occlusal plane
Overjet The horizontal projection of upper incisor beyond the lower incisor, measured parallel to the occlusal plane
Soft tissue
Facial contour angle It is contained between lines drawn from Glabella (G) to Subnasale (Sn) and a line connecting soft Pogonion (Pogs)
and Sn
Nasolabial angle The angle between a line tangent to the base of the nose and a line tangent to the upper lip
Upper lip to E-line The distance of the upper lip to the E-line
Nose prominence The distance between the tip of the nose and a perpendicular line drawn to the Frankfort plane from the vermillion

outcomes of maxillary expansion (ME) and protraction
(MP) treatment remain unknown. Therefore, the purpose
of this study was to investigate whether the outcomes of
orthodontic treatment differ after two types of palatoplas-
ty. The ndings of this report are expected to provide
insight into the capability of growth modication following
ME and MP in patients with UCLP.
PATIENTS AND METHODS
Patients
The subjects consisted of 38 patients with UCLP who
were divided into two groups: the ETS group (9 boys and
10 girls; mean age, 7 years 2 months; treated with early
two-stage Furlow palatoplasty; Nishio et al., 2001) and the
PB group (12 boys and 7 girls; mean age, 7 years 5 months;
treated with one-stage PB between 12 and 18 months). In
the ETS group, the hard palate was closed by two sets of
mucoperiosteal aps on the oral and nasal side. The lateral
relaxing incision was routinely performed. All patients
received palatoplasty at Osaka University Dental Hospital
First Department of Oral and Maxillofacial Surgery
(Osaka, Japan). To eliminate technical bias, all palatoplas-
ty procedures were performed by the same senior surgeon.
All patients exhibited a short maxilla on the initial
visit to the orthodontic clinic and were treated using
maxillary expansion with a quad helix appliance and
protraction with a face mask. The average treatment
period using a face mask was 27.3 months in the ETS
group and 29.4 months in the PB group. The
orthodontic treatments were performed by experienced
orthodontists who had already completed a university
postgraduate program in orthodontics. This study was
approved by the ethics committee.
Measurements
Lateral cephalometric radiographs were taken in the
initial treatment stage (mean age, 7 years 2 months in
the ETS group and 7 years 5 months in the PB group)
and at the end of orthodontic treatment (mean age, 11
years 6 months in the ETS group and 11 years 5 months
in the PB group). All cephalometric radiographs were
traced and measured by one examiner. Each cephalo-
metric radiograph was measured twice, and the mean
value was used. A total of 10 randomly selected
cephalometric radiographs were reexamined to calculate
the intraexaminer error after an interval of 1 day. The
reference points and measurements are shown in Table
 Tome et al., MAXILLARY PROTRACTION OUTCOMES AFTER TWO TYPES OF PALATOPLASTY 0

TABLE 2 Comparison Between the ETS Group and the PB Group

PB Group (n 19) ETS Group (n 19)

Comparison Between ETS and
Pretreatment Posttreatment Pretreatment Posttreatment PB Group After Treatment
Rate of Rate of 95% Condence
Mean SD Mean SD Change (%) Mean SD Mean SD Change (%) P Value Interval

SNA, 8 78.4 3.5 74.7 4.5 4.7 79.2 3.8 77.9 3.4 1.6 .018 5.87 to 0.60
SNB, 8 75.3 3.2 74.1 3.2 1.5 76.3 3.2 76.3 2.9 0.0 .033 4.15 to 0.12
ANB, 8 3.1 2.6 0.6 2.9 69.2 2.9 3.3 0.9 2.9 62.2 .743 2.98 to 0.77
SN-Mp, 8 41.1 5.1 41.8 5.7 2.0 37.5 4.3 37.7 4.8 0.7 .020 0.67 to 7.54
SN-Rp, 8 92.2 5.0 93.2 5.3 1.1 89.6 5.1 91.6 5.6 2.3 .379 2.02 to 5.18
SN-Pp, 8 11.1 4.3 9.3 4.3 11.9 9.4 6.7 7.5 5.2 34.2 .257 1.16 to 5.11
GoA, 8 128.9 6.8 128.2 7.8 0.5 128.1 6.3 126.1 7.2 1.5 .387 2.81 to 7.07
ptm-A/PP, mm 44.0 3.1 42.5 3.7 3.3 43.8 2.8 44.1 3.6 0.3 .196 3.94 to 0.94
ptm-ANS/PP, mm 45.8 3.3 48.1 4.0 4.9 46.3 3.1 49.1 3.5 6.0 .407 3.47 to 1.52
Go-Me, mm 60.7 3.2 68.2 2.6 12.6 60.6 4.2 67.9 4.8 12.3 .835 2.27 to 2.80
Ar-Go, mm 36.7 4.4 41.4 3.6 13.8 38.9 3.6 43.5 3.9 11.4 .514 4.18 to 0.50
Ar-Me, mm 90.1 4.7 100.7 4.6 12.0 91.7 4.5 101.8 5.7 10.9 .101 4.35 to 2.46
U1/PP, 8 89.2 11.5 105.6 8.8 20.1 92.6 10.2 111.7 7.5 22.1 .027 11.51 to 0.75
U1 to NA, mm 5.7 3.7 4.0 2.8 164.8 3.3 4.3 4.3 3.7 259.6 .787 2.45 to 1.87
U1-FH, mm 45.9 5.1 53.2 5.2 16.5 45.9 3.4 52.4 3.4 14.4 .586 2.12 to 3.70
U1-PP, mm 25.2 3.3 27.7 2.9 11.3 25.8 2.4 27.9 2.2 8.7 .755 1.96 to 1.43
U6-FH, mm 36.2 4.8 44.4 4.4 24.2 36.1 5.5 44.4 3.7 24.9 .984 2.70 to 2.65
U6-PP, mm 16.4 3.9 20.1 3.0 31.4 17.4 4.3 20.7 2.0 26.9 .470 2.29 to 1.07
OB, mm 2.1 1.7 1.8 1.8 21.1 2.1 1.6 1.3 2.0 64.4 .456 0.80 to 1.75
OJ, mm 4.6 2.0 0.3 4.1 131.3 3.4 3.4 0.1 3.3 102.5 .894 2.60 to 2.33
Facial contour angle, 8 1.9 5.5 5.0 5.5 164.3 3.8 6.2 3.7 6.1 60.1 .509 2.57 to 5.08
Nasolabial angle, 8 95.4 17.2 86.6 13.8 6.2 94.0 12.9 88.3 13.0 4.7 .688 10.59 to 7.06
Upper lip to E-line, mm 1.5 2.0 1.2 2.3 37.0 0.7 2.4 0.8 2.4 71.7 .541 1.98 to 1.06
Nose prominence, mm 8.2 2.2 10.5 2.5 32.0 7.2 2.9 9.7 2.6 48.2 .356 0.89 to 2.42

1. The details of the denitions are described in our
previous report (Tome et al., in press).
The variation and rate of change during treatment
were also calculated. The characteristics of the dental,
skeletal, and facial proles after orthodontic treatment
were compared using the Mann-Whitney U test.
The statistical analysis was performed using a
statistical analysis software program (SPSS v17.0, SPSS
Inc., Chicago, IL). The signicance of coefcients and
mean differences was tested at the a .05 level.
RESULTS
Comparison of the Measurements After Maxillary
Protraction Treatment
According to Students t test for paired samples, there
was no statistically signicant intraexaminer error. The
intergroup comparison between the ETS group and PB
group after treatment using a face mask is shown in
Table 2 and Figure 1. The ETS group showed
signicantly greater SNA and SNB angles than the PB
group (P .018 and .033, respectively). A signicant
difference in the U1-Pp angle was also observed between
the two groups (P .027).
There were no signicant differences in the antero-
posterior length of the maxilla or the ANB angle
between the ETS and PB groups. The PB group
exhibited greater SN-Mp angles than the ETS group
(P .020). Each subject group exhibited reduced
overjet. Moreover, there were no signicant differences
in the distance from E-line to the upper lip after using a
face mask between the two groups.
Comparison of the Variation and Rate of Change During
Treatment
The variation of SNA was signicantly smaller in the
ETS group than in the PB group (P .016). The
variation in the length of ptm-A/PP between the pre-
and posttreatment values was signicantly greater in the
ETS group than in the PB group (P .031; Table 3).
Meanwhile, there were no signicant differences in the
variation in the length of ptm-ANS/PP between the two
groups (P .440).
The variation in the distance from the E-line to the
upper lip between the pre- and posttreatment values was
signicantly smaller in the ETS group than in the PB
group (P .011). The distance from the E-line to the
upper lip was reduced in the ETS group compared with
that observed in the PB group.
DISCUSSION
A previous report of children with UCLP at 4 years of
age (Yamanishi et al., 2009; Nishio et al., 2010; Yamanishi
et al., 2011) demonstrated longer anteroposterior lengths of
the maxilla and larger overjet in the children treated with
ETS than in those treated with PB. In our previous study,
we found that ETS results in a favorable facial prole with
0 Cleft PalateCraniofacial Journal, May 2016, Vol. 53 No. 3

TABLE 3 Changes During Treatment

PB ETS P
Group Group Value 95% CI

SNA, 8 3.71 1.29 .016 4.35 to 0.49

SNB , 8 1.18 0.03 .089 2.50 to 0.18
ANB, 8 2.53 1.26 .189 3.18 to 0.65
SN-Mp, 8 2.87 0.21 .244 1.84 to 7.15
SN-Rp, 8 0.97 2.05 .339 3.33 to 1.18
SN-Pp, 8 1.79 2.13 .813 2.57 to 3.25
GoA, 8 0.66 1.97 .314 1.30 to 3.93
ptm-A/PP, mm 1.47 0.16 .031 3.10 to 0.17
ptm-ANS/PP, mm 2.24 2.74 .440 1.80 to 0.80
Go-Me, mm 7.53 7.37 .882 1.98 to 2.29
Ar-Go, mm 4.68 4.34 .734 1.68 to 2.36
Ar-Me, mm 10.68 9.97 .614 2.12 to 3.54
U1/PP, 8 16.37 19.16 .495 11.00 to 5.43
U1 to NA, mm 9.66 7.58 .125 0.61 to 4.77
U1-FH, mm 7.34 6.53 .430 1.26 to 2.89
U1-PP, mm 2.47 2.13 .676 1.30 to 1.99
U6-FH, mm 8.21 8.34 .925 2.93 to 2.67
U6-PP, mm 3.68 3.32 .762 2.08 to 2.82
OB, mm 0.29 0.82 .425 0.80 to 1.85
OJ, mm 4.26 3.22 .419 1.55 to 3.64
Facial contour angle, 8 3.08 0.11 .124 0.90 to 7.27
Nasolabial angle, 8 8.82 5.63 .562 14.21 to 7.84
Upper lip to E-line, mm 0.24 1.46 .035 0.14 to 3.25
Nose prominence, mm 2.31 2.50 .775 1.56 to 1.17
FIGURE 1 Schematic diagram of the facial and dentoskeletal features
of the patients after maxillary protraction treatment in each subject
group. location of point A (Bongaarts et al., 2008). The most
meaningful ndings of this study are that the point A in the
more anteriorly positioned upper incisors compared with ETS group was displaced anteriorly, instead of ndings
PB at the early mixed dentition stage (Tome et al., in press). indicating relatively greater proclination of the upper
At the early mixed dentition stage, patients with UCLP incisors. Considering the more anterior position of the
complain of a concave facial prole with an anterior and upper incisor after ETS as compared with PB at 7 years of
posterior crossbite. Therefore, the important clinical age (Tome et al., in press), it can be inferred that although
question remains as to whether the type of palatoplasty PB is technically easier and yields good immediate results,
inuences the effects of early treatment intervention in there may be considerable scarring (Markus et al., 1993),
order to address these problems. which can be detrimental to the response of the maxillary
Although care should be taken with respect to the dental arch in the incisor region.
interpretation of cephalometric ndings concerning pa- Biomechanically, it has been reported that maxillary
tients with UCLP at younger ages, there are no better expansion effectively facilitates orthopedic treatment of
alternative points than the traditional points of A, ANS, MP (Chen et al., 2013). Based on our results, the ETS group
and PNS (Bongaarts et al., 2008). Similar amounts of showed greater SNA angles; that is, the maxilla was located
anterior shift at ANS were found in the ETS and PB groups more anteriorly compared with that observed in the PB
in this study. On the other hand, the face mask treatment group after treatment. However, there were no signicant
displaced the point A anteriorly after the ETS treatment, differences in the ptm-A/PP between the ETS and PB
whereas it displaced the point A posteriorly after the PB groups. In terms of lateral expansion and protraction of the
treatment. The sensitivity of the point A location to the maxilla in children with UCLP, it can be stated that ETS
tooth root that molds the anterior contour of the maxilla may have a favorable inuence on the anteroposterior
(Hotz and Gnoinski, 1976) may have had a controversial position of the maxilla rather than the bony size.
inuence of MP between point A and ANS in the PB group. In a previous study, the mandible in the UCLP group
Based on the veried reproducibility of identifying the was rotated inferiorly and posteriorly, while the control
cephalometric landmarks by a single examiner in this study, group showed inferior and anterior changes (Dogan, 2012).
it seems likely that the palatal movement of the incisor root Prior to puberty, MP accelerates maxillary forward growth
resulting from the proclination of the upper incisor by MP in UCLP patients, with changes similar to those observed in
may lead to signicant posterior displacement of point A noncleft patients. The occlusal relationship and soft tissue
after PB. A previous investigation of reliability for prole are improved signicantly in both patients with and
identifying point A in patients with UCLP veried that without cleft palate. Because of the vertical displacement of
the position of the incisor is the most important factor the upper molar, the amount of mandibular posterior
increasing the horizontal distribution of the measured rotation in patients with UCLP is larger than that seen in
 Tome et al., MAXILLARY PROTRACTION OUTCOMES AFTER TWO TYPES OF PALATOPLASTY
those with no cleft (Jia et al., 2008). In the present study, the
SN-Mp angle was signicantly greater and the SNB angle
was smaller in the PB group than in the ETS group.
Meanwhile, there were no signicant differences in the
vertical displacement of the upper molar between the two
groups. Based on the fact that children with UCLP have a
tendency for mandibular posterior rotation (Jia et al.,
2008), the current ndings imply that the tendency toward
posterior rotation of the mandible in children after ETS
may be reduced as a result of the relatively anteriorly
positioned maxilla following expansion and protraction.
There were no signicant differences in the ANB angle
between the ETS and PB groups. These ndings suggest
that the, although not signicant but relatively large,
backward rotation of the mandible during face mask
treatment observed in the PB group masked the actual
anteroposterior skeletal relationship of the maxilla and
mandible. Accordingly, the current ndings are in agree-
ment with the reported more favorable treatment results of
ETS versus PB (Wells et al., 2006).
Regarding the soft tissue prole, no signicant differ-
ences in the upper lip prominence or nasolabial angle were
found between the two groups after face mask treatment in
the current study, despite the signicant differences in the
SNA angle and the upper incisor relative to the palatal
plane. One possible reason for this nding is that the upper
lip prominence is affected by the anteroposterior position of
the maxilla and upper incisors as well as the presence of scar
tissue after cleft lip repair or as a result of the lip thickness.
CONCLUSION
This study focused on the effects of different types of
palatoplasty on the orthodontic treatment outcomes. As a
result, we found that early two-stage palatoplasty and
performing early orthodontic treatment bring about more
favorable skeletal relationships of the maxilla and mandible
in patients with UCLP compared with that seen in patients
treated using PB. Therefore, in the multidisciplinary team
approach to the care of patients with CLP, it is necessary to
consider that the selection of the type of palatoplasty can
have an effect on the orthodontic treatment outcome.
0
REFERENCES
Bongaarts CA, vant Hof MA, Prahl-Andersen B, Kuijpers-Jagtman
AM. Identication of cephalometric landmarks in unilateral cleft
lip and palate patients: are there alternatives for point A, ANS, and
PNS? Cleft Palate Craniofac J. 2008;45:8186.
Chen Z, Pan X, Shao Q, Chen Z. Biomechanical effects on maxillary
protraction of the craniofacial skeleton with cleft lip and palate
after alveolar bone graft. J Craniofac Surg. 2013;24:446453.
Dogan S. The effects of face mask therapy in cleft lip and palate
patients. Ann Maxillofac Surg. 2012;2:116120.
Fujita S, Suzuki A, Nakamura N, Sasaguri M, Kubota Y, Ohishi M.
Retrospective evaluation of craniofacial growth of Japanese
children with isolated cleft palate: from palatoplasty to adolescence.
Cleft Palate Craniofac J. 2005;42:625632.
Hotz M, Gnoinski W. Comprehensive care of cleft lip and palate
children at Zurich university: a preliminary report. Am J Orthod.
1976;70:481504.
Jia H, Li W, Lin J. Maxillary protraction effects on anterior crossbites:
repaired unilateral cleft versus noncleft prepubertal boys. Angle
Orthod. 2008;78:617624.
Kitagawa T, Kohara H, Sohmura T, Takahashi J, Tachimura T,
Wada T, Kogo M. Dentoalveolar growth of patients with complete
unilateral cleft lip and palate by early two-stage Furlow and push-
back method: preliminary results. Cleft Palate Craniofac J.
2004;41:519525.
Markus AF, Smith WP, Delaire J. Primary closure of cleft palate: a
functional approach. Br J Oral Maxillofac Surg. 1993;31:7177.
Nishio J, Adachi T, Kashima Y, Hirano Y, Sako M. A new designed
two-stage palatoplasty using Furlows veloplasty. Transactions of
the 9th International Conference on Cleft Palate and Related
Craniofacial Anomalies. Goteborg, Sweden; 2001:173276.
Nishio J, Yamanishi T, Kohara H, Hirano Y, Sako M, Adachi T,
Mukai T, Miya S. Early two-stage palatoplasty using modied
Furlows veloplasty. Cleft Palate Craniofac J. 2010;47:7381.
Ross RB. Clinical implications of facial growth in cleft lip and palate.
Cleft Palate J. 1970;7:3747.
Smahel Z. Effect of certain therapeutic factors on facial development
in isolated cleft palate. Acta Chir Plast. 1989;31:3547.
Tome W, Yashiro K, Otsuki K, Kogo M, Yamashiro T. Inuence of
different palatoplasties on the facial morphology of early mixed
dentition stage children with unilateral cleft lip and palate. Cleft
Palate Craniofac J. In press.
Wells AP, Sarver DM, Proft WR. Long-term efcacy of reverse pull
headgear therapy. Angle Orthod. 2006;76:915922.
Yamanishi T, Nishio J, Kohara H, Hirano Y, Sako M, Yamanishi Y,
Adachi T, Miya S, Mukai T. Effect on maxillary arch development
of early 2-stage palatoplasty by modied Furlow technique and
conventional 1-stage palatoplasty in children with complete
unilateral cleft lip and palate. J Oral Maxillofac Surg.
2009;67:22102216.