17 alveolar bone grafting - aligarh muslim … bone grafting.pdf · oronasal communication and a...
TRANSCRIPT
Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 80
University J Dent Scie 2017; No. 3, Vol. 1
Case Report
Keywords :
Bone grafting, Iliac crest.
Source of support : NilConflict of interest: None
Alveolar cleft,
ABSTRACT : When bone grafting is performed in the permanent dentition after the completion of
orthodontic treatment, it is called a tertiary or late graft. Tertiary grafts are performed to enable
prosthodontic and periodontal rehabilitation and to assist in the closure of persistent bucconasal
fistulae. A tertiary or late bone grafting cannot repair bone loss in teeth adjacent to the cleft. Grafted
cancellous bone fills in the residual alveolar cleft and is anatomically joined to the adjacent bone,
becoming indistinguishable in radiographic images after an average period of 3 months. Here we are
presenting a 21 yr old female patient treated with bilateral cleft lip and persistent unilateral cleft
alveolus, alveolar cleft was grafted using autogenous cancellous iliac bone graft.
1 2 3 4Vikas Kunwar Singh, Ruchika Tiwari, Sunil Sharma, Mridula Trehan1,2 3Reader, Professor & Head, Dept. of Oral & Maxillofacial Surgery
Mahatma Gandhi Dental College, Jaipur, India4Professor & Head, Dept. of Orthodontics & Dentofacial Orthopaedics
Mahatma Gandhi Dental College, Jaipur, India
INTRODUCTION : Secondary alveolar bone grafting of the
cleft alveolar ridge in the mixed dentition is a well-established
treatment for patients with cleft lip and palate (CLP). The
graft surgery has many reported benefits including
periodontal support for the cleft-adjacent teeth, establishment
of an osseous matrix for the eruption of permanent teeth,
closure of oronasal fistulae, and stabilization of the maxillary
segments in cases of bilateral CLP.1
The main difference in the interdisciplinary treatment
protocol in the management of cleft lip and palate is the timing
of bone grafting. Accordingly the graft may be classified as
primary, secondary and tertiary. When performed during
early childhood, at the same time as the primary repair
surgeries, bone graft is called as primary. Some authors
believe that this early procedure can cause impairment of the
maxillary growth. Bone grafting is called as secondary when
performed later at the end of the mixed dentition. It is the most
accepted procedure and is performed preferably before
eruption of the permanent canine in order to provide adequate
periodontal support for eruption and preservation of the teeth
adjacent to the cleft. When bone grafting is performed in the
permanent dentition after the completion of orthodontic
treatment, it is called a tertiary or late graft. Tertiary grafts are
performed to enable prosthodontic and periodontal
rehabilitation and to assist in the closure of persistent
bucconasal fistulae.2-6
Studies show that secondary bone grafting can repair the cleft
alveolus without increasing the already known iatrogenic
effect of primary surgeries on maxillary growth. 7, 8, 1
Secondary bone grafting has been extensively reported in the
literature, mostly by the Oslo cleft lip and palate (CLP) team,
9 and is based on the biological and technical principles
described by Boyne and Sands.6 Grafted cancellous bone
fills in the residual alveolar cleft and is anatomically joined to
the adjacent bone, becoming indistinguishable in
radiographic images after an average period of 3 months. This
structural incorporation has been histologically proved in
young Rhesus monkeys10and seems to occur more rapidly in
younger patients.
The traditional autogeneous donor sites for alveolar bone
grafting include the iliac crest, the mandible (chin and ramus),
the tibia and the calvarium 11. The iliac crest is the
goldstandard; it is easy to access and supplies large quantities
of cancellous bone with pluripotent or osteogenic precursor
cells that support early osteogenesis and neovascularization
within 3 weeks after grafting 12. Hence, it is our regular
choice of donor site.13
ALVEOLAR BONE GRAFTING OF ALVEOLAR CLEFT WITH CANCELLOUS ILIAC BONE GRAFT : A CASE REPORT
CASE REPORT : A 21 year old female patient reported to
Department of oral and maxillofacial surgery with unilateral
alveolar cleft on right side, was an operated case of bilateral
cleft lip four years back. On examination, there was an
oronasal communication and a wide alveolar cleft on the right
side. The surgical plan consisted of reconstructing the cleft
with cancellous iliac bone graft and closure of nasal and oral
defects. Prior to surgery, all the necessary preoperative blood
and radiographic investigations were carried out, surgery was
performed under general anesthesia and written informed
consent was taken prior to surgery.
TECHNIQUE FOR HARVESTING THE BONE
GRAFT : About 1 - 1.5 cm posterior to the anterior superior
iliac spine, a linear incision, 4 - 5 cm long is made over and
parallel to the iliac crest after slightly retracting the skin
upward. With gentle sharp dissection, we proceed directly to
the iliac crest. After exposing the iliac crest, an osteotome is
used initially to make vertical stop cuts into the iliac crest at
the two ends of the incision. Further, the ostetome is used to
“open” the bony crest while leaving it pedicled medially on its
muscular attachments and periosteum. A curette is used to
scoop cancellous bone while preserving the cortices. (fig1)
The graft is then gently minced and mixed into slurry with
blood aspirated from the donor site. The pedicled iliac crest
cap is returned like a trap door to its anatomical location and
held in place with 3-0 vicryl sutures after which the wound is
closed by layers in a standard method. (fig 2, 3)
Exposure, preparation of soft tissue envelope and closure of
the recipient site
The most important factors in accomplishing a successful
bone grafting are understanding and managing the soft tissues
and blood supply. Causes of failure include dehiscence and
resorption of the graft. Both of these can be minimized with
proper handling of the tissues and careful surgical planning.
Nasal intubation in noncleft nasal passage is preferred. The
anterior iliac crest graft is procured. A throat pack is placed,
and Lidocaine with epinephrine is infiltrated. A No. 15 blade
is used to create sulcular incisions facially and palatally, with
a vertical release at the premolar molar junction of the lesser
segment. The scalpel is then used to separate the oral and nasal
mucosa of the cleft fistula on both the labial and palatal sides.
On the labial side it is helpful to use scissors along the nasal
submucosa until the bone margin is reached. Finger pressure
on the bone while dissection is carried toward it prevents nasal
mucosal perforation. Periosteal elevators are used to elevate
three full-thickness mucoperiosteal flaps—the oral labial
flap, oral palatal flap, and nasal flaps. (Fig 4)
Care is used to ensure preservation of the greater palatine
vessels. Curved periosteal elevators are used to elevate the
nasal floor, allowing the nasal tissues previously drawn into
the oral cavity to retract superiorly. They are imbricated into
the nose and reapproximated using 4-0 resorbable vicryl
suture in a tension free manner (Fig 5).Once the nasal layer is
closed, the oral palatal tissues are reapproximated with 3-0
absorbable suture .The oral labial flap on the lesser segment is
then advanced as a buccal sliding fl ap. It will easily advance
one tooth segment if the periosteum is scored. A horizontal
mattress suture is placed in each interdental papilla, securing
the flaps in place.
The bone graft is fashioned into small pieces using Mayo
scissors or a rongeur.(Fig 6) It is then packed tightly into the
recipient site, allowing the nasal floor and alar rim to be lifted,
as well as the anterior maxilla to be reconstructed .(Fig 7)
Closure commences with horizontal mattress interrupted
sutures. By sliding the oral labial flap on the lesser segment
forward, the surgeon will achieve tension-free primary
closure. (Fig 8)
POSTOPERATIVE CARE : Patient was placed on a full
liquid diet for 1 week and then advanced to nonchewing foods
for an additional 2 weeks.
DISCUSSION : Joseph Daw and Pravin Katel16 observed
that historically, the management of alveolar clefts has lagged
behind the surgical correction of cleft lip and palate in terms
of appreciating its significance and in the evolution of
surgical techniques. This apparent lack of cognizance reflects
in our environment where many adult patients live with
alveolar cleft deformity despite having had their cleft lips and
palates repaired. Even from some more surgically developed
environments where alveolar bone grafting is already a
common place, very few reports on the outcome of adult
alveolar bone grafting emanate. This article reports outcome
of tertiary alveolar bone grafting in our center and the
rationale for our techniques.
The choice of iliac crest as a cancellous bone resource for
alveolar bone grafting is well supported in the literature.
6,8,11,12 It has easy access, large quantity, easy compaction,
rich and rapid revascularization, high volume of osteogenic
precursor cells and relatively low donor site morbidity as
advantages over cranial, t ibia and mandibular
bones.11,12,17,18 Although our harvesting technique is not
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 81
University J Dent Scie 2017; No. 3, Vol. 1
significantly different from the one described by Boyne and
sands6 , we introduced stop cuts at either end of the exposed
iliac crest and found it very helpful in preserving the integrity
of the iliac crest cap while flipping it medially. This block
harvest is usually minced and mixed with blood.
It is most essential to prepare adequate soft tissue envelope
before packing and compacting the cancellous chips into the
defect. To achieve this, the mucoperiosteal flaps were
extensively elevated to expose areas for graft augmentation.
The objective is to ensure adequate coverage of the grafts
while ensuring tension free closure. Uneventful soft tissue
healing is critical to the success of the graft.19
Persistent unhindered growth of the premaxilla in adult
alveolar cleft presents the worst deformation in bilateral cases
where presurgical orthopaedics and/or cleft lip repair were
not performed earlier.
The objectives of secondary bone grafting are the formation
of a continuous and stable dental arch, elimination of oronasal
fistulae, the provision of greater periodontal support for teeth
adjacent to the cleft and the augmentation of bony support for
the lip and alar base. These objectives depend on satisfactory
bone formation within the alveolar cleft. The three main
processes involved in physiology of bone graft are
osteoconduction, osteoinduction and osteogenesis.20, 21
CONCLUSION : The goals of bone grafting determine the
selection of grafting material such as cortical or cancellous,
membranous or endochondral. The recipient site
requirements of bone rigidity and bone regeneration need to
be considered as well as mechanical and physiologic
characteristics. All of these broad parameters will have an
impact on the bone graft – host bed and determine whether
complications will occur or not. In addition, vascularity, host-
bed, overall physiologic status of the patient, propensity of
infection and surgical expertise needs to be considered. Thus
success depends on panoply of variables including the
physiologic and mechanical properties of the graft material
and the biology of recipient site. Autogenous bone grafting is
a means to an end. The iliac crest is the goldstandard; it is easy
to access and supplies large quantities of cancellous bone with
pluripotent or osteogenic precursor cells that support early
osteogenesis and neovascularization within 3 weeks after
grafting. Hence, it is our regular choice of donor site for
alveolar bone grafting in cases of cleft lip and palate. This
produces less morbidity and reproducible results in our
alveolar bone grafting cases with excellent results
Fig 1: Iliac crest graft site exposed & graft being harvested.
Fig 2: Wound closure in donor site.
Fig 3: Preoperative picture of Right Cleft Alveolus with
Oronasal fistula
Fig 4: Flaps raised for nasal closure in cleft alveolus
Fig 5: Nasal layer closed
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 82
University J Dent Scie 2017; No. 3, Vol. 1
Fig 6: Harvested cancellous bone graft
Fig 7: Cancellous bone graft tightly packed at the recipient
site
Fig 8: Closure
REFERENCES
1. Turvey TA, Vig K, Moriarty J, Hoke J. Delayed
bone grafting in the cleft maxilla and palate: a
retrospective multidisciplinary analysis. Am J
Orthod. 1984;86:244-256.
2. Johanson B, Ohlsson A. Bone grafting and dental
orthopedics in primary and secondary cases of cleft
lip and palate. Acta Chir Scand 1961 ;122:112-124.
3. Friede H, Johanson B. A followup study of cleft
children treated with primary bone grafting. 1.
Orthodontic aspects.Scand J Plast Reconstr Surg
1974;8:88-103.
4. Lilja J, Moller M, Friede H, Lauritzen C, Petterson
LE,Johanson B. Bone grafting at the stage of mixed
dentition in cleft lip and palate patients. Scand J Plast
Surg Hand Surg1987;21:73-79.
5. Witsenburg B. The reconstruction of anterior
residual bone defects in-patients with cleft lip,
alveolus and palate. A review. J Maxillofac Surg
1985;13:197-208.
6. Boyne PJ, Sands NR. Secondary bone grafting of
residual alveolar and palatal clefts. J Oral Surg
1972;30:87-92.
7. Abyholm FE, Bergland O, Semb G. Secondary bone
grafting of alveolar clefts. A surgical/orthodontic
treatment enabling a non- prosthodontic
rehabilitation in cleft lip and palate patients.Scand J
Plast reconstr Surg.1981;15:127–140.
8. Enemark H, Sindet-Pedersen S, Bundgaard M.
Long-term results after secondary bone grafting of
alveolar clefts . J Oral Maxil lofacSurg.
1987;45:913–919.
9. Bergland O, Semb G, Abyholm FE. Elimination of
the residual alveolar cleft by secondary bone
grafting and subsequent orthodontic treatment. Cleft
Palate J.1986;23:175–205.
10. Boyne PJ. Use of marrow-cancellous bone grafts in
maxillary alveolar and palatal clefts.J Dent
Res.1974;53:821–824
11. Eppley, B.L. and Sadove, A.M. (2000) Management
of alveolar cleft bone grafting -State of the art. Cleft
Pal- ate-Craniofacial Journal, 37, 229-233.
12. Rawashdeh, M.A. and Telfah, H. (2008) Secondary
alveolar bone grafting: The dilemma of donor site
selection and morbidity. British Journal of Oral and
Maxillofacial Surgery, 46, 665-670.
13. Abramowicz, S., Katsnelson, A., Forbes, P.W., et al.
(2012) Anterior versus posterior approach to iliac
crest for alveolar cleft bone grafting. Journal of Oral
and Maxillo- facial Surgery, 70, 211-215.
14. Bähr, W. and Coulon, J.P. (1996) Limits of the
mandibular symphysis as a donor site for bone grafts
in early secondary cleft palate osteoplasty.
International Journal of Oral and Maxillofacial
Surgery, 25, 389-393.
15. Horswell, B.B. and Henderson, J.M. (2003)
Secondary osteoplasty of the alveolar cleft defect.
Journal of Oral and Maxillofacial Surgery, 61, 1082-
1090.
16. Daw, J.L. and Patel, P.K. (2004) Management of
alveolar clefts. Clinics of Plastic Surgery, 31, 303-
313.
17. Sadove, A.M., Nelson, C.L., Eppley, B.L., et al.
(1990) An evaluation of calvarial and iliac donor
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 83
University J Dent Scie 2017; No. 3, Vol. 1
sites in alveolar cleft grafting. Cleft Palate Journal,
27, 225-259.
18. Canady, J.W., Zeitler, D.P., Thompson, S.A., et al.
(1993) Suitability of the iliac crest as a site for
harvest of autogenous bone grafts. Cleft Palate-
Craniofacial Journal, 30, 579-581.
19. Petrungaro, P. (2001) Platelet-rich plasma for dental
implants and soft-tissue grafting. Interview by Arun
K. Garg. Dental Implantology Update, 12, 41-46.
20. Pedersen S, Enemark H: Reconstruction of alveolar
clefts with mandibular or iliac crest bone grafts: A
comparative study. J.Oral Maxillofac Surg 1990;
48: 554-558.
21. Precious DS, Smith W.P: The use of mandibular
symphyseal bone in maxillofacial surgery. Br J Oral
and Maxillofac Surg. 1992; 30: 148-152.
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 84
University J Dent Scie 2017; No. 3, Vol. 1