alveolar bone grafting

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Frederick Mars Frederick Mars Untalan MDUntalan MD

http://entmdclinic.blogspot.com/

2http://entmdclinic.blogspot.com/

RationaleDefinition of terms Type of Bone and Donor Site Techniques


400 %

300 %

> 500,000 bone graft procedures / year6http://entmdclinic.blogspot.com/

Vast number of :Vast number of :• Dental/maxillofacialDental/maxillofacial• Basic Basic

Science/AnimalScience/Animal• SpineSpine• Small seriesSmall series• Review articlesReview articles

46%46%25%25%

11%11%

5%5%

14%14%


Provide bone for the eruption and/or orthodontic repositioning of teeth

Closure of oro-nasal fistulasSupport and elevation of the alar

baseStabilization of the pre-maxilla in

bilateral casesProvide continuity of the alveolar

ridge8http://entmdclinic.blogspot.com/

Repair of Cleft Lip and Palate A Parent's Guide Susan M. Revesz, M.S.N., R.N. M. Haskell Newman, M.D. Karen L. Holtsberry, B.B.A. C.S. Mott Children's Hospital, Craniofacial Anomalies Program University of Michigan Medical Center


Background: The contemporary treatment of cleft lip and palate involves a sequence of surgical procedures and orthodontic management. Alveolar bone grafting (ABG) is usually undertaken after orthodontic expansion of the maxillary segments between the ages of eight and 12 years. Two of the important goals of alveolar bone grafting are the provision of bony support for the eruption of the canine and the closure of residual oro-nasal fistulae. The purpose of this study was to retrospectively evaluate the root development and eruption of the canine following ABG.

Methods: Group 1: radiographic and clinical records of a sample of 19 cleft patients who underwent alveolar bone grafting procedures, performed between 1996 and 1999 were reviewed. Group 2: a random sample of 15 cleft patients attending for routine dental review were clinically examined. The age of patient, degree of root development and eruption status of the canine, and presence of oronasal fistulae pre and post alveolar bone grafting were evaluated.

Results: Most cleft canines had continued root development and descended in the alveolus towards eruption following ABG. Four canine teeth (8 per cent) were impacted and required surgical exposure and orthodontic treatment following failure of eruption. Closure of anterior oro-nasal fistulae at the time of grafting was maintained post-operatively.

Conclusions: This study demonstrated that canine root development and eruption continued satisfactorily through grafted alveolar clefts in most cases and closure of anterior oro-nasal fistulae was achieved in all cases.

canine root development and eruption continued satisfactorily through grafted

alveolar clefts in most cases and closure of anterior oro-nasal fistulae was achieved in

all cases.


Primary Bone Grafting Bone graft done at the time of primary

cheiloplasty Bone graft done during the first 2 years

of life Bone graft done prior to the eruption of

the primary canine


Secondary Bone Grafting Early Intermediate (Secondary) Late


Done before eruption of the permanent canine

Usually when the root of the canine is 1/3 to 2/3 formed

Usually between ages 8-10 In CLP dental age is usually behind

chronological age


Performed most commonlyParticulate autogenous

cancellous bone

most common graftNo observed growth disturbance


Done before eruption of the permanent lateral incisor

Usually when the lateral is 1/3 to 2/3 formed

Ages 5-6Lateral incisor is frequently

hypoplastic


Done after eruption of the permanent canine

Usually during adolescence or adulthood

Sometimes done concomitantly with orthognathic surgery


Popular in the 1950’s -60’sUsually done in conjunction with

maxillary orthopedicsRib grafts placed either

simultaneously with lip repair or shortly after

Largely abandoned due to questions about maxillary growth and development

Still done in some centers


Rational Prevention of maxillary arch collapse Migration of teeth into the alveolar

process Stabilization of the pre-maxilla in

bilateral cases Support for the alar base

Dado DV. Early Primary Bone Grafting. In: Kernahan DA, Rosenstein SW, eds. Cleft Lip and Palate. A System of Management. Williams and Wilkins, Baltimore, 1990. pp 182-188.

Nelson CL: Primary Alveolar Cleft Bone Grafting. Oral Maxillofac Surg Clin NA 3:599, 1991.


Disadvantages Data suggest that primary bone grafting

has a negative effect on maxillary growth and nasolabial appearance

May necessitate further bone grafting in childhood due to insufficient alveolar bulk

Friede H, Johanson B: Adolescent facial morphology of early bone grafted cleft lip and palate patients. Scand J Plast Reconstr Surg 16:41-53, 1982

Trotman CA, etal: Comparison of facial form in primary alveolar bone-grafted and nongrafted unilateral cleft lip and palate patients. Cleft Palate Craniofac J 33:91, 1996


Management of Alveolar Clefts Anureet K. Bajaj, MD,Amnart A. Wongworawat, MD,Anil Punjabi, BDS, DDS, MD Loma Linda, California


Boneless primary bone graftRelies on the osteoinductive

capabilities of the periosteum

Skoog T: The use of periosteum and surgicel for bone restoration in congenital clefts of the maxilla. Scan J Plast Reconst Surg 1: 113, 1967

Wood RJ, Grayson BH, Cutting CB: Gingivoperiosteoplasty and midfacial growth. Cleft Palate Craniofac J 34:17-20, 1997

Carstens MH: Functional matrix cleft repair: principles and techniques. Clin Plast Surg 31:159-189, 2004


The primary gingivoperiosteoplasty by Millard consists of presurgical active orthognathic treatment (‘Latham device’) of the alveolar margins at the age of 3 months and of surgical closure of the alveolar cleft with local gingivoperiosteal flaps at the age of 5 months.

The aim of this investigation was to analyse the facial growth following this treatment.

The following material was studied: lateral head X-rays and plaster casts from 146 patients with unilateral (UCLP) and bilateral (BCLP) clefts of lip and palate from birth to 16 years of age. Ninety-one of these patients formed the control group, who received neither gingivoperiosteoplasty nor pre-surgical active orthognathic treatment. The same surgeon and orthodontist treated all 146 patients.

A three-dimensional growth disturbance after gingivoperiosteoplasty was observed: 42% patients with UCLP and 40% patients with BCLP had an ‘open bite’ following closure of the alveolar cleft (control group 5%/10%). The length of the upper jaw in patients who underwent gingivoperiosteoplasty was shorter than in the control group. The frequency of posterior cross bite was also higher in the gingivoperiosteoplasty group.

These results demonstrate that treatment with a ‘Latham device’ disturbs facial growth. Therefore, this treatment should be abandoned.

K.-O. Henkel and K.K.H. Gundlach Department for Maxillofacial Surgery (Head: Prof. K. K. H. Gundlach) Rostock

University, Germany

A three-dimensional growth disturbance after

gingivoperiosteoplasty was observed: 42% patients with UCLP and 40%

patients with BCLP had an ‘open bite’ following closure of the alveolar cleft

(control group 5%/10%)The length of the upper jaw in patients who underwent

gingivoperiosteoplasty was shorter than in the control group. The

frequency of posterior cross bite was also higher in the

gingivoperiosteoplasty group.26http://entmdclinic.blogspot.com/

Aim. The study evaluates the repair of residual alveolar cleft through secondary bone graft, consisting in the transplantation of autologous bone to restore the continuity of the maxillary arch and achieve normal functioning and esthetics.

Methods. During 2001-2002, 15 patients (age range 9-26 years; 7 males, 8 females) were submitted to secondary bone graft at the Maxillo-facial Surgery Operative Unit, University Hospital, Sassari. Eleven patients had complete unilateral cleft, 4 had complete bilateral cleft. All patients were operated upon by the same surgeon; they received a graft of autologous bone from the iliac crest. For preoperative and postoperative evaluation at 1 year, the following were utilised: plaster casts of the tooth arches, OPT, photographs and complete clinical documentation.

Results. Postoperative results were: 100% formation of a bone bridge between the maxillary segments; 70% closure of oro-nasal fistula; 100% maxillary stability; 80% spontaneous eruption of the canine within the graft; 70% height of alveolar ridge level I, 25% level II, 5% level III; 70% orthodontic closure; 80% optimal periodontal condition and 20% presence of gingival recession. In 1 subject the graft site became infected, in 4 cases an oro-nasal fistula remained.

Conclusion. This method was found to be the most valid one at present. The best period to intervene is during late childhood (9 years). Results and functional and esthetic recovery were satisfactory and encouraging to continue utilising this technique.

MINERVA STOMATOLOGICA Minerva Stomatologica 2004 October;53(10):571-80 De Riu G., Lai V., Congiu M., Tullio A.

the repair of residual alveolar cleft through secondary bone graft, consisting in the

transplantation of autologous bone

This method was found to be the most valid one at present. The best period to intervene

is during late childhood (9 years). Results and functional and esthetic recovery were satisfactory and encouraging to continue

utilising this technique.


Autogenous Cancellous- iliac crest▪ Block▪ Particulate

Cortical- calvarium, mandible▪ Bone dust▪ Blocks

Cortico-cancellous- iliac, rib, tibia, mandible (tibia and mandible only in late secondary grafting)


site advantage disadvantage consideration

iliumlarge quantity cancellous bone;

two teams mild transient gait disturbanceall clefts, particularly large

& bilateral clefts

calvaria

minimal posoperative discomfort; incision hidden; low

morbiditylimited cancellous/diploic bone;

increased operative timeunilateral clefts; lower

success

mandibular symphysis

same operative field; rapid procurement; minimal pain limited bone

older children with small defects

rib two teams

poor source cancellous bone; postoperative pain; visible scar;

risk of pneumothoraxnot recommended except

for primary grafting

proximal tibia

abundant cancellous bone; easy procedure; mild

postoperative pain; two teams -

not recommended in patients that have not

completed growth29

COMPARISON OF GRAFT SOURCESCOMPARISON OF GRAFT SOURCES



iliumlarge quantity cancellous

bone; two teamsmild transient gait

disturbanceall clefts, particularly large & bilateral clefts

calvaria




success




rib two teams




proximal tibia




completed growth30






& bilateral clefts

calvaria

minimal posoperative discomfort; incision hidden;

low morbiditylimited cancellous/diploic

bone; increased operative timeunilateral clefts; lower

success




rib two teams




proximal tibia




completed growth31






& bilateral clefts

calvaria




success


same operative field; rapid procurement; minimal

pain limited boneolder children with

small defects

rib two teams




proximal tibia




completed growth 32






& bilateral clefts

calvaria




success




rib two teams

poor source cancellous bone; postoperative pain;

visible scar; risk of pneumothorax

not recommended except for primary

grafting

proximal tibia




completed growth 33




iliumlarge quantity cancellous bone; two

teams mild transient gait disturbanceall clefts, particularly large &

bilateral clefts

calvariaminimal posoperative discomfort;

incision hidden; low morbiditylimited cancellous/diploic bone;


success




rib two teams

poor source cancellous bone; postoperative pain; visible scar; risk of

pneumothoraxnot recommended except for

primary grafting

proximal tibia

abundant cancellous bone; easy procedure;

mild postoperative pain; two teams -


completed growth

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•Autograft•Growth

Factors •Allograft•Biosynthetic•Composite•Future?


GOLD STANDARD

• Osteoconductive•Hydroxyapatite ,

Collagen• Osteoinductive

•BMP, TGF-B, ect• Osteogenic

•Osteoprogenitor cells


LIMITATIONS

•Limited Quantity•Limited Structure and

shape•Variable osteogenic

potential

•DONOR SITE MORBIDITY- 2-35%!


Bone grafting plays an important role in the dental rehabilitation of patients with alveolar cleft. During the period between 1993 and 2001, 12 patients with alveolar clefts have been treated in our clinic. Cancellous iliac bone grafts were used in all 12 patients. Seven patients had left and five patients had right complete unilateral cleft lip and complete cleft palate operations. All patients had palatal fistulas. The ages were between 4 and 18 years (mean age, 10.5 y). Seven of them were female (58.4%) and 5 were male (41.6%). All the cancellous grafts survived. Enough filling and the closure of the fistulas were achieved except one patient who had wound dehiscence and partial graft loss. The patients experienced a limp for 2 days (mean time) because of the donor site. This surgical procedure achieves successful results if it is used with the proper indication in suitable cases.

Journal of Craniofacial Surgery. 13(5):658-663, September 2002.Bilkay, Ufuk MD; Tokat, Cenk MD; Ozek, Cuneyt MD; Gundogan, Hakan MD; Gurler, Tahir MD; Tegsel, Zuhal MD; Songur, Ecmel MD

Cancellous iliac bone grafts

This surgical procedure achieves successful results if it is used with the proper indication in suitable

cases.


Background: Traditional practice for alveolar cleft closure requires postoperative hospital convalescence in an unfamiliar, disruptive hospital setting. An outpatient iliac crest alveolar bone grafting protocol was devised to optimize patient care.

Methods: A retrospective review of the senior author's experience over 5 years (1998 to 2004) of ambulatory alveolar cleft closure was compared with the previous 5-year period (1993 to 1998) of inpatient convalescence. An iliac crest donor site and standard techniques of alveolar grafting were followed in both groups. Although local analgesia with lidocaine and epinephrine was used in both groups, the ambulatory group received preemptive local anesthesia augmented with Marcaine. Postoperative nausea also was treated preemptively in the outpatient group with the addition of dexamethasone (Decadron) and ondansetron (Zofran), whereas the control patients were treated as needed. Patient charts were reviewed for demographic information, technical aspects, length of donor-site incision, bone graft volume, and time of operation. A Fisher's exact test was used for statistical analysis. Complications including morbidity, readmission, and reoperations were recorded.

Results: Twenty consecutive patients were treated on an outpatient basis. Eight consecutive patients were convalesced as inpatients in the previous 5-year period. The ambulatory series average patient age was 12.1 years (range, 8 to 15 years). Four bilateral proce-dures were performed. The follow-up period averaged 3.5 years (range, 5 to 76 months). Two minor complications were identified: cellulitis at a donor site and a recipient suture line dehiscence with minor graft exposure. There were no readmissions, revision operations, hernias, wound infections, or graft losses identified. In the inpatient series, the average stay was 1.8 days (range, 1 to 3 days). One gingival suture line dehiscence requiring no further intervention was identified, for an average complication rate of 12.5 percent, which was not significant compared with the ambulatory group (10 percent) (p = 1.00).

Conclusions: Alveolar cleft bone grafting using the iliac crest donor site can be safely performed on an outpatient basis when local pain control is followed by predictable anesthetic recovery and sufficient oral intake, and reliable motivated parents or caregivers provide a comfortable postoperative setting. Safe outpatient surgery provides patients and family the opportunity to recover in the familiar home environment.

Plastic and Reconstructive Surgery: 1 September 2005 - Volume 116 - Issue 3 - pp 736-739 Perry, Charles W. M.D.; Lowenstein, Adam M.D.; Rothkopf, Douglas M. M.D

Alveolar cleft bone grafting using the iliac crest donor site can be safely performed on an outpatient basis

when local pain control is followed by predictable anesthetic recovery and sufficient oral intake, and reliable motivated parents or caregivers

provide a comfortable postoperative setting.


Allogeneic Graft resorbs, remodels, may contribute to

osteoinduction and osteoconductionNique T, Fonseca RJ, et al: Particulate allogeneic bone

grafts into maxillary alveolar clefts in humans- A preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987

Alloplast Bone grows into, around alloplast No active osteoinduction but some osteoconduction Teeth do not erupt through alloplastHorswell BB, El Deeb M: Nonporous HA in the repair of

alveolar cleft defect in a primate model. J Oral Maxiilofac Surg 47:946-952, 1989


Before Alveolar Bone Grafting Primarily for later secondary grafting Optimal positioning of cleft segments

and reorientation of teeth collapsed into defect

After Alveolar Bone Grafting Earlier secondary grafting


The ideal technique will meet the following criteria:

Predictable closure of the nasal floor produces a watertight barrier between the graft and the nasal cavity

There is access to closure of residual palatal and labial fistula

Keratinized attached tissue is maintained around the teeth adjacent to the cleft and in the site where the yet unerupted lateral incisor and caninewill erupt

Mobilization of tissue is adequate to close large defects without tension,when such defects are present

The vestibule is not shortened, and scarring is not excessive


Incision and flap design for unilateral cleft defect repair

Sulcular incision are used to develop sliding flaps

Hall HD, Posnick JC. Early results of secondarybone grafts in 106 alveolar clefts. J OralMaxillofac Surg 1983;41:289–94.


Elevation of labial and buccal mucoperiosteal flaps

Creation of labial and palatal flaps after excision of intradefect fistula 46http://entmdclinic.blogspot.com/

Buccal flap elevated superiorly

Palatal flaps elevated and pushed posteriorly

Palatal flaps are developed sharply with scissors. This also separates the nasal mucosafrom the palatal tissue.


Closure of nasal floor mucosa superiorly (NF) and palatal mucosa (PM) posteriorly

NFNF

PM

Palatal closure .This can be done before or after the nasal mucosa is closed


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Nasal mucosal flaps are reflected from the bony walls of the cleft.

Nasal flaps are approximated withsutures burying the knots when possible


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Bone is packed into the defect with a periosteal elevator or orthodontic band pusher. Digital pressure against the palatal flap facilitates packing and protects the palatal closure

Placement of particulate cancellous bone into defect


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The labial flaps are advanced toward each other and closed. This provides attached keratinized tissue. Exposed areas distally where the flaps have been advanced are left to granulate http://entmdclinic.blogspot.com/

Labial pedicled “finger” flap elevated to cover bone graft as alternative to sliding buccal mucoperiosteal flap


Bone in a healthy person will adapt to the loads it is placed under.

If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist

that sort of loading. The external cortical portion of the bone

becomes thicker as a result.57http://entmdclinic.blogspot.com/

58

Frederick Mars Frederick Mars Untalan MDUntalan MD


alveolar bone grafting

Documents

primary alveolar bone

alveolar bone grafting

secondary bone grafting

primary canine http

early primary bone grafting

alveolar ridge http

centers http

hypoplastic http