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alveolar bone grafting
1.
2. Introduction
The successful treatment of patients
suffering from complete clefts of the lip
and palate requires a continuous
interdisciplinary therapy from birth until
early adulthood, which involves the
application of all available operative and
conservative procedures for treatment.
The osseous closure of the alveolar cleft,
is required for the formation of a regular
upper dental arch, occupies a special
position within the whole concept of cleft
lip and palate therapy.
4. Various Forms of Cleft Alveolus
Cleft between laterals & canine (most
common)Tessier classification: No.4
(Tessiers, 1976)
Cleft between centrals& Laterals
Tessier No.3 cleft
Between centrals Tessier No.0 cleft
More distally in the maxillary arch
Tessier No.5& No.7
5.
6. History
In 1901 – Von Eiselberg: Used pedicled flap (bone of little
finger) to fill alveolar cleft.
In 1908 – Lexur: Free bone graft in cleft
1914 – Drachter: Ist successful bone graft using tibial bone
and periosteum.
1931 – Veau: Classification of cleft & attempted tibial bone
graft in alveolar cleft.
1950 – Schmid: Successful ABG using iliac bone graft
1955 – Johanson & Nordin: Primary ABG using tibial bone
in a stage procedure lip, palate, alveolus – closure by 1 yr.
of age.
7. 1960 – Schuchardt & Pfeifer: Primary ABG using rib graft
at the time of lip closure.
1964–Pruzansky: Bone grafting should be delayed until
after eruption of permanent dentition
1968–Jolley: Detrimental effects of early bone graft on
maxillary growth
1972–Boyne&Sands: Protocol for secondary ABG
1983–Wolfe et al: Favourable result with calvarial bone
1987–Nique&Fonseca: ABG with allogenic bone
8. Developmental Anatomy
of
Alveolar Bone Premaxilla is a separate skeletal unit
(Moss )
It develops from median nasal process
Fusion of premaxilla with maxilla (at
Canine region)
Starts 8th week in utero
9. PHARYNGEAL ARCHES
Pharyngeal arches developes in the 4TH
and 5TH week.
5 Pharyngeal arches
Each arch contains cartilagenous muscular
and nerve components
Pre maxilla and maxilla developes from 1st
arch
10.
11. At about24 days – 1st arch –maxillary
and mandibular process
At about 28 days – lateral medial and
fronto nasal process
Formation of middle portion of lip
upper and portion of maxilla and
primary palate
12. At Birth
Premaxilla remains separate from maxilla
by suture
Closure of suture starts from 6-7 years of
age
Site of active osteogenesis
Antero Posterior Development of
Premaxilla influenced by
Intrinsic activity of membrananous bone
Vomer - premaxillary suture
Nasolabial muscles
Tongue Posture & Function
Tooth development
13. Cleft Alveolus due to
Failure of fusion of MNP &
maxillaryprocess
Ossification centres in the premaxilla &
maxilla cannot migrate & fuse cause cleft
alveolus
Vertical growth still active upto 9-10
years
Transverse & AP Growth 95%
Completed at 8yrs.
14.
15. Derivatives of the first pair of
the six pharyngeal arches
Maxillary prominence
Mandibular prominence
Facial development
17. Hereditary
Less than 40% of cleft lip & palate are
of genetic origin
Unaffected parents with a child who
has a cleft have a chance of (4.4%) a
second child with cleft
If one parent has a cleft there is 3.2%
chance that first born will have a cleft.
19. Incidence of Cleft
1:750 births in USA
Caucasians 1:1000 births
African American 1:2000 births
Asians 1:500 births
Isolated cleft palate 1:2000 births
Isolated cleft lip : 32%
Lip & palate 68%
Palate 2:1 :
Side - Left : Right: Bilateral Þ 6:3:1
20. Treatment Goals and
Objectives
Patient may Complaints of
Food or fluid coming out of their nose
Inability to blow balloon / suck a straw
A persistent smell / discharge from nose
Poor speech
Inability to clean their teeth in cleft area
Decayed / deformed teeth in cleft area
Missing / extra teeth in cleft area
Lack of bone support for teeth in cleft
area
Poor alignment of teeth
21. Mobility & overgrowth of premaxilla in
bilateral case
Lack of support for the ala, base of the
nose & lip (Columella in bilateral case)
22. Rationale for Closure of Cleft
Alveolus
To provide stability for maxillary arch
Mainly in mobile premaxilla – bilateral
case
To provides room for the canine and
lateral incisors to erupt into the arch into
stable alveolar bone and maintains bony
support of teeth adjacent to the cleft.
To close oronasal fistula
To construct pyriform rim & to provide a
better nasal symmetry
To prevent inferior turbinate prolapse into
cleft
23. Establishment of functional nasal airway
To support accurate nasolabial
reconstruction
Periodontal support for teeth lining the
cleft
Oral & dental health improved
Speech improved
Improved orthodontic result
Provide bony support for implant
placement
24. Timing of ABG
Primary (0–2.5 years, usually at the
time of lip repair)
Early secondary (2–5 years, before
the eruption of permanent incisors)
Secondary (6–13 years, before the
eruption of the permanent canines)
Late (> 13 years, after the eruption of
the permanent canines)
25. Primary ABG
primary alveolar bone grafting as that
which is performed simultaneously
with lip repair
any grafting that is performed at less
than 2 years of age is considered
primary grafting.
primary grafting as grafting that is
performed before the palate is
repaired.
26. Primary grafting performed at the time
of lip repair has failed to result in
acceptable outcome.
Long-term studies show
◦ abnormal maxillary development with
maxillary retrognathia,
◦ concave profile,
◦ increased frequency of crossbite
compared with patients without grafts.
27. Primary grafting performed after the
closure of the lip and before the
closure of the palate has proven
successful in a limited number of
centers when a very specific protocol
is followed.
Eppley B. Alveolar cleft bone grafting (part 1): Primary bone
grafting. J Oral Maxillofac Surg 1996;54:74–82.
11. Rosenstein SW. Early bone grafting of alveolar cleft
deformities. J Oral Maxillofac Surg 2003;61:1078–81.
28. Advantage
Early maxillary arch stabilization
Improved arch form with out collapse
Teeth adjacent to cleft erupt into grafted
bone.
Disadvantage
Maxillary growth affected(Sagittal &
Transverse Growth )
Compensatory changes in mandible
increased lower facial height
30. Early Secondary ABG
2 – 6 years of age
To provide support for eruption of
laterals
Disadvantage
Significant transverse growth and
sagittal growth may be affected
Literature not support the early
secondary grafting
31. Secondary
ABG
9-11 years
most commonly done before eruption
of canine
When ½ to 2/3rd of canine root has
formed
Only vertical growth remains at this
age.
Physiological migration &
spontaneous eruption through grafted
bone observed.
32. Rationale for grafting and for timing of grafting
during this time period include the following:
Minimal maxillary growth after age 6 to 7
years
The effect of grafting at this time will result in
minimal to no alteration of facial growth
Cooperation with orthodontic and
perioperative care is predictable.
The donor site for graft harvest is of
acceptable volume for predictable grafting with
autogenous bone
33. Bone volume may be improved by
eruption of the tooth into the newly
grafted bone
Grafting during this phase allows
placement of the graft before eruption of
permanent teeth into the cleft site - one
of the primary goals of grafting.
34. Factors Contributing to timing of
Grafting During the mixed dentition
Dental age vs chronologic age
Presence and position of the lateral
incisor
Degree of rotation/angulation of the
central incisor
Trauma/mobility of premaxillary segment
(bilateral clefts)
Size of the patient and of the cleft
Occlusion
Need for adjunctive procedures
Social issues
35. The graft be determined on the basis of
dental rather than chronologic age.
If a lateral incisor is present and appears
to be well formed, earlier grafting may be
beneficial
If the lateral incisor is located in the
posterior segment, earlier grafting may
be necessary to preserve the lateral
incisor
36. The maxillary permanent central incisor will
often erupt in a rotated and angled position If
a decision is made to rotate these teeth into
alignment, it may be necessary to graft the
alveolar defect prior to this orthodontic tooth
movement
Large defects, later grafting is often better, to
wait for growth of the patient and orthodontic
alignment of the cleft segments.
Patients are often evaluated for
velopharyngeal incompetence, minor
esthetic revision of the nose or the lip, and
pressure-equalizing tubes for otitis media
37. Late Secondary Grafting
Patients older than12 years of age
who undergo grafting have been
reported to have decreased success
when evaluated using the Bergland
scale, loss of osseous support of teeth
adjacent to the cleft, and increased
morbidity.
38. Pre Vs Post surgical
orthodontics
Controversy exists regarding the use of
orthopedic expansion of the cleft
segments and the relationship between
expansion and grafting
Most authors prefer presurgical
expansion because of less resistance,
improved access to the cleft for closure
of the nasal floor, better postoperative
hygiene, and less chance of reopening
the oronasal fistula
39. Orthodontic movement of the erupted
teeth adjacent to the cleft is another
controversial topic
Some authors suggest that aligning
the teeth adjacent to the cleft
produces better hygiene and an
improved result
40. History & Physical
Examination
Focused examination on:
Any previous repair
Oro nasal fistula
Alar support
Size of alveolar defect
Mal positioned teeth in cleft region
Alignment / cross bite of teeth
Position & mobility of premaxilla
Adequacy of soft tissue for tension free
closure
Oral hygiene
42. Pre Surgical Preparation of a
Patient
The Premaxillary Segment in bilateral
case stabilized by arch wire, Since
mobile premaxilla will cause the grafted
bone fail to consolidate.
Oral Hygiene Prophylaxis
Ortho treatment -Correction of cross
bite & alignment of arch
43. Supernumerary or Retained Deciduous
teeth in cleft area should be removed
atleast 6 – 8 week before surgery to
ensure adequate width & continuity of
soft tissue
flaps.
44. Treatment options for cleft
alveolus
Bone grafting
Gingivo periosteoplasty
Distraction osteogenesis
46. CANCELLOUS BONE CORTICAL BONE
Early vascularization Not Completely revascularised
for 2 months
Increased number of viable
cells
Relatively less
Apposition followed by
resorbtion
Resorbtion followed by
apposition
Completely replaced by new
bone
Remains as composite of new
&
necrotic bone
Greater mechanical strength
earlier
More susceptible to infection
47. Graft use for ABG
Site Advantages Disadvantages
Iliac
crest
•Large quantity of
cancellous bone.
•Decreased operative-
time with 2 team
approach.
•No growth
disturbance
•Easy to condense &
pack
•Proven successful
•Mild transient
gait
disturbance
•Donor site
morbidity
reported in
literature
48. Site Advantages Disadvantages
Proximal
tibia
•Adequate cancellous
bone
•Minimal soft tissue
dissection
•Two team approach
• Mild post-op
discomfort
•Less bone than
iliac bone
•Interferes with
growth
•(due to
epiphyseal
growth
•plate)
Rib
Two team approach
possible
Mainly used in primary
ABG
•Poor source of
cancellous bone
•Post-op-pain
•Visible scar
•Associated
morbidity
•Un predictable
result
49. Site Advantages Disadvantages
Cranial bone
•Incision hidden
in hair bearing
area
•Minimal postop
discomfort
•Sparse cancellous
bone
•Increased
operative time
•Associated
morbidity
•Poor results than
ilium
(less cellular)
•Stigma & fear for
patient
Mandible
symphysis
Same operative
field
Rapid post-op
recovery
No external scar
•Sparse amount of
•cancellous bone
•Associated
morbidity
•Poor result than
50. Type Advantages Disadvantages
Allogenic:
derived from a
genetically
unrelated
member of same
species
(osteoconductive
, osteoinductive
Comparable to
autogenous
Allows for
eruption of teeth
Avoids donor
site morbidity
No
osteogenic
potential
Delayed
incorporation
Alloplastic: inert
foreign body
material
(osteoconductive
, osteoinductive
Avoids donor
site morbidity
Delayed healing
Inability of teeth
to erupt
51. Surgical technique
Three basic surgical principles must
be satisfied for the successful
treatment of the alveolar cleft grafting:
(1) closure of oronasal fistula,
(2) adequate volume of graft material,
(3) water tight and tension-free
closure.
53. The closure of the nasal mucosa
and the introduction of the bone
graft to the alveolar defect.
Depiction of the nasal
mucosa flap along with the
closure of the oral mucosa.
54. Final mucosal
closure of the
oblique sliding flap.
A palatal splint placed
over the closure area
to prevent formation of
a hematoma and
stabilize the bone graft.
55. Bilateral alveolar cleft repair
A bilateral alveolar
cleft palate
Needle palpation of the
bony edges of the
alveolar cleft while
injecting local anesthesia
56. The incision line
(dashed line)
Elevation of the nasal mucosa
on the left and closure of the
nasal mucosa on the right.
Placement of the bone graft
over the closed
57. Palatal depiction of the movement of the adjacent
mucosa in the oblique sliding flap technique
59. Final closure of the bilateral alveolar
cleft repair using a oblique sliding flap
technique
60. Post-operative instructions
Liquid diet 7 days
Avoidance of trauma to the site
Antibiotics & nasal decongestants
Meticulous oral hygiene with
chlorhexidine
61. Complications
Failure of bone grafts (Mainly in
mobile
premaxilla)
Infection
Wound breakdown & loss of graft
(incomplete oral/nasal closure)
External root resorbtion
Bone loss
Residual fistula
62. Success of
ABG
Good nasal side closure
Use of adequate amount of cancellous
bone
A water tight oral side closure
Adequate amount of attached mucosa
in the area of cleft for development of
normal periodontal attachment of
erupting canine
63. Gingivo-Periosteoplasty
Boneless primary bone graft
Relies 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
64. Advantages
Repairs the cleft in
anatomic way by a
precise reconstruction
of the functional
matrix(mucoperiosteal
matrix of maxilla)
Avoids the need for
ABG
65. Distraction osteogenesis
Advantage
No need for bone graft
No donor site morbidity
Minimal surgical time
Bone height & width similar to normal
adjacent alveolus
Dental implants possible
Final orthodontic tooth movement is
good
Minimal morbidity
67. Conclusion
Although the repair of the alveolar cleft
may be one of the last considerations
in the global treatment of a cleft
patient, if these goals are achieved, it
provides tremendous enhancement of
oral function and aesthetics for a cleft
patient.
68. References
Peterson 2nd edition vol II
OUTLINE OF ORAL &MAXILLOFACIAL
SURGERY- Peterwardbooth vol II
Oral Maxillofacial Surg Clin N Am 14
(2002) 477–490
Medical embryology by langman