Secondary grafting in the alveolar cleft patient

Anterior Dental Implant in Grafted Cleft Alveolus: A Clinical Comparison Between Intramembranous and Endochondral Bone Graft

BACKGROUND

Alveolar bone graft is usually performed during the early mixed dentition phase, at the chronological age of 6 to 8 years old, to reconstruct the cleft alveolus. As the appropriate time for implant placement is after completion of full growth, it can result in a likelihood of resorption. The aim of this study is to compare the clinical outcomes of anterior dental implants with delayed bone grafting using iliac crest (endochondral) and mandibular ramus or symphysis (intramembranous) bone in adolescents to adulthood patients with cleft alveolus.

MATERIALS AND METHODS

This study included 10 patients with cleft alveolus who underwent delayed bone grafting with autogenous block bone and particulate cancellous bone and marrow (PCBM) from the mandibular ramus and symphysis with dental implant placement, and iliac crest. The success of the treatment was evaluated through clinical and radiographic examination including marginal bone loss measurement of the implants.

RESULTS

All patients underwent delayed bone grafting between the ages of 11 and 21.1 years (mean age: 15.1±4.3 y). The implant diameters ranged from 3.8 to 4.5 mm and the lengths ranged from 8.0 to 11.5 mm. All of the implants were integrated successfully and survived during the 3-year follow-up period.

CONCLUSIONS

Delayed bone grafting followed by implant placement showed long-term stability with satisfactory esthetic and functional rehabilitation. One of the main advantages of delayed bone grafting is to achieve adequate bone support for future dental implant placements with less bone resorption compared with those of primary, early secondary, and secondary bone grafting.

Cleft Size and Success of Secondary Alveolar Bone Grafting-A Systematic Review

OBJECTIVE

This study aimed to review all research evidence of presurgical cleft size and related factors to success of secondary alveolar bone grafting (SABG).

DESIGN AND SETTING

The systematic review searched the OVID-Medline®, PubMed®, Embase®, and Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2020. Two reviewers independently selected potential abstracts for full review. Disagreeements were resolved by consensus. The first author extracted data and assessed the risk of bias using Risk of Bias in Non-randomized studies-of Interventions tool.

PATIENTS AND INTERVENTIONS

Patients with non-syndromic clefts who received SABG were selected. Presurgical cleft size/volume and treatment results must be available.

MAIN OUTCOME MEASURES

Level of the grafted bone, achievement of orthodontic tooth movement into the grafted area, need for re-operation.

RESULTS

From 962 abstracts, 23 publications were included. Mean cleft width was 6.80 ± 1.98 mm, cleft area 20-240 mm², and mean volume 0.89 ± 0.33 cm³. No definite conclusion was achieved on whether a narrow or wide cleft showed better treatment outcomes, but other potentially related factors were good oral hygiene and eruptive force of the maxillary canines. Lack of a standard definition of cleft size, a small sample size, varying outcome parameters, and moderate-to-high risk of bias contributed to the summary. A meta-analysis could not be performed because of the heterogeneity.

CONCLUSION

Due to insufficient evidence, cleft width/volume could not be specified leading to more successful SABG. Care of patients could be improved in both research by following rigorous methodology, and practice by clear communication.

Reverse Facial-Submental Artery Osteomyocutaneous Flap, a Novel Choice for Previously Operated Huge Alveolar Clefts

Adult previously operated alveolar cleft palate presents a pronounced challenge for optimal surgical reconstruction. This optimal reconstruction dictates the restoration of soft tissues in addition to hard tissues to achieve prime functional results. Regional flaps usually used for the reconstruction of such defects were considered as either bulky or none bone bearing flaps. Furthermore, using free flaps for reconstruction can rise the concerns of increased intraoperative complications and greater suspected donor site morbidities. Here we present three unfavorably previously operated patients with current huge alveolar cleft palates, planned for the reconstruction with reverse facial-submental artery osteomyocutaneous flap. Besides, detailed flap harvesting technique, results, prosthetic restoration post to flap surgery, and follow up are presented in this article. We found the reverse facial- submental osteomyocutaneous flap as a novel and reliable choice for functional reconstruction of challenging huge alveolar cleft palates. The reverse facial-submental flap has not been yet mentioned in the medical literature for the reconstruction of alveolar clefts.

Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report

Aim and objective

This case report aims to describe the management of alveolar cleft defect by iliac crest secondary bone grafting.

Background

The secondary alveolar bone grafting performed during the mixed dentition period is an essential module of modern-day rehabilitation of cleft lip and palate patients with alveolar defects. Iliac crest bone graft is a frequent secondary graft used and is technique sensitive.

Case description

A 12-year-old girl with alveolar cleft defect having problems with speech and regurgitation of fluids from nostril was presented and its management by a combination of iliac crest bone grafting and platelet-rich fibrin (PRF) was described.

Conclusion

One year recall radiograph showed successful bone augmentation with this secondary alveolar bone grafting along with application of platelet rich plasma (PRP).

Clinical significance

Osseous integration can be enhanced by PRP application over the graft which gives greater clinical outcome with less invasiveness.

How to cite this article

Vemagiri CT, Damera S, Pamidi VRC, et al. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. Int J Clin Pediatr Dent 2022;15(4):472-474.

Compositions and Structural Geometries of Scaffolds Used in the Regeneration of Cleft Palates: A Review of the Literature

Cleft palate (CP) is one of the most common birth defects, presenting a multitude of negative impacts on the health of the patient. It also leads to increased mortality at all stages of life, economic costs and psychosocial effects. The embryological development of CP has been outlined thanks to the advances made in recent years due to biomolecular successions. The etiology is broad and combines certain environmental and genetic factors. Currently, all surgical interventions work off the principle of restoring the area of the fissure and aesthetics of the patient, making use of bone substitutes. These can involve biological products, such as a demineralized bone matrix, as well as natural–synthetic polymers, and can be supplemented with nutrients or growth factors. For this reason, the following review analyzes different biomaterials in which nutrients or biomolecules have been added to improve the bioactive properties of the tissue construct to regenerate new bone, taking into account the greatest limitations of this approach, which are its use for bone substitutes for large areas exclusively and the lack of vascularity. Bone tissue engineering is a promising field, since it favors the development of porous synthetic substitutes with the ability to promote rapid and extensive vascularization within their structures for the regeneration of the CP area.

Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate?

OBJECTIVE

To determine if secondary alveolar bone grafting (SABG) timing in patients with cleft lip and palate (CLP) influences the future need for additional maxillary advancement procedures, particularly Le Fort I osteotomy with rigid external distraction (RED).

DESIGN

Retrospective cohort study. Groups were separated by SABG timing: early mixed dentition (ages 68 years) or late mixed dentition (ages 9-11 years). The criterion for RED was negative overjet ≥8 mm, and sufficient dental development for RED.

SETTING

Single tertiary care institution.

PATIENTS

Patients with CLP that underwent SABG from 2010 to 2015. Exclusion criteria included syndromic conditions, SABG surgery at age >12 years, current age <12 years, and <2 years follow-up. 104 patients were included.

MAIN OUTCOME MEASURES

The number of RED candidates and treated patients.

RESULTS

There was no statistical difference in the number of RED candidates (P  =  .0718) nor treated patients (P  =  .2716) based on SABG timing; stratification by laterality was also insignificant. Early SABG is associated with higher odds of being a RED candidate (pooled, unilateral, bilateral) and treated patient (pooled and unilateral); however, there were no statistically significant associations between SABG timing and the number of RED candidates and treated patients as determined by logistic regression models.

CONCLUSION

There is no statistically significant association between SABG timing and the odds of being a RED candidate or treated patient. Future prospective studies are recommended to assess the relationship between SABG timing and maxillary growth in patients with CLP.

A Novel Bone Substitute Based on Recombinant Type I Collagen for Reconstruction of Alveolar Cleft

This study aimed to examine the optimal cross-link density of recombinant peptide (RCP) particles, based on human collagen type I, for bone reconstruction in human alveolar cleft. Low- (group 1), medium- (group 2), and high- (group 3) cross-linked RCP particles were prepared by altering the duration of the heat-dependent dehydration reaction. Rat palatine fissures (n = 45), analogous to human congenital bone defects, were examined to evaluate the potential of bone formation by the three different RCP particles. Microcomputed tomography images were obtained to measure bone volume and bone mineral density at 4, 8, 12, and 16 weeks post grafting. Specimens were obtained for histological analysis at 16 weeks after grafting. Additionally, alkaline phosphatase and tartrate acid phosphatase staining were performed to visualize the presence of osteoblasts and osteoclasts. At 16 weeks, bone volume, bone mineral density, and new bone area measurements in group 2 were significantly higher than in any other group. In addition, the number of osteoblasts and osteoclasts on the new bone surface in group 2 was significantly higher than in any other group. Our results demonstrated that medium cross-linking was more suitable for bone formation—and could be useful in human alveolar cleft repairs as well.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction

OBJECTIVE

To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas.

DESIGN

A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted.

PATIENTS

A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities.

MAIN OUTCOME MEASURES

Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss.

RESULTS

Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions.

CONCLUSIONS

The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Rat Palatine Fissure: A Suitable Experimental Model for Evaluating Bone Regeneration

IMPACT STATEMENT

The rat palatine fissure is anatomically similar to human alveolar cleft. In this study, we examined potential bone repair by an autologous bone implant and beta-tricalcium phosphate (β-TCP) using rat palatine fissure as a model. Autologous bone chips or β-TCP granules were implanted into the rat palatine fissure. Our model demonstrated that higher bone volume and bone mineral density were achieved with autologous bone graft than with β-TCP. We have provided the first demonstration of the suitability of the rat palatine fissure as the implant site to simulate the transplantation of bone graft materials into human alveolar cleft.

Time to Recovery of Feeding After Alveolar Bone Graft Is Associated With Postoperative Nausea and Vomiting Within 2 Hours in Children

Objective:

To examine the relationship between the method of anesthesia for alveolar bone graft surgery and postoperative nausea and vomiting (PONV) based on the difference in surgical timing and to assess factors related to the postoperative quality of life.

Design:

Retrospective observational study.

Setting:

Hospital.

Participants:

Patients with cleft lip and palate who underwent alveolar bone graft surgery under general anesthesia. The subjects were divided into two groups based on surgical timing: secondary bone graft (SBG) and late secondary bone graft (LSBG) groups.

Main Outcome Measures:

Relationship between time to recovery of feeding and the types of anesthesia, PONV, and postoperative pain period.

Results:

The mean patient age was 9.97 ± 1.33 years in the SBG group and 15.39 ± 0.31 years in the LSBG group. In the SBG group, patients who were administered fentanyl or remifentanil had significantly higher incidence of PONV than those who were not administered these drugs. In the SBG group, the time to recovery of feeding was significantly longer in patients experiencing PONV within 2 hours or that lasted for 24 hours than in those without PONV. In the LSBG group, there was no significant difference regarding any of the above factors.

Conclusions:

Our results suggest that the occurrence of PONV within 2 hours or lasting for 24 hours postoperatively in school-age children prolonged the time to recovery of feeding. This indicates that the time to recovery of feeding can be predicted based on the occurrence of PONV within the first 2 hours.

A New Technique in Alveolar Cleft Bone Grafting for Dental Implant Placement in Patients With Cleft Lip and Palate

OBJECTIVE

To evaluate 2 iliac corticocancellous-block grafting techniques for dental implant placement in residual alveolar clefts.

DESIGN

Nonrandomized prospective clinical trial between March 2010 and December 2014.

SETTING

National Hospital of Odonto-Stomatology, Hanoi, Vietnam.

PARTICIPANTS

Thirty-two patients (23 female, 9 male; mean age, 21.28 years; range, 16-31 years) with unilateral complete alveolar cleft after reconstructive surgery for cleft lip and palate (CLP).

INTERVENTIONS

Harvested iliac crest bone was cut into 2 corticocancellous blocks. The smaller block was adapted against the sutured nasal mucoperiosteum and overlaid with cancellous bone; the larger one overlapped the labial cleft margin and was fixed with screws. Endosteal dental implants were placed after 4 to 6 months, and final restorations were delivered 6 months later.

MAIN OUTCOME MEASURES

Flap statuses were assessed clinically. Bone formation was assessed using the Enemark scale. Cone-beam computed tomography was used for graft height and width measurements. Implant health was assessed by the Misch criteria.

RESULTS

The mean postgrafting follow-up period was 36.7 ± 10.4 (range, 18-53) months. Three patients (9.4%) showed flap dehiscence but no infection 7 days after bone grafting. Twenty-nine patients (90.6%) had 75% to 100% bone fill (Enemark score of 1). The mean graft height and width were 11.4 ± 2.4 and 6.1 ± 1.0 mm, respectively. Sufficient bone for implant placement was noted in 29 patients (90.6%); the others required partially fixed prostheses. All implants functioned for at least 18 months.

CONCLUSION

The proposed technique is reliable to reconstruct the alveolar cleft for implant placement in CLP patients.

Cleft Palate Repair, Gingivoperiosteoplasty, and Alveolar Bone Grafting

Repair of the cleft palate intends to establish the division between the oral and nasal cavity, thereby improving feeding, speech, and eustachian tube dysfunction all while minimizing the negative impact on maxillary growth. Before palate repair candidacy, timing and surgical method of repair is dependent on comorbid conditions, particularly cardiac disease, mandibular length, and palate width. Additionally, management of the alveolar cleft and the indications for gingivoperiosteoplasty versus secondary alveolar bone grafting is a controversial topic that weighs the risks and benefits of potentially sparing the patient an additional surgery against iatrogenic restriction of facial growth and malocclusion.

Alveolar Bone Grafting in Cleft Patients from Bone Defect to Dental Implants

Cleft lip and palate is the most common congenital deformity affecting craniofacial structures. Orofacial clefts have great impact on the quality of life which includes aesthetics, function, psychological impact, dental development and facial growth. Incomplete fusion of facial prominences during the fourth to tenth week of gestation is the main cause. Cleft gaps are closed with alveolar bone grafts in surgical procedure called osteoplasty. Autogenic bone is taken from the iliac crest as the gold standard. The time of grafting can be divided into two stages: primary and secondary. The alveolar defect is usually reconstructured between 7 and 11 years and is often related to the development of the maxillary canine root. After successful osteoplasty, cleft defect is closed but there is still a lack of tooth. The space closure with orthodontic treatment has 50-75% success. If the orthodontic treatment is not possible, in order to replace the missing tooth there are three possibilities: adhesive bridgework, tooth transplantation and implants. Dental implant has the role of holding dental prosthesis, prevents pronounced bone atrophy and loads the augmentation material in the cleft area. Despite the fact that autologous bone from iliac crest is the gold standard, it is not a perfect source for reconstruction of the alveolar cleft. Bone morphogenic protein (BMP) is appropriate as an alternative graft material. The purpose of this review is to explain morphology of cleft defects, historical perspective, surgical techniques and possibilities of implant and prosthodontic rehabilitation.

Review of secondary alveolar cleft repair

INTRODUCTION

The alveolar cleft is a bony defect that is present in 75% of the patients with cleft lip and palate. Although secondary alveolar cleft repair is commonly accepted for these patients, nowadays, controversy still remains regarding the surgical technique, the timing of the surgery, the donor site, and whether the use of allogenic materials improve the outcomes. The purpose of the present review was to evaluate the protocol, the surgical technique and the outcomes in a large population of patients with alveolar clefts that underwent secondary alveolar cleft repair.

MATERIALS AND METHODS

A total of 109 procedures in 90 patients with alveolar cleft were identified retrospectively after institutional review board approval was obtained. The patients were treated at a single institution during a period of 10 years (2001-2011). Data were collected regarding demographics, type of cleft, success parameters of the procedure (oronasal fistulae closure, unification of the maxillary segments, eruption and support of anterior teeth, support to the base of the nose, normal ridge form for prosthetic rehabilitation), donor site morbidity, and complications. Pre- and postoperative radiological examination was performed by means of orthopantomogram and computed tomography (CT) scan.

RESULTS

The average patient age was 14.2 years (range 4-21.3 years). There were 4 right alveolar-lip clefts, 9 left alveolar-lip clefts, 3 bilateral alveolar-lip clefts, 18 right palate-lip clefts, 40 left palate-lip clefts and 16 bilateral palate-lip clefts. All the success parameters were favorable in 87 patients. Iliac crest bone grafts were employed in all cases. There were three bone graft losses. In three cases, allogenic materials used in a first surgery performed in other centers, underwent infection and lacked consolidation. They were removed and substituted by autogenous iliac crest bone graft.

CONCLUSIONS

THE USE OF AUTOGENOUS ILIAC CREST FOR SECONDARY ALVEOLAR BONE GRAFTING ACHIEVES ALL THESE SEVERAL OBJECTIVES: (1) to obtain maxillary arch continuity, (2) to maximize bone support for the dentition, (3) to stabilize the maxillary segments after orthodontic treatment, (4) to eliminate oronasal fistulae, (5) to provide nasal alar cartilage support, (6) to establish ideal alveolar morphology, and (7) to provide available bone with attached soft tissue for future endosteal implant placement in cases where there is a residual dental space. We advocate for the use of a minimal incision to obtain the iliac crest bone graft and for the use of a corticocancellous block of bone in combination with bone chips.

Need for revision surgery after alveolar cleft repair

The study assessed the need for revision surgery and the relating factors in alveolar cleft autogenous bone grafting in patients with complete cleft. It was a retrospective study carried out in 2009. The medical records of the 54 patients with alveolar cleft who underwent autogenous bone grafting in the maxillofacial department in Shariati Hospital from 2005 to 2008 were studied. The patients' age, sex, cleft type, age at palatal and alveolar clefts repair, tooth missing, surgery turn, and presence of orthodontic treatment were assessed. The patients' alveolar bone height was evaluated from their postoperative and follow-up panoramic radiographs. In general, 41% (n = 22) of patients needed revision surgery. Among all patients, 20 (37%) had secondary bone grafting and 34 (63%) had tertiary bone grafting. For 77% of the secondary unilateral clefts and 71% of bilateral ones, the remaining bone was at least three-fourths of the normal. Logistic regression model controlling for grafting time, surgery turn, orthodontic supervision, and age at palatal cleft closure showed that orthodontic treatment is associated with a lower need for revision surgery (odds ratio = 0.3; 95% confidence interval, 0.1-1.0). In conclusion, although alveolar cleft bone grafting is necessary for the reconstruction of the complete clefts, all these patients must be under the supervision of orthodontists to benefit from the surgical treatment.

Retrospective review of 99 patients with secondary alveolar cleft repair

PURPOSE

The purpose of the present review was to evaluate the protocol and technique used in a large population of patients with cleft lip and palate when secondary grafting is performed during the early mixed dentition stage, as determined by eruption of the central incisor. In the United States, most investigators have recommended alveolar grafting at the 9- to 11-year age range or before eruption of the permanent canines.

MATERIALS AND METHODS

An institutional review board-approved chart review of 99 patients undergoing alveolar cleft bone grafting during a 7-year period at a single institution was performed. Data were collected regarding demographics, operative time, length of hospitalization, follow-up time, complications, and additional procedures performed. The cases were divided by patient age into 2 groups: group 1, aged 6 to 8 years (n = 61); and group 2, aged 9 years and older (n = 38). Statistical analysis was performed for various comparisons in the study.

RESULTS

The average operative time for groups 1 and 2 was 86 and 103 minutes, respectively. The complication rate, length of stay, and follow-up time between the 2 groups was not statistically significant at the P = .05 significance level.

CONCLUSIONS

We recommend earlier bone grafting at or before the eruption of the central incisor, rather than delaying until the cuspid tooth root is 25% formed. We believe this will provide better bone support for the dentition, a decreased burden of treatment for the patient, and improved quality of life. Performing the procedure at this time can lead to decreased operative times, with comparable postoperative outcomes.