17 ALVEOLAR BONE GRAFTING - Aligarh Muslim … BONE GRAFTING.pdf · oronasal communication and a wide alveolar cleft on the right side. ... alveolar bone grafting in cases of cleft

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



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



Fig 6: Harvested cancellous bone graft

Fig 7: Cancellous bone graft tightly packed at the recipient

site

Fig 8: Closure

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17 ALVEOLAR BONE GRAFTING - Aligarh Muslim … BONE GRAFTING.pdf · oronasal communication and a wide alveolar cleft on the right side. ... alveolar bone grafting in cases of cleft

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