alveolar bone grafting

1. 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.

2. Alveolus Means Trough (Latin Word); Trough Containing Tooth Buds.

3. 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

4. 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.

5. 1960 Schuchardt & Pfeifer: Primary ABG using rib graft at the time of lip closure. 1964Pruzansky: Bone grafting should be delayed until after eruption of permanent dentition 1968Jolley: Detrimental effects of early bone graft on maxillary growth 1972Boyne&Sands: Protocol for secondary ABG 1983Wolfe et al: Favourable result with calvarial bone 1987Nique&Fonseca: ABG with allogenic bone

6. 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

7. 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

8. 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

9. 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

10. 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.

11. Derivatives of the first pair of the six pharyngeal arches Maxillary prominence Mandibular prominence Facial development

12. Aetiology Hereditary Environmental

13. 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.

14. Environmental Infection (Rubella & Toxoplasmosis) Drugs steroid, BZD, anticonsulsants Smokers

15. 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 6:3:1

16. 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

17. Mobility & overgrowth of premaxilla in bilateral case Lack of support for the ala, base of the nose & lip (Columella in bilateral case)

18. 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

19. 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

20. Timing of ABG Primary (02.5 years, usually at the time of lip repair) Early secondary (25 years, before the eruption of permanent incisors) Secondary (613 years, before the eruption of the permanent canines) Late (> 13 years, after the eruption of the permanent canines)

21. 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.

22. 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.

23. 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;54:7482. 11. Rosenstein SW. Early bone grafting of alveolar cleft deformities. J Oral Maxillofac Surg 2003;61:107881.

24. 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

25. Reasons for Maxillary Growth Disturbance Disruption of vomer premaxillary suture Extensive mucoperiosteal stripping scar formation Vomerine flap disruption

26. 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

27. Secondary ABG 9-11 years most commonly done before eruption of canine When to 2/3rd of canine root has formed Only vertical growth remains at this age. Physiological migration & spontaneous eruption through grafted bone observed.

28. 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

29. 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.

30. 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

31. 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

32. 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

33. 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.

34. 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

35. 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

36. 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

37. Radiographic Evaluation OPG Occlusal view Peri apical view

38. 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

39. 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.

40. Treatment options for cleft alveolus Bone grafting Gingivo periosteoplasty Distraction osteogenesis

41. OPTIONS FOR ABG AUTOGENOUS ILIAC BONE RIB TIBIA CALVARIUM SYMPHYSIS ALLOPLASTIC ALLOGENIC

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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.

48. Unilateral alveolar cleft Incision line for an oblique sliding flap (dashed line)

49. 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.

50. 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.

51. Bilateral alveolar cleft repair A bilateral alveolar cleft palate Needle palpation of the bony edges of the alveolar cleft while injecting local anesthesia

52. 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

53. Palatal depiction of the movement of the adjacent mucosa in the oblique sliding flap technique

54. Mucosal closure in a bilateral alveolar cleft.

55. Final closure of the bilateral alveolar cleft repair using a oblique sliding flap technique

56. Post-operative instructions Liquid diet 7 days Avoidance of trauma to the site Antibiotics & nasal decongestants Meticulous oral hygiene with chlorhexidine

57. 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

58. 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

59. 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

60. Advantages Repairs the cleft in anatomic way by a precise reconstruction of the functional matrix(mucoperiosteal matrix of maxilla) Avoids the need for ABG

61. 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

62. Disadvantage Long treatment requires patient cooperation & close follow-up

63. 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.

64. References Peterson 2nd edition vol II OUTLINE OF ORAL &MAXILLOFACIAL SURGERY- Peterwardbooth vol II Oral Maxillofacial Surg Clin N Am 14 (2002) 477490 Medical embryology by langman

alveolar bone grafting

Healthcare

alveolar cleft

cleft lip palate

concept of cleft lip

calvarial bone

allogenic bone

bone grafting

iliac bone graft

free bone graft