Evaluation of clinical outcomes ofGingivoperiosteoplasty in Patients with Bilateral Cleft Annual Report Pang-Yun Chou Philip KT Chen
Introduction• Primary reconstruction of the alveolar cleft – Bone grafting – Gingivoperiosteoplasty• Debate continuing – Quantity and quality of the resulting bone – Long-term repercussions to subsequent growth – Development of the maxilla
Introduction• Alveolar repair – Secondary alveolar bone graft • Current standard – Gingivoperiosteoplasty • Principal alternative – Introduced by Skoog – Modified by Millard and Latham • Performed at 3 to 6 months of age • Allows closure of the nasoalveolar fistula • Aligns the cleft segments through early union of the dental arch – Preventing collapse • Reduce the need for future bone graft, and there is no donor site
Introduction• The success rate of gingivoperiosteoplasty – No need of additional alveolar bone grafting – 60 percent by Santiago et al – 73 percent by Sato et al – In Chang-Gung Memorial Hospital • Less need for alveolar bone grafting following gingivoperiosteoplasty• In the past – Patients, who underwent gingivoperiosteoplasty • Maxillary retrusion • Decreased vertical maxillary height – However, the fact of growth disruption was not as significant as former studies
Introduction• Retrospective study• Purpose – Evaluation the clinical outcome of gingivoperiosteoplasty • (1) quantifying the amount of bone at the alveolar cleft site • (2) identifying the location of the bone • (3) evaluating the success of closure of the nasoalveolar fistula • (4) measuring the midfacial growth
Patient and Method• This is a retrospective study of clinical evaluation was performed in seventeen bilateral cleft patients underwent gingivoperiosteoplasty. The surgical protocol for the gingivoperiosteoplasty group included initial treatment with the Latham presurgical appliance, which reduced the alveolar gap to 1 to 3 mm, minimizing cleft width variability. Dr. R. A. Latham was the orthodontist and directly supervised the fit, application, and use of the appliance in all patients.• Gingivoperiosteoplasty was performed at 3 months together with either a lip adhesion or definitive lip repair. The technique described by Millard was used for all gingivoperiosteoplasties.19 Palate surgery was performed at 12 months and formal lip repair (for patients with a lip adhesion) was completed by 18 months.
Radiographic Evaluations• Radiographs were obtained either from orthodontic records or following study participation during clinical examination. The level of noncleft interdental alveolar bone, adjacent tooth roots, and the contour of alveolar bone at the former cleft site were recorded. The rater evaluated the films according to the scales of Bergland, Long et al., and Witherow et al. and was blinded to each patient’s surgical history.
• Fig.1 Cephalometric landmark• For evaluation of midfacial growth, standard cephalometric landmark was plotted, (Fig. 1) and derived into specific statics . Linear and angular measurements were based on both the anterior cranial base using the sella turcica in addition to the basion. Because the variable position of the sella turcica in patient with clefts, the basion-nasion was used as an additional reference plane to increase reliability of measurement. Linear measurements were converted into ratios to the basion-nasion.
Grading Scales• Three grading scales were used within this study to overcome limitations of any one method and to provide internal correlation for results.
Bergland• The Bergland classification system is the current standard for evaluating bone production at the former cleft site.7,8,18 It is based on the height of the interalveolar septum. It is generally accepted that films categorized as type I or II represent successful bone production at the cleft site, whereas types III and failure represent inadequate bone production (Fig. 2)
Long et al.• Long et al. developed a system to evaluate alveolar ridge notching and bone support for cleft adjacent teeth. The ratios B/A and C/A reflect total bone support and height of the alveolar crest bone, respectively, relating to the adjacent tooth root length of the proximal segment. Ratios F/E and G/E are analogous to ratios B/A and C/A and are based on the cleft adjacent tooth of the distal segment. Ratio D/A allows measurement of the extent of alveolar ridge notching (Fig. 3).
Witherow et al.• The classification of Witherow et al. assesses two variables: bone area and location. The eight point scale indicates the area of ossification within the former cleft site based on the cleft midline (Fig. 4). The location classification supplements the other methods by assigning one of six classes based on the position of ossification (Fig. 5). Classifications A and C are analogous to Bergland types I and II.