Secondary Alveolar Bone Grafting is a procedure used in patients with cleft alveolus to maintain adequate and good arch size and shape , provide support for nasal base, to provide adequate bone stock for canine eruption
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Secondary Alveolar Bone Grafting
1. SECONDARY ALVEOLAR BONE GRAFTING
DR. K. KRISHNA LOHITHA , II MDS
DEPT. OF ORAL & MAXILLOFACIAL SURGERY
2. CONTENTS
INTRODUCTION
HISTORY
DEVELOPMENT OF ALVEOLAR BONE
ANATOMY OF ALVEOLAR CLEFT
GOALS
TIMING
RATIONALE
PATIENT HISTORY AND PHYSICAL EXAMINATION
RADIOGRAPHIC INVESTIGATIONS
PRESURGICAL PREPARATION OF PATIENT
DIFFERENT GRAFTS USED
SURGICAL TECHNIQUE
COMPLICATIONS
3. INTRODUCTION
Treatment of the child with cleft lip and palate
begins with the considerations primarily directed
towards cosmetic repair of lips and nasal
deformities and functional repair for lip musculature
and palate.
Concern over the cleft in region of alveolar process
is often recognised later.
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. HISTORY
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.
1960’s- Scoog: bonless bone grafting- GPP
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
1981- Abyholm: SABG
1983–Wolfe et al: Favourable result with calvarial
bone
1987–Nique&Fonseca: ABG with allogenic bone
Alveolar segmental osteotomies
Alveolar distraction osteogenesis
6. DEVELOPMENT OF ALVEOLAR BONE
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.
7. ANATOMY OF ALVEOLUS
The alveolar cleft is more than a linear gap in the maxillary arch.
With soft tissue removed, the cleft is best visualized as a tornado,
increasing in size from incisal to apical, becoming widest as it
extends into the nasal cavity and distorts the surrounding anatomy
Cleft patients with a permanent osseous defect of the alveolar arch
and maxilla will, even after the best surgical and orthodontic
treatment, be left with the following deficiencies:
1. Limited prospects for orthodontic treatment. The osseous defect
makes a nonprosthodontic dental rehabilitation impossible and
necessitates a dental bridge to close the gap in the dental arch.
2. Instability of the maxillary segments, particularly of the premaxilla in
bilateral clefts.
3. Oronasal fistulae or mucosal recesses that impede
oral hygiene.
4. Insufficient support of the alar base contributing to
the nasal asymmetry.
8.
9. GOALS OF TREATMENT OF THE ALVEOLAR CLEFT
Stabilisation of maxillary arch
Separation of oral and nasal cavities
Appropriate maxillary arch form and transverse width
Stable environment for eruption of cleft-side canine
Maintenance and bone support of all erupting teeth
Keratinized gingival environment for erupted teeth
Piriform bone support of nasal base
Preserved anterior vestibule
Uninhibited facial growth
Minimized donor site morbidity
Provision of adequate bone stock for implant placement
10. TIMING OF ALVEOLAR BONE GRAFTING
< 2 Years of Age: Primary Grafting
After lip repair
Before palate repair
≥ 2 Years of Age: Secondary Grafting
Age in years
2–5: Early secondary
6–12: Mixed dentition secondary (after central incisor
eruption and before the canine erupts)
6–8: Early mixed dentition
9–12: Late mixed dentition
> 12: Late secondary grafting
11. PRIMARY BONE GRAFTING
AIM: Acheive early
stabilisation of maxilla
Obliterate oro antral
fistulae
In bimaxillary clefts, pre
maxillary setback
INDICATIONS:
elimination of bone deficiency
stabilisation of pre maxilla
creation of new bone matrix
augmentation of alar base
CHOICE OF GRAFT: Rib
ADVANTAGES:
Improved arch forms
Decreased incidence of arch
collapse
Decreased need for
orthognathic surgery
Preservation of lateral incisor
Disadvantages:
Decreased midfacial growth
Inadequate bone formation
Rib harvest morbidity
Need for bone grafting later
in life
12. Long term studies show that:
• abnormal maxillary development with maxillary retrognathia,
Reasons for Maxillary Growth Disturbance
Disruption of vomer – premaxillary suture
Extensive mucoperiosteal stripping
scar formation
Vomerine flap disruption
• concave profile,
• increased frequency of crossbite compared with patients
without grafts
13. EARLY SECONDARY ALVEOLAR BONE
GRAFTING
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
14. SECONDARY ALVEOLAR BONE
GRAFTING
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
Pre requisites:
Precise timing
Operating technique
Sufficiently vascularised soft tissue
15. RATIONALE FOR GRAFTING AND FOR TIMING OF GRAFTING
during this time period include the following:
Minimal maxillary growth after age 6 to 7 years
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
Bone volume may be improved by eruption of the tooth
into the newly grafted bone
allows placement of the graft before eruption of
permanent teeth into the cleft site – one of the primary
goals of grafting.
Bone grafting when erupting teeth is still covered by a
thin layer of bone acheived greater alveolar height
Prevents external root resorption
16. Factors Contributing to Timing of Grafting During
the Mixed Dentition
Dental age vs chronologic age
Presence of the lateral incisor
Position of the lateral incisor
Degree of rotation/angulation of the central incisor
Trauma/mobility of premaxillary segment(bilateral
clefts)
Social issues
Size of the patient and of the cleft
Occlusion
Need for adjunctive procedures
17. LATE SECONDARY GRAFTING
Patients older than12 years of age who undergo grafting
have been reported
to have decreased success when evaluated using the
Berglandscale,
loss of osseous support of teeth adjacent to the cleft
increased morbidity.
18. 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
less chance of reopening the oronasal fistula
19. 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
20. 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
22. 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
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.
23. TREATMENT OPTIONS FOR CLEFT ALVEOLUS
Bone grafting
Gingivo periosteoplasty
Distraction osteogenesis
25. CANCELLOUS BONE
Forms on the surface of
pre existing trabeculae
More vascular
More osteogenic
potential
Better ingrowth of new
bone from adjacent bone
segment
Apposition followed by
resorption
Greater mechanical
strength
CORTICAL BONE
Metabolic turnover and
remodelling is slower
Resorption followed by
apposition
Remains as a composite
of new and necrotic bone
Prone to infections
Not completely
vascularised upto 2
months
26. Site
Iliac crest: gold standard for SABG
Advantages
Large quantity of cancellous bone.
Decreased operativetime with 2 team approach.
No growth disturbance
Easy to condense & pack
Proven successful
Disadvantages
Mild transient gait disturbance
Donor site morbidity reported in literature
Consideration
All clefts , particularly large & bilateral clefts
27. Site
Proximal tibia
Advantages
•Adequate cancellous bone
Minimal soft tissue dissection
Two team approach
Disadvantages
Mild post-op discomfort
Less bone than iliac bone
Interferes with growth(due to epiphyseal growth
Consideration
Not recommended in patients that have not completed
growth
28. Site
Rib
Advantages
Two team approach possible
Mainly used in primary ABG
Disadvantages
Poor source of cancellous bone
Post-op-pain
Visible scar
Associated morbidity
Unpredictable result
Consideration
Not recommended except for primary grafting
29. Site
Cranial bone
Advantages
Incision hidden in hair
bearing area
Minimal postop
discomfort
Disadvantages
Sparse cancellous bone
Increased operative time
Associated morbidity
Poor results than ilium(less
cellular)
Stigma & fear for patient
Consideration:
Unilateral clefts: lower
success rate
Site
symphysis
Advantages
Same operative field
Rapid post-op recovery
No external scar
Disadvantages
Sparse amount
of,cancellous bone
Associated morbidity
Poor result
Consideration:
Older children with small
defects
30. Type
Allogenic:
derived from a genetically
unrelated member of
same
species(osteoconductive,
osteoinductive
Advantages
Comparable to
autogenous
Allows for eruption of
teeth
Avoids donor site
morbidity
No osteogenic potential
Disadvantages
Delayed incorporation
Type
Alloplastic: inert foreign
body
material(osteoconductive,
osteoinductive
Advantages
Avoids donor site
morbidity
disAdvantages
Delayed healing
Inability of teeth to erupt
31. 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.
33. 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
34. Final mucosal closure of the
oblique sliding flap.
A palatal splint placedmover the
closure area to prevent formation of
a hematoma andstabilize the bone
graft.
35. The grafted bone responds physiologically to
the erupting canine:
a Alveolar cleft prior to bone grafting.
b The canine erupting normally through the grafted bone
36. BILATERAL ALVEOLAR CLEFT REPAIR
A bilateral alveolar
cleft palate
Needle palpation of the
bony edges of the
alveolar cleft while
injecting local anesthesia
37. 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
nasal mucosa.
38. Palatal depiction of the movement of the adjacent
mucosa in the oblique sliding flap technique
40. Final closure of the bilateral alveolar cleft repair using a
oblique sliding flap technique
41. POST-OPERATIVE INSTRUCTIONS
Liquid diet 7 days
Avoidance of trauma to the site
Antibiotics & nasal decongestants
Meticulous oral hygiene with chlorhexidine
42. 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
43. 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
44. GINGIVO-PERIOSTEOPLASTY
Boneless primary bone graft
Relies on the osteoinductive
capabilities of the periosteum
If the alveolar anatomy and
presurgical molding outcome
are favorable, a GPP can be
offered to the family at the
same time as the primary lip
repair
Advantages
Repairs the cleft in anatomic
way by a precise
reconstruction of the functional
matrix(mucoperiosteal matrix
of maxilla)
Avoids the need for ABG
45. 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
Disadvantage
Long treatment requires patient cooperation & close
follow-up
46. INDICATIONS
“ungraftable” or “recalcitrant” alveolar clefts
The typical patient who falls into this category has
unhealthy, scarred gingiva, a large nasolabial
and/or oronasal fistula, and a history of repeated
unsuccessful bone grafts with infections and
exposure.
Another possible presentation is a previously
grafted maxilla that has severe vertical deficiency
along with scarred mucogingiva preventing
additional graft augmentation
past mixed dentition due to the risk to unerupted
tooth follicles during the segmental osteotomies
47. HORIZONTAL TDO
The principle is to create a transport segment by
separating an adjacent two- or three-tooth-bearing
segment of the distal alveolus from the maxilla
without damage to the tooth roots and without
violation of the attached gingiva
48. VERTICAL TDO
Vertical alveolar TDO is useful for augmentation of
a previously grafted cleft when the gingiva or
previous surgeries have made augmentation with
standard grafting techniques not possible
49. 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.
50. REFERENCES
Peterson principles of oral and maxilofacial surgery :2nd edition
vol II
OUTLINE OF ORAL &MAXILLOFACIAL
SURGERY- Peterwardbooth vol II
Alveolar clefts ;Richard A. Hopper and Gerhard S. Mundinger
Secondary Bone Grafting of Alveolar Clefts Frank E.AbyholmOral
Maxillofacial Surg Clin N Am 14 (2002) 477–490
Alveolar bone grafting;Jan Lilja; SwedenIndian J Plast Surg
Supplement 1 2009 Vol 42
Grafting materials for alveolar cleft reconstruction: a systematic
review and bestevidence synthesis
Management of Alveolar Clefts Using Dento-osseous Transport
Distraction Osteogenesis;Angle Orthodontist, Vol 73, No 6, 2003
Editor's Notes
SABG represents an integral component of any concept for comprehensive treatment of cleft lip & palate patients & their dental rehabilitation
SABG represents an integral component of any concept for comprehensive treatment of cleft lip & palate patients & their dental rehabilitation
For grafting dental age is considered rather than....LI is present and well formed,or present in pt segment early grafting is considered.if CI is rotated or angulated, grafting is done prior to ortho treatment . In large fefects, wait for growth then graft.