Late management of secondarily grafted clefts

doi:10.1016/S0901-5027(05)80203-6

International Journal of Oral and Maxillofacial Surgery

Volume 19, Issue 2, April 1990, Pages 97-102

https://doi.org/10.1016/S0901-5027(05)80203-6 Get rights and content

Abstract

34 patients (40 sides) received alveolo-palatal bone grafts for closure of the residual cleft, thus guiding a lateral incisor or canine into the arch. Long-term follow-up shows that in 41% of the patients uninterrupted arches were achieved with a normal relationship by orthodontic treatment only. 38% needed segmental osteotomies to eliminate the edentulous space, and in only 20% were bridges made to restore the dental arch. 9 (25%) patients still required a Le Fort I advancement osteotomy, despite optimal orthodontic treatment. The use of segmental osteotomies for eliminating edentulous spaces in cleft palate patients is discussed, and their advantage in relation to nasal base support is emphasized. It should be the aim to achieve in every cleft palate patient a complete archform without the need for bridges or removable prostheses. A rational orthodonticsurgical approach to the cleft, lip and palate patient is suggested with respect to naso-maxillary growth and development.

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Cited by (48)

Retrospective analysis of clinical outcomes in bilateral cleft lip and palate patients after secondary alveolar bone grafting and premaxilla osteotomy, using a new dento-maxillary scoring system
2021, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Successful bone grafting facilitates dental rehabilitation with the patient's dentition or with a fixed prosthesis (Vellone et al., 2017). The timing of the procedure is chosen to support successful eruption of the canine or lateral incisor into the bone graft, and therefore reduce the risk of the development of complications at the end of growth (Stoelinga et al., 1990; Bittermann et al., 2020). The reason for performing an SABG + PMO procedure is not only the support of teeth or dental implants.
Evaluation of relevant clinical outcomes in patients with bilateral cleft lip and palate (BCLP) after secondary aveolar bone grafting (SABG) and premaxilla osteotomy (PMO), through the use of a new scoring system.
Data were collected retrospectively from all patients with BCLP who were operated on between 2004 and 2014, at the end of follow-up. The treatment protocol consisted of SABG + PMO in patients aged between 9 and 13 years. At the end of follow-up, the following parameters were scored: (un)interrupted dental arch, skeletal sagittal relationship, bone height using the Bergland/Abyholm criteria, and the presence of postoperative fistula. These parameters were combined to produce a dento-maxillary scoring system, giving a final score between 1 and 10. For statistical analysis, the independent t-test was used.
Of 55 children, 45 were suitable for analysis. The mean age at time of surgery was 12.0 years (8.9–16.4 yrs), and the mean follow-up time was 11.7 years (5.8–15.8 yrs). The average number of surgeries executed under general anesthesia was 6 (range: 3–11). The average dento-maxillary score in this patient cohort was 7.6 (1–10; median: 8). Among these patients, 31 had an uninterrupted dental arch; the average Bergland/Abyholm score was 2.07; 30 patients exhibited an Angle class I incisor relationship; and, in 38 cases, the oronasal communication was closed after SABG + PMO treatment. A significant effect of fistulas was seen on dento-maxillary score (p = 0.001). Specifically, a significant effect of fistulas was seen on interrupted dental arch (p = 0.002) and on Bergland/Abyholm score (p = 0.037).
The proposed dento-maxillary scoring system is a straightforward tool that can be used to describe and analyze the amount of dento-maxillary rehabilitation at the end of the treatment. Persistence of oronasal fistulas in patients with BCLP has a significant impact on interruption of the dental arch, and can influence dental results at the end of the second decade.
Development of surgical techniques of secondary osteoplasty in cleft patients following 12 years experience
2014, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
The key points include complete exposure of the defect by reflecting over-extended vestibular and palatal flaps, sealing the nasal side of the cleft, preparing the graft as already described and safely suturing flaps over it. In previous reports, surgical details similar to ours have been described; removal of deciduous or unerupted teeth 3 months pre-operatively (Stoelinga et al., 1990; Bilkay et al., 2002); use of cortical plate to form the floor of the nose (Stoelinga et al., 1990); graft fixation with wire ligature or screws (Kokkinos et al., 1997), extended vestibular and palatal flaps (Kokkinos et al., 1997; Dempf et al., 2002); bone mill to mash the graft (Denny et al., 1999) and preference for cancellous bone (Bilkay et al., 2002; Dempf et al., 2002; Miller et al., 2010). Revision operations for additional bone grafting have been previously reported.
To evaluate the results of secondary osteoplasty in cleft patients, over a 12 years period, and to propose certain modifications and improvements of the cleft repair technique.
Data were retrieved for all young patients treated from 2000 to 2011. Patients were divided in 3 groups, of 4 years duration each; parameters registered among others included peri-operative orthodontics, type of graft used, techniques applied and revisions required until final repair.
65 patients (mean age 11.6 years) were included in the study. 80 cleft sites were treated. All clefts were finally repaired and bone continuity was achieved. Peri-operative orthodontics was applied in 84.6% of the cases. Bone grafts were harvested 60 times (84.5%) from the left anterior iliac crest and 11 times (15.5%) from the genial region of the mandible. During the 12 years period ameliorations and changes were made at the recipient site, regarding the technique applied and the type of the graft. Revision operations for additional bone grafting were required in 6 cases in all (6/80 or 7.5% of the cleft sites). A gradual reduction of the number of revision osteoplasties was recorded in the 3 time periods, attributed to the improvements afore mentioned.
Cleft bone repair, even in difficult bilateral cases, may be achieved with standardised preparation of the recipient site, adequate graft from the iliac crest, used in the form of both particulate bone and cortical plate on top, as well as full coverage of the graft.
Cleft-Orthognathic Surgery: The Bilateral Cleft Lip and Palate Deformity
2013, Orthognathic Surgery: Principles and Practice
Cleft-Orthognathic Surgery: The Unilateral Cleft Lip and Palate Deformity
2013, Orthognathic Surgery: Principles and Practice
Influence of pharyngeal flap surgery on maxillary outgrowth in cleft patients
2013, International Journal of Oral and Maxillofacial Surgery
The aim of this study was to investigate the influence of the pharyngeal flap procedure on the frequency of Le Fort I osteotomies in full-grown nonsyndromic cleft patients. A retrospective review of 508 full-grown cleft patients born between 1 January 1983 and 31 December 1992 was performed. Following data analysis, 140 males older than 18 years and 111 females over the age of 16 years were included. 69 of the 251 included cleft patients required pharyngeal flap surgery (27.5%). Revision flap surgery was performed in 17.4% of the cases. A significantly lower age at time of the initial pharyngeal flap procedure was found in patients requiring revision surgery (5.6 years versus 6.8 years). The frequency of Le Fort I osteotomies was significantly higher in the patients with a pharyngeal flap (19%) compared to those without (8%) (p < 0.05). The results of this study point towards the pharyngeal flap procedure being one of the possible limiting factors for maxillary antero-posterior growth in cleft patients.
Morbidity associated with iliac crest harvesting in the treatment of maxillary and mandibular atrophies: A 10-year analysis
2011, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Dawson et al16 indicated that donor site morbidity after intervention is frequently overstated, thus confirming the aforementioned conclusions. Stoelinga et al66 suggested that preserving the cartilage cap and repositioning it after intervention may decrease morbidity. Comparing the iliac crest with the rib in terms of discomfort, Laurie et al51 concluded that patients greatly preferred the ilium approach in the long-term.
The iliac crest provides an important donor site for cancellous, cortical, and corticocancellous bone because it has the highest concentration of osteocompetent cells, offers sufficient volume, and is readily accessible. Although iliac crest harvesting is considered a common procedure in different medical specialities, donor site morbidity is a subject that requires further discussion. Moreover, the increasing number of bone grafts being undertaken stresses the importance of donor site morbidity in surgical planning and for patient consent. This study evaluated morbidity associated with iliac crest harvesting over a 10-year period and patients' overall satisfaction.
This prospective study involved 235 patients who were scheduled for iliac harvesting procedures from April 2001 through May 2010. A standardized surgical procedure with an anterior approach was used for the harvesting of all iliac crest grafts. The following variables were considered: pain, discomfort, presence of functional disorders, presence of sensory disturbances, esthetic outcome, and patients' general satisfaction, which were evaluated using specific tests or questionnaires.
Ninety-nine percent of patients complained of mild pain 1 week after intervention but the pain rapidly disappeared after a few weeks. Functional disorders such as alterations in walking and lifting strength were reported by 100% of patients after intervention, but after 5 weeks this percentage had decreased substantially. Sensory disturbances such as hypoesthesia were recognized as transitory complications of iliac crest harvesting. A large percentage of patients were satisfied with the esthetic outcome of the intervention.
Although the anterior iliac crest is a donor site with low morbidity, many studies have reported contrasting results. These data support the idea that the surgical approach plays a crucial role in decreasing postoperative morbidity. Moreover, this study confirmed that the anterior iliac crest can be considered a first-rate option for bone-defect reconstruction because of its low morbidity. However, future improvements in bone substitutes may well change this situation.

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Late management of secondarily grafted clefts

Abstract

Am J Orthodont

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Craniomaxfac Surg

J Oral Maxillofac Surg

Am J Orthodont

Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment

Cleft Palate J

Bone grafting of alveolar clefts

J Oral Surg