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Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 8689

Contents lists available at SciVerse ScienceDirect

Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j o m s m p

Clinical observation

Evaluation of secondary bone grafting of the alveolar cleft in adult cleft lip and

palate patients

Masato Yamazaki a,c , Shin Kanzaki a , Kazuhiro Tominaga b , Ikuya Miyamoto a , Kensuke Yamauchi a ,Masayuki Fukuda c, Tetsu Takahashi a,

a Division of Oral and Maxillofacial Reconstructive Surgery, Department of Oral and Maxillofacial Surgery, Kyushu Dental College, 2-6-1 Manazuru, Kokurakita-ku, Kitakyusyu, Japanb Division of Maxillofacial Diagnostic and Surgical Science, Department of Oral and Maxillofacial Surgery, Kyushu Dental College, Kitakyusyu, Japanc Division of Dentistry and Oral Surgery, Akita University School of Medicine, Akita, Japan

a r t i c l e i n f o

Article history:

Received 26 July 2011

Received in revised form

16 September 2011

Accepted 5 October 2011

Available online 26 November 2011

Keywords:

Cleft lip and palate

Autogenous particulate cancellous bone

and marrow

Bone graft

Adult patients

a b s t r a c t

Objective: The aim of this study was to evaluate 13 adult cleft lip and palate patients who underwent

secondary bone grafting using short-term follow-up examinations.

Materials and methods: The subjects were 13 cleft lip and palate patients. The mean age of the subjects

were 28.6 years old (range: 2047 years). Seven of the patients had BCLP, seven had UCLP, and one

had UCLA. None of them had BCLA. Autogenous particulate cancellous bone and marrow (PCBM) was

grafted onto the alveolar clefts. The marginal bone levels of the grafted bone were assessed by means of

periapical films, which were taken after an observation period of sixmonths, accordingto the Enemarks

classification.

Results: Eight bone grafted alveoli had scores of 1 (53.3%), six had scores of 2 (40%), and one had score of

4 (6.3%). None had score of 3. The formation of bone bridges was satisfactory in 93% of the bone-grafted

alveoli. The postoperative prostheses used in this study (15 bone grafted alveoli) included seven dental

implants; one straightening of the teeth alone; one straightening of the teeth and dentures; and two

cases in which the prostheses used were unknown. Patients who underwent dental implant surgery had

obviously higher score of Enemarks score (1.8) than those without dental implant (3.1).

Conclusion: This study confirmed that PCBM grafting of alveolar clefts works as well for adult patientsas it does for pediatric patients and the effectiveness of use of implants in the grafted alveoli to the

maintenance of the grafted bone.

2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights

reserved.

1. Introduction

The ultimate goal of the treatment of cleft lip and palate (CLP)

is to normalize the anatomy of the cleft alveolar process. One of

the treatments used to achieve this goal is bone grafting onto alve-

olar process defects. Numerous reports on the treatment results

of secondary bone grafting using iliac crest bone have been pub-

lished [14]. Based on these studies, there seems to be a trendtowards bone grafting between seven and nine years of age, before

canine eruption and subsequent orthodontic closure of the dental

arch, without the use of prostheses such as dentures or bridges.

Secondary bone grafting of residual alveolar clefts in the mixed

dentition is therefore a well-established method.

Secondary bone grafting is performed to (1) close the oronasal

fistula; (2) allow the teeth to erupt in the cleft region or allow for

Corresponding author. Tel.: +81 93 285 3070; fax: +81 93 592 3056.

E-mail address: tetsu@kyu-dent.ac.jp(T. Takahashi).

orthodontic closure of the gap in the dental arch; (3) to give proper

bony support to the teeth adjacent to the cleft, stabilize the pre-

maxillary segment of bilateral cases with bone support, and create

support for the alar base. Currently, most CLP patients undergo

bone grafting and receive CLP treatment, but a small number of

patients do not receive or break off CLP treatment. Therefore, a

question arises regarding whether bone grafting onto the cleft is

effective in such patients.Theaim of this studywas toevaluate 13adultpatients (15clefts)

who underwent secondary bone grafting using short-term follow-

up examinations.

2. Materials and methods

2.1. Patients

The subjects were 13 CLP patients (8 males and 5 females)

who underwent bone grafts between July 2000 and July 2009 at

the Department of Oral and Maxillofacial Surgery, Kyushu Dental

2212-5558/$ see front matter 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.ajoms.2011.10.001

http://localhost/var/www/apps/conversion/tmp/scratch_1/dx.doi.org/10.1016/j.ajoms.2011.10.001http://www.sciencedirect.com/science/journal/22125558http://www.elsevier.com/locate/jomsmpmailto:tetsu@kyu-dent.ac.jphttp://localhost/var/www/apps/conversion/tmp/scratch_1/dx.doi.org/10.1016/j.ajoms.2011.10.001http://localhost/var/www/apps/conversion/tmp/scratch_1/dx.doi.org/10.1016/j.ajoms.2011.10.001mailto:tetsu@kyu-dent.ac.jphttp://www.elsevier.com/locate/jomsmphttp://www.sciencedirect.com/science/journal/22125558http://localhost/var/www/apps/conversion/tmp/scratch_1/dx.doi.org/10.1016/j.ajoms.2011.10.001

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M. Yamazaki et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 8689 87

Table 1

Demographic and clinical characteristics of the subjects.

Patient no. Sex Clef type Age at bone

grafting

(yr)

Enemarks score

(after an

observation period

of 6 months)

Enemarks score

(the latest follow

up score)

Follow-up

period

Comments Complications

1 F BCLP 26 1 1 37 Le Fort I, IVRO and

dental implant

surgery

Expose of a

little bone

2 M BCLP 26 1 2 12 Le Fort I, IVROsurgery (left-side

cleft only)

3 M BCLP 20, 20 2, 2 3, 3 72 Dental implant

surgery

4 M UCLP 23 1 Unknown 6

5 F BCLP 20 2 2 27 Distraction, SSRO

and dental implant

surgery

6 M UCLP 21 1 1 36 Tow-jaw surgery

7 M UCLA 24 1 Unknown 6

8 M UCLP 31 2 4 24 Straightening of

the teeth

9 F BCLP 37, 37 2, 2 4, 4 30 Straightening of

the teeth and

dentures

10 M UCLP 21 1 1 19 Dental implant

surgery

11 F UCLP 45 1 2 8 Dental implant

surgery

12 F UCLP 47 1 1 9 Dental implant

surgery

13 M UCLP 31 4 4 27 Infection

Mean 28.6 1.6

SD 9.3 0.9

College (Table 1). The mean age of the subjects was 28.6 years old

(range: 2047 years). Five of the patients had bilateral cleft lip and

palate (BCLP), seven had unilateral cleft lip and palate (UCLP), and

one had unilateral cleft lip and alveolus (UCLA). None of them had

bilateral cleft lip and alveolus (BCLA).

2.2. Methods

2.2.1. Bone grafting

All operations were performed under general anesthesia. The

surgical technique was similar to the method described by Boyne

and Sands [1], with minor modifications. An incision was made

along the labial side of the cleft margin, and a mucoperiosteal flap

was developed. The mucoperiosteum of the fistula was dissected,

and the palatal and nasal portions were separated with scissors.

The mucoperiosteum was then stitched closed in both portions.

Therefore, nasal and palatal layers of the mucoperiosteum had

been created. Autogenous particulate cancellous bone and marrow

(PCBM) from the ilium were packed into any spaces and as well as

the area surrounding the alar base. After an adequate osseous form

had been obtained, the labial mucoperiosteum was underminedand relaxed, before being closed with stiches.

2.2.2. Assessment of the marginal bone level

The marginal bone levels of grafted bone were assessed by

means of periapical films, which were taken six months after bone

grafted and the latest follow-up after dental implant insertion,

according to the Enemarks classification [4] (Fig. 1.). Statistical sig-

nificance was determined using the Students t-test. A p value of

less than 0.05 was considered significant.

3. Results

A total of 15 bone grafts were performed in the 13 patients

(Table 1): five patients had BCLP, seven patients had UCLP, and

one patient had UCLA. Only two BCLP patients received bone grafts

on both sides of the cleft. Dental implants were inserted in the

seven bone grafted alveoli (six patients). The others did not receive

bone grafts of both sides and broke off treatment. Total follow-

up period were 24.1 months (range: 672 months). One year after

the bone grafting, orthognathic surgery (Le Fort I osteotomy and

intraoral vertical ramus osteotomy (IVRO) in cases 1 and 2, Le FortI osteotomy and sagittal split ramus osteotomy (SSRO) in case 6,

and SSRO alone in case 5) were performed to correct dentofacial

deformities after the bone grafting.

The marginal bone level scores after an observation period of 6

months is shown in Table 2. Eight bone grafted alveoli (cases 1, 2,

4, 6, 7, and 1012) had scores of 1 (53.3%); six cases (cases 3, 5, 8,

and 9) had scores of 2 (40%); and one case (case 13), whose bone

Fig. 1. Marginal bone level scores determined by intraoral films.

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88 M. Yamazaki et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 8689

Table 2

Total number of patients that displayed each Enemarks score.

Enemarks score 1 2 3 4

Number of patients (n = 15) 8 (53.3%) 6 (40.0%) 0 (0%) 1 (6.7%)

grafted alveoli were infected and so suffered a significant reduc-

tion of the marginal bone level, had a score of 4 (6.3%) because

of wounded area opened. None of the patients had a score of 3.The formation of bone bridges was satisfactory in 93% of the bone-

grafted alveoli. The postoperative prostheses used in this study (15

bone grafted alveoli) included seven dental implants, which were

insertedsix months afterthe bone grafting;one straightening ofthe

teeth alone; one straightening of the teeth and dentures; and two

cases in which the prostheses used were unknown. The marginal

bone levels compared between dental implants and other prosthe-

ses (Table 3). Patients who underwent dental implant surgery had

Table 3

Comparison betweenthe patientswho underwent dental implant surgeryand those

without dental implant.

Dental

implants

Other

prostheses

Mean of Enemarks score (the latest follow-up) 1.8 (n = 7)* 3.1 (n = 6)

Mean o f f ollo w-u p pe riod ( mo nths ) 28. 6 (n = 6) 25.8 (n = 5)

* p < 0.05, t-test.

obviously higher score of Enemarks score (1.8) than those without

dental implant (3.1).

4. Case report (case 12)

A 47-year-old woman with UCLP, who displayed a very mobile

left maxillary central incisor, a low alveolar bone level, the absence

of the bilateral lateral incisors, and a persistent oronasal fistula

Fig. 2. A 47-year-old female UCLP (case 12). (AC) Preoperative intraoral view, 3 dimensional computed tomography and intraoral films showing missing left lateral incisor

and alveolar cleft. (D) Intraoral view after final prosthetic rehabilitation. (E) Intraoral film taken after implant i nsertion.

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M. Yamazaki et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 8689 89

(Fig.2AC), wasreferredfor cleft repairand dentalarch reconstruc-

tion. The oronasal fistula was closed, the alveolar cleft was grafted

with PCBM taken from the ilium, and the left maxillary central

incisor was extracted.Seven months later, a dental implant (4.0mm

in diameter, 13 mm in length; Astra Tech, Mlndal, Sweden) was

inserted into the grafted bone. Twenty-nine months after the

implant insertion, the prosthesis was stable with no clinical or

radiographic signs of implant failure (Fig. 2D and E).

5. Case report (case 13)

A 31-year-old man with ltUCLP who had a persistent oronasal

fistula.The oronasal fistula was closed, the alveolarcleft wasgrafted

with PCBM taken from the ilium. One week after bone grafted,

wounded area was opened and performed resuture. But his bone

grafted alveoli were infected andso suffered a significant reduction

of the marginal bone level after six months. We concluded that the

reasons of infection and significant reduction of the marginal bone

level were wounded area had not sufficiently relaxed and opened.

6. Discussion

In this study, we evaluated marginal bone level of CLP patients

who were older than 20 years old during short-term follow-up

examinations. Compared with other adult and pediatric cases in

which bone grafting was performed before canine eruption, our

results were similar to those of other adult cases, but they were a

little worse than the results of bone grafting in pediatric patients

[512]. This was due to the fact that adult patients carry a risk of

infection related to periodontal problems. We consider that the

solution strategies were (1) mucoperiosteum is carefully under-

mined and relaxed, before being closed with stiches; (2) protect

wounded area completely; (3) use antibiotics longer than a week

and irrigation carefully. To the best of our knowledge, this is the

first consistent clinical evaluation of bone grafting in adult cleft

patients.

The resorption of grafted bone can be problematic. It is well

known that grafted bone undergoes resorption in 3 dimensions[4,8,1315]. In a previous study, the volume of the grafted alve-

oli at one year was significantly decreased compared with that at

3 months [8]; and in other studies, approximately 30% of the vol-

ume of bone transplanted from the iliac crest had been resorbed in

the first year [13,14], and the total volume loss was approximately

43.1%at one year after secondaryalveolar cleft repair from the iliac

crest [15]. In addition,interdental alveolar boneheight was reduced

in 24% of cleftsafter long-termfollow-up [4]. In this study,we eval-

uated the marginal bone level of grafted bone after an observation

periodof sixmonths using periapical radiography.Six monthsafter

bone grafting, 93% of the patients marginal bone levels displayed

scores of 1 or 2.

Recently, the placement of dental implants in the alveoli after

PCBMgraftinghas become an establishedtreatment method for thedental rehabilitation of patients with CLP [1620]. The advantages

of dental implants are as follows: cosmetic reconstruction can be

accomplished usinga single dental implant, prosthesessuch as den-

tures and bridges can be avoided, and the orthodontic treatment

period is shortened. In general, grafted alveoli only maintain their

bone height when they are associated with functioning occlusive

teeth [19,21,22]. It is recommendedthat dental implants should be

placed in the alveolar cleft region for no longer than 46 months

after secondary bone grafting [19]. Six months after bone grafting,

we inserted dental implants, and all of them were successful. The

dental implants placed into the grafted alveoli not only closed the

gap, butresultedin functional stimulation of thetransplanted bone

through mastication [21]. In a long-termfollow-up study, the over-

all survival rate of implants that were placed in grafted alveoli was

90.9% [22]. Theplacement of dentalimplantsin thegrafted alveolar

cleft seems to aid the maintenance of grafted bone in patients who

have undergone secondary bone grafting for cleft repair.

In conclusion, this study confirmed that PCBM grafting into the

alveolar clefts works well in adult patients, as it does in pediatric

patients. We performed seven implants involving 15 grafted alve-

oli, and no implant failure was observed (data not shown). This

study suggested that PCBM grafting into adult CLP patients is an

effective method, and the use of implants in the grafted alveoli

is recommended. However, further well-controlled clinical stud-

ies are necessary to conclude that PCBM grafting into adult CLP

patients is an excellent treatment method.

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