7/29/2019 1-s2.0-S0915699211001348-main
1/4
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: [email protected](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:[email protected]://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:[email protected]://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.2011.10.0017/29/2019 1-s2.0-S0915699211001348-main
2/4
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.
7/29/2019 1-s2.0-S0915699211001348-main
3/4
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.
7/29/2019 1-s2.0-S0915699211001348-main
4/4
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.
References
[1] Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatalclefts. J Oral Surg 1972;30:8792.
[2] Boyne PJ, Sands NR. Combined orthodontic surgical management of residualalveolar and palatal cleft. Am J Orthod 1976;70:2037.
[3] Miller LL, Kauffmann D, St John D, Wang D.Retrospectivereviewof 99patientswith secondary alveolar cleft repair. J Oral Maxillofac Surg 2010;68:12839.
[4] EnemarkH, Sindet-PedersenS, BundgaardM. Long-term resultsaftersecondarybone grafting of alveolar clefts. J Oral Maxillofac Surg 1987;45:9139.[5] HallHD, Posnick JC.Early results of secondary bonegraftsin 106alveolar clefts.
J Oral Maxillofac Durg 1983;41:28994.[6] Sindet-Pedersen S, Enemark H. Comparative study of secondary and late
secondary bone-grafting in patients with residual cleft defects. Short-termevaluation. Int J Oral Surg 1985;14:38998.
[7] Berglad O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft bysecondary bone grafting and subsequent orthodontic treatment. Cleft Palate J1986;23:175205.
[8] Honma K, Kobayashi T, Nakajima T, Hayasi T. Computed tomographic evalua-tion of bone formation after secondary bone grafting of alveolar clefts. J OralMaxillofac Surg 1999;57:120913.
[9] McIntyre GT, Devlin MF. Secondary alveolar bone grafting (CLEFTSiS)20002004. Cleft Palate Craniofac J 2010;47:6672.
[10] Meazzini MC, Tortora C, Morabito A, Garattini G, Brusati R. Alveolar boneformation in patients with unilateral and bilateral cleft lip and palate afterearly secondary gingivoalveoloplasty: long-term results. Plast Reconstr Surg2007;119:152737.
[11] Murthy AS, Lehman JA. Secondary alveolarbone grafting: an outcome analysis.Can J Plast Surg 2006;14:1724.
[12] De Riu G, Lai V, Congiu M, Tullio A. Secondary bone grafting of alveolar cleft.Minerva Stomatol 2004;53:5719.
[13] Van der Meij AJ, Baart JA, Prahl-Andersen B, Valk J, Kostense PJ, Tuinzig DB.Computed tomography in evaluation of early secondary bone grafting. Int JOral Maxillofac Surg 1994;23:1326.
[14] Van der Meij AJ, Baart JA, Prahl-Andersen B, Valk J, Kostense PJ, Tuinzing DB.Bone volume after secondary bone grafting in unilateral and bilateral cleftsdetermined by computed tomographyscans. Oral Surg Oral Med Oral PatholOral Radiol Endod 2001;92:13641.
[15] Tai CC, Sutherland IS, McFadden L. Prospective analysis of secondary alve-olar bone grafting using computed tomography. J Oral Maxillofac Surg2000;58:12419, discussion 1250.
[16] Verdi Jr FJ, SLanzi GL, Cohen SR, Powell R. Use of the Branemark implant inthe cleft palate patient. Cleft Palate Craniofac J 1991;28:3013, discussion304.
[17] Ronchi P, Chiapasco M, Frattini D. Endosseous implants for prosthetic rehabil-itation in bone grafted alveolar clefts. J Craniomaxillofac Surg 1995;23:3826.
[18] Takahashi T, Fukuda M, Yamaguchi T, Kochi S. Use of endosseous implants fordental reconstruction of patients with grafted alveolar clefts. J Oral MaxillofacSurg 1997;55:57683, discussion 584.
[19] Kearns G, Perrott DH, Sharma A, Kaban LB. Placement of endosseous implantsin grafted alveolar clefts. Cleft Palate Craniofac J 1997;34:5205.
[20] de Barros Ferreira S, Esper LA, Sbrana MC, Ribeiro IW, de Almeida AL. Survivalof dental implants in the cleftarea-aretrospective study. CleftPalateCraniofac
J 2010;47:58690.[21] DempfR, TeltzrowT, KramerFJ, HausamenJE.Alveolarbonegrafting in patients
with complete clefts: a comparative study between secondary and tertiarybone grafting. Cleft Palate Craniofac J 2002;39:1825.
[22] Takahashi T, Inai T, Kochi S, Fukuda M, Yamaguchi T, Matsui K, et al. Long-term follow-upof dental implants placed in a grafted alveolarcleft: evaluationof alveolar bone height. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2008;105:297302.
Recommended