Craniomaxillofacial Reconstructive and Corrective Bone Surgery - part 8 ppsx

Different donor sites for autologous bone grafts have been proposed and used including anterior and posterior iliac crest, 112,113 rib, 113 mandible, 114–117 calvarium, 82,118 tibia, 83 pe- riosteal flaps, 119–121 and periosteal grafts. 120,122,123 The decision in favor of one or other of the different donor sites depends among other things on the age of the patient at operation, that is, the quantity of cancellous bone at the different donor sites in different ages. In an optimal recipient site, one can obtain good results with every graft, although autologous cancellous bone is the most proven successful graft. With it one can fill out the de- fect completely. It allows vessels to grow into the graft from the recipient site and to transform the graft into the locally adapted bone in the easiest and most rapid way. Moreover, cancellous bone has the highest resistance against infection. In patients older than 2 years, cancellous bone can be har- vested from the iliac crest with the help of a trocar (Figures 48.2 and 48.3). This procedure diminishes the extension of the secondary intervention and the pain at the donor site, and the resulting graft is compressed. Alternatively, and especially when large quantities are required, the iliac crest itself can be raised as an osteoplastic flap, cancellous bone chips removed, and the lid replaced. The key to prevention of postoperative morbidity at this site is the avoidance of any muscle stripping in particu- lar on the lateral aspect of the crest and the use of a long- acting local anesthetic agent (e.g., bupivicaine) titrated over 24 hours postoperatively into the wound via an epidural cannula. Adequate stability is always important especially in bilat- eral alveolar clefts. During the first postoperative weeks, bone grafting cannot abolish the mobility of the premaxilla. Indeed, mobility of the fragments may well prevent bone union be- tween the fragments and across the cleft(s). Some form of fix- ation of the fragments is needed, for example, by external de- vices such as dentally fixed splints or arch wires. Internal fixation methods such as plates and screws can be applied in a simultaneous osteotomy of the premaxilla or in a sec- ondary intervention with the need for bigger grafts (Figures 48.4–48.6). Some authors describe a simultaneous palato- osteoplasty. Their intention is to reconstruct all the layers cor- responding to the normal anatomic situation. We have no per- sonal experience with this procedure because we cannot see the functional need. The Basel Approach In 1983, Honigmann described a method that had been adopted in 1980. 124 This technique involved closure of the soft palate and the lip in one stage in uni- and bilateral com- plete clefts at the age of 6 months. The alveolar and the hard palate cleft were closed in a second intervention at the age of 3 to 5 years with bone grafting into the alveolar cleft. The bone graft was harvested from the iliac crest, and from 1985 onward using a trocar. In some cases the bone chips were mixed with a granulate of tricalcium phosphate. 125 The aims of the timing were to construct the labial and velar muscle systems as soon as possible for optimal functional development, to re- 544 K. Honigmann and A. Sugar F IGURE 48.2 Bone collection from the iliac crest by trocar. FIGURE 48.3 Bone harvested from the iliac crest by trocar. F IGURE 48.4 A bilateral cleft lip and palate with a big bone defect; status after Le Fort I osteotomy and fixation with 2.0-mm plates and screws. duce the number of interventions for primary cleft repair, and to enable the children to enter school with a completely closed cleft and normal colloquial speech. The failure rate in bone grafting at that time was 11.3%. Normal colloquial speech at school entrance was achieved in 91.6% of the children. 28 In 1991, this concept was changed with the aim of obtain- ing a completely closed cleft at the end of the first year of life for a better functional and psychological development of the cleft child. Based on the aim of reducing the number of surgical interventions and thus hospitalizations, an attempt was made to try to close all forms of clefts in one stage at least by the age of 6 months. Because of modern methods of pediatric anaesthesia, there were no significant problems even in a 4-hour operation, which was needed in complete bilat- eral clefts. Subsequently it was found that this all-in-one pro- cedure for unilateral cleft lip and palate patients had been pro- posed in 1966. 126 The late results of that work were reported at the 7th International Congress on Cleft Palate and Related Craniofacial Anomalies in 1993 at Broadbeach, Australia. 127 The operative steps in detail are as follows. The child’s head is placed in the ‘Rose’ position, that is, the surgeon is seated with the child’s head on his/her knees. The mouth is opened by a Rosenthal retractor (the widely used Dingman retractor covers the lip and the alveolar cleft with its extraoral frame, so it is impossible to get the view needed for the alveolo-osteoplasty). The incision of the soft palate edges continues with the dissection of pedicled palatal flaps including the preparation and mobilization of the palatal ves- sels (Figure 48.7). This provides a good view for the intra- velar muscle dissection. With the aid of mucoperiosteal vomerine flaps and the mobilized lateral nasal mucoperios- teum, the nasal meatus can be formed in the complete alve- olar and palatal cleft (Figure 48.8), and in bilateral clefts the two nasal meati can be separated (Figure 48.9). Suture of the mobilized and posteriorly directed soft palate muscle stumps and pushback of the totally mobile palatal soft 48. CLP Osseous Defects and Deformities 545 FIGURE 48.5 Same patient as in Figure 48.4 grafted with cortico- cancellous bone from the iliac crest; fixation with 2.0-mm plates and screws. F IGURE 48.7 Dissection of the soft palate muscles and the pedicled palatal flaps. F IGURE 48.6 Same patient as in Figure 48.6; oral cover of the graft with a tongue flap. F IGURE 48.8 Formation of the nasal meatus in the unilateral alveo- lar and palatal cleft. tissues lengthens the soft palate into a normalized anatomic situation (see Figure 48.1). The palatal flaps are sutured only in the midline and then lightly pressed against the palatal bone with the aid of a palatal dressing. Thus a dead space between the palatal bone and soft tissues can be avoided, and with it a hematoma and the resulting thicker scar. After reposition- ing the child onto the table, a rib bone graft is harvested (Fig- ure 48.10) and the alveolar cleft(s) filled with the cancellous bone (Figure 48.11). Integrated into the final lip repair is cover of the bone graft by mucoperiosteum advanced from the vestibular side of the lesser maxillary segment and its sutur- ing with the tips of the palatal flaps. In this manner, alveolar bone grafting is a part of an all- in-one closure of all clefts. More than 80 complete uni- and bilateral clefts have been closed in this all-in-one procedure (case 1: Figure 48.12 and case 2: Figure 48.13). At this time, the rate of healing complications is 5.9% (3 partial hard palate dehiscences, 2 bone graft losses), and the first functional re- sults with regard to speech development and hearing disor- ders are very encouraging. The Swansea Approach By contrast, Sugar’s approach to alveolar bone grafting in Swansea (and until 1994 in Chepstow) has been unchanged since 1985. Grafting has been carried out ideally in the mixed dentition shortly before the eruption of the permanent maxil- lary canine teeth, the classic secondary graft. This approach has varied little from the method proposed by Boyne and Sands 80 and reported by Abyholm and colleagues. 81 However, in our patients, operating on children whose primary surgery has been carried out by a number of surgeons, there has been a clear need for a significant amount of orthodontics, primarily to correct collapsed or misplaced alveolar segments, before grafting can take place. Only cancellous bone harvested from the anterior iliac crest has been used and with consistently good results. During this period, a significant number of cleft patients presented who had, for various reasons, missed the opportu- nity of receiving a graft into their alveolar clefts during the mixed dentition phase. In most cases these have been man- aged with careful orthodontic preparation with fixed bands and tertiary alveolar grafting in exactly the same way as men- tioned. 128 This has applied equally to those patients who have not required orthognathic surgery, the graft not only facili- tating closure of fistulae but also giving support to dental restorations with or without osseointegrated implants. When- ever grafting is carried out during orthodontic therapy, the or- thodontist places in advance either lateral retaining arms from molar bands or rigid arch wires to maintain arch width. This is usually reinforced by a transpalatal bar, positioned suffi- ciently far posteriorly and relieved from the mucosa to enable any required palatal surgery to be performed. In all cases the complete alveolar cleft is identified. Any labial fistula is excised and this excision incorporated into the mucoperiosteal flap(s) of the lesser segment(s) (see Figures 48.14a–g–48.22). These flaps critically include keratinized gin- givae. In unilateral cases, a mucoperiosteal flap is also raised up to one unit on the greater segment. In bilateral cases, virtu- 546 K. Honigmann and A. Sugar F IGURE 48.9 Separation of the two nasal meati in a bilateral cleft. FIGURE 48.10 Rib graft resection. FIGURE 48.11 Primary alveolar cleft bone grafting. 48. CLP Osseous Defects and Deformities 547 FIGURE 48.12 Case 1. (a) Five-month-old boy with a unilateral cleft lip and palate (CLP). (b) Intraoral aspect. (C) Two years old, after the one-stage closure. (d) Intraoral aspect. (e) X-ray of the grafted alveolar cleft, 18 months postoperative. a b c d e ally no dissection is permitted on the premaxilla, whose blood supply is perilous. The closure of anterior palatal fistulae in two layers at this stage is mandatory. The repair of posterior palatal fistulae away from the alveolar cleft is optional, but the opportunity to do this simultaneously is difficult to resist. Scar tissue within the alveolar cleft is excised and the nasal mucosa repaired. It is important that this repair is carried out in such a way that the nasal floor lies at the same height as the normal side. This, together with excision of the scar tis- sue in the cleft, redefines the complete alveolar deficit into which are then packed the cancellous bone chips. The lateral flaps are then advanced, aided by appropriate division of pe- riosteum, and closed with keratinized fixed gingivae over the alveolar crest. These flaps are sutured across the crest to the palatal oral mucosa. The posterior deficits of mucoperiosteum over the alveolus buccally from where the flaps have been advanced are allowed to heal by secondary epithelialization. Antibiotics are administered intravenously during the opera- tion. Even when large fistulae have been present we have al- ways been able to use local flaps, although on occasion the palatal flaps have had to be ‘islanded’ (i.e., Millard island flaps) when advancement has been required. We have never needed or used a Burion flap in this situation. Case 3 (Figure 48.14) A 10-year-old with left unilateral complete cleft of lip and alveolus. Treatment: 1. Raising of mucoperiosteal flaps 2. Excision of sinus and scar tissue within cleft 3. Removal of supernumerary tooth 4. Repair of nasal mucosa at level of normal nasal floor 5. Harvesting of cancellous bone from anterior iliac crest 6. Insertion of graft into alveolar defect 7. Flap advancement and closure over graft The Role of Osseointegrated Implants Although modern cleft surgery aims to create a dentition with- out gaps, this aim is not always achieved. The incidence of hypodontia in cleft patients is higher than in the noncleft pop- ulation, and it is not always possible for this to be disguised with the help of grafting, orthodontic treatment, and orthog- nathic surgery alone. There are also many patients who have not received alveolar bone grafts and also those who have lost 548 K. Honigmann and A. Sugar FIGURE 48.13 Case 2. (a) Bilateral complete CLP in a 6-month-old boy. (b) Same boy, aged 1 year and 6 months, after the one-stage closure. (c) In- traoral aspect. a c b 48. CLP Osseous Defects and Deformities 549 FIGURE 48.14 Case 3. (a) X-ray of secondary alveolar defect. (b) In- cisions for alveolar bone grafting outlined with excision of labial fis- tula. (c) Scar tissue within the alveolar cleft. (d) Alveolar defect af- ter excision of scar tissue and repair of the nasal mucosa. (e) Inci- sion (continuous line) marked lateral to the left anterior iliac crest (interrupted line) for harvesting of cancellous bone. Continued. a c e b d 550 K. Honigmann and A. Sugar f h i g j FIGURE 48.14. Case 3. Continued. (f) Alveolar defect packed with cancellous bone chips harvested from the anterior iliac crest. (g) Flap closure over the bone graft; note the advancement of the flap from the lesser segment including gingivae and leaving a posterior defect over the lateral maxilla, which is left to epithelialize by secondary intention. (h) Diagram of procedure. (i) X-ray of the alveolus in the grafted area in the same patient 6 months after surgery. (j) Oral view of the same patient 6 months after surgery. teeth early and whose conventional dental restorative treat- ment is problematic. The restoration of gaps in the dentition is ultimately the re- sponsibility of the restorative dentist. Their options include dentures and fixed bridgework supported by teeth. The avail- ability of titanium osseointegrated implants now adds to this repertoire the possibility of crowns or bridges supported by implants, as well as implant-supported overdentures. Case 4 (Figure 48.15) A 25-year-old with left unilateral complete cleft lip and palate, not having received an alveolar bone graft and missing the left maxillary lateral incisor. Treatment: 1. Alveolar bone grafting with autogenous cancellous iliac bone as described in Figure 48.14 2. Orthodontic arch alignment 3. Insertion of Bränemark titanium fixture into grafted area with additional small bone graft for labial defect provided from suction filter during the drilling process and covered with resorbable membrane (two-stage implant procedure) 4. Construction of implant-retained crown (Restorative treatment courtesy of Will McLaughlin, Consul- tant in Restorative Dentistry, University Dental Hospital, Cardiff, Wales) Case 5 (Figure 48.16) A 16-year-old with bilateral complete cleft lip and palate as- sessed following orthodontics and bilateral alveolar bone grafting and with regard to two missing teeth in the left cleft. Treatment: 1. Insertion of two Bränemark titanium fixtures (two-stage procedure) into maxillary alveolus, previously grafted in conjunction with orthodontics 2. Construction of implant-retained bridge (Restorative treatment courtesy of Arshad Ali, Consultant in Restorative Dentistry, Morriston Hospital, Swansea, Wales) Maxillary Osteotomies Secondary deformities in patients with repaired cleft lip and palate present an interesting, if not difficult, surgical chal- lenge. Careful assessment of the patient in the years follow- ing primary repair needs to take into consideration speech, hearing, facial growth, and dental development. The presence of fistulae, lip scars, and poor lip function, as well as resid- ual nasal deformity and nasal resistance, needs to be assessed for correction. Alveolar defects and occlusion should be con- sidered along with dental overcrowding, missing, malformed and misplaced teeth, caries, and periodontal health. The abil- ity and desire of the patient (and in the case of children, their family) to comply with what can often be prolonged treat- ment needs to be determined and taken into account. This heterogeneity of problems requires the cooperation of a number of different specialties, foremost of which are a sur- geon, speech therapist/pathologist, hearing specialist, and or- thodontist, all preferably with a special interest in cleft prob- lems. In late adolescence, a specialist in restorative dentistry is a valuable addition to the team. It is particularly useful to attempt to identify at as early an age as possible those chil- dren with significant midface hypoplasia that may require later surgical correction. If orthognathic surgery is to be de- layed until approximately 16 years of age when most jaw growth is complete, early identification of those children is helpful. Timing In most cases speech patterns will have developed by the age of 4, and it should be possible to assess the need for a pharyn- goplasty to correct velopharyngeal incompetence. Speech as- sessment and recording, anenometry, nasendoscopy, and video-fluoroscopy all assist in that decision. Ideally this should be carried out before school entry. At the age of 8 years, and with the aid of orthopantomo- gram (OPT) and oblique occlusal and lateral cephalometric radiographs, it is useful to start to consider the need for den- tal extractions for orthopedic alignment of displaced and col- lapsed arches and for grafting of alveolar defects. When fa- cial growth appears to be essentially normal, definitive orthodontics can then continue. A clinical evaluation of facial form, noting the presence or absence of midface hypoplasia, a class III malocclusion, and dental compensation, may lead the team to the conclu- sion that jaw osteotomies are indicated in due course. This in turn allows the decision that orthodontics should be lim- ited at that stage to the orthopedic alignment of segments and perhaps the correction of minor anterior incisal dis- crepancies. Definitive presurgical fixed-band orthodontics can then be delayed until the approximate age of 14 years when the patient can be prepared for orthognathic correc- tion by osteotomies at 16. This has the merit of saving the child from 6 to 8 years of continuous orthodontic treatment with the inconvenience and almost inevitable lack of com- pliance that can result. The Role of Alveolar Bone Grafting Primary Grafting We have described in our previous section the purpose of con- sidering and carrying out alveolar bone grafting as well as a number of different approaches to it. Primary alveolar bone 48. CLP Osseous Defects and Deformities 551 a c e d b f 48. CLP Osseous Defects and Deformities 553 g h i FIGURE 48.15 Case 4. (a) X-ray of alveolar defect. (b) Diagram of alveolar defect. (c) X-ray of grafted alveolar defect. (d) Diagram of grafted alveolar defect. (e) Intraoral x-ray of implant in grafted alve- olar defect. (f) Lateral cephalogram showing position of implant. (g) Oral view with implant/abutment in situ. (h) Diagram showing im- plant in situ. (i) Oral view showing implant retained crown in situ. [...]... bei Lippen-Kiefer-Gaumenspalten beim Säugling Zentrabl Chir 19 58; 83 :84 9 85 9 79 Schuchardt K, Pfeifer G Erfahrungen Über primäre Knochentransplantationen bei Lippen-Kiefer-Gaumenspalten Langenbecks Arch Klin Chir 1960;295 :88 1 88 4 80 Boyne P, Sands N Secondary bone grafting of residual alveolar and palatal clefts J Oral Surg 1972;30 :87 –92 81 Abyholm FE, Bergland O, Semb G Secondary bone grafting of alveolar... 87 Blanchard-Moreau P, Breton P, Lebescond Y, Beziat JL, Freidel M L’osteoplastie secondaire dans les fentes congenitales du palais primaire Technique et resultats a propos de 43 observations Rev Stomatol Chir Maxillofac 1 989 ;90 :84 88 88 Witsenburg B, Remmelink H-J Reconstruction of residual alveolo-palatal bone defects in cleft patients J Cranio-Maxillo-Fac Surg 1993;21:239–244 89 McNeil CK Oral and. .. Palate J 1 987 ;24:291–2 98 Garliner D Myofunctional Therapy Philadelphia: WB Saunders; 1976 Codoni S Anwendung der myofunktionellen Diagnostik und Therapie bei de Behandlung des LKG-Spalten-Kindes Spaltträger Forum 1992;4:22– 28 Graf-Pinthus B, Campiche M Die Suche nach einem holistischen Behandlungskonzept bei Lippen-Kiefer-Gaumen-Spalten Myofunktion Ther 1994;1: 58 66 Obwegeser H Chirurgische Behandlungsmöglichkeiten... cleft lip and/ or palate are as follows 1 To improve facial aesthetics and in particular the appearance of the midface, including the upper lip and nose 5 58 K Honigmann and A Sugar a b c d e 48 CLP Osseous Defects and Deformities f h FIGURE 48. 18 Case 7 Anteroposterior mandibular deficiency in a patient with bilateral cleft lip and palate (BCLP) (a–d) After orthodontic preparation but before surgery (e)... the infant with a cleft lip and palate Quintessence Int 1 989 ;20:907–910 42 Weatherly-White RCA, Kuehn DP, Mirrett P, Gilman JI, Weatherly-White CC Early repair and breast-feeding for infants with cleft lip Plast Reconstr Surg 1 987 ;79 :87 9 88 5 43 Duncan B, Ey J, Holberg CJ Exclusive breast-feeding for at least 4 months protects against otitis media Pediatrics 1993; 91 :86 7 87 2 44 Honigmann K, Herzog C... from the 8th International Conference on Oral and Maxillofacial Surgery Chicago: Quintessence; 1 985 113 Helms JA, Speidel TM, Denis KL Effect of timing on longterm clinical success of alveolar cleft bone grafts Am J Orthod Dentofac Orthop 1 987 ;92:232–240 114 Bosker H, van Dijk L Het bottransplantaat van de mandibular voor herstel na de gnatho-palatoschisis Ned Tijdschr Tandheelkd 1 980 ;87 : 383 – 389 ... cleft lip and palate (a,b) Facial views before orthognathic surgery (c,d) Occlusion before surgery (e,f) Facial views after large Le Fort I ad- b d vancement osteotomy, with fixation by four 2-mm titanium L-shaped miniplates, and bone grafting anteriorly with bone harvested from the anterior iliac crest (g,h) Occlusion after the surgery with temporary prosthesis in situ  48 CLP Osseous Defects and Deformities... Zahn-, Mund- und Kieferchirurgie Leipzig: Johann Ambrosius Barth; 1951 Honigmann K The celluloid-acetone-dressing in palatoplasty Cleft Palate Craniofac J 1994;31:2 28 229 Kapp-Simon K Self-concept of primary-school-age children with cleft lip, cleft palate, or both Cleft Palate J 1 986 ;23: 24–27 Strauss RP, Broder H, Helms RW Perceptions of appearance and speech by adolescent patients with cleft lip and. .. Arbeitskreis LKG-Spalten, 1994, Mainz 4 Jirasek JE The development of the face and mouth cavity Acta Chir Plast 1966 ;8: 237–2 48 577 5 Klaskova O An epidemiological study of cleft lip and palate in Bohemia Acta Chir Plast 1973;15:2 58 262 6 Jensen BL, Kreiborg S, Dahl E Cleft lip and palate in Denmark, 1976–1 981 : epidemiology, variability, and early somatic development Cleft Palate J 1 988 ;25:2 58 269 7 Saxen... enabling a non-prosthodontic rehabilitation in cleft lip and palate patients Scand J Plast Reconstr Surg 1 981 ;15:127–140 82 Wolfe SA, Berkowitz S The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts Plast Reconstr Surg 1 983 ;72:659–671 83 Kalaaji A, Lilja J, Friede H Bone grafting at the stage of mixed and permanent dentition in patients with clefts of the lip and primary . alveolar bone grafting is a part of an all- in-one closure of all clefts. More than 80 complete uni- and bilateral clefts have been closed in this all-in-one procedure (case 1: Figure 48. 12 and case. autologous bone grafts have been proposed and used including anterior and posterior iliac crest, 112,113 rib, 113 mandible, 114–117 calvarium, 82 ,1 18 tibia, 83 pe- riosteal flaps, 119–121 and periosteal. a 6-month-old boy. (b) Same boy, aged 1 year and 6 months, after the one-stage closure. (c) In- traoral aspect. a c b 48. CLP Osseous Defects and Deformities 549 FIGURE 48. 14 Case 3. (a) X-ray