Secondary alveolar bone grafting

alveolar bone grafting

1. SECONDARY ALVEOLAR BONE GRAFTING - SEMINAR BY TEJASWINI PSS, PG - III

2. Embryology Treatment goals & objectives Timing of alveolar cleft repair & grafting Patient evaluation & assessment Source of graft Types of grafts Pre-surgical orthodontic care Preparation of cleft alveolus Types of tissue flaps used with bone grafts Post-op care Complications Post- surgical orthodontic care Other substitutes for bone grafting Case illustrations CONTENTS :

3. C left lip with or without cleft palate – 1 : 800 live births . Complete clefts - transverse the alveolar ridge  disparate palatal segments The remaining alveolar defect following early lip and palate repair requires grafting Alveolar bone grafting

4. The cleft of the alveolus was not initially perceived as a problem on the same order as cleft lip V on Eiselberg’s - fifth digit to span the cleft in 1901. Initially , it was mostly performed in conjunction with orthopedic appliances during deciduous dentition with the goal of preventing maxillary collapse Pickrell et al 1968 - primary grafts did not grow with the skull and that teeth did not reliably erupt into primarily grafted clefts  secondary grafting > primary grafting

5. ( 1) the exact timing within the secondary period ( 2) the appropriate use of preoperative orthodontic/orthopedic appliances (3 ) questions of technique and bone source ( 4) evaluation of bone graft outcomes. Studies ON ABG focused on :

6. Embryology Of Clefts…

7. Alveolar Bone Grafting and Cleft Lip and Palate : A Review Plast Reconstr Surg. 2016 Dec;138(6): 12871295

8. ( Left ) Alveolar bone grafting is optimally performed in the stage of mixed dentition. ( Right ) Descent of the cleft-adjacent canine into the alveolar graft puts functional stress on the graft to increase graft take and reestablishes normal dentition. (Created by Jill K. Gregory, CMI, FAMI. Printed with permission \from ©Mount Sinai Health System.) ( Left ) Alveolar bone grafting is optimally performed in the stage of mixed dentition. ( Right )Descent of the cleft-adjacent canine into the alveolar graft puts functional stress on the graft to increasegraft take and reestablishes normal dentition. (Created by Jill K. Gregory, CMI, FAMI. Printed with permissionfrom ©Mount Sinai Health System.)

9. Treatment Goals And Objectives...

10. Closure of oro antral fistula Establishing continuity between cleft segments Establishing proper alveolar contour Supporting tooth eruption and orthodontic movement of teeth Providing for the periodontal health of teeth adjacent to cleft Providing support to the base of the nose and lip Facilitate nasolabial muscle and soft issue reconstruction Establishing functional airway Allow for placement of dental implants

11. Timing Of Alveolar Cleft Grafting

12. Primary ABG : 0-2.5 yrs usually at the time of lip repair Early secondary ABG : 2-5 yrs before the eruption of permanent incisors Secondary ABG : 6-13yrs before the eruption of permanent canines Late secondary ABG : >13 yrs after the eruption of permanent canines

13. Usually done at the time of lip repair Disadvantages : poor maxillary growth negative effects on anterior and inferior growth of maxilla inadequate contour of bone graft higher propensity for cross bites Primary Alveolar Grafting

14. usually done in childhood before the eruption of permanent incisors early surgery is not evaluated as thoroughly as late surgery Boyne indicated this when permanent central and lateral incisors appear to be developing in such a direction that it may erupt abnormally into the cleft resulting in inadequate tooth position or severe malposition jeopardized bone support because of anatomy of tooth eruption. Early Secondary Bone Grafting

15. classic time for alveolar grafting Advantages : high percentage of good results allows eruption of canine healthy teeth on either side of cleft minimal impact on facial growth allows for orthodontic alignment Secondary Alveolar Bone Grafting

16. Disadvantage: central and lateral incisors must have erupted carries increased risk of periodontal bone loss and root resorption . Posnick mentions that waiting allows maximum transverse growth of maxilla to occur before bone grafting. 95 % of anteroposterior and transverse growth of maxilla is completed by the age of 8yrs.

17. It is done after the eruption of canine It has got lower incidence of successful grafts due to poor oral hygiene and decreased blood supply or altered oral flora in older children. Late Secondary Alveolar Bone Grafting

18. Patient Evaluation And Assessment :

19. Patient evaluated for any oronasal fistula caries malposed teeth state of occlusion oral hygiene mobility and position of pre maxilla adequacy of soft tissue for tension free closure

20. Orthopantomograph Occlusal radiographs Periapical radiographs Cephalometrics in patients who have problems with premaxillary position Radiographic evaluation

21. Source of graft material

22. Types of grafts :

23. Eiselsberg ( 1901) made the earliest attempts to transplant autogenous cancellous bone into cleft maxilla, using little finger as a pedicled graft. Dracher used tibial bone and periosteum . Since then, usual sites for obtaining cancellous bone grafts have included iliac bone, rib , calvarium . Sindet et al - chin bone as a graft.

24. Endochondral Vs Membranous Bone Ossification …

25. Studies on onlay grafts ( cortico-cancellous grafts ) : Membranous bone superior to endochondral bone Embryological origin More cortical ; less cancellous  less resorption over time Studies on inlay grafts : Focused on maintainence of volume Endochondral ( ileum ) vs membranous ( symphysis ) Studies on rabbit calvarium – “ E ndochondral cancellous bone volume increased most over time “ Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

26. Relevance to alveolar clefts :

27. Alveolar cleft : Osseous deformity Continuity defect of alveolar process & pyriform rim Reconstructed with bone inlayed between osseous segments instead of onlay on maxilla Dynamics of inlay bone graft different from onlay grafts Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

28. Various factors affect the decision making process in choosing an appropriate donor site for alveolar cleft : size of the cleft volume of bone needed whether teeth will erupt through graft material health of donor site healing potential of the patient

29. ILIAC BONE : Gold standard Easy access high success rates rapid bone formation and calcification ( large supply of pleuripotent / osteogenic cells ) Earlier cortico-cancellous blocks were used but lately only cancellous bone is harvested using cylindrical punch with minimal incision. Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

30. Cancellous bone graft > cortical graft high content of osteogenic cells Compacting : > no. of osteogenic cells Rapid revascularization of graft ( 3 weeks ) Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

31. VARYING CONCEPTS OF BONE GRAFTING OF ALVEOALAR PALATAL DEFECTS- NICHOLAS et al, presented at 1963 convention of The American Cleft Palate Association, Washington DC

32. The patient is in supine position iliac crest is made prominent by keeping a bolster under the ipsilateral buttock. The ASIS, the iliac tubercle and the lateral and medial edges of the iliac crest are marked local anesthesia for hydro dissection and hemostasis. The incision is placed marginally medial and away from the ASIS to prevent damage to the lateral femoral cutaneous nerve. Preparation of Donor Site:

33. While choosing the anteromedial approach care should be taken to preserve the attachment of tensor fascia lata . Disturbance of the tensor from the lateral crest will lead to gait disturbances. In the lateral approach due to the tensor separation there is gait disturbance and hence not very popular . Anterior Iliac Crest Open:

34. Donor site is exposed an opening is made using osteotomy (trap door or open book type of exposure ) The overlying cortical bone along with the cancellous bone can be harvested or only the underlying cancellous bone can be harvested using bone gouge . Closure The scar should be in a position where it doesn’t get irritated away from the belt lines.

35. The cancellous bone here is approached through a small opening of around 1 to 1.5 cm using a drill or stab incision and the cancellous bone is scooped out of the bed. Advantages of the trephine technique are that the postoperative pain, gait abnormalities and complications are less common Anterior Trephination:

36. The posterior iliac crest can be approached for larger quantities of bone. The use in intraoral oral procedures is limited due to the fact that a prone position is required to harvest the bone from the posterior ilium. This shifting the patient between recipient site preparation and donor site harvesting is cumbersome. Posterior Iliac crest approach

37. Disadvantages questionable effects on growth possible gait disturbance post operative hematoma donor site morbidity Advantages adequate quantity easily condensed and placed proven successful results little donor site morbidity two team approach Iliac crest graft

38. Johanson and Ohlsson Drachter 1941 – facial clefts young infants of pre-weight bearing age. medial , slightly curved incision with excellent exposure of the tibial shafts. large supply of cancellous bone is available. Cosmetically the post operative incision appears to be quite acceptable. TIBIAL BONE :

39. VARYING CONCEPTS OF BONE GRAFTING OF ALVEOALAR PALATAL DEFECTS- NICHOLAS et al, presented at 1963 convention of The American Cleft Palate Association, Washington DC

40. Disadvantages concern with ambulation epiphyseal injury Advantages adequate volume quality similar to iliac crest predictable results two team approach Tibial graft

41. Disadvantages donor site morbidity unpredictable results Advantages for infants two team approach Rib grafts

42. Three techniques may be used for implanting the harvested rib graft into the oral cavity An eccentrically placed H shaped rib strut is wedged into the cleft with the more prominent portion facing the labial side to elevate the depression caused by cleft . A solid piece of rib can be used following linear separation at the ends exposing the cancellous part of the bone . The rib can be broken into many small chips and packed into the cleft

43. VARYING CONCEPTS OF BONE GRAFTING OF ALVEOALAR PALATAL DEFECTS- NICHOLAS et al, presented at 1963 convention of The American Cleft Palate Association, Washington DC

44. Both cortical & cancellous bone Young patients Wolfe & Berkowitz – diploe from cranium for SABG Denny et al – curved osteotome + mallet ; shavings from outer table & diploe Jacksen et al – craniotome technique ; powdered bone run into slurry mixed with blood Cranial bone : Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

45. Disadvantages donor site esthetics /defect stigma and fear for patient less cellular component difficult to harvest long contoured strips like rib graft difficult to obtain sufficient cancellous bone Advantages adequate quantity less resorption (membranous bone ) rapid vascularization predictable quality two team approach camouflaged scar Cranial bone

46. Hematomas Seromas Infected wounds Dural tears Subdural hemorrhage CSF Leak Complications of cranial bone graft harvesting : Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

47. Bosker & Von Dijt – mandibular symphysis Attractive donor site Low morbidity Limitations : Limited volume increased percentage of impacted canines (increased cortical content of the harvested bone) loss of unerupted permanent teeth early mixed dentition necrosis of the pulp, or devitalisation of teeth; injury to the mental nerve Mandibular symphysis

48. Disadvantages limited amount of bone inability to remove bone graft simultaneously with preparation of recipient site.   Advantages embryonic origin and earlier vascularization - superior maintenance of contour less resorption (membranous) no external scar Mandibular symphysis Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

49. may be indicated in late secondary grafting may be reasonable in young adults with small alveolar cleft. III molar area

50. Pre-Surgical Orthodontic Care

51. 2 orthodontic considerations integrate with timing of alveolar cleft grafting correction of cross bites alignment of anterior teeth cross bite due to narrowed transverse dimension of maxilla  maxillary expansion performed before grafting when graft is performed before expansion 3 months should elapse before expansion. ( full revascularization of cancellous bone takes place in 3weeks but it takes 3months for bone to get complete trabecular pattern )

52. bilateral cleft with a pre-maxilla  maxilla must be expanded first before distalizaton of pre-maxilla to ensure proper space . It is better not to begin teeth alignment before grafting as movement of teeth adjacent to cleft may result in root exposure through this alveolar bone in this area.

53. Five Principles in approaching the cleft alveolus: Wide exposure and appropriate Flap design. Reconstruction of Nasal floor closing the oro nasal fistula Adequate graft material harvest. Adequate packing of the defect with cancellous bone Watertight closure of bone graft with gingival mucoperiosteal flaps. Preparation of the Cleft Alveolus:

54. Pre procedural consideration by the surgeon amount of mucosa available for closure best flap design to maintain adequate blood supply tension free closure extent of oro nasal communication level of support needed for the alar base donor site evaluation

55. An important factor  design of the flap preserve the maximum vestibular architecture provide maximum attached mucosa in the area of alveolar cleft allow for normal periodontal sulcus and attachment of permanent canine. Procedure:

56. A lateral angled relieving incision is placed into the gingival sulcus on the cleft side . The muco-periosteum raised off the bone. The nasal layer is created on either side by incising around the margin of cleft alveolus and mucoperiosteal flap is pushed upwards till the depth of the vestibule to allow bone graft. The cancellous bone is then packed into the cleft defect. Once packed the flaps are gently repositioned over the sulcus and the cleft alveolus and sutured to ensure a watertight closure.

57. A crevicular incision is placed through the sulcus of the anterior teeth extending upto the first molar on the cleft side and on the non-cleft side two teeth lateral to the cleft alveolus. A vertical relieving incision is placed on the cleft alveolus side and there’s no release incision on the non-cleft side.

58. Alveolar Bone Graft Technique Incision and flap design for unilateral cleft defect repair

59. Alveolar Bone Graft Technique Elevation of labial and buccal mucoperiosteal flaps

60. Alveolar Bone Graft Technique Creation of labial and palatal flaps after excision of intradefect fistula

61. Buccal flap elevated superiorly Palatal flaps elevated and pushed posteriorly

62. Closure of nasal floor mucosa superiorly ( NF ) and palatal mucosa ( PM ) posteriorly NF PM

63. Placement of particulate cancellous bone into defect Alveolar Bone Graft Technique

64. Closure …

65. Labial pedicled “finger” flap elevated to cover bone graft as alternative to sliding buccal mucoperiosteal flap

66. unilateral cleft alveolus - major palatine artery, anterior and posterior superior alveolar artery and branches of sphenopalatine arteries . In bilateral patients : union of superior labial arteries is non-existent blood supply to philtrum is grossly compromised deficient anastomosis of posterior septal artery and greater palatine artery. The posterior septal artery and lateral (terminal branches of anterior ethmoidal vessels) may contribute as they pass through the columella . Alveolar bone grafting in bilateral cleft:

67. A variation of vessel on either side of the incisive foramen is believed to tackle the compromised state. Thus it is prudent to modify the technique for bilateral alveolus preparation. A common technique that can be employed is trying to stage the two sides

68. LOCAL FLAPS : Local flaps obtained from the labial alveolar ridge and rotated in a hinge like fashion based either medially or laterally towards the palate exposing the bony segments of the alveolar clefts . The labial defect is then closed with any of the labial flaps which can be rotated from the medial or lateral side. TYPES OF TISSUE FLAPS USED WITH BONE GRAFTS :

69. DISTANT FLAPS :   Distant flaps ( one stage vomer ) used for the closure of wider alveolar clefts. It was used by Stellmach and Schrudde easily elevated and transferred in one stage directly anteriorly to meet oncoming flap from the labial side. The denuded vomer can be covered with palatal pack for 24-48 hrs if necessary to minimize loosening if necessary.

70. Bilateral vomer flaps used in bilateral clefts are formed in two stages with intervals of two or three months as simulatenous denudation and elevation of two vomer flaps  jeopardize the blood supply to vomer

71. Post operative care :

72. Avoidance of trauma to the site Avoidance of activities like swimming for 5-7 days Patient placed on antibiotics and nasal decongestants for atleast 1week Meticulous oral hygiene with chlorhexidine mouth washes Recognition and treatment of upper respiratory tract infection Early ambulation

73. Infection Wound dehiscence Loss of graft Incomplete closure of oronasal fistula Complications

74. Post-Surgical Orthodontics:

75. 3 months after the bone graft procedure depending on the radiographic image of the area  orthodontic treatment is restarted to correct the position of the permanent teeth. Teeth adjacent to the alveolar cleft - rotations & severe tipping due to lack of adequate alveolar bone support. The pattern of eruption of the maxillary central incisor follows the pattern of alveolar development in the cleft subjects.  Dental alignments are possible if the alveolar cleft is grafted.

76. Correction of malpositioned teeth – fixed / Semi-fixed or fully bonded appliance  permitting adjacent teeth to migrate or be orthodontically moved into the grafted bone. Often lateral incisor - congenitally missing, rudimentary or malformed . canine brought into the space of the lateral incisor moving the tooth through the alveolar bone graft and reshaped into a lateral incisor and residual spaces closed with fully fixed bonded appliance. Thus a complete dental arch can be obtained without prosthodontics in the great majority of patients.

77. Ensuring Success in Alveolar Bone Grafting: A Three-Dimensional Approach - Cameron Craven, MD The Journal Of Craniofacial Surgery / Volume 18, Number 4 July 2007

78. The alveolar and hard palate cleft should be viewed as a three dimensional defect resembling a triangle or pyramid.

79. Schematic of incisions used to create gingivoperiosteal flaps for coverage of the alveolar cleft.

80. Elevation of mucoperiosteal flaps from the medial and lateral margins of the cleft. These are used to close the nasal floor and the roof of the oral cavity.

81. The alveolar cleft after packing with cortical and cancellous bone. ( B and C) Cortical bone reinforcing the roof of the cleft (nasal floor) and the anterior wall of the alveolus.

82. Closure of the mucoperiosteal and gingivoperiosteal flaps with Vicryl sutures.

83. Other Substitutes For Bone Grafting … Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A . Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

84. reduce morbidity not necessary to harvest autogenous bone, reduce the cost of rehabilitating patients with clefts . more than a century ago HCL demineralized bone chips from ox tibia - implanted into canine cranial defects Limitations : unpredictability in resorption / amount of bone formed Recently - recombinant human bone morphogenetic protein ( rhBMP ) Autogenous bony substitutes

85. rhBMP-2  effective in the regeneration of alveolar bone and associated periodontal attachment apparatus promotes the differentiation of pluripotential cells into bone-forming cells that lay down new host bone in the site of the defect ( osteoinduction ) remodelling equilibrium  prevents loss of bone through resorption However, it requires a suitable carrier for its clinical applications in human conditions to prevent rapid diffusion of the protein R ecombinant human bone morphogenetic protein ( rhBMP ).

86. Boneless-bone grafting ( gingivoperiosteoplasty ) was popularized by Skoog in the 1960s most widely debated “if healthy periosteum is closed over the alveolar defect, favourable osteogenic conditions would allow bone to bridge it “ degree of ossification after gingivoperiosteoplasty varies between 50% and 100%, and a third step of bone grafting may be required. Boneless-bone grafting Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A . Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008 ) 665–670

87. Case illustrations..

88. Preoperative Cleft Defect Postoperative Bone Graft

89. THANK YOU…