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Retrospective analysis of 135 secondary alveolar cleft grafts using iliac or calvarial bone
J Oral Maxillofac Surg 49:493-499.1991
Retrospective Analysis of 135 Secondary Alveolar Cleft Grafts Using Iliac or Calvarial Bone MARK J. KORTEBEIN, DDS,* CHARLES L. NELSON, DDS,t AND A. MICHAEL SADOVE, MD* This retrospective study summarizes experience with 135 secondary alveolar cleft bone graft procedures over 8 years. The overall success rate was 83.7%. The group of patients (n = 108) that had particulate cancellous bone and marrow obtained from the iliac crest as donor bone had an 89.8% success rate. The group (n = 27) that had calvarial bone as the donor material had a success rate of only 63%. It is felt that inferior results with calvarial bone are probably related to the procurement technique. In both the iliac crest and calvarial groups, there was a trend toward declining success rates with advancing age of the patient. Morbidity associated with these procedures, consistent with other reported series, was low.
eration of oronasal fistulae, and 6) increased bone support for the alar base of the nose. To meet these objectives, Boyne and Sands* suggested that particulate cancellous bone and marrow (PCBM), obtained from the iliac crest, is the donor material of choice. They emphasized that this viable graft material, once incorporated into the recipient site, not only stabilizes the maxillary arch segments, but also responds to physiologic and functional demands such as tooth movement and arch expansion. With these concepts in mind, it is fair to say that PCBM has become the most widely used donor material for secondary grafts and the “gold standard” against which bone from other donor sites is judged. Recently, Wolfe and Berkowitz14 and Harsha et al” described satisfactory results using cranial bone as donor material, whereas Sindet-Pederson and Enemark16 advocated the use of bone harvested from the symphysis of the mandible. Nique et alI7 published a preliminary report suggesting that particulate allogenic bone also may have the capability to satisfy the objectives of alveolar cleft bone grafting. There is little dispute among clinicians that the best results are obtained when grafting is done prior to the eruption of the canine teeth. Boyne and Sands,’ in their original article, stated that the ideal age for grafting is between 9 and 11 years. Others
Secondary alveolar cleft bone grafting has become a well-accepted procedure used in the rehabilitation of the cleft lip/palate patient. The literature is replete with articles reporting high rates of success and a low incidence of morbidity associated with this procedure. ‘-I3 Objectives of secondary alveolar cleft bone grafting have evolved over time, and include 1) stabilization of the maxillary arch segments, 2) improvement of bone support for teeth adjacent to the cleft, 3) provision of bone in the cleft through which teeth can erupt or be moved orthodontically, 4) improvement of ridge height and contour to aid in prosthetic rehabilitation, 5) oblit-
Received from Indiana University, Indianapolis. * Formerly, Chief Resident, Oral and Maxillofacial Surgery, School of Dentistry; currently, in Fellowship, Dallas, TX. t Associate Professor of Oral and Maxillofacial Surgery, Director, Residency Training Program, School of Dentistry. $ Associate Professor of Surgery, Plastic Surgery Section, School of Medicine. Presented at the American Association of Oral and Maxillofacial Surgeons Annual Meeting in San Francisco, October 1989, and at the American Cleft Palate Association Annual Meeting in St Louis, May 1990. Address correspondence and reprint requests to Dr Nelson: Department of Oral and Maxillofacial Surgery, Indiana University, 1121 W Michigan St, Indianapolis, IN 46202. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391191/4905-0008$3.00/O
493
494
SECONDARY ALVEOLAR
have emphasized that dental age is more important than chronologic age in determining the optimum time for the graft, and that it should be done when the unerupted permanent canine root is one-half to two-thirds formed. ‘,* In their later article, Boyne and Sands2 suggested that secondary grafts using PCBM could be done at any time in the mixed dentition stage, but preferably earlier than the age of 7, before the lateral incisor has erupted and been lost through exfoliation into the cleft area. This retrospective study was designed to evaluate our experience with secondary alveolar cleft bone grafts specifically as it related to the rate of graft success versus age of the patient and the type of donor bone used. We also evaluated complications, blood loss, length of hospital stay, and operating time as additional parameters that quantified our experience. Materials and Methods
The clinical records of 171 patients who underwent secondary alveolar cleft grafting between 1982 and 1988 were reviewed. All patients had undergone previous cheiloplasty and/or palatoplasty. None of these patients underwent simultaneous Le Fort I procedures. One hundred thirty patients were found to have clinical and radiographic follow-up adequate for inclusion in the study. There were 135 cleft graft procedures performed on these 130 patients. Five cleft grafts were reoperation of failed grafts. One hundred four patients had unilateral grafts and 31 had bilateral grafts, making the total number of individual cleft sites grafted 166. There were 78 females and 52 males, ranging in age from 5 to 25 years. Follow-up ranged from 6 months to 5 years, with a mean of 2.6 years. Particulate cancel-
CLEFT BONE GRAFTING
lous bone and marrow obtained from the iliac crest were used in 108 patients and 27 had calvarial bone as the donor material. The technique of recipient site preparation represented an amalgamation of the techniques described by Boyne and Sands,‘y2 Troxell et aL6 and Hall and Posnick.’ To evaluate success rates related to age, patients were divided into four groups: age 5-7 (51 patients), age 8-11 (42 patients), age 12-15 (26 patients), and age 16 and above (16 patients). The grafting procedure was considered successful if there was an adequate bulk of bone both clinically and radiographically to support adjacent teeth and teeth erupting or being moved orthodontically into the cleft area (Figs 1 and 2). The overall patient success rate for both iliac crest and calvarial bone groups was determined. In addition, the success rates in each donor group were determined according to the four age groups. The success rates were based on the number of procedures performed (135) and not the actual number of cleft sites grafted. The x2 test was used to compare the iliac crest group to the calvarial group. The iliac crest group was further evaluated with analysis of variance (ANOVA) and a Newman-Keuls test for multiple comparisons in order to compare success rates between the various age groups. Estimated blood loss, length of procedure, and length of hospital stay were averaged. Morbidity and complications were listed as they occurred. Results
Of 135 secondary alveolar cleft bone graft procedures, 114 had successful results for a success rate of 83.7%. Overall, unilateral graft patients had an 84.6% success rate and bilateral graft patients had
FIGURE 1. A, Preoperative radiograph shows a thin lamina dura on the distal of the central incisor and an otherwise open alveolar cleft. B, Postgrafting radiograph at 6 months shows the cleft filled with bone, supporting teeth adjacent to the cleft site. (Reprinted with permission.*‘)
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ET AL
FIGURE 2. A, Preoperative radiograph demonstrates an open alveolar cleft prior to eruption of the central incisors. The patient was grafted at this time. B, After grafting and eruption of the central incisors, the cleft is filled with bone. This supports the orthodontic movement of the central incisor adjacent to the cleft. To try and correct the rotation prior to grafting might result in the root being exposed into the cleft site.
an 83.8% success rate. When age-related success was analyzed, the 5- to 7-year age group had 45 of 51 successful grafts, for an 88.2% success rate. The 8- to 11-year age group had 39 of 42 successful grafts (92.8%), the 12- to 15-year age group had 22 of 26 successful grafts (84.6%), and the 16-year and older age group had 8 of 16 successful grafts (50%). Secondary alveolar cleft bone grafts using PCBM obtained from the iliac crest were successful in 97 of 108 cases, giving a success rate of 89.8%. The success rates for the various age groups were 97.2% (34135) for the 5- to 7-year age group, 92.5% (37/40) for the 8- to 1l-year age group, 90.5% (19/21) for the 12- to 15-year age group, and 58.3% (7/12) for those 16 years of age and older. The success rates across the age groups were compared statistically by subjecting the data to arc sine (angular) transformation followed by an analysis of variance (ANOVA). A P value of less than .025 was derived, indicating that a significant difference existed among the success rates of the various age groups. These data were then subjected to the Newman-Keuls Test for multiple comparisons, allowing each age group to be compared independently to the other age groups. This analysis indicated the 16 and older age group differed significantly from the other three age groups, with a P value of less than .Ol. There were no significant differences when comparing the S- to 7-year, 8- to 11-year, and 12- to 15-year age groups with each other. The calvarial bone donor group consisted of 27 patients, 17 of whom had successful grafts for a success rate of 63%. Age-related success was 68.8% (1 l/16) for the 5- to 7-year group, 100% (2/2) for the 8- to 1l-year group, 60% (315) for the 12- to 15-year
group, and 25% (l/4) for the 16-year and older group. It was felt that the numbers in each age group were too small to make further comparison between the age groups. The overall success rates of the iliac crest group (89.8%) and the calvarial group (63%) were compared using a x2 test. A significant difference was shown by a P value of less than .OOl. The average length of the bone graft procedure was 2.4 hours. The average estimated blood loss was 164 mL, and three patients required transfusion during the procedure. The average hospital stay was 3.1 days. Morbidity associated with the secondary alveolar cleft bone graft procedures was low. One patient developed a seroma along the iliac crest incision. Another patient had temporary paresthesia over the distribution of the lateral femoral cutaneous nerve. There were no infections in either donor or recipient sites of any patient. Other than graft resorption, there was no other specific morbidity associated with the recipient site. Discussion The 83.7% overall success rate of our secondary alveolar bone graft procedures is lower than that generally reported by others.2,4-7 This reflects the relatively poor performance of calvarial bone grafts in our series, and the significantly decreased success rate for those patients age 16 and over in both the iliac crest and calvarial groups. Several authors have recently commented on the efficacy of calvarial donor bone for reconstruction of alveolar clefts. Wolfe and Berkowitz14 and Harsha et al” have described favorable results, whereas Jackson
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et all8 indicated they had abandoned the use of calvarial bone as a donor source for reconstruction of alveolar clefts because they felt that the quality of bone obtained from this source was not satisfactory. Further analysis of our own series of calvarial grafts has revealed that procurement technique is importan~.19 Some of our calvarial group had bone obtained using a handheld Hudson brace to drill five or six holes through the outer table and the cancellous bone. The resultant shavings were collected and packed into the recipient site. We made no attempt to separate cortical from cancellous bone. Other patients had bone harvested using a powerdriven craniotome, again drilling five or six holes through both the outer table and cancellous bone. The procured bone was packed into the prepared cleft site. As we have reported,” calvarial bone obtained with the hand brace yielded significantly better results (80% successful grafts) than calvarial bone obtained with a power-driven craniotome (53% successful grafts). We believe that the difference in the success rates of these two methods is attributable to the difference in the consistency and composition of the obtained material. Bone procured with the craniotome tended to be of very small particle size, often a dustlike consistency. This small particle size undoubtedly exposed more of the cellular elements of the procured bone to the deleterious effects of both mechanical and thermal trauma. Bone obtained with the hand brace had a more preserved structure both macroscopically and microscopically. The procured bone consisted of larger shavings that histologically showed more preserved Haversian systems and intact osteocytes when compared with craniotome-procured bone. In either case, the success of calvarial bone as a donor material for alveolar cleft bone grafting fell below the success rate for bone obtained from the iliac crest. We feel that this most likely relates to the high ratio of less cellular cortical bone to cancellous bone that results from not specifically separating cortical from cancellous components in these procurement techniques. Wolfe and Berkowitzi4 and Harsha et al” describe techniques that discard the cortical component and procure only the more cellular cancellous bone. Using these techniques they have described consistently good results. When plotted against age, there was a trend toward declining success with advancing age of the patient in iliac crest procurement group, although only the 16-years and older age group had a statistically significant decline. This is consistent with the observation of Ames et al5 that age at time of operation was the primary variable that seemed to
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affect the success of the graft. In their series, the overall success rate for those patients grafted over age 14 was 64.3%, compared with 96% for those under 14 years of age. Hall and Posnick7 also commented that in their series that good healing was especially evident in patients 12 years of age or younger. It is our feeling that the general health of the oral tissues often begins to deteriorate soon after eruption of the permanent dentition. Gingival tissues, especially those adjacent to the alveolar cleft and oronasal fistulae, become inflamed due to compromised oral hygiene. This type of tissue is very friable and difficult to handle when developing and closing mucosal flaps. If this tissue necroses, even causing minor dehiscence, it seems to have less capacity to heal and protect the integrity of the bone graft. It has been our experience, on the other hand, that healthy gingival tissues withstand the surgery well and, even in the face of occasional wound dehiscences postoperatively, will heal quickly before there is any significant loss of the graft. Optimizing oral hygiene before bone grafting, especially in this older group of patients, is of extreme importance in contributing to the success of the graft. Another adverse factor we have observed in this older patient group is that significant periodontal defects may already exist associated with teeth adjacent to the cleft. Rotation and malposition of the central incisors or canines can lead to reduced bone support on the proximal surfaces, decreasing chances for graft success. The optimum timing for bone grafting alveolar clefts has long been debated. It is now fairly well accepted that the best time for grafting is 8 to 10 years of age, when the canine root is one-half to two-thirds formed. Growth considerations have entered into the basis for this recommendation. Since maxillary alveolar growth is nearly complete by 8 years of age,” a procedure performed at this age or older would have minimal chance of adversely affecting growth. While we certainly respect these concerns for potential growth attenuation, it is obvious we have grafted a number of cases at earlier ages. In each of these cases we have made decisions to proceed with grafting for specific reasons. In some cases there were lateral incisors present that showed promise of reasonable development and subsequent eruption into the arch. In such cases, it was necessary to reconstruct the alveolus early, through bone grafting, to support these teeth (Fig 3). In other cases, there were developing or erupting central incisors that needed bone support in the area of the cleft to protect their integrity. We have thus saved teeth that, without this earlier grafting, may have been lost. On a few occasions an anterior
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FIGURE 3. A, Preoperative radiograph of a (i-year-old boy with a lateral incisor in early stages of development. The supemumary tooth was removed and the cleft was grafted at this stage. B, Radiograph of the same boy at age 12 aBer completion of orthodontic therapy. Notice the natural-appearing alveolus and the well-supported lateral incisor, which erupted without assistance after grafting.
oronasal fistula through an open alveolar cleft had allowed so much air escape that speech was compromised. We chose to bone graft these patients early to obliterate the large fistulae. It is our clinical impression that we have not adversely affected maxillary or midface growth with these earlier procedures, but this remains to be proven with firm data and analysis. Other than loss of the bone graft, there was no specific morbidity associated with the recipient site. This graft loss was most often the result of wound dehiscence and flap breakdown in the cleft area leading to exposure and contamination of the graft. It should be emphasized that the presence of small wound dehiscences at the flap margins did not always indicate impending graft failure. In fact, most small wound dehiscences healed secondarily with no apparent adverse effects on the graft. There was no donor site morbidity associated with the calvarial procurement. Donor site morbidity associated with the iliac crest consisted of one case of temporary paresthesia over the course of the lateral femoral cutaneous nerve and one wound seroma. Both resolved without lingering sequelae. There were no infections of either donor or recipient sites in any patient. Our current antibiotic prophylaxis regimen consists of an intravenous cephalosporin administered just prior to surgery and for two doses postsurgery. Average estimated blood loss for the procedure was 164 mL. This was a combined total for both the procurement and grafting procedures. Three patients, early in our experience, did require transfusion. It is interesting to note that by today’s revised transfusion guidelines we would probably not have elected to transfuse these patients. The average hospital stay was 3.1 days. This reflects a time
when all patients were admitted the day before surgery. Our typical bone graft patient now is admitted the morning of surgery and discharged the next day. Two areas germaine to secondary cleft grafting were not studied: the fate of unerupted teeth adjacent to the cleft and whether arch expansion was done before or after grafting. Our patients are referred from all over the state, are treated by various orthodontists and pediatric dentists, and represent a wide age range, making these parameters difficult to quantify. Our impression is that most canines will erupt through the graft and our experience would seem to parallel that of Turvey et al* and Troxell et al,6 who report early eruption of the canine through the bone graft. We have also had central and occasionally lateral incisors erupt through the graft. We prefer presurgical arch expansion primarily because it usually allows better access for recipient site preparation and nasal floor closure through the alveolar cleft. This is not a requirement, however, as Boyne and Sands* have indicated that successful expansion can take place postoperatively. We have also found that arch expansion after grafting can be effective. References 1. Boyne PJ, Sands NR: Secondary bone graftiq of residual alveolar and palatal clefts. J Oral Surg 30:87, 1972 2. Boyne PJ, Sands NR: Combined orthodontic-surgical management of residual palatoalveolar cleft defects. Am J Orthod 70:20,1976 3. Abyholm FE, Bergland 0, Semb G: Secondary bone graft& of alveolar clefts. Stand J Plast Reconstr Surg 15:127, 1981 4. Bertz JE: Bone graft@ of alveolar clefts. J Oral Surg 39:874, 1981 5. Ames JR, Ryan DE, Maki KA: The autogenous particulate cancellous bone marrow graft in alveolar clefts. A report of forty-one cases. Oral Surg 51588, 1981
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6. Troxeh JB, Fonseca RJ, Osbon DB: A retrospective study of alveolar cleft grafting. J Oral Maxillofac Surg 40:721, 1982 7. Hall HD, Posnick JC: Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 41:289, 1983 8. Turvey TA, Vig K, Moriarty J, et al: Delayed bone grafting in the cleft maxilla and palate: A retrospective multidisciplinary analysis. Am J Orthod 86:244, 1984 9. Enemark H, Simonsen EK, Schramm JE: Secondary bone grafting in unilateral cleft lip palate patients: Indications and treatment procedure. Int J Oral Surg 14:2, 1985 10. Sindet-Pederson S, Enemark H: Comparative study of secondary and late secondary bone grafting in patients with residual cleft defects. Short term evaluation. Int J Oral Surg 14:389, 1985 11. Simonsen EK: Secondary bone grafting for repair of residual cleft defects in the alveolar process and hard palate. Int J Oral Maxillofac Surg 15:1, 1986 12. Bergland 0, Semb G, Abyhohn FE: Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 23: 175, 1986 13. Enemark H, Sindet-Pederson S, Bundgaard M: Long-term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg 45:913, 1987
J Oral Maxillofac
14. Wolfe SA, Berkowitz S: The use of cranial bone grafts in the closure of alveolar and anterior palate clefts. J Plast Reconstr Surg 72:659, 1983 15. Harsha BC, Turvey TA, Powers SK: Use of autogenous cranial bone grafts in maxillofacial surgery. J Oral Maxillofac Surg 44: 11, 1986 16. Sindet-Pederson S, Enemark H: Mandibular bone grafts for reconstruction of alveolar clefts. J Oral Maxillofac Surg 46:533, 1988 17. Nique T, Fonseca RJ, Upton LG, et al: Particulate ahogeneic bone grafts into maxillary alveolar clefts in humans. J Oral Maxillofac Surg 45:386, 1987 18. Jackson IT, Helden G, Marx R: Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg 44:949, 1986 19. Sadove AM, Nelson CL, Eppley BL, et al: An evaluation of calvarial versus iliac donor sites in alveolar cleft grafting. Cleft Palate J 27:225, 1990 20. Lebret L: Growth change of the palate. J Dent Res 41: 1391, 1962 21. Nelson CL, Jones JE, Sadove AM: Indiana’s craniofacial anomalies team: Dentists play an important role. J Ind Dent Assoc 65:9, 1986
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Discussion Retrospective Analysis of 135 Secondary Alveolar Cleft Grafts Using Iliac or Calvarial Bone Timothy A. Turvey, DDS University of North Carolina at Chapel Hill
This article is complementary to the literature on bone grafting the cleft maxilla and palate. The success of this procedure is age-dependent and a contribution of this article is the statistical validation of this finding. The success rates in both the iliac and combined groups are lower than in previous reports, but remain favorable. The failure rate for the cranial bone group is alarmingly high. The method of bone procurement and the failure to separate the cortical from the cancellous bone are reasonable explanations for this disappointing result. The question of donor source superiority for grafting will only be answered when a study is designed that compares grafts of similar consistencies obtained from different donor sites. Figures 3A and B impressively illustrate a goal of con-
temporary cleft habilitation: to facilitate the development of the maxillary arch without periodontal defects and without the need for prosthetics. Bone grafting also improves the success of fistula closure and reliably adds support to the nasal base, making it an important part of cleft care. A shortcoming of this project is the limited criteria used to define success. The study fails to include an evaluation of the efficacy of this procedure to close fistulas or to support the nasal base. Radiographic evaluation and observation of ridge contour only evaluate some of the six objectives offered by the authors for bone grafting. Using these two criteria alone to evaluate success in the population studied can be misleading, especially because the population has not yet reached maturity. It is tempting to rate a result disappointing based on a 6-month postoperative radiograph when grafts are remodeling and calcification may be incomplete. In many instances, the 3-year postoperative clinical and radiographic picture is much improved, turning a 6-month disappointment into a 3-year postsurgical success. This occurs because bone matures and descends as the permanent dentition erupts.
Retrospective Analysis of 135 Secondary Alveolar Cleft Grafts Using Iliac or Calvarial Bone MARK J. KORTEBEIN, DDS,* CHARLES L. NELSON, DDS,t AND A. MICHAEL SADOVE, MD* This retrospective study summarizes experience with 135 secondary alveolar cleft bone graft procedures over 8 years. The overall success rate was 83.7%. The group of patients (n = 108) that had particulate cancellous bone and marrow obtained from the iliac crest as donor bone had an 89.8% success rate. The group (n = 27) that had calvarial bone as the donor material had a success rate of only 63%. It is felt that inferior results with calvarial bone are probably related to the procurement technique. In both the iliac crest and calvarial groups, there was a trend toward declining success rates with advancing age of the patient. Morbidity associated with these procedures, consistent with other reported series, was low.
eration of oronasal fistulae, and 6) increased bone support for the alar base of the nose. To meet these objectives, Boyne and Sands* suggested that particulate cancellous bone and marrow (PCBM), obtained from the iliac crest, is the donor material of choice. They emphasized that this viable graft material, once incorporated into the recipient site, not only stabilizes the maxillary arch segments, but also responds to physiologic and functional demands such as tooth movement and arch expansion. With these concepts in mind, it is fair to say that PCBM has become the most widely used donor material for secondary grafts and the “gold standard” against which bone from other donor sites is judged. Recently, Wolfe and Berkowitz14 and Harsha et al” described satisfactory results using cranial bone as donor material, whereas Sindet-Pederson and Enemark16 advocated the use of bone harvested from the symphysis of the mandible. Nique et alI7 published a preliminary report suggesting that particulate allogenic bone also may have the capability to satisfy the objectives of alveolar cleft bone grafting. There is little dispute among clinicians that the best results are obtained when grafting is done prior to the eruption of the canine teeth. Boyne and Sands,’ in their original article, stated that the ideal age for grafting is between 9 and 11 years. Others
Secondary alveolar cleft bone grafting has become a well-accepted procedure used in the rehabilitation of the cleft lip/palate patient. The literature is replete with articles reporting high rates of success and a low incidence of morbidity associated with this procedure. ‘-I3 Objectives of secondary alveolar cleft bone grafting have evolved over time, and include 1) stabilization of the maxillary arch segments, 2) improvement of bone support for teeth adjacent to the cleft, 3) provision of bone in the cleft through which teeth can erupt or be moved orthodontically, 4) improvement of ridge height and contour to aid in prosthetic rehabilitation, 5) oblit-
Received from Indiana University, Indianapolis. * Formerly, Chief Resident, Oral and Maxillofacial Surgery, School of Dentistry; currently, in Fellowship, Dallas, TX. t Associate Professor of Oral and Maxillofacial Surgery, Director, Residency Training Program, School of Dentistry. $ Associate Professor of Surgery, Plastic Surgery Section, School of Medicine. Presented at the American Association of Oral and Maxillofacial Surgeons Annual Meeting in San Francisco, October 1989, and at the American Cleft Palate Association Annual Meeting in St Louis, May 1990. Address correspondence and reprint requests to Dr Nelson: Department of Oral and Maxillofacial Surgery, Indiana University, 1121 W Michigan St, Indianapolis, IN 46202. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391191/4905-0008$3.00/O
493
494
SECONDARY ALVEOLAR
have emphasized that dental age is more important than chronologic age in determining the optimum time for the graft, and that it should be done when the unerupted permanent canine root is one-half to two-thirds formed. ‘,* In their later article, Boyne and Sands2 suggested that secondary grafts using PCBM could be done at any time in the mixed dentition stage, but preferably earlier than the age of 7, before the lateral incisor has erupted and been lost through exfoliation into the cleft area. This retrospective study was designed to evaluate our experience with secondary alveolar cleft bone grafts specifically as it related to the rate of graft success versus age of the patient and the type of donor bone used. We also evaluated complications, blood loss, length of hospital stay, and operating time as additional parameters that quantified our experience. Materials and Methods
The clinical records of 171 patients who underwent secondary alveolar cleft grafting between 1982 and 1988 were reviewed. All patients had undergone previous cheiloplasty and/or palatoplasty. None of these patients underwent simultaneous Le Fort I procedures. One hundred thirty patients were found to have clinical and radiographic follow-up adequate for inclusion in the study. There were 135 cleft graft procedures performed on these 130 patients. Five cleft grafts were reoperation of failed grafts. One hundred four patients had unilateral grafts and 31 had bilateral grafts, making the total number of individual cleft sites grafted 166. There were 78 females and 52 males, ranging in age from 5 to 25 years. Follow-up ranged from 6 months to 5 years, with a mean of 2.6 years. Particulate cancel-
CLEFT BONE GRAFTING
lous bone and marrow obtained from the iliac crest were used in 108 patients and 27 had calvarial bone as the donor material. The technique of recipient site preparation represented an amalgamation of the techniques described by Boyne and Sands,‘y2 Troxell et aL6 and Hall and Posnick.’ To evaluate success rates related to age, patients were divided into four groups: age 5-7 (51 patients), age 8-11 (42 patients), age 12-15 (26 patients), and age 16 and above (16 patients). The grafting procedure was considered successful if there was an adequate bulk of bone both clinically and radiographically to support adjacent teeth and teeth erupting or being moved orthodontically into the cleft area (Figs 1 and 2). The overall patient success rate for both iliac crest and calvarial bone groups was determined. In addition, the success rates in each donor group were determined according to the four age groups. The success rates were based on the number of procedures performed (135) and not the actual number of cleft sites grafted. The x2 test was used to compare the iliac crest group to the calvarial group. The iliac crest group was further evaluated with analysis of variance (ANOVA) and a Newman-Keuls test for multiple comparisons in order to compare success rates between the various age groups. Estimated blood loss, length of procedure, and length of hospital stay were averaged. Morbidity and complications were listed as they occurred. Results
Of 135 secondary alveolar cleft bone graft procedures, 114 had successful results for a success rate of 83.7%. Overall, unilateral graft patients had an 84.6% success rate and bilateral graft patients had
FIGURE 1. A, Preoperative radiograph shows a thin lamina dura on the distal of the central incisor and an otherwise open alveolar cleft. B, Postgrafting radiograph at 6 months shows the cleft filled with bone, supporting teeth adjacent to the cleft site. (Reprinted with permission.*‘)
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ET AL
FIGURE 2. A, Preoperative radiograph demonstrates an open alveolar cleft prior to eruption of the central incisors. The patient was grafted at this time. B, After grafting and eruption of the central incisors, the cleft is filled with bone. This supports the orthodontic movement of the central incisor adjacent to the cleft. To try and correct the rotation prior to grafting might result in the root being exposed into the cleft site.
an 83.8% success rate. When age-related success was analyzed, the 5- to 7-year age group had 45 of 51 successful grafts, for an 88.2% success rate. The 8- to 11-year age group had 39 of 42 successful grafts (92.8%), the 12- to 15-year age group had 22 of 26 successful grafts (84.6%), and the 16-year and older age group had 8 of 16 successful grafts (50%). Secondary alveolar cleft bone grafts using PCBM obtained from the iliac crest were successful in 97 of 108 cases, giving a success rate of 89.8%. The success rates for the various age groups were 97.2% (34135) for the 5- to 7-year age group, 92.5% (37/40) for the 8- to 1l-year age group, 90.5% (19/21) for the 12- to 15-year age group, and 58.3% (7/12) for those 16 years of age and older. The success rates across the age groups were compared statistically by subjecting the data to arc sine (angular) transformation followed by an analysis of variance (ANOVA). A P value of less than .025 was derived, indicating that a significant difference existed among the success rates of the various age groups. These data were then subjected to the Newman-Keuls Test for multiple comparisons, allowing each age group to be compared independently to the other age groups. This analysis indicated the 16 and older age group differed significantly from the other three age groups, with a P value of less than .Ol. There were no significant differences when comparing the S- to 7-year, 8- to 11-year, and 12- to 15-year age groups with each other. The calvarial bone donor group consisted of 27 patients, 17 of whom had successful grafts for a success rate of 63%. Age-related success was 68.8% (1 l/16) for the 5- to 7-year group, 100% (2/2) for the 8- to 1l-year group, 60% (315) for the 12- to 15-year
group, and 25% (l/4) for the 16-year and older group. It was felt that the numbers in each age group were too small to make further comparison between the age groups. The overall success rates of the iliac crest group (89.8%) and the calvarial group (63%) were compared using a x2 test. A significant difference was shown by a P value of less than .OOl. The average length of the bone graft procedure was 2.4 hours. The average estimated blood loss was 164 mL, and three patients required transfusion during the procedure. The average hospital stay was 3.1 days. Morbidity associated with the secondary alveolar cleft bone graft procedures was low. One patient developed a seroma along the iliac crest incision. Another patient had temporary paresthesia over the distribution of the lateral femoral cutaneous nerve. There were no infections in either donor or recipient sites of any patient. Other than graft resorption, there was no other specific morbidity associated with the recipient site. Discussion The 83.7% overall success rate of our secondary alveolar bone graft procedures is lower than that generally reported by others.2,4-7 This reflects the relatively poor performance of calvarial bone grafts in our series, and the significantly decreased success rate for those patients age 16 and over in both the iliac crest and calvarial groups. Several authors have recently commented on the efficacy of calvarial donor bone for reconstruction of alveolar clefts. Wolfe and Berkowitz14 and Harsha et al” have described favorable results, whereas Jackson
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et all8 indicated they had abandoned the use of calvarial bone as a donor source for reconstruction of alveolar clefts because they felt that the quality of bone obtained from this source was not satisfactory. Further analysis of our own series of calvarial grafts has revealed that procurement technique is importan~.19 Some of our calvarial group had bone obtained using a handheld Hudson brace to drill five or six holes through the outer table and the cancellous bone. The resultant shavings were collected and packed into the recipient site. We made no attempt to separate cortical from cancellous bone. Other patients had bone harvested using a powerdriven craniotome, again drilling five or six holes through both the outer table and cancellous bone. The procured bone was packed into the prepared cleft site. As we have reported,” calvarial bone obtained with the hand brace yielded significantly better results (80% successful grafts) than calvarial bone obtained with a power-driven craniotome (53% successful grafts). We believe that the difference in the success rates of these two methods is attributable to the difference in the consistency and composition of the obtained material. Bone procured with the craniotome tended to be of very small particle size, often a dustlike consistency. This small particle size undoubtedly exposed more of the cellular elements of the procured bone to the deleterious effects of both mechanical and thermal trauma. Bone obtained with the hand brace had a more preserved structure both macroscopically and microscopically. The procured bone consisted of larger shavings that histologically showed more preserved Haversian systems and intact osteocytes when compared with craniotome-procured bone. In either case, the success of calvarial bone as a donor material for alveolar cleft bone grafting fell below the success rate for bone obtained from the iliac crest. We feel that this most likely relates to the high ratio of less cellular cortical bone to cancellous bone that results from not specifically separating cortical from cancellous components in these procurement techniques. Wolfe and Berkowitzi4 and Harsha et al” describe techniques that discard the cortical component and procure only the more cellular cancellous bone. Using these techniques they have described consistently good results. When plotted against age, there was a trend toward declining success with advancing age of the patient in iliac crest procurement group, although only the 16-years and older age group had a statistically significant decline. This is consistent with the observation of Ames et al5 that age at time of operation was the primary variable that seemed to
SECONDARY ALVEOLAR CLEFT BONE GRAFTING
affect the success of the graft. In their series, the overall success rate for those patients grafted over age 14 was 64.3%, compared with 96% for those under 14 years of age. Hall and Posnick7 also commented that in their series that good healing was especially evident in patients 12 years of age or younger. It is our feeling that the general health of the oral tissues often begins to deteriorate soon after eruption of the permanent dentition. Gingival tissues, especially those adjacent to the alveolar cleft and oronasal fistulae, become inflamed due to compromised oral hygiene. This type of tissue is very friable and difficult to handle when developing and closing mucosal flaps. If this tissue necroses, even causing minor dehiscence, it seems to have less capacity to heal and protect the integrity of the bone graft. It has been our experience, on the other hand, that healthy gingival tissues withstand the surgery well and, even in the face of occasional wound dehiscences postoperatively, will heal quickly before there is any significant loss of the graft. Optimizing oral hygiene before bone grafting, especially in this older group of patients, is of extreme importance in contributing to the success of the graft. Another adverse factor we have observed in this older patient group is that significant periodontal defects may already exist associated with teeth adjacent to the cleft. Rotation and malposition of the central incisors or canines can lead to reduced bone support on the proximal surfaces, decreasing chances for graft success. The optimum timing for bone grafting alveolar clefts has long been debated. It is now fairly well accepted that the best time for grafting is 8 to 10 years of age, when the canine root is one-half to two-thirds formed. Growth considerations have entered into the basis for this recommendation. Since maxillary alveolar growth is nearly complete by 8 years of age,” a procedure performed at this age or older would have minimal chance of adversely affecting growth. While we certainly respect these concerns for potential growth attenuation, it is obvious we have grafted a number of cases at earlier ages. In each of these cases we have made decisions to proceed with grafting for specific reasons. In some cases there were lateral incisors present that showed promise of reasonable development and subsequent eruption into the arch. In such cases, it was necessary to reconstruct the alveolus early, through bone grafting, to support these teeth (Fig 3). In other cases, there were developing or erupting central incisors that needed bone support in the area of the cleft to protect their integrity. We have thus saved teeth that, without this earlier grafting, may have been lost. On a few occasions an anterior
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FIGURE 3. A, Preoperative radiograph of a (i-year-old boy with a lateral incisor in early stages of development. The supemumary tooth was removed and the cleft was grafted at this stage. B, Radiograph of the same boy at age 12 aBer completion of orthodontic therapy. Notice the natural-appearing alveolus and the well-supported lateral incisor, which erupted without assistance after grafting.
oronasal fistula through an open alveolar cleft had allowed so much air escape that speech was compromised. We chose to bone graft these patients early to obliterate the large fistulae. It is our clinical impression that we have not adversely affected maxillary or midface growth with these earlier procedures, but this remains to be proven with firm data and analysis. Other than loss of the bone graft, there was no specific morbidity associated with the recipient site. This graft loss was most often the result of wound dehiscence and flap breakdown in the cleft area leading to exposure and contamination of the graft. It should be emphasized that the presence of small wound dehiscences at the flap margins did not always indicate impending graft failure. In fact, most small wound dehiscences healed secondarily with no apparent adverse effects on the graft. There was no donor site morbidity associated with the calvarial procurement. Donor site morbidity associated with the iliac crest consisted of one case of temporary paresthesia over the course of the lateral femoral cutaneous nerve and one wound seroma. Both resolved without lingering sequelae. There were no infections of either donor or recipient sites in any patient. Our current antibiotic prophylaxis regimen consists of an intravenous cephalosporin administered just prior to surgery and for two doses postsurgery. Average estimated blood loss for the procedure was 164 mL. This was a combined total for both the procurement and grafting procedures. Three patients, early in our experience, did require transfusion. It is interesting to note that by today’s revised transfusion guidelines we would probably not have elected to transfuse these patients. The average hospital stay was 3.1 days. This reflects a time
when all patients were admitted the day before surgery. Our typical bone graft patient now is admitted the morning of surgery and discharged the next day. Two areas germaine to secondary cleft grafting were not studied: the fate of unerupted teeth adjacent to the cleft and whether arch expansion was done before or after grafting. Our patients are referred from all over the state, are treated by various orthodontists and pediatric dentists, and represent a wide age range, making these parameters difficult to quantify. Our impression is that most canines will erupt through the graft and our experience would seem to parallel that of Turvey et al* and Troxell et al,6 who report early eruption of the canine through the bone graft. We have also had central and occasionally lateral incisors erupt through the graft. We prefer presurgical arch expansion primarily because it usually allows better access for recipient site preparation and nasal floor closure through the alveolar cleft. This is not a requirement, however, as Boyne and Sands* have indicated that successful expansion can take place postoperatively. We have also found that arch expansion after grafting can be effective. References 1. Boyne PJ, Sands NR: Secondary bone graftiq of residual alveolar and palatal clefts. J Oral Surg 30:87, 1972 2. Boyne PJ, Sands NR: Combined orthodontic-surgical management of residual palatoalveolar cleft defects. Am J Orthod 70:20,1976 3. Abyholm FE, Bergland 0, Semb G: Secondary bone graft& of alveolar clefts. Stand J Plast Reconstr Surg 15:127, 1981 4. Bertz JE: Bone graft@ of alveolar clefts. J Oral Surg 39:874, 1981 5. Ames JR, Ryan DE, Maki KA: The autogenous particulate cancellous bone marrow graft in alveolar clefts. A report of forty-one cases. Oral Surg 51588, 1981
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6. Troxeh JB, Fonseca RJ, Osbon DB: A retrospective study of alveolar cleft grafting. J Oral Maxillofac Surg 40:721, 1982 7. Hall HD, Posnick JC: Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 41:289, 1983 8. Turvey TA, Vig K, Moriarty J, et al: Delayed bone grafting in the cleft maxilla and palate: A retrospective multidisciplinary analysis. Am J Orthod 86:244, 1984 9. Enemark H, Simonsen EK, Schramm JE: Secondary bone grafting in unilateral cleft lip palate patients: Indications and treatment procedure. Int J Oral Surg 14:2, 1985 10. Sindet-Pederson S, Enemark H: Comparative study of secondary and late secondary bone grafting in patients with residual cleft defects. Short term evaluation. Int J Oral Surg 14:389, 1985 11. Simonsen EK: Secondary bone grafting for repair of residual cleft defects in the alveolar process and hard palate. Int J Oral Maxillofac Surg 15:1, 1986 12. Bergland 0, Semb G, Abyhohn FE: Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 23: 175, 1986 13. Enemark H, Sindet-Pederson S, Bundgaard M: Long-term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg 45:913, 1987
J Oral Maxillofac
14. Wolfe SA, Berkowitz S: The use of cranial bone grafts in the closure of alveolar and anterior palate clefts. J Plast Reconstr Surg 72:659, 1983 15. Harsha BC, Turvey TA, Powers SK: Use of autogenous cranial bone grafts in maxillofacial surgery. J Oral Maxillofac Surg 44: 11, 1986 16. Sindet-Pederson S, Enemark H: Mandibular bone grafts for reconstruction of alveolar clefts. J Oral Maxillofac Surg 46:533, 1988 17. Nique T, Fonseca RJ, Upton LG, et al: Particulate ahogeneic bone grafts into maxillary alveolar clefts in humans. J Oral Maxillofac Surg 45:386, 1987 18. Jackson IT, Helden G, Marx R: Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg 44:949, 1986 19. Sadove AM, Nelson CL, Eppley BL, et al: An evaluation of calvarial versus iliac donor sites in alveolar cleft grafting. Cleft Palate J 27:225, 1990 20. Lebret L: Growth change of the palate. J Dent Res 41: 1391, 1962 21. Nelson CL, Jones JE, Sadove AM: Indiana’s craniofacial anomalies team: Dentists play an important role. J Ind Dent Assoc 65:9, 1986
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Discussion Retrospective Analysis of 135 Secondary Alveolar Cleft Grafts Using Iliac or Calvarial Bone Timothy A. Turvey, DDS University of North Carolina at Chapel Hill
This article is complementary to the literature on bone grafting the cleft maxilla and palate. The success of this procedure is age-dependent and a contribution of this article is the statistical validation of this finding. The success rates in both the iliac and combined groups are lower than in previous reports, but remain favorable. The failure rate for the cranial bone group is alarmingly high. The method of bone procurement and the failure to separate the cortical from the cancellous bone are reasonable explanations for this disappointing result. The question of donor source superiority for grafting will only be answered when a study is designed that compares grafts of similar consistencies obtained from different donor sites. Figures 3A and B impressively illustrate a goal of con-
temporary cleft habilitation: to facilitate the development of the maxillary arch without periodontal defects and without the need for prosthetics. Bone grafting also improves the success of fistula closure and reliably adds support to the nasal base, making it an important part of cleft care. A shortcoming of this project is the limited criteria used to define success. The study fails to include an evaluation of the efficacy of this procedure to close fistulas or to support the nasal base. Radiographic evaluation and observation of ridge contour only evaluate some of the six objectives offered by the authors for bone grafting. Using these two criteria alone to evaluate success in the population studied can be misleading, especially because the population has not yet reached maturity. It is tempting to rate a result disappointing based on a 6-month postoperative radiograph when grafts are remodeling and calcification may be incomplete. In many instances, the 3-year postoperative clinical and radiographic picture is much improved, turning a 6-month disappointment into a 3-year postsurgical success. This occurs because bone matures and descends as the permanent dentition erupts.