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Secondary bone-grafting for repair of residual cleft defects in the alveolar process and hard palate
Int. J. Oral Maxillofac. Surg, 1986: 15: 1-7 (Key words: cleft, lips and palate; transplantation, bone; surgery, oral and maxillofacial)
Secondary bone-grafting for repair of residual cleft defects in the alveolar process and hard palate A new surgical technique ERIK KRANTZ SIMONSEN Department of Oral & Maxlllofacial Surgery, Aarhus Kommunehospital, Denmark
ABSTRACT - A new surgical technique for secondary bone-grafting for closure of residual clefts in the alveolar process and hard palate is described. The technique improves the anatomy in the cleft region and, thus improves the possibility of total dental rehabilitation. The treatment results based on experiences with 293 patients will be published in a future paper", and must be estimated as promising. The technique minimizes hospitalization as well as post-operative discomfort.
(Accepted for publication 1 September 1984)
Various methods of bone-grafting have been developed for compensation of the lack of maxillary bone in congenital cleft lip, alveolus and palate (CLAP). Primary bone-grafting is by definition performed during primary cleft repair, whereas secondary bone-grafting refers to procedures undertaken thereafter. KOBERG9 reviewing the literature on different concepts of bone-grafting in cleft surgery (up to 1972) concluded that most severe maxillary deformities are to be expected as late results of primary bonegrafting. Primary bone-grafting has since been abandoned at most centres. BOYNE2 and BOYNE & SANDS3 described a new concept
of secondary bone-grafting which forms the basis of our procedures with regard to optimal age for grafting, and the choice of particulate iliac crest bone marrow as a graft material. In Denmark, the primary operations have been centralized. Closure of cleft lip is performed at circa 2 months of age (a.m. Tennison), and closure of hard palate clefts with a Vomer-flap at the same age. Clefts in the soft palate are closed at about 2 years of age, with a Wardill-procedure. Bilateral clefts are usually closed in 2 sessions. Primary bone-grafting is never performed. Experience with a new soft-tissue flap design and bone-grafting procedure in 293 patients has motivated the description of our
2
SIMONSEN
method, and the results of these operations will be published in a separate paper".
A
Method Preoperatively, orthodontic expansion of the maxilla is performed. During this, an attempt is made to displace the teeth from the cleft, obtaining the widest possible mucosal area at the cleft. Two months preoperatively, deciduous teeth, as well as malformed and dubious permanent teeth in the cleft area, are extracted to create a broad margin of mucosa between cleft and teeth. Surgical procedure Under general anaesthesia, the bone-graft, a cortical bone-plate, as well as cancellous bone, is removed from the iliac crest. The bone-graft is stored in physiological saline. The oral procedure is started by infiltrating a local anaesthetic solution with vasoconstrictor, noradrenalin 1:2,000,000, into the vestibular sulcus, incisal- and palatine foramen bilaterally. Penicillin treatment is usually initiated 1 h before anaesthesia with a intramuscular injection of one mill. units of penicillin G. Immediately before replacement of the bone-graft, two mill. units are infused intravenously. Unilateral clefts A horizontal incision is made level with the cranial limit of the cleft, from the midline to the first molar in the cleft side (Fig. IA). The mucosa cranial to the incision is mobilized, exposing the lower parts of the nasal spine and piriform aperture and further mobilized by submucosal dissection . The exposed tissue at the cleft is thinned -out without perforating the nasal mucosa. Oblique incisions are made, usually of one tooth width on both sides of the cleft (Fig. IB). The mucosa in the vestibular part of the cleft is incised level with the bottom of the nasal cavity and the incision is continued
"
11
Fig. 1.
horizontally into the hard palate through the cleft. Two lateral sagittal incisions are made in the palatal mucosa from the hamulus of the pterygoid process and continued along the teeth at a distance 'of 3-4 mm (Figs. 2A, 3A) to the oblique incisions to the vestibular part of the cleft (Fig. IB). Depending on the position of the teeth adjacent to the cleft, the incision is made on the alveolar process or in the gingival sul-
Fig. 2.
BONE GRAFTS IN RESIDUAL CLEFTS
3
cus. Where the width from cleft to tooth is more than I em, the incision is continued for 2-3 mm lateral to the marginal gingiva of the tooth (Fig. 3A). These directions concern teeth on both sides of the cleft (Figs. 2A, 3A). A sagittal incision is made in the midline from the soft palate to the posterior parts of the cleft (Figs. 2B, 3B). The mucosa is initially elevated on both
sides of the vestibular part of the cleft and, thereafter, elevated to the posterior limit of the hard palate, preserving the neurovascular bundle at the palatine foramen. This procedure is continued so far dorsally that the 2 flaps are sagitally extensible (Fig. 4). The cranial part of the mucosa in the cleft is elevated from the nasal spine dorsally along the nasal septum into the soft palate or the dorsal osseous limit of the clefts. Similarly, the mucosa is elevated from the lateral aspects of the cleft, beginning at the piriform aperture along the lateral wall of the nasal cavity into the soft palate or the dorsal limit of the cleft. The 2 nasal mucosal flaps are mobilized to form a mucosal diaphragm by evaginating the flaps into the nasal cavity. The periosteal surfaces are sutured with mattress-sutures. Very often, it is necessary to remove tissue in excess, as, from time to time, it is necessary to reduce the inferior nasal concha. The medial margins of the palatal flaps are trimmed and the edges are cleaved sagittally forming a periosteal and a mucosal edge of the wound (Fig. 5). The flaps are sutured on the periosteal, as well as on the mucosal, surfaces (Fig. 6).
Fig. 4.
Fig. 5.
Fig. 3.
4
SIMONSEN
Fig. 6.
plate, corresponding to the cleft morphology is made. The bone-plate is wedged between the nasal spine, the groove in the piriform aperture and the dorsal limit of the cleft. The rest of the defect including the alveolar process is filled to excess with cancellous bone. Cancellous bone is placed at the base of the nasal ala and the osseous defect in the hard palate is filled to excess, reducing the vault of the palatal dome (Fig. 6). This packing to excess with bone in the hard palate will compensate for transversal insufficiency of the palatal flaps, thus, making sutures without tension possible. The palatal diaphragm is sutured along the teeth with ventral tension to obtain a ventral extension. The extensibility of the flap makes it possible for the ventral parts of the diaphragm to be extended over the newly formed alveolar process in the cleft region and into the alveolar sulcus. Finally, the vestibular incisions are sutured. Sutures arc made with 4-0 Vicryl>.
Suturing is continued for the entire length of the flaps, making a mucosal diaphragm extensible in the sagittal direction. In the vestibular parts, this diaphragm contains attached gingiva mobilized from the vestibular part of the alveolar process . The exposed bone in the cleft region is decorticated, a groove is cut in the lateral part of the piriform aperture on a level with the nasal spine (Fig . 7). An iliac crest bone-
Bilateral clefts In some important aspects there are deviations in flap design from the unilateral clefts. The horizontal incisions medial to the
Fig. 7.
Fig. 8.
BONE GRAFTS IN RESIDUAL CLEFTS
5
Fig. 9.
Fig. 11.
clefts are not continued, as in the unilateral clefts, to the nasal spine (Fig. 8A). The spine is exposed by tunnelling, preserving vascularized vestibular mucosa on the premaxilla, and oblique incisions are only placed distally to the clefts (Fig. 88). Where the width from cleft to tooth is more than I em, the incision is continued 2-3 mm laterally to the marginal gingiva of teeth lateral to the cleft (Fig. 9), otherwise
in the gingival sulcus (Fig . lOA). The elevation of mucosa is commenced laterally to the cleft in bilateral cleft patients. Medially to the clefts, the mucosa is only partly elevated from the alveolar process. The tissue remains attached by the marginal gingiva around the teeth in the premaxilla (Fig. II). In this way, most of the dorsal surface, as well as both cleft surfaces, of the premaxilla are exposed. The mobilized palatal flaps are
Fig. 10.
Fig. 12.
6
SIMONSEN
then reduced by excising triangular parts (Fig. 11, dotted areas). By suturing, the anterior junction between the palatal flaps is moved ventrally from point P to point Q (Figs. 11, 12). The evagination of the flaps around the premaxilla is ensured by horizontal mattress-sutures. Additional precautions The hard palate is covered with Surgiccl >. A pre-operatively produced acrylic plate is lined with Ward's wonder pack and ligated to the teeth, to cover the palate. The penicillin medication is continued for one week, usually one mill. units twice daily. Postoperatively, the patients receive a liquid diet, which is then gradually normalized. Usually, the patients can eat normally after one week. In most cases, patients experience only limited discomfort, and patients are not confined to bed from the second postoperative day. As a rule, the patients can be discharged 3 days post-operatively. Mouthwash of 0.2% chlorhexidine is administered twice daily until the acrylic plate is removed. 4 weeks post-operatively.
Discussion The technique as described here, mobilizing attached vestibular gingiva adhering to 2 palatal flaps, has not appeared in the literature. In many reports, Veau-flaps or modifications together with mobilization of the vestibular tissue have been described 1.3.4l ,..lo. Also vestibular rotational flaps have been described':". From a surgical technical point of view, a separation of the palatal and vestibular tissue with subsequent suturing on top of the alveolar process may increase the risk of flap necrosis and rupture of suturing. Furthermore, rotational flaps without attached gingiva compromises periodontal hygiene and prosthetic therapy. By mobili-
zing the flaps into the soft palate, sagittal sufficiency of the flaps is ensured with only minor risk of a post-operatively insufficient alveolar sulcus. Furthermore, the technique increases the amount of attached gingiva on the facial part of the reconstructed alveolar process. Velar insufficiency as sequela has not been found. A tight mucosal closure against the nas al cavity, as well as the oral cavity must be stressed as very important to avoid sequestration and infection. The iliac crest has been used as donor site, which is in accordance with the literature l •3,4,6,7,8,1I . The present method differs from earlier described methods by the insertion of a cortical bone plate in the bottom of the cleft, whereas only cancellous bone has been employed in previous studies. Filling-out, the hard palate with bonegraft in excess, has not previously been described, thereby ensuring a transversal sufficiency of the palatal flaps. When employing Veau-flaps, bone is exposed in the lateral parts of the hard palate, increasing the risk of treatment failure. There have been no observed speech difficulties as a sequela to the excessive bone-grafting in the palate', The author has the impression that the excessive amount of bone is gradually resorbed post-operatively. The effects of antibiotic treatment have never been studied in a controlled trial. However, the best treatment results have been reported in studies, where antibiotics have been used as part of the routine l ,4.7.1I . Employment of an acrylic plate to cover the wounds in the hard palate has been reported by othersw', but not as a standard procedure. By using the acrylic plate, orthodontic retention can be continued, the maxillary segments are blocked and the bone-grafting is stabilized. The plate makes normal diet possible within few days , and furthermore, the acrylic splint presses the palatal mucosal diaphragm in tight contact
BONE GRAFTS IN RESIDUAL CLEFTS
with bone and prevents hematoma. Application of Surgicelf prevents the periodontal paste from being pressed into the sutured incisions. The plate is removed 4 weeks post-operatively. Acknowledgement - The author wishes to thank Hanne Pallesen, Aarhus, for preparation of the manuscript.
References 1. AMES, J. R., DORAN E. & MAKI KARL, A.: The autogenous particulate cancellous bone marrow graft in alveolar clefts, Oral Surg. 1981: 51: 588-591. 2. BoYNE, PmLlP J.: Use of marrow-cancellous bone-grafts in maxillary alveolar and palatal clefts. J. Dent, Res. 1974: 53: 821-24. 3. BOYNE, PmLlP J. & SANDS, NED R.: Secondary bone-grafting of residual alveolar and palatal clefts. J. Oral Surg. 1972: 30: 87-92. 4. BRAUN, THOMAS W.: Alveolar reconstruction in adolescent patients with cleft palates. J. Oral Surg. 1981: 39: 510--517. 5. ENHIARK, H., KRANTZ SIMONSEN, E., SCHRAMM, J. E.: Secondary bone-grafting in unilateral cleft lip palate patients: indications and treatment procedure. Int J. Oral Surg. (in press).
7
6. GEORGIADE, NICHOLAS G.: Anterior palatalalveolar closure by means of interpolated flaps. Plast. Reconstr. Surg. 1967: 39: 162-167. 7. HOGEMANN, KARL ERIK, JACODSSON, STEN & SAMAS, KARL-VICTOR: Secondary bone-grafting in cleft palate: a follow-up of 145 patients. Cleft Palate J. 1972: 9: 39-42. 8. JACKSON, IANT.: Closure of secondary palatal fistulae with intra-oral tissue and bone-grafting. Br. J. Plast. Surg. 1972: 25: 93-105.' 9. KODERG, WOLFGANG R.: Present view on bone-grafting in cleft palate: a review of the literature. J. Max-Fac. Surg. 1973: 1: 185-193. 10. SCHRUDDE, J. & STELLMACH, R.: Die Primare Osteoplastik der Defekte des Kiefer-bogens bei Lippen-Kiefer-Gaurnenspalten am Saugling. Zbl. Chir. 1958: 83: 849. 11. SINDET-PEDERSEN, S. & E"'EMARK, H.: A comparative study of secondary and late secondary bone-grafting in patients with residual cleft defects: short term evaluation. lilt. J. Oral. Surg. (in press).
Address:
Department of Oral and Maxillofacial surgery Ar/llIs Kommunehospital 8000 Arhus C Denmark
Secondary bone-grafting for repair of residual cleft defects in the alveolar process and hard palate A new surgical technique ERIK KRANTZ SIMONSEN Department of Oral & Maxlllofacial Surgery, Aarhus Kommunehospital, Denmark
ABSTRACT - A new surgical technique for secondary bone-grafting for closure of residual clefts in the alveolar process and hard palate is described. The technique improves the anatomy in the cleft region and, thus improves the possibility of total dental rehabilitation. The treatment results based on experiences with 293 patients will be published in a future paper", and must be estimated as promising. The technique minimizes hospitalization as well as post-operative discomfort.
(Accepted for publication 1 September 1984)
Various methods of bone-grafting have been developed for compensation of the lack of maxillary bone in congenital cleft lip, alveolus and palate (CLAP). Primary bone-grafting is by definition performed during primary cleft repair, whereas secondary bone-grafting refers to procedures undertaken thereafter. KOBERG9 reviewing the literature on different concepts of bone-grafting in cleft surgery (up to 1972) concluded that most severe maxillary deformities are to be expected as late results of primary bonegrafting. Primary bone-grafting has since been abandoned at most centres. BOYNE2 and BOYNE & SANDS3 described a new concept
of secondary bone-grafting which forms the basis of our procedures with regard to optimal age for grafting, and the choice of particulate iliac crest bone marrow as a graft material. In Denmark, the primary operations have been centralized. Closure of cleft lip is performed at circa 2 months of age (a.m. Tennison), and closure of hard palate clefts with a Vomer-flap at the same age. Clefts in the soft palate are closed at about 2 years of age, with a Wardill-procedure. Bilateral clefts are usually closed in 2 sessions. Primary bone-grafting is never performed. Experience with a new soft-tissue flap design and bone-grafting procedure in 293 patients has motivated the description of our
2
SIMONSEN
method, and the results of these operations will be published in a separate paper".
A
Method Preoperatively, orthodontic expansion of the maxilla is performed. During this, an attempt is made to displace the teeth from the cleft, obtaining the widest possible mucosal area at the cleft. Two months preoperatively, deciduous teeth, as well as malformed and dubious permanent teeth in the cleft area, are extracted to create a broad margin of mucosa between cleft and teeth. Surgical procedure Under general anaesthesia, the bone-graft, a cortical bone-plate, as well as cancellous bone, is removed from the iliac crest. The bone-graft is stored in physiological saline. The oral procedure is started by infiltrating a local anaesthetic solution with vasoconstrictor, noradrenalin 1:2,000,000, into the vestibular sulcus, incisal- and palatine foramen bilaterally. Penicillin treatment is usually initiated 1 h before anaesthesia with a intramuscular injection of one mill. units of penicillin G. Immediately before replacement of the bone-graft, two mill. units are infused intravenously. Unilateral clefts A horizontal incision is made level with the cranial limit of the cleft, from the midline to the first molar in the cleft side (Fig. IA). The mucosa cranial to the incision is mobilized, exposing the lower parts of the nasal spine and piriform aperture and further mobilized by submucosal dissection . The exposed tissue at the cleft is thinned -out without perforating the nasal mucosa. Oblique incisions are made, usually of one tooth width on both sides of the cleft (Fig. IB). The mucosa in the vestibular part of the cleft is incised level with the bottom of the nasal cavity and the incision is continued
"
11
Fig. 1.
horizontally into the hard palate through the cleft. Two lateral sagittal incisions are made in the palatal mucosa from the hamulus of the pterygoid process and continued along the teeth at a distance 'of 3-4 mm (Figs. 2A, 3A) to the oblique incisions to the vestibular part of the cleft (Fig. IB). Depending on the position of the teeth adjacent to the cleft, the incision is made on the alveolar process or in the gingival sul-
Fig. 2.
BONE GRAFTS IN RESIDUAL CLEFTS
3
cus. Where the width from cleft to tooth is more than I em, the incision is continued for 2-3 mm lateral to the marginal gingiva of the tooth (Fig. 3A). These directions concern teeth on both sides of the cleft (Figs. 2A, 3A). A sagittal incision is made in the midline from the soft palate to the posterior parts of the cleft (Figs. 2B, 3B). The mucosa is initially elevated on both
sides of the vestibular part of the cleft and, thereafter, elevated to the posterior limit of the hard palate, preserving the neurovascular bundle at the palatine foramen. This procedure is continued so far dorsally that the 2 flaps are sagitally extensible (Fig. 4). The cranial part of the mucosa in the cleft is elevated from the nasal spine dorsally along the nasal septum into the soft palate or the dorsal osseous limit of the clefts. Similarly, the mucosa is elevated from the lateral aspects of the cleft, beginning at the piriform aperture along the lateral wall of the nasal cavity into the soft palate or the dorsal limit of the cleft. The 2 nasal mucosal flaps are mobilized to form a mucosal diaphragm by evaginating the flaps into the nasal cavity. The periosteal surfaces are sutured with mattress-sutures. Very often, it is necessary to remove tissue in excess, as, from time to time, it is necessary to reduce the inferior nasal concha. The medial margins of the palatal flaps are trimmed and the edges are cleaved sagittally forming a periosteal and a mucosal edge of the wound (Fig. 5). The flaps are sutured on the periosteal, as well as on the mucosal, surfaces (Fig. 6).
Fig. 4.
Fig. 5.
Fig. 3.
4
SIMONSEN
Fig. 6.
plate, corresponding to the cleft morphology is made. The bone-plate is wedged between the nasal spine, the groove in the piriform aperture and the dorsal limit of the cleft. The rest of the defect including the alveolar process is filled to excess with cancellous bone. Cancellous bone is placed at the base of the nasal ala and the osseous defect in the hard palate is filled to excess, reducing the vault of the palatal dome (Fig. 6). This packing to excess with bone in the hard palate will compensate for transversal insufficiency of the palatal flaps, thus, making sutures without tension possible. The palatal diaphragm is sutured along the teeth with ventral tension to obtain a ventral extension. The extensibility of the flap makes it possible for the ventral parts of the diaphragm to be extended over the newly formed alveolar process in the cleft region and into the alveolar sulcus. Finally, the vestibular incisions are sutured. Sutures arc made with 4-0 Vicryl>.
Suturing is continued for the entire length of the flaps, making a mucosal diaphragm extensible in the sagittal direction. In the vestibular parts, this diaphragm contains attached gingiva mobilized from the vestibular part of the alveolar process . The exposed bone in the cleft region is decorticated, a groove is cut in the lateral part of the piriform aperture on a level with the nasal spine (Fig . 7). An iliac crest bone-
Bilateral clefts In some important aspects there are deviations in flap design from the unilateral clefts. The horizontal incisions medial to the
Fig. 7.
Fig. 8.
BONE GRAFTS IN RESIDUAL CLEFTS
5
Fig. 9.
Fig. 11.
clefts are not continued, as in the unilateral clefts, to the nasal spine (Fig. 8A). The spine is exposed by tunnelling, preserving vascularized vestibular mucosa on the premaxilla, and oblique incisions are only placed distally to the clefts (Fig. 88). Where the width from cleft to tooth is more than I em, the incision is continued 2-3 mm laterally to the marginal gingiva of teeth lateral to the cleft (Fig. 9), otherwise
in the gingival sulcus (Fig . lOA). The elevation of mucosa is commenced laterally to the cleft in bilateral cleft patients. Medially to the clefts, the mucosa is only partly elevated from the alveolar process. The tissue remains attached by the marginal gingiva around the teeth in the premaxilla (Fig. II). In this way, most of the dorsal surface, as well as both cleft surfaces, of the premaxilla are exposed. The mobilized palatal flaps are
Fig. 10.
Fig. 12.
6
SIMONSEN
then reduced by excising triangular parts (Fig. 11, dotted areas). By suturing, the anterior junction between the palatal flaps is moved ventrally from point P to point Q (Figs. 11, 12). The evagination of the flaps around the premaxilla is ensured by horizontal mattress-sutures. Additional precautions The hard palate is covered with Surgiccl >. A pre-operatively produced acrylic plate is lined with Ward's wonder pack and ligated to the teeth, to cover the palate. The penicillin medication is continued for one week, usually one mill. units twice daily. Postoperatively, the patients receive a liquid diet, which is then gradually normalized. Usually, the patients can eat normally after one week. In most cases, patients experience only limited discomfort, and patients are not confined to bed from the second postoperative day. As a rule, the patients can be discharged 3 days post-operatively. Mouthwash of 0.2% chlorhexidine is administered twice daily until the acrylic plate is removed. 4 weeks post-operatively.
Discussion The technique as described here, mobilizing attached vestibular gingiva adhering to 2 palatal flaps, has not appeared in the literature. In many reports, Veau-flaps or modifications together with mobilization of the vestibular tissue have been described 1.3.4l ,..lo. Also vestibular rotational flaps have been described':". From a surgical technical point of view, a separation of the palatal and vestibular tissue with subsequent suturing on top of the alveolar process may increase the risk of flap necrosis and rupture of suturing. Furthermore, rotational flaps without attached gingiva compromises periodontal hygiene and prosthetic therapy. By mobili-
zing the flaps into the soft palate, sagittal sufficiency of the flaps is ensured with only minor risk of a post-operatively insufficient alveolar sulcus. Furthermore, the technique increases the amount of attached gingiva on the facial part of the reconstructed alveolar process. Velar insufficiency as sequela has not been found. A tight mucosal closure against the nas al cavity, as well as the oral cavity must be stressed as very important to avoid sequestration and infection. The iliac crest has been used as donor site, which is in accordance with the literature l •3,4,6,7,8,1I . The present method differs from earlier described methods by the insertion of a cortical bone plate in the bottom of the cleft, whereas only cancellous bone has been employed in previous studies. Filling-out, the hard palate with bonegraft in excess, has not previously been described, thereby ensuring a transversal sufficiency of the palatal flaps. When employing Veau-flaps, bone is exposed in the lateral parts of the hard palate, increasing the risk of treatment failure. There have been no observed speech difficulties as a sequela to the excessive bone-grafting in the palate', The author has the impression that the excessive amount of bone is gradually resorbed post-operatively. The effects of antibiotic treatment have never been studied in a controlled trial. However, the best treatment results have been reported in studies, where antibiotics have been used as part of the routine l ,4.7.1I . Employment of an acrylic plate to cover the wounds in the hard palate has been reported by othersw', but not as a standard procedure. By using the acrylic plate, orthodontic retention can be continued, the maxillary segments are blocked and the bone-grafting is stabilized. The plate makes normal diet possible within few days , and furthermore, the acrylic splint presses the palatal mucosal diaphragm in tight contact
BONE GRAFTS IN RESIDUAL CLEFTS
with bone and prevents hematoma. Application of Surgicelf prevents the periodontal paste from being pressed into the sutured incisions. The plate is removed 4 weeks post-operatively. Acknowledgement - The author wishes to thank Hanne Pallesen, Aarhus, for preparation of the manuscript.
References 1. AMES, J. R., DORAN E. & MAKI KARL, A.: The autogenous particulate cancellous bone marrow graft in alveolar clefts, Oral Surg. 1981: 51: 588-591. 2. BoYNE, PmLlP J.: Use of marrow-cancellous bone-grafts in maxillary alveolar and palatal clefts. J. Dent, Res. 1974: 53: 821-24. 3. BOYNE, PmLlP J. & SANDS, NED R.: Secondary bone-grafting of residual alveolar and palatal clefts. J. Oral Surg. 1972: 30: 87-92. 4. BRAUN, THOMAS W.: Alveolar reconstruction in adolescent patients with cleft palates. J. Oral Surg. 1981: 39: 510--517. 5. ENHIARK, H., KRANTZ SIMONSEN, E., SCHRAMM, J. E.: Secondary bone-grafting in unilateral cleft lip palate patients: indications and treatment procedure. Int J. Oral Surg. (in press).
7
6. GEORGIADE, NICHOLAS G.: Anterior palatalalveolar closure by means of interpolated flaps. Plast. Reconstr. Surg. 1967: 39: 162-167. 7. HOGEMANN, KARL ERIK, JACODSSON, STEN & SAMAS, KARL-VICTOR: Secondary bone-grafting in cleft palate: a follow-up of 145 patients. Cleft Palate J. 1972: 9: 39-42. 8. JACKSON, IANT.: Closure of secondary palatal fistulae with intra-oral tissue and bone-grafting. Br. J. Plast. Surg. 1972: 25: 93-105.' 9. KODERG, WOLFGANG R.: Present view on bone-grafting in cleft palate: a review of the literature. J. Max-Fac. Surg. 1973: 1: 185-193. 10. SCHRUDDE, J. & STELLMACH, R.: Die Primare Osteoplastik der Defekte des Kiefer-bogens bei Lippen-Kiefer-Gaurnenspalten am Saugling. Zbl. Chir. 1958: 83: 849. 11. SINDET-PEDERSEN, S. & E"'EMARK, H.: A comparative study of secondary and late secondary bone-grafting in patients with residual cleft defects: short term evaluation. lilt. J. Oral. Surg. (in press).
Address:
Department of Oral and Maxillofacial surgery Ar/llIs Kommunehospital 8000 Arhus C Denmark