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The use of allogeneic bone for alveolar cleft grafting
The use of allogeneic bone for alveolar cleft grafting Richard TRIPLER
A. Kraut, ARMY
Colonel, DC. USA*
MEDICAL
CENTER,
HONOLULU,
HAWAII
Freeze-dried bone marrow has been used for grafting alveolar clefts. In all instances in which canines were present, they erupted through the grafted allogeneic bone. The ability to avoid donor site morbidity, coupled with successful eruption of canines through the grafted allogeneic bone, represents an additional technique for treating alveolar clefts. (ORAL SURC. ORAL MED. ORAL PATHOL. 1987;64:278-82)
T
he advantages of alveolar cleft grafting are generally accepted as being premaxillary stabilization, closure of ornasal fistulas, support for the alar base, and creation of an alveolus for the eruption or support of teeth located along the cleft.rm4 Although there is diversity of opinion regarding the preferred time for closure of the secondary palate,5-10 most authors agree that the preferred time to graft the alveolar process is between the ages of 7 and 12 years, when the canine root is one-fourth to one-half formed. Most authors report excellent results with the use of autogenous bone and marrow harvested from the patient’s ilium. *-‘I Other sites have also been used in an effort to reduce the morbidity of harvesting bone. Many authors report success with rib or tibia.12-14 Recently, cranial bone has been used for alveolar cleft grafts, with the advantages of less postoperative pain and shorter hospitahzation than with autogenous iliac bone grafts.15. I6 Studies have shown that about 75% of the canines in grafted alveolar clefts require either surgical exposure or exposure plus orthodontic force to erupt.“-I9 It has been stated that, to be successful, an alveolar cleft graft must support a properly aligned canine with adequate attached gingiva.17-19 The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Currently Department
278
Chief of Oral of Dentistry.
and
Maxillofacial
Surgery
and
Chief,
1. Reconstituted allbgeneic freeze-dried bone marrow blocks.
Fig.
In an effort to reduce surgical morbidity, allogeneic tissue has been recommended for various maxillofacial surgical procedures.2Q22 Allogeneic freezedried bone is a biologically useful alternative to autogenous bone. 22-24Histologic evidence has shown similarity in response to autogenous bone grafts, with negligible immunogenicity when the bone is freezedried.2S*26 The concept that bone induction can be initiated by the use of undecalcified allogeneic freeze-dried bone has been accepted .22*23Marx et al.27 have shown that bone morphogeneic protein activity is present in undecalcified allogeneic freeze-dried canine bone,
Volume Number
Allogeneic
64 3
bone for alveolar
cleft grafting
279
Fig. 2. Cleft with boneslightly overcontouredto providealar supportand properpontic contour for fixed partial denture.
Fig.
3. Panoramicradiographdemonstratessuccessfulgraft 6 monthsafter allogeneicbonegraft.
which they used to graft surgically created alveolar clefts in dogs. METHODS
A 17-year-old girl came for grafting of a right alveolar cleft before fabrication of a fixed partial denture to replace her congenitally missing right maxillary lateral incisor. She was scheduled for admission to the hospital. Allogenic freeze-dried bone marrow was obtained from the U.S. Navy Tissue Bank for use in treating this patient. After admission to the hospital, she was taken to the operating room and placed under nasoendotracheal general anesthesia via the left naris. A subperiosteal pocket was developed by means of the flap design
advocated by Epker and Wolford.28 The pocket consisted of a new nasal and palatal floor developed from the mucosa that lined the cleft. Allogeneic freeze-dried bone marrow (Fig. 1) that had been reconstituted with 2 million units of aqueous K+ penicillin and 1 gm of streptomycin was packed against the osseous walls of the cleft and used to slightly overfill the cleft (Fig. 2). Emphasis was placed on providing adequate bone in the area of the piriform rim to provide alar support (Fig. 3). The palatal and buccal flaps were sutured as described by Epker and Wolford2* to assure water-tight closure over the grafted cleft. A 14-year-old boy was referred by his orthodontist for grafting of a left alveolar cleft. At the time of
280
Kraut
Oral Surg. September 1987
Fig.
4. Panoramicradiographdemonstratesbone graft 3 monthsafter graft placement.
stituted allogeneic
freeze-dried bone marrow was used to graft the alveolar cleft (Figs. 4 and 5). One year after placement of the allogeneic graft, the canine had erupted into the grafted bone and was exposed for placement of orthodontic guidance into the arch (Fig. 6). At the time of exposure, the allogeneic graft was indistinguishable from the nongrafted alveolar bone around the adjacent central incisor and first premolar. Six months after exposure, the canine was in the arch in proper alignment (Figs. 7 and 8). Three other girls, two aged 12 and one aged 10, had left alveolar clefts grafted with allogeneic freezedried bone. In all three of those patients, the canine erupted through the graft. DISCUSSION
The five cases presented demonstrate the practicality of using allogeneic freeze-dried bone marrow for grafting of alveolar clefts. The fact that four canines erupted through the grafted bone indicates that the technique is applicable in cases where the alveolar cleft is grafted to provide bone for the canine to erupt into rather allowing the canine to erupt into the ungrafted cleft. SUMMARY
5. Left alveolar cleft with ailogeneicfreeze-dried boni: marrow. Fig.
presentation, the canine root was two-thirds formed. The transverse maxillary width and alignment of the greater and lesser segments were satisfactory. The patient was taken to the operating room, and recon-
The use of allogeneic freeze-dried bone marrow for alveolar cleft grafting is reported. The ability to avoid donor site morbidity is the greatest advantage gained by the use of allogeneic bone for grafting of alveolar clefts. The successful eruption of canines through the grafted bone makes this technique suitable for alveolar cleft grafting before canine eruption.
Allogeneic bone for alveolar cleft grafting
Volume 64 Number3
Fig.
6. Canineerupting through grafted allogeneicfreeze-driedbone.
Fig.
7. Maxillary left caninein occlusion,
Fig. 8. Panoramic radiograph demonstratesexcellent bone support around maxillary left canine 18 monthsafter bonegraft wasplaced.
281
282
Kraut
Oral Surg. September 1987
REFERENCES
1. Boyne PJ. Use of marrow-cancellous bone grafts in maxillary alveolar and palatal clefts. J Dent Res 1974;53:821. 2. Troxell JB, Fonseca RJ, Osbon DB. A retrospective study of alveolar cleft grafting. J Oral Maxillofac Surg 1982;40:721. 3. Eldeeb ME, Hinrichs JE, Waite DE, Bandt CL, Bevis R. Repair of alveolar cleft defects with autogenous bone grafting: periodontal evaluation. Cleft Palate J 1986;23:126. 4. Ames JR, Ryan DE, Maki KA. The autogenous particulate cancellous bone marrow graft in alveolar clefts-a report of forty-one cases. ORAL SURG ORAL MED ORAL PATHOL 1981; 51:588. 5. Fonseca RJ, Davis WH. Reconstructive preprosthetic oral and maxillofacial surgery. Philadelphia: WB Saunders Company, 1986;453. 6. Witsenburg B. The reconstruction of anterior residual bone defects in patients with cleft lip, alveolus and palate-a review. J Maxillofac Surg 1985;13:197. 7. Abyholm FE, Bergland 0, Semb G. Secondary bone grafting of alveolar clefts. Stand J Plast Reconstr Surg 1981;15:127. 8. Bertz JE. Bone grafting of alveolar clefts. J Oral Surg 1981;39:874. 9. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. ORAL SURG ORAL MED ORAL PATHOL 1972;30:87.
10. Hall DH, Posnick JC: Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 1983;41:289. 11. Braun TW, Sotereanos GC. Alveolar reconstruction in adolescent patients with cleft palates. J Oral Surg 1981;39:510. 12. Schultz RC: Free periosteal graft repair of maxillary clefts in adolescents. Plast Reconstr Surg 1984;73:556. 13. Lauries SW, Kaban LB, Mulliken JB, Murray JE. Donor-site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 1984;73:933. 14. Jackson IT, Scheker LR, Vandervord JG, McLennan JG. Bone marrow grafting in the secondary closure of alveolarpalatal defects in children. Br J Plast Surg 1981;34:422. 15. Wolfe SA, Berkowitz S. The use of cranial bone grafts in the closure of alveolar and anterior palatal celfts. Plast Reconstr Surg 1983;72:659. 16. Edwab RR, Roberts MJ, Sole MS, Reed LS, Rappaport SC. Autogenous calvarial bone dust for mandibular reconstruction. J Oral Maxillofac Surg 1982;40:3 13. 17. Deeb ME, Messer LB, Lehnert MW, Hebda TW, Waite DE.
18. 19. 20. 21.
22. 23. 24.
25.
Canine eruption into grafted bone in maxillary alveolar cleft defects. Cleft Palate J 1982;19:9. Sullivan KO. Tooth eruption in the bone-grafted maxillary cleft alveolus. Int J Oral Surg 1981;1O(Suppl 1):309. Hinrichs JE, Deeb ME, Waite DE, Bevis RR, Bandt CL. Periodontal evaluation of canines erupted through grafted alveolar cleft defects. J Oral Maxillofac Surg 1984;42:7 17. Kraut RA. Composite graft for mandibular alveolar ridge augmentation: a preliminary report. J Oral Maxillofac Surg 1985;43:856. Mulliken JB, Glowacki J, Kaban LB, Folkman J, Murray JE. Use of demineralized allogeneic bone implants for the correction of maxillocraniofacial deformities. Ann Surg 1981; 194~366. Fonseca RJ, Davis WH. Reconstructive preprosthetic oral and maxillofacial surgery, Philadelphia: WB Saunders Company, 1986;30. Kelly JF, Friedlander GE. Preprosthetic bone graft augmentation with allogeneic bone: a preliminary report. J Oral Surg 1977;35:268. Fonseca RJ, Nelson JF, Clark PJ, Frost DE, Olson RA. Revascularization and healing of onlay particulate allogeneic bone grafts in primates. J Oral Maxillofac Surg 1983; 41:153. Wolford LM, Epker BN. The use of freeze-dried bone as a biologic crib for ridge augmentation: a preliminary report. ORAL SURG ORAL MED ORAL PATHOL 1977;43:499.
26. Schaberg SJ, Petri WH, Gregory EW, Auclair PL, Jacob E. A comparison of freeze-dried allogeneic and fresh autologous vascularized rib grafts in dog radial discontinuity defects. J Oral Maxillofac Surg 1985;43:932. 27. Marx RE, Miller RI, Ehler WJ, Hubbard G, Malinin TI. A comparison of particulate allogeneic and particulate autogenous bone grafts into maxillary alveolar clefts in dogs. J Oral Maxillofac Surg 1984;42:3. 28. Epker BN, Wolford LM. Dentofacial deformities; surgicalorthodontic correction. St. Louis: The CV Mosby Company, 1980:332-49. Reprint
requests
to:
Colonel Richard A. Kraut Department of Dentistry Tripler Army Medical Center Honolulu, HI
A. Kraut, ARMY
Colonel, DC. USA*
MEDICAL
CENTER,
HONOLULU,
HAWAII
Freeze-dried bone marrow has been used for grafting alveolar clefts. In all instances in which canines were present, they erupted through the grafted allogeneic bone. The ability to avoid donor site morbidity, coupled with successful eruption of canines through the grafted allogeneic bone, represents an additional technique for treating alveolar clefts. (ORAL SURC. ORAL MED. ORAL PATHOL. 1987;64:278-82)
T
he advantages of alveolar cleft grafting are generally accepted as being premaxillary stabilization, closure of ornasal fistulas, support for the alar base, and creation of an alveolus for the eruption or support of teeth located along the cleft.rm4 Although there is diversity of opinion regarding the preferred time for closure of the secondary palate,5-10 most authors agree that the preferred time to graft the alveolar process is between the ages of 7 and 12 years, when the canine root is one-fourth to one-half formed. Most authors report excellent results with the use of autogenous bone and marrow harvested from the patient’s ilium. *-‘I Other sites have also been used in an effort to reduce the morbidity of harvesting bone. Many authors report success with rib or tibia.12-14 Recently, cranial bone has been used for alveolar cleft grafts, with the advantages of less postoperative pain and shorter hospitahzation than with autogenous iliac bone grafts.15. I6 Studies have shown that about 75% of the canines in grafted alveolar clefts require either surgical exposure or exposure plus orthodontic force to erupt.“-I9 It has been stated that, to be successful, an alveolar cleft graft must support a properly aligned canine with adequate attached gingiva.17-19 The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Currently Department
278
Chief of Oral of Dentistry.
and
Maxillofacial
Surgery
and
Chief,
1. Reconstituted allbgeneic freeze-dried bone marrow blocks.
Fig.
In an effort to reduce surgical morbidity, allogeneic tissue has been recommended for various maxillofacial surgical procedures.2Q22 Allogeneic freezedried bone is a biologically useful alternative to autogenous bone. 22-24Histologic evidence has shown similarity in response to autogenous bone grafts, with negligible immunogenicity when the bone is freezedried.2S*26 The concept that bone induction can be initiated by the use of undecalcified allogeneic freeze-dried bone has been accepted .22*23Marx et al.27 have shown that bone morphogeneic protein activity is present in undecalcified allogeneic freeze-dried canine bone,
Volume Number
Allogeneic
64 3
bone for alveolar
cleft grafting
279
Fig. 2. Cleft with boneslightly overcontouredto providealar supportand properpontic contour for fixed partial denture.
Fig.
3. Panoramicradiographdemonstratessuccessfulgraft 6 monthsafter allogeneicbonegraft.
which they used to graft surgically created alveolar clefts in dogs. METHODS
A 17-year-old girl came for grafting of a right alveolar cleft before fabrication of a fixed partial denture to replace her congenitally missing right maxillary lateral incisor. She was scheduled for admission to the hospital. Allogenic freeze-dried bone marrow was obtained from the U.S. Navy Tissue Bank for use in treating this patient. After admission to the hospital, she was taken to the operating room and placed under nasoendotracheal general anesthesia via the left naris. A subperiosteal pocket was developed by means of the flap design
advocated by Epker and Wolford.28 The pocket consisted of a new nasal and palatal floor developed from the mucosa that lined the cleft. Allogeneic freeze-dried bone marrow (Fig. 1) that had been reconstituted with 2 million units of aqueous K+ penicillin and 1 gm of streptomycin was packed against the osseous walls of the cleft and used to slightly overfill the cleft (Fig. 2). Emphasis was placed on providing adequate bone in the area of the piriform rim to provide alar support (Fig. 3). The palatal and buccal flaps were sutured as described by Epker and Wolford2* to assure water-tight closure over the grafted cleft. A 14-year-old boy was referred by his orthodontist for grafting of a left alveolar cleft. At the time of
280
Kraut
Oral Surg. September 1987
Fig.
4. Panoramicradiographdemonstratesbone graft 3 monthsafter graft placement.
stituted allogeneic
freeze-dried bone marrow was used to graft the alveolar cleft (Figs. 4 and 5). One year after placement of the allogeneic graft, the canine had erupted into the grafted bone and was exposed for placement of orthodontic guidance into the arch (Fig. 6). At the time of exposure, the allogeneic graft was indistinguishable from the nongrafted alveolar bone around the adjacent central incisor and first premolar. Six months after exposure, the canine was in the arch in proper alignment (Figs. 7 and 8). Three other girls, two aged 12 and one aged 10, had left alveolar clefts grafted with allogeneic freezedried bone. In all three of those patients, the canine erupted through the graft. DISCUSSION
The five cases presented demonstrate the practicality of using allogeneic freeze-dried bone marrow for grafting of alveolar clefts. The fact that four canines erupted through the grafted bone indicates that the technique is applicable in cases where the alveolar cleft is grafted to provide bone for the canine to erupt into rather allowing the canine to erupt into the ungrafted cleft. SUMMARY
5. Left alveolar cleft with ailogeneicfreeze-dried boni: marrow. Fig.
presentation, the canine root was two-thirds formed. The transverse maxillary width and alignment of the greater and lesser segments were satisfactory. The patient was taken to the operating room, and recon-
The use of allogeneic freeze-dried bone marrow for alveolar cleft grafting is reported. The ability to avoid donor site morbidity is the greatest advantage gained by the use of allogeneic bone for grafting of alveolar clefts. The successful eruption of canines through the grafted bone makes this technique suitable for alveolar cleft grafting before canine eruption.
Allogeneic bone for alveolar cleft grafting
Volume 64 Number3
Fig.
6. Canineerupting through grafted allogeneicfreeze-driedbone.
Fig.
7. Maxillary left caninein occlusion,
Fig. 8. Panoramic radiograph demonstratesexcellent bone support around maxillary left canine 18 monthsafter bonegraft wasplaced.
281
282
Kraut
Oral Surg. September 1987
REFERENCES
1. Boyne PJ. Use of marrow-cancellous bone grafts in maxillary alveolar and palatal clefts. J Dent Res 1974;53:821. 2. Troxell JB, Fonseca RJ, Osbon DB. A retrospective study of alveolar cleft grafting. J Oral Maxillofac Surg 1982;40:721. 3. Eldeeb ME, Hinrichs JE, Waite DE, Bandt CL, Bevis R. Repair of alveolar cleft defects with autogenous bone grafting: periodontal evaluation. Cleft Palate J 1986;23:126. 4. Ames JR, Ryan DE, Maki KA. The autogenous particulate cancellous bone marrow graft in alveolar clefts-a report of forty-one cases. ORAL SURG ORAL MED ORAL PATHOL 1981; 51:588. 5. Fonseca RJ, Davis WH. Reconstructive preprosthetic oral and maxillofacial surgery. Philadelphia: WB Saunders Company, 1986;453. 6. Witsenburg B. The reconstruction of anterior residual bone defects in patients with cleft lip, alveolus and palate-a review. J Maxillofac Surg 1985;13:197. 7. Abyholm FE, Bergland 0, Semb G. Secondary bone grafting of alveolar clefts. Stand J Plast Reconstr Surg 1981;15:127. 8. Bertz JE. Bone grafting of alveolar clefts. J Oral Surg 1981;39:874. 9. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. ORAL SURG ORAL MED ORAL PATHOL 1972;30:87.
10. Hall DH, Posnick JC: Early results of secondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 1983;41:289. 11. Braun TW, Sotereanos GC. Alveolar reconstruction in adolescent patients with cleft palates. J Oral Surg 1981;39:510. 12. Schultz RC: Free periosteal graft repair of maxillary clefts in adolescents. Plast Reconstr Surg 1984;73:556. 13. Lauries SW, Kaban LB, Mulliken JB, Murray JE. Donor-site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 1984;73:933. 14. Jackson IT, Scheker LR, Vandervord JG, McLennan JG. Bone marrow grafting in the secondary closure of alveolarpalatal defects in children. Br J Plast Surg 1981;34:422. 15. Wolfe SA, Berkowitz S. The use of cranial bone grafts in the closure of alveolar and anterior palatal celfts. Plast Reconstr Surg 1983;72:659. 16. Edwab RR, Roberts MJ, Sole MS, Reed LS, Rappaport SC. Autogenous calvarial bone dust for mandibular reconstruction. J Oral Maxillofac Surg 1982;40:3 13. 17. Deeb ME, Messer LB, Lehnert MW, Hebda TW, Waite DE.
18. 19. 20. 21.
22. 23. 24.
25.
Canine eruption into grafted bone in maxillary alveolar cleft defects. Cleft Palate J 1982;19:9. Sullivan KO. Tooth eruption in the bone-grafted maxillary cleft alveolus. Int J Oral Surg 1981;1O(Suppl 1):309. Hinrichs JE, Deeb ME, Waite DE, Bevis RR, Bandt CL. Periodontal evaluation of canines erupted through grafted alveolar cleft defects. J Oral Maxillofac Surg 1984;42:7 17. Kraut RA. Composite graft for mandibular alveolar ridge augmentation: a preliminary report. J Oral Maxillofac Surg 1985;43:856. Mulliken JB, Glowacki J, Kaban LB, Folkman J, Murray JE. Use of demineralized allogeneic bone implants for the correction of maxillocraniofacial deformities. Ann Surg 1981; 194~366. Fonseca RJ, Davis WH. Reconstructive preprosthetic oral and maxillofacial surgery, Philadelphia: WB Saunders Company, 1986;30. Kelly JF, Friedlander GE. Preprosthetic bone graft augmentation with allogeneic bone: a preliminary report. J Oral Surg 1977;35:268. Fonseca RJ, Nelson JF, Clark PJ, Frost DE, Olson RA. Revascularization and healing of onlay particulate allogeneic bone grafts in primates. J Oral Maxillofac Surg 1983; 41:153. Wolford LM, Epker BN. The use of freeze-dried bone as a biologic crib for ridge augmentation: a preliminary report. ORAL SURG ORAL MED ORAL PATHOL 1977;43:499.
26. Schaberg SJ, Petri WH, Gregory EW, Auclair PL, Jacob E. A comparison of freeze-dried allogeneic and fresh autologous vascularized rib grafts in dog radial discontinuity defects. J Oral Maxillofac Surg 1985;43:932. 27. Marx RE, Miller RI, Ehler WJ, Hubbard G, Malinin TI. A comparison of particulate allogeneic and particulate autogenous bone grafts into maxillary alveolar clefts in dogs. J Oral Maxillofac Surg 1984;42:3. 28. Epker BN, Wolford LM. Dentofacial deformities; surgicalorthodontic correction. St. Louis: The CV Mosby Company, 1980:332-49. Reprint
requests
to:
Colonel Richard A. Kraut Department of Dentistry Tripler Army Medical Center Honolulu, HI