How To Repair Elevate Alveoli
Arch Plast Surg. 2022 May; 44(3): 188–193.
Current Methods for the Treatment of Alveolar Crevice
Nak Heon Kang
Department of Plastic and Reconstructive Surgery, Chungnam National University Schoolhouse of Medicine, Daejeon, Korea.
Received 2022 January thirty; Revised 2022 Apr fifteen; Accepted 2022 April 21.
Abstruse
Alveolar crack is a tornado-shaped bone defect in the maxillary arch. The treatment goals for alveolar crack are stabilization and provision of bone continuity to the maxillary arch, permitting support for tooth eruption, eliminating oronasal fistulas, providing an improved esthetic result, and improving spoken language. Treatment protocols vary in terms of the operative time, surgical techniques, and graft materials. Early on approaches including boneless os grafting (gingivoperiosteoplasty) and primary bone graft fell into disfavor because they dumb facial growth, and they remain controversial. Secondary os graft (SBG) is not the most perfect method, but long-term follow-upwardly has shown that the graft is captivated to a lesser extent, does non impede facial growth, and supports other teeth. Accordingly, SBG in the mixed dentition phase (6–eleven years) has become the preferred method of treatment. The virtually usually used graft material is cancellous os from the iliac crest. Recently, many researchers have investigated the utilize of allogeneic bone, artificial os, and recombinant human being os morphogenetic protein, forth with growth factors because of their ability to subtract donor-site morbidity. Further investigations of bone substitutes and additives will go along to be needed to increase their effectiveness and to reduce complications.
Keywords: Alveolar os grafting, Os substitutes, Bone morphogenetic proteins
INTRODUCTION
Alveolar crevice occurs in response to departure from normal development during frontonasal prominence growth, contact, and fusion. The most common alveolar portion of the crack is located between the lateral incisor and the canine. Reconstruction of the alveolar scissure was introduced by von Eiselsberg [1] using autologous tissue, while Lexer [2] first described a nonvascular bone graft. Drachter [3] reported the repair of an alveolar cleft using the tibial bone, and Schmid [4] starting time utilized this procedure for implanting iliac os grafts into the bony gap. Skoog [v] developed a boneless bone graft technique known every bit gingivoperiosteoplasty. Until the 1970s, primary os grafting (PBG) with rib os at the infant stage was the chief surgical procedure used to treat alveolar cleft [6]. Even so, negative responses to PBG, such as midface retrusion and anterior crossbite, have been reported upon closer examination and over the course of long-term follow-upwardly. In dissimilarity, positive responses to secondary bone grafting (SBG) accept been reported, and reconstruction of the alveolar cleft is performed virtually frequently in the mixed dentition period (between 6 and xi years) [seven]. Although diverse analytical methods have been proposed, it is difficult to determine the outcomes of bone grafting. Choi et al. [8] compared the corporeality of graft measured with preoperative 3-dimensional computed tomography (3D CT) to the amount actually used for surgery and institute that 3D CT could accurately measure the corporeality of os graft needed prior to surgery. Recently, depression-dose maxillary 3D cone-beam computed tomography (CBCT) has been widely used for preoperative planning and postoperative evaluations. Amirlak et al. [9] compared the amount of bone defect to the corporeality of graft by using CBCT before and after simulated surgery. Methods for using materials such every bit allogeneic freeze-dried bone (FDB), demineralized freeze-dried bone (DFDB), demineralized bone matrix (DBM), and recombinant man bone morphogenetic protein (rh-BMP) have also been investigated to reduce the morbidity of donor sites and to obtain good results [10].
SECONDARY ALVEOLAR BONE GRAFTING
Secondary repair is divided into early on, conventional, and late grafting. Early on secondary repair usually occurs between 2 years and v or 6 years before the eruption of permanent teeth after complete eruption of the primary dentition. Transitional (conventional) secondary repair is performed in the mixed dentition stage, and belatedly secondary (tertiary) repair is performed later on permanent eruption. The purpose of SBG is to eliminate oronasal communication and prevent the retention of food particles in guild to meliorate oral hygiene and prevent inflammation [eleven]. This method besides stabilizes the maxillary segment and improves facial aesthetics and symmetry by inducing tooth eruption, orthodontic movement of the teeth, nasal support, and projection with appropriate alveolar bone support. Initially, it was not of import to encompass the grafted bone and little attention was paid to flap design. However, since Abyholm et al. [12] get-go discussed the importance of flap blueprint in 1981, completely roofing the implanted os with the elevated mucoperiosteal flaps without tension after the bone graft (watertight closure) has been considered one of the most of import factors affecting the surgical effect. When performing SBG, special care should be taken to non crusade inflammation past opening the nasal lining. Semb [13] reported on the footing of a long-term evaluation that SBG did not affect the anteroposterior or vertical maxillary growth. Chang et al. [14] reported that no divergence in maxillofacial growth was observed in the cephalograms of a bonegrafted group and a not-grafted group. Several other researchers accept too investigated molar eruption. Troxell et al. [15] reported that tooth eruption occurred through a bone graft in 9% of cases, while El Deeb et al. [16] reported that tooth eruption was observed in only 27% of the bone graft recipients. Appropriate os graft thickness is as well of import because a prosthetic tooth tin can be inserted into the bone-grafted alveolar bone in the absenteeism of teeth eruption [7].
Source of bone graft material
Both cortical and cancellous bones can exist used for a bone graft, just cancellous bone is known to be better considering of the cell transfer and revascularization in osteoinduction and osteoconduction. A diversity of autologous, allogeneic, and xenogeneic bone materials; rhBMP; and growth factors have been used for correcting alveolar cleft. Of these, fresh autologous cancellous bone is the ideal bone graft source [17].
Iliac crest
Iliac bone is the near unremarkably used bone in os grafting because it is easy to harvest, it can provide a big amount of cancellous os, and cleft training can be performed at the aforementioned time. All the same, the disadvantages of using this bone are possible scarring, postoperative pain, delayed ambulation, and gamble of cutaneous nerve injury. To reduce complications, express incision, minimal musculature elevation, meticulous hemostasis, reapproximation of the cartilage cap, adequate hurting control, and early ambulation should be employed. Ilankovan et al. [xviii] reported that sufficient cancellous bone could exist obtained using the trephine technique. Sharma et al. [19] reported that bone harvesting with a ability-driven trephine system resulted in reduced operative time and length of hospital stay, low hurting scores, and low analgesic utilise.
Cranium
The cranium has little resorption, less postoperative pain, and the advantage of a concealed scar. According to Hudak et al. [20], the survival charge per unit of cranial bone grafts is approximately 85.0%, which is similar to that of iliac os grafts reported by Oberoi et al. [21] (84%). Withal, a long operative time and serious side effects such as hematoma, seroma, dural tear, dural exposure, and cerebrospinal fluid leakage are possible [22].
Tibia
The employ of the tibia results in less bleeding, postoperative pain, operative fourth dimension, and scarring, besides as faster ambulation and a shorter infirmary stay. Still, most studies are based on the collection of relatively pocket-sized amounts of bone in adult patients, and it may be necessary to obtain the product from both legs if a big amount is required. Moreover, its success in children is poor because of the possibility of growth disturbance due to injury of the epiphyseal cartilage [xviii].
Mandibular symphysis
The mandible has the same embryonic origin as the maxilla. Considering it is a membranous os, revascularization is relatively fast and resorption is low. Surgery tin can be performed in the same operative field and postoperative discomfort is reduced, thus reducing the length of the hospital stay. However, at that place is a take a chance of canine, incisor root, and mental nerve impairment, and the corporeality that can exist collected depends on the development of the mandible [23].
Bone-graft substitutes
There are several types of allogeneic bones that tin be used as autologous graft substitutes in alveolar crevice repair. DFDB or DBM possess superior osteoinduction characteristics, and FDB, a mineralized os, is known to have high osteoconduction activeness [24]. With the advantages of both types of bone materials, these materials have been widely implanted together when replacing autologous bone. Although these substitutes take the advantage of reducing donor-site morbidities, infection, disease transmission, and host incompatibility have been reported [25]. Further, bogus bone materials such every bit hydroxyapatite (HA) and tricalcium phosphate (TCP) are mixed with rhBMP, only there may be teratogenic and carcinogenic effects because of overgrowth [26]. Contempo studies investigating the addition of growth factors such equally platelet-rich plasma (PRP) and plateletrich fibrin (PRF) with graft materials have been carried out during os grafting, but these methods take non nonetheless been widely used [27]. In some studies, rhBMP has been used for maxillofacial surgical purposes and has been shown to be better than an autologous iliac bone graft, but the bone volume remaining after surgery has been found to be lower when this method is employed [28]. All the same, most studies using DBM and rhBMP have reported acceptable results. In improver, Francis et al. [29] compared the results in diverse ways and suggested the possibility of substituting an iliac bone graft for a bone graft by adding rhBMP to the DBM scaffold. Some studies of the application of this technique in spinal column repair surgery revealed meaning operative site edema and resorption of vertebral bodies as postoperative complications. In animal studies, premature fusion and growth restriction of the suture line take been reported [28].
Surgical procedure
Under general anesthesia and vasoconstrictor infiltration, gingival mucoperiosteal flaps are designed forth the cleft margins, and elevated medial and lateral mucoperiosteal flaps are generated from the cleft and the gingival sulcus of the teeth. To obtain adequate mobility of the posterior flap, the flap must be extended to the first or the second molar and back-cutting up to the buccal sulcus while taking intendance not to hurt the alveolar bone covering the roots of the teeth. These flaps are raised up to and around the piriform aperture, and then are separated from the nasal mucosa. The palatal mucoperiosteal flaps along the cleft margins are then elevated from the palate. Afterward complete exposure of all the bony clefts, the nasal lining of the nostril flooring is approximated and sutured, and the palatal flaps are then turned back and sutured to make a soft-tissue pocket. Grafting of the defect is accomplished with a cancellous bone from the ilium. The grafted bone should be compressed into the cleft defect to maximize the number of osteo-competent cells and the osteoid material per unit graft book. When packing bone particles, information technology is better to create the maxilla and alveolar ridges and elevate the depressed nostril past appropriately supporting the nasal base and aligning the symmetry. The residuum tin then be covered with gingival mucoperiosteal flaps through tension-free transposition (Figs. 1, ii, iii) [11,12].
Alveolar cleft repair
(A) Preoperative view of an unilateral alveolar scissure after the orthodontic alignment of maxillary segments and teeth. (B) The flaps were raised over the greater and lesser segments of the maxilla in the subperiosteal plane, and the cleft mucosa was separated from the labial mucosa. The author elevated the flap to the subperiosteal aeroplane, leaving little gingival attachment. (C) Iliac cancellous bone graft was packed inside the cleft defect. (D) The larger posterior mucoperiosteal flap was transposed beyond the labial surface of the graft and sutured to the inductive flap without tension. When closing the mucosal flap, it was important to repair it with a watertight graft so that the roots of the teeth were not exposed.
Unilateral alveolar crack in a 12-twelvemonth-old patient
(A) The nasal lining of the floor and the palatal flaps were repaired. (B) Autologous cancellous bone mixed with DBM was packed in the cleft. (C) Tension-gratuitous coverage was obtained by redraping the mucoperiosteal flaps. (D) Autologous bone and DBM. DBM, demineralized bone matrix.
CT scans of alveolar cleft
(A) Preoperative and (B) 6-month postoperative CT scans of rightside alveolar crevice in an 11-year-old patient. CT, computed tomography.
In the case of bilateral clefts, the orthodontic alignment of the premaxilla is set and the cleft is repaired using a method similar to that used for repairing a unilateral alveolar cleft [8]. It is very important to design the mucoperiosteal flap to be sufficiently elevated and to seal the flap without tension, so that the grafted bone particles are not exposed. To attain this, there should be no excessive tension on the flap closure, particularly on the roof side of the defect, and the nasal lining site must be sealed watertight to prevent postoperative inflammation or infection.
Complications
An alveolar bone graft may be exposed past excessive tension or trauma during recovery afterward surgery. Minor exposure can be improved by conservative treatment, only bone graft exposure should be avoided if possible. Even if bone grafts are overpacked, graft resorption and alveolous notching can occur. Pregnant graft failure may occur in less than 5% of the patients, in which case reoperation is required [twenty]. Sivak et al. [thirty] reported that BMP or DBM was better than an autologous iliac bone graft after bone graft failure.
Survival of alveolar bone grafts
The results of bone grafts in patients with alveolar crack can vary from a highly successful graft with small-scale reabsorption to a poor result with a small amount or a lack of bone bridging. Since Bergland et al. [31] introduced what is known equally the Bergland scale in 1986 to quantify the amount of implanted bone, several researchers have proposed diverse methods such equally the Enemark score, the Long rating scale, the Kindelan scale, and the Chelsea scale [32,33,34,35]. Recently, about methods for evaluating the results of an alveolar bone graft accept used dental radiographs and CBCT.
In 2007, Feichtinger et al. [36] evaluated the volumetric changes of 24 cases over iii years. The grafted bone was absorbed by 49.v% in the first year, and 52% in 3 years. In item, an 8.0% increment in os volume was reported. Honma et al. [37] studied the grafted os-bridge book of 15 cases at 3 months and ane year postoperatively. The hateful preoperative volume of the grafted os was 1.1± 0.3 cmthree post-surgery, 1.2±0.6 cmiii at 3 months postoperatively, and ane.1±0.five cm3 at 1 year postoperatively. Still, ane year afterward surgery, the volume showed a considerable degree of variability, ranging from 0.3 to 2.0 cm3. Another study by Trindade et al. [38] assessed 65 secondary alveolar os grafts at a i-year-postoperative follow-up. Of the 65 cases, 68%–71% were classified every bit Bergland type I, implying that the interdental septum height was normal, and xv% as Bergland type II, implying that the height was 75% of normal. In the rest of the cases, the absorption rate could not be measured, as the volume connected to modify because of the orthodontic treatment and the eruption of the permanent teeth [38]. In a 5-year prospective report of 100 cases by Tan et al. [39], longterm changes in the grafted bone were assessed. At 5 years postoperatively, the authors reported that 88.9% of the patients with unilateral clefts and 84.6% of the patients with bilateral clefts were scored equally Bergland blazon I, implying that the septal bone elevation was normal. Enemark et al. [32] observed 95 cases of unilateral and bilateral alveolar clefts for 4 years. Of these 95 patients, 76 exhibited no difference in the bone peak, and in another 14 cases, the os pinnacle inverse to 75% of the normal alveolar bone pinnacle. It is reasonable to await that the amount of grafted os volition change slightly over time. The observation that the grafted bone changes over a long period of time may exist helpful in evaluating the surgical event.
CONCLUSIONS
Treatment of alveolar cleft has inverse over the by century. The nearly widely accustomed handling protocol is grafting using autologous cancellous bone from the iliac crest in patients aged between 6 and 11 years, in the mixed dentition period. Although autologous os is the platonic graft material, bone substitutes have been used in recent years because of limited os retrieval. A combination of allogeneic demineralized bone, which has superior osteoinduction activity, with mineralized bone, which has loftier osteoconduction activeness, low resorption, and good volume retention, is widely used equally an alternative to autologous bone grafts. Further, growth factors such equally PRP and PRF, and transplantation additives such as rhBMP accept been used; rhBMP may be used past being mixed with an artificial bone cloth such every bit HA or TCP. The utilize of new technologies such every bit allogeneic, xenogeneic, and synthetic bones; rhBMP; and growth factors has been reported to reduce donor-site morbidity and tin be particularly useful in the case of a lack of bone source or in complicated cases. Even so, alveolar bone grafting must include autologous bone, and none of the currently available methods can replace autologous bone completely. Therefore, further studies investigating the platonic correction fourth dimension, donor site, graft substitutes, and additives should be conducted.
Footnotes
No potential conflict of interest relevant to this article was reported.
References
1. von Eiselsberg F. Zur technik der uranoplastik. Arch Klin Chir. 1901;64:509–529. [Google Scholar]
2. Lexer E. Dice Verwendung der freien knochenplastik nebst versucher uber gelenkversteinfung und gelenktransplantation. Arch Klin Chir. 1908;86:939–943. [Google Scholar]
3. Drachter R. Die Gaumenspalte und deren operative Behandlung. Dtsch Z Chir. 1914;131:1–89. [Google Scholar]
iv. Schmid East. Die aufbauende kieferkamm plastik. Ost J Stomat. 1954;51:582–583. [PubMed] [Google Scholar]
v. Skoog T. The use of periosteum and Surgicel for os restoration in built clefts of the maxilla: a clinical report and experimental investigation. Scand J Plast Reconstr Surg. 1967;1:113–130. [PubMed] [Google Scholar]
7. Cohen M, Polley JW, Figueroa AA. Secondary (intermediate) alveolar bone grafting. Clin Plast Surg. 1993;20:691–705. [PubMed] [Google Scholar]
8. Choi HS, Choi HG, Kim SH, et al. Influence of the alveolar crevice type on preoperative interpretation using 3D CT assessment for alveolar scissure. Arch Plast Surg. 2012;39:477–482. [PMC free article] [PubMed] [Google Scholar]
9. Amirlak B, Tang CJ, Becker D, et al. Volumetric analysis of simulated alveolar crack defects and bone grafts using cone beam computed tomography. Plast Reconstr Surg. 2013;131:854–859. [PubMed] [Google Scholar]
x. Santiago PE, Schuster LA, Levy-Bercowski D. Management of the alveolar cleft. Clin Plast Surg. 2014;41:219–232. [PubMed] [Google Scholar]
eleven. Daw JL, Jr, Patel PK. Management of alveolar clefts. Clin Plast Surg. 2004;31:303–313. [PubMed] [Google Scholar]
12. Abyholm Atomic number 26, Bergland O, Semb M. Secondary os grafting of alveolar clefts. A surgical/orthodontic handling enabling a non-prosthodontic rehabilitation in cleft lip and palate patients. Scand J Plast Reconstr Surg. 1981;15:127–140. [PubMed] [Google Scholar]
13. Semb G. Effect of alveolar os grafting on maxillary growth in unilateral scissure lip and palate patients. Cleft Palate J. 1988;25:288–295. [PubMed] [Google Scholar]
fourteen. Chang HP, Chuang MC, Yang YH, et al. Maxillofacial growth in children with unilateral cleft lip and palate following secondary alveolar bone grafting: an acting evaluation. Plast Reconstr Surg. 2005;115:687–695. [PubMed] [Google Scholar]
15. Troxell JB, Fonseca RJ, Osbon DB. A retrospective study of cleft grafting. J Oral Maxillofac Surg. 1982;40:721–725. [PubMed] [Google Scholar]
16. El Deeb Grand, Messer LB, Lehnert MW, et al. Canine eruption into grafted bone in maxillary alveolar cleft defects. Cleft Palate J. 1982;19:ix–sixteen. [PubMed] [Google Scholar]
17. Rawashdeh MA, Telfah H. Secondary alveolar os grafting: the dilemma of donor site option and morbidity. Br J Oral Maxillofac Surg. 2008;46:665–670. [PubMed] [Google Scholar]
xviii. Ilankovan Five, Stronczek M, Telfer Thousand, et al. A prospective study of trephined bone grafts of the tibial shaft and iliac crest. Br J Oral Maxillofac Surg. 1998;36:434–439. [PubMed] [Google Scholar]
xix. Sharma S, Schneider LF, Barr J, et al. Comparing of minimally invasive versus conventional open up harvesting techniques for iliac bone graft in secondary alveolar cleft patients. Plast Reconstr Surg. 2011;128:485–491. [PubMed] [Google Scholar]
twenty. Hudak KA, Hettinger P, Denny Advertisement. Cranial bone grafting for alveolar clefts: a 25-twelvemonth review of outcomes. Plast Reconstr Surg. 2014;133:662e–668e. [PubMed] [Google Scholar]
21. Oberoi South, Chigurupati R, Gill P, et al. Volumetric assessment of secondary alveolar os grafting using cone axle computed tomography. Cleft Palate Craniofac J. 2009;46:503–511. [PubMed] [Google Scholar]
22. Cohen M, Figueroa AA, Haviv Y, et al. Iliac versus cranial bone for secondary grafting of residual alveolar clefts. Plast Reconstr Surg. 1991;87:423–427. [PubMed] [Google Scholar]
23. Rahpeyma A, Khajehahmadi S. Chin os graft for maxillary alveolar crevice: indications and limitations. J Craniofac Surg. 2014;25:1650–1652. [PubMed] [Google Scholar]
24. Misch CE, Dietch FM. Keys to bone grafting and bone grafting materials. In: Misch CE, editor. Contemporary implant dentistry. St. Louis: Mosby Elsevier; 2008. pp. 839–868. [Google Scholar]
25. Bajaj AK, Wongworawat AA, Punjabi A. Management of alveolar clefts. J Craniofac Surg. 2003;fourteen:840–846. [PubMed] [Google Scholar]
26. Rodella LF, Favero One thousand, Labanca M. Biomaterials in maxillofacial surgery: membranes and grafts. Int J Biomed Sci. 2011;7:81–88. [PMC gratuitous article] [PubMed] [Google Scholar]
27. Steven MR, Emam HA. Dental implant prosthetic rehabilitation: allogeneic grafting/bone graft substitutes in implant dentistry. In: Bagheri SC, Bong RB, Khan HA, editors. Current therapy in oral and maxillofacial surgery. St. Louis, Mo: Elsevier Saunders; 2022. pp. 157–162. [Google Scholar]
28. Kinsella CR, Jr, Cray JJ, Durham EL, et al. Recombinant man bone morphogenetic protein-2-induced craniosynostosis and growth restriction in the immature skeleton. Plast Reconstr Surg. 2011;127:1173–1181. [PubMed] [Google Scholar]
29. Francis CS, Mobin SS, Lypka MA, et al. rhBMP-ii with a demineralized bone matrix scaffold versus autologous iliac crest os graft for alveolar cleft reconstruction. Plast Reconstr Surg. 2013;131:1107–1115. [PubMed] [Google Scholar]
30. Sivak WN, Macisaac ZM, Rottgers SA, et al. Management of failed alveolar bone grafts: improved outcomes and decreased morbidity with allograft alone. Plast Reconstr Surg. 2014;133:345–354. [PubMed] [Google Scholar]
31. Bergland O, Semb G, Abyholm Iron. Elimination of the residual alveolar cleft past secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J. 1986;23:175–205. [PubMed] [Google Scholar]
32. Enemark H, Sindet-Pedersen S, Bundgaard Thou. Long-term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg. 1987;45:913–919. [PubMed] [Google Scholar]
33. Long RE, Jr, Spangler Exist, Yow Yard. Cleft width and secondary alveolar bone graft success. Crevice Palate Craniofac J. 1995;32:420–427. [PubMed] [Google Scholar]
34. Kindelan JD, Nashed RR, Bromige MR. Radiographic assessment of secondary autogenous alveolar bone grafting in cleft lip and palate patients. Crack Palate Craniofac J. 1997;34:195–198. [PubMed] [Google Scholar]
35. Witherow H, Cox S, Jones E, et al. A new scale to assess radiographic success of secondary alveolar bone grafts. Cleft Palate Craniofac J. 2002;39:255–260. [PubMed] [Google Scholar]
36. Feichtinger One thousand, Mossbock R, Karcher H. Cess of bone resorption later on secondary alveolar bone grafting using three-dimensional computed tomography: a three-year study. Crack Palate Craniofac J. 2007;44:142–148. [PubMed] [Google Scholar]
37. Honma K, Kobayashi T, Nakajima T, et al. Computed tomographic evaluation of bone germination afterward secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg. 1999;57:1209–1213. [PubMed] [Google Scholar]
38. Trindade IK, Mazzottini R, Silva Filho OG, et al. Long-term radiographic assessment of secondary alveolar os grafting outcomes in patients with alveolar clefts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:271–277. [PubMed] [Google Scholar]
39. Tan AE, Brogan WF, McComb HK, et al. Secondary alveolar os grafting: five-yr periodontal and radiographic evaluation in 100 sequent cases. Cleft Palate Craniofac J. 1996;33:513–518. [PubMed] [Google Scholar]
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How To Repair Elevate Alveoli,
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