ALVEOLAR BONE GRAFTING OF ALVEOLAR CLEFT WITH CANCELLOUS ILIAC BONE GRAFT : A CASE REPORT. Case Report. University Journal of Dental Sciences

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1 ALVEOLAR BONE GRAFTING OF ALVEOLAR CLEFT WITH CANCELLOUS ILIAC BONE GRAFT : A CASE REPORT Vikas Kunwar Singh, Ruchika Tiwari, Sunil Sharma, Mridula Trehan 1,2 3 Reader, Professor & Head, Dept. of Oral & Maxillofacial Surgery Mahatma Gandhi Dental College, Jaipur, India 4 Professor & Head, Dept. of Orthodontics & Dentofacial Orthopaedics University Journal of Dental Sciences Case Report Mahatma Gandhi Dental College, Jaipur, India ABSTRACT : When bone grafting is performed in the permanent dentition after the completion of orthodontic treatment, it is called a tertiary or late graft. Tertiary grafts are performed to enable prosthodontic and periodontal rehabilitation and to assist in the closure of persistent bucconasal fistulae. A tertiary or late bone grafting cannot repair bone loss in teeth adjacent to the cleft. Grafted cancellous bone fills in the residual alveolar cleft and is anatomically joined to the adjacent bone, becoming indistinguishable in radiographic images after an average period of 3 months. Here we are presenting a 21 yr old female patient treated with bilateral cleft lip and persistent unilateral cleft alveolus, alveolar cleft was grafted using autogenous cancellous iliac bone graft. Keywords : Alveolar cleft, Bone grafting, Iliac crest. Source of support : Nil Conflict of interest: None INTRODUCTION : Secondary alveolar bone grafting of the cleft alveolar ridge in the mixed dentition is a well-established treatment for patients with cleft lip and palate (CLP). The graft surgery has many reported benefits including periodontal support for the cleft-adjacent teeth, establishment of an osseous matrix for the eruption of permanent teeth, closure of oronasal fistulae, and stabilization of the maxillary segments in cases of bilateral CLP.1 The main difference in the interdisciplinary treatment protocol in the management of cleft lip and palate is the timing of bone grafting. Accordingly the graft may be classified as primary, secondary and tertiary. When performed during early childhood, at the same time as the primary repair surgeries, bone graft is called as primary. Some authors believe that this early procedure can cause impairment of the maxillary growth. Bone grafting is called as secondary when performed later at the end of the mixed dentition. It is the most accepted procedure and is performed preferably before eruption of the permanent canine in order to provide adequate periodontal support for eruption and preservation of the teeth adjacent to the cleft. When bone grafting is performed in the permanent dentition after the completion of orthodontic treatment, it is called a tertiary or late graft. Tertiary grafts are performed to enable prosthodontic and periodontal rehabilitation and to assist in the closure of persistent bucconasal fistulae.2-6 Studies show that secondary bone grafting can repair the cleft alveolus without increasing the already known iatrogenic effect of primary surgeries on maxillary growth. 7, 8, 1 Secondary bone grafting has been extensively reported in the literature, mostly by the Oslo cleft lip and palate (CLP) team, 9 and is based on the biological and technical principles described by Boyne and Sands.6 Grafted cancellous bone fills in the residual alveolar cleft and is anatomically joined to the adjacent bone, becoming indistinguishable in radiographic images after an average period of 3 months. This structural incorporation has been histologically proved in young Rhesus monkeys10and seems to occur more rapidly in younger patients. The traditional autogeneous donor sites for alveolar bone grafting include the iliac crest, the mandible (chin and ramus), the tibia and the calvarium 11. The iliac crest is the goldstandard; it is easy to access and supplies large quantities of cancellous bone with pluripotent or osteogenic precursor cells that support early osteogenesis and neovascularization within 3 weeks after grafting 12. Hence, it is our regular choice of donor site.13 University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 80

2 CASE REPORT : A 21 year old female patient reported to Department of oral and maxillofacial surgery with unilateral alveolar cleft on right side, was an operated case of bilateral cleft lip four years back. On examination, there was an oronasal communication and a wide alveolar cleft on the right side. The surgical plan consisted of reconstructing the cleft with cancellous iliac bone graft and closure of nasal and oral defects. Prior to surgery, all the necessary preoperative blood and radiographic investigations were carried out, surgery was performed under general anesthesia and written informed consent was taken prior to surgery. TECHNIQUE FOR HARVESTING THE BONE GRAFT : About cm posterior to the anterior superior iliac spine, a linear incision, 4-5 cm long is made over and parallel to the iliac crest after slightly retracting the skin upward. With gentle sharp dissection, we proceed directly to the iliac crest. After exposing the iliac crest, an osteotome is used initially to make vertical stop cuts into the iliac crest at the two ends of the incision. Further, the ostetome is used to open the bony crest while leaving it pedicled medially on its muscular attachments and periosteum. A curette is used to scoop cancellous bone while preserving the cortices. (fig1) The graft is then gently minced and mixed into slurry with blood aspirated from the donor site. The pedicled iliac crest cap is returned like a trap door to its anatomical location and held in place with 3-0 vicryl sutures after which the wound is closed by layers in a standard method. (fig 2, 3) Exposure, preparation of soft tissue envelope and closure of the recipient site The most important factors in accomplishing a successful bone grafting are understanding and managing the soft tissues and blood supply. Causes of failure include dehiscence and resorption of the graft. Both of these can be minimized with proper handling of the tissues and careful surgical planning. Nasal intubation in noncleft nasal passage is preferred. The anterior iliac crest graft is procured. A throat pack is placed, and Lidocaine with epinephrine is infiltrated. A No. 15 blade is used to create sulcular incisions facially and palatally, with a vertical release at the premolar molar junction of the lesser segment. The scalpel is then used to separate the oral and nasal mucosa of the cleft fistula on both the labial and palatal sides. On the labial side it is helpful to use scissors along the nasal submucosa until the bone margin is reached. Finger pressure on the bone while dissection is carried toward it prevents nasal mucosal perforation. Periosteal elevators are used to elevate three full-thickness mucoperiosteal flaps the oral labial flap, oral palatal flap, and nasal flaps. (Fig 4) Care is used to ensure preservation of the greater palatine vessels. Curved periosteal elevators are used to elevate the nasal floor, allowing the nasal tissues previously drawn into the oral cavity to retract superiorly. They are imbricated into the nose and reapproximated using 4-0 resorbable vicryl suture in a tension free manner (Fig 5).Once the nasal layer is closed, the oral palatal tissues are reapproximated with 3-0 absorbable suture.the oral labial flap on the lesser segment is then advanced as a buccal sliding fl ap. It will easily advance one tooth segment if the periosteum is scored. A horizontal mattress suture is placed in each interdental papilla, securing the flaps in place. The bone graft is fashioned into small pieces using Mayo scissors or a rongeur.(fig 6) It is then packed tightly into the recipient site, allowing the nasal floor and alar rim to be lifted, as well as the anterior maxilla to be reconstructed.(fig 7) Closure commences with horizontal mattress interrupted sutures. By sliding the oral labial flap on the lesser segment forward, the surgeon will achieve tension-free primary closure. (Fig 8) POSTOPERATIVE CARE : Patient was placed on a full liquid diet for 1 week and then advanced to nonchewing foods for an additional 2 weeks. DISCUSSION : Joseph Daw and Pravin Katel16 observed that historically, the management of alveolar clefts has lagged behind the surgical correction of cleft lip and palate in terms of appreciating its significance and in the evolution of surgical techniques. This apparent lack of cognizance reflects in our environment where many adult patients live with alveolar cleft deformity despite having had their cleft lips and palates repaired. Even from some more surgically developed environments where alveolar bone grafting is already a common place, very few reports on the outcome of adult alveolar bone grafting emanate. This article reports outcome of tertiary alveolar bone grafting in our center and the rationale for our techniques. The choice of iliac crest as a cancellous bone resource for alveolar bone grafting is well supported in the literature. 6,8,11,12 It has easy access, large quantity, easy compaction, rich and rapid revascularization, high volume of osteogenic precursor cells and relatively low donor site morbidity as advantages over cranial, tibia and mandibular bones.11,12,17,18 Although our harvesting technique is not University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 81

3 significantly different from the one described by Boyne and sands6, we introduced stop cuts at either end of the exposed iliac crest and found it very helpful in preserving the integrity of the iliac crest cap while flipping it medially. This block harvest is usually minced and mixed with blood. It is most essential to prepare adequate soft tissue envelope before packing and compacting the cancellous chips into the defect. To achieve this, the mucoperiosteal flaps were extensively elevated to expose areas for graft augmentation. The objective is to ensure adequate coverage of the grafts while ensuring tension free closure. Uneventful soft tissue healing is critical to the success of the graft.19 Persistent unhindered growth of the premaxilla in adult alveolar cleft presents the worst deformation in bilateral cases where presurgical orthopaedics and/or cleft lip repair were not performed earlier. The objectives of secondary bone grafting are the formation of a continuous and stable dental arch, elimination of oronasal fistulae, the provision of greater periodontal support for teeth adjacent to the cleft and the augmentation of bony support for the lip and alar base. These objectives depend on satisfactory bone formation within the alveolar cleft. The three main processes involved in physiology of bone graft are osteoconduction, osteoinduction and osteogenesis.20, 21 Fig 1: Iliac crest graft site exposed & graft being harvested. Fig 2: Wound closure in donor site. CONCLUSION : The goals of bone grafting determine the selection of grafting material such as cortical or cancellous, membranous or endochondral. The recipient site requirements of bone rigidity and bone regeneration need to be considered as well as mechanical and physiologic characteristics. All of these broad parameters will have an impact on the bone graft host bed and determine whether complications will occur or not. In addition, vascularity, hostbed, overall physiologic status of the patient, propensity of infection and surgical expertise needs to be considered. Thus success depends on panoply of variables including the physiologic and mechanical properties of the graft material and the biology of recipient site. Autogenous bone grafting is a means to an end. The iliac crest is the goldstandard; it is easy to access and supplies large quantities of cancellous bone with pluripotent or osteogenic precursor cells that support early osteogenesis and neovascularization within 3 weeks after grafting. Hence, it is our regular choice of donor site for alveolar bone grafting in cases of cleft lip and palate. This produces less morbidity and reproducible results in our alveolar bone grafting cases with excellent results Fig 3: Preoperative picture of Right Cleft Alveolus with Oronasal fistula Fig 4: Flaps raised for nasal closure in cleft alveolus Fig 5: Nasal layer closed University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 82

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