BONE GRAFTING IN TREATMENT OF CLEFT LIP AND PALATE 337

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1 PRIMARY BONE GRAFTING IN THE TREATMENT OF CLEFT LIP AND PALATE WITH SPECIAL REFERENCE TO ALVEOLAR COLLAPSE By FRANK ROBINSON, F.R.C.S., and BARRIE WOOD, L.D.S. Burns and Plastic Surgery Unit, Booth Hall Children's Hospital, Manchester, 9 THIS paper reports a series of 44 cases of cleft palate, 30 of which were treated by bone grafting in the five-year period January 1963 to December One surgeon carried out all the operative work and the orthodontic care was managed largely by one colleague in a department of two ; the results are thus subject to less variation than if several specialists had been involved. Prior to 1963 orthodontic care was only available for late cases, after the eruption of the permanent teeth. The surgical programme then consisted of lip repair at 3 months of age or later, the anterior palate being closed at the same time by a vomer flap, and the repair of the residual palate cleft at 9 to 12 months. Children treated in this way looked well and the great majority spoke well, but the dental articulation was imperfect with overcrowding, early caries and loss of teeth. Most cases showed alveolar collapse and when orthodontic care became available this was studied in detail and efforts made to avoid it. Orthodontic Considerations.--Pre-surgical orthopmdic correction of the affected maxillary arch as advocated by McNeil (1954) and Burston (I96O) does much to improve the malpositioned segments by mechanically repositioning them. At the same time growth of the detached segments is stimulated by the widening of the circummaxillary sutures ; as a result the lesser segment is encouraged to grow to a more normal size. We have used the technique of Burston. Usually four to six appliances are necessary before the arch is in an acceptable position for surgery. During this period of intra-oral correction the mal-positioned premaxilla may be moulded into a more favourable arch position by the use of extra-oral traction. Orthopmdic correction should be completed by 4 months. After this time, realignment of the real-positioned bones becomes more difficult owing to the increasing density of the bone. The lip and primary palate are closed therefore at approximately 4 months, when the corrected maxillary arch presents an improved bony base for balance of the nose and lip. After lip and primary palate closure alone, the lesser segment is still in a state of mechanical instability and is subject to a medial pressure created by the normal contraction of the now competent buccinator and orbicularis oris muscles, by the natural tension restored by lip closure and perhaps from scar tissue contraction. In consequence, although satisfactory pre-surgical correction has been achieved, there is frequently postoperative collapse of the lesser segment; it is essential therefore that this medial pressure be opposed. Retaining splints will prevent arch collapse, but babies will-usually tolerate the appliance only until about 8 months of age when the deciduous dentition starts erupting and the splint becomes an increasing irritant. It is during this period from 8 months to 3½ years (by which time the deciduous dentition has usually fully erupted and a satisfactory intra-oral appliance can be inserted), when the necessity of wearing a retaining splint is of greatest importance, that the baby's intolerance of it will permit the lesser segment to collapse (Fig. I).

BONE GRAFTING IN TREATMENT OF CLEFT LIP AND PALATE 337 An alternative method of preventing medial collapse is the insertion of an internal splint of autogenous bone in the alveolar space.

vomer flap (Stellmach, 1959) and in most cases a buccal flap. Rarely, in very narrow clefts, it was found difficult to use a vomer flap in this way and a larger buccal flap was rotated.

2 BONE GRAFTING IN TREATMENT OF CLEFT LIP AND PALATE 337 An alternative method of preventing medial collapse is the insertion of an internal splint of autogenous bone in the alveolar space. This was carried out from June 1964, whenever possible by the following technique : After paring the lip for repair, a" box " for the bone graft was constructed from the repaired nasal floor, a split vomer flap (Stellmach, 1959) and in most cases a buccal flap. Rarely, in very narrow clefts, it was found difficult to use a vomer flap in this way and a larger buccal flap was rotated. Simultaneously an assistant excised a piece of the right eighth or ninth rib, 5 to 8 cm. long, which was split longitudinally and packed as small chips into the cleft and over the defective maxilla. The lip was then closed with a triangular flap repair similar to that of Randall (1959). The soft palate only was closed later to avoid damage to the maxillary segment, the hard palate being repaired at 4 years of age, or later, when the septal growth centre had ossified. In certain instances bone grafting was delayed. Such cases included very wide, complete, unilateral clefts where it was feared at first that soft tissue cover would be FIG. I Post-operative collapse in spite of pre-operative orthodontic treatment. B, At the time of lip closure. C, Three years later. A, At birth. inadequate, and patients in whom the response to pre-surgical correction had been slow and imperfect. Delayed grafting was then carried out three or more months after primary lip repair. In resistant cases pressure of the closed lip will mould the premaxilla into a more favourable arch position and retaining splints are used during this period to prevent medial collapse of the lesser segment. In total bilateral clefts of the primary and secondary palates early cases were treated by unilateral soft tissue closure and bone graft, but it was found that post-operative orthodontic measures did not adequately control the forward thrust of the septum on the untreated side of the pre-maxilla and its subsequent rotation. For this reason, bilateral soft tissue closure is now followed three or more months later by bilateral bone graft. These clefts usually need more pre-surgical correction than do unilateral cases and the initial operation is frequently delayed until 6 months of age. After the first operation, screw expansion appliances are used when necessary to move the anterior borders of the lateral segments outwards into a more favourable arch position, while simultaneously the bilateral lip closure exerts a backward pressure on the protruding pre-maxilla with consequent improvement in the shape of the maxillary arch. It is essential, of course, that the maxillary segments are in good arch alignment prior to fixation by bone graft. Faulty positioning at the time of grafting perpetuates the deformity and leads to future orthodontic problems which are very difficult to correct.

3 338 BRITISH JOURNAL OF PLASTIC SURGERY Results.--The cases fall naturally into three groups : Group A (January 1963 to September I963).uNo orthodontic care in pre-operative or early post-operative periods (Table I). TABLE I--Group A Total Type No. Alveolar Collapse Unilateral cleft lip and primary palate. Bilateral cleft lip and primary palate Bilateral cleft lip and palate Alveolar collapse occurred in four out of five cases where it could be expected. TABLE IImGroup B Alveolar Total Type No. Collapse 4 Unilateral cleft lip and palate 3 3 Bilateral cleft lip and palate. I I Alveolar collapse occurred in four out of four cases. TABLE IIIuGroup C Alveolar Collapse Total Type No. Bone Graft and Remarks 35 Unilateral cleft lip and primary palate. 3 3 o I graft absorbed Unilateral cleft lip and palate ' (4 delayed) 5 3 grafted 2 not grafted Bilateral cleft lip and primary or total palate. 6 3 grafted 3 not grafted Alveolar collapse in grafted cases occurred in six out of 3. Group B (October 1963 to May I964).--All cases received orthodontic care in the pre-surgical period and surgical treatment was thereby delayed for one to three months until it was agreed by orthodontist and surgeon that no further control of the alveolar arch was possible. Post-operative orthodontic measures were then applied where possible (Table II). Group C (June 1964 to December I967).--The disappointing results in Groups A and B, taken together with those of the many cases treated before 1963, encouraged the writers to use alveolar bone grafts whenever possible (Table III).

B, At time of lip closure and bone graft.

3 A, Occlusal film to show width of cleft and

4 BONE GRAFTING IN TREATMENT OF CLEFT LIP AND PALATE 339 A B C FIG. 2 Maintenance of normal arch after bone grafting. A, At birth. B, At time of lip closure and bone graft. C, Three and a half years later. A B FIG. 3 A, Occlusal film to show width of cleft and position of teeth before bone grafting. B, The bone chips in position. C, The remodelled buttress I8 months later. C

340 BRITISH JOURNAL OF PLASTIC SURGERY The progress of the cases was followed by pre- and post-operative plaster models and occlusal radiographs and the results are summarised in the Tables.

5 340 BRITISH JOURNAL OF PLASTIC SURGERY The progress of the cases was followed by pre- and post-operative plaster models and occlusal radiographs and the results are summarised in the Tables. It is apparent that the 3o cases treated with bone grafts are in complete contrast to those 14 treated without, in that alveolar collapse did not occur in 2 4 of them whereas in the others it was almost invariable in I3 out of I4. The overall picture of the serialised plaster models is that the bone graft prevents collapse of the lesser segment and, in addition to this, the lesser segment, now united to the greater segment, comes under the growth stimulus of the nasal septal cartilage and appears to grow three dimensionally at the same rate as the greater segment ; in other words, the maxillary arch grows as one unit (Fig. 2). The first post-operative occlusal films show the bone chips filling the alveolar cleft and by six months post-operatively they have coalesced into solid bone. At I8 months Ft6. 4 A~ Pre-operative view of cleft and adjacent teeth. Be Migration of teeth into the bone graft one year later. there is usually a degree of resorption on the labial aspect of the grafted area but the grafted bone within the alveolus attains a density which, it is thought, must prevent collapse of the arch (Fig. 3). Teeth which have formed at the cleft margins tend to migrate into the grafted area (Fig. 4). This migration improves the position of the teeth within the arch and this in turn provides a better inter-dental articulation. DISCUSSION Many surgeons in the United Kingdom and America consider that primary bone grafting of the cleft palate is still unjustified despite its continued advocacy over many years in Germany, Scandinavia and America itself. The main criticism is that the combined soft tissue and bone grafting procedure is time consuming--taking longer than the classical hour allowed for operation on these children--and possibly dangerous. In practice, with a competent assistant who procures the graft while the bed is prepared, the whole procedure takes only one and a half hours on the average. A blood transfusion of 5o to I5o ml. is always given. All patients have been returned to the ward in good condition and there were no deaths. Local complications were uncommon. In the unilateral cases, bone chips were extruded and the graft lost in whole or in part in only three cases, two of which showed collapse. In one further case, the graft was inserted despite inadequate orthodontic correction and it maintained the malposition in a state of alveolar collapse. It was thought initially that the use of the buccal flap, which inevitably tethered the

BONE GRAFTING IN TREATMENT OF CLEFT LIP AND PALATE 341 lip to some extent, might be followed by permanent tightness and perhaps a buccal inlay would become necessary later.

In unilateral cases the results have been impressive in that only three examples of alveolar collapse occurred in 21 cases.

6 BONE GRAFTING IN TREATMENT OF CLEFT LIP AND PALATE 341 lip to some extent, might be followed by permanent tightness and perhaps a buccal inlay would become necessary later. It now appears, however, that gradual relaxation with deepening of the buccal sulcus occurs and inlay procedures will probably not be required. In unilateral cases the results have been impressive in that only three examples of alveolar collapse occurred in 21 cases. In the other 18, the upper dental arch contrasts remarkably with those previously met with (Fig. 5). As already described, bilateral clefts have presented greater difficulty ; orthodontic correction has been more prolonged and less satisfactory and only six cases of the nine in the series were grafted. Three of these collapsed and the procedure is thus by no means as well proved as in unilateral clefts. Further study is continuing. It will take several years before definite conclusions can be made but our interim conclusions on primary bone grafting are : r. That collapse of the lesser maxillary segment is prevented. 2. That the lesser segment is brought under the growth stimulus of the nasal septal cartilage and the middle third of the face grows as one unit. 3. That teeth which have formed at the margins of the cleft tend to migrate into the grafted zone. Addendum.--This paper was given at the B.A.P.S. meeting at Newcastle in July It was suggested by Joss and others that the improved results in this series might be due largely to the accurate two-layer soft tissue closure of the alveolar space, a point already made by Muir (1966). Furthermore, a review of certain cases treated by soft tissue flaps without inserting bone grafts had revealed new bone formation in the space, largely comparable with the strut remaining after the partial absorption of the bone graft, the so-called "bone-less bone-graft" (Skoog, 1967; Joss, 1968). 4 D B

7 342 BRITISH JOURNAL OF PLASTIC SURGERY In view of this, the present authors have already begun to carry out a series of control cases using the technique described above, substituting Sterispon for bone to support the flaps forming the box. Identical follow-up will be carried out and the results reported in due course. REFERENCES BURSTON, W. R. (196o). Trans. int. Soc. plast. Surg., 2nd Congr., London, 1959, ed. Wallace, A. B., p. 28. Edinburgh : Livingstone. Joss, G. (I968). Personal communication and demonstration. MCNEIL, C. K. (1954). " Oral and Facial Deformity." London : Pitman. MUIR, I. F. K. (1966). Br. J. plast. Surg. 19, 3o. RANDALL, P. (1959). Plastic reconstr. Surg. 23, 33I. SKOOG, T. (1967). Scand. J. plast, reconstr. Surg. I, 113. STELLMACHj R. (1959)- Arch. klin. Chir. 292, 865.

OF THE LIP AND PALATE. By T. D. FOSTER, M.D.S., F.D.S., D.Orth.R.C.S. School of Dental Surgery, University of Birmingham

OF THE LIP AND PALATE. By T. D. FOSTER, M.D.S., F.D.S., D.Orth.R.C.S. School of Dental Surgery, University of Birmingham MAXILLARY DEFORMITIES IN REPAIRED CLEFTS OF THE LIP AND PALATE By T. D. FOSTER, M.D.S., F.D.S., D.Orth.R.C.S. School of Dental Surgery, University of Birmingham IN patients with repaired clefts of the