uytr34rftghy

The International Journal of Periodontics & Restorative Dentistry

2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 32, Number 1, 2012

103

Periodontal Plastic Surgery for Management of Cleft Alveolar Ridge: A Case Report

Amit A. Agrawal, MDS* Ramreddy K. Yeltiwar, MDS**

Cleft lips, alveoli, and palates (CLAPs) are the most common con-genital malformations of the head and neck and are the second most common congenital malformations of the entire body. These birth de-fects are often most disturbing to the individuals themselves, since they affect the appearance of their face. CLAP can be syndromic or nonsyndromic. Syndromic CLAP is by definition associated with other malformations, such as Pierre Robin syndrome, Treacher Collins malfor-mation, trisomies 13 and 18, Apert syndrome, Stickler syndrome, and Waardenburg syndrome. At last count, more than 300 syndromes were associated with CLAP.1,2 Syn-dromic etiologies include single-gene transmission such as trisomies or teratogenic causes such as fetal alcohol syndrome. Nonsyndromic CLAP is a diagnosis by exclusion and is considered to be of multi-factorial inheritance. It is currently believed that less than 40% of cleft lips and palates are of genetic ori-gin. Environmental causes include infections (rubella, toxoplasmosis), growth hormone deficiency, drugs

Cleft lips, alveoli, and palates are the most common congenital malformations of the head and neck region, all of which often can be managed successfully when presented at a young age. It is a common belief that clefts in the alveolar ridge should be treated with the help of bone grafting materials. This could be the best option when the cleft is to be treated in early age, when the patient is still developing and has high regenerative potential. However, in adults, the literature supports the fact that bone grafting in alveolar clefts has a higher chance for failure. The present case report exemplifies a periodontal plastic surgical procedure involving a combination of connective tissue and free gingival grafting to restore the form and function of a cleft alveolar ridge in an adult patient. (Int J Periodontics Restorative Dent 2012;32:103109.)

* Reader, Department of Periodontics, Karmaveer Bhausaheb Hireys Mahatma Gandhi Vidyamandir Dental College and Hospital, Panchvati, Nasik, Maharashtra, India.

** Director of Postgraduate Studies and Professor and Head, Department of Periodontology, Rungta College of Dental Sciences and Research, Bhilai, India; Formerly, Professor and Head, Department of Periodontics, Government Dental College and Hospital, Nagpur, Maharashtra, India. Correspondence to: Dr Amit Agrawal, Department of Periodontics, KBH MGVs Dental College and Hospital, Near Kannamwar Bridge, Mumbai-Agra Highway, Panchvati, Nishik 422003, Maharashtra, India; email: [email protected].



104

(corticosteroids, benzodiazepines, anticonvulsants), amniotic band syndrome, and maternal diabetes mellitus.1

There is no universally accept-ed classification of clefts, although the most commonly used is the Veau classification, which was de-scribed in 1931.14 Veau Class I is an isolated cleft soft palate, Class II is a cleft hard/soft palate, Class III is a unilateral cleft lip and palate, and Class IV is a bilateral cleft lip and palate. Most surgeons describe the defect rather than using the Veau system. For example, a Veau Class III would be described as a unilat-eral complete cleft of the lip, al-veolus, and primary and secondary palates. The primary palate is the portion anterior to the incisive fora-men. A cleft of the primary palate results in a gap from the incisive fo-ramen through the alveolus. Clefts of this type are always associated with cleft lips. The alveolar ridge cannot be closed at the time of the lip or palate repair. Children whose clefts go through the alveolar ridge will need surgery to fill the gap once their permanent teeth erupt, which allows stabilization of the alveolus along with orthodontic movement of teeth into the new bone graft.2 Restoring the alveolar ridge form, improving the overall esthetic ap-pearance, and allowing for under-lying teeth to erupt through the grafted area are some objectives of alveolar bone grafting.519 An im-portant issue in cleft alveolar ridge management, albeit not without considerable controversy, is the timing of bone graft placement.17

With increased age, bone healing is impaired and graft success di-minishes.18 This could be caused by changes in the healing potential with increasing age.19 Helms et al13 found increased incidence of graft failure in late secondary and de-layed grafting groups.

In a socioeconomically weak adult patient whose bone growth is complete with no underlying teeth to erupt, no orthodontic tooth movement required through the cleft region, and who requires cleft ridge repair only for esthetic rea-sons, is it justifiable to stress the pa-tient surgically (if autogenous bone is used) or financially (if commercial bone is used) to restore the form and esthetics of the alveolar ridge through bone grafting? Taking this into consideration, this article pre-sents a patient treated with a peri-odontal plastic surgical procedure rather than bone grafting to achieve the final treatment goals.

Case report

A 21-year-old woman reported to the Department of Prosthodon-tics, Government Dental College and Hospital, Nagpur, India, for re-placement of her missing maxillary right central and lateral incisors. Her history revealed that she had undergone surgery for cleft lip cor-rection in childhood and the teeth were congenitally missing. On ex-amination, she presented with a cleft alveolar ridge with missing maxillary right central and lateral incisors. The lip was normal except

for the scar left by the first surgery. The patient was not interested in removable dentures and was not economically strong enough to af-ford implants. Therefore, a fixed partial denture (FPD) was planned from the right canine to left cen-tral incisor. The unesthetic black triangle that could have formed af-ter FPD placement was of concern, and hence, the patient was referred to the department of periodontics for alveolar ridge augmentation.

On general examination, the patient was calm and cooperative. There was no defect in her speech. Intraorally, a deep cleft alveolar ridge involving the right lateral inci-sor region was noted (Figs 1a and 1b). The right incisors were con-genitally missing, and there was spacing in the maxillary and man-dibular anterior regions. Routine blood investigations were within normal limits, and the purpose for selecting the treatment plan was explained to the patient.

Surgical procedure

An acrylic stent covering the pal-ate was fabricated, wherein the ap-proximate area from where a free gingival graft is usually taken was relieved using spacer wax. This was given to the patient 7 days prior to surgery to initiate habitual use and overcome any speech problems or excessive salivation, which can be more prominent during the early postoperative period. When the patient returned after 7 days for surgery, informed consent was ob-



105

tained. After aseptic measures, lo-cal anesthesia was achieved in the region, and a no. 15 surgical blade was used to de-epithelialize the cleft along with the surrounding region to create a surgical bed for grafting. De-epithelialization of the cleft al-veolar ridge resulted in formation of a notch surrounded by healthy con-nective tissue and butt joint margins (Figs 2a and 2b). Then, a connective

tissue graft was harvested from the region, extending from the left ca-nine to the palatal root of the left first molar, approximately 2 mm from the palatal gingival margin, using the single-incision technique. This graft was then snuggly fit into the recipient site notch to eliminate any dead space and provide bulk to the alveolar ridge (Fig 3). A similar technique where a connective tissue

Figs 1a and 1b Initial presentation of cleft alveolar ridge. (left) Labial view; (right) occlusal view.

Figs 2a and 2b (left) Labial and (right) occlusal views of the defect after de- epithelialization, exposing the healthy connective tissue bed.

Fig 3 Connective tissue graft snuggly fit into the notch of the defect.



106

graft was sandwiched between the split flap was described by Langer and Calagna in 1980.20 Then, a saddle-shaped ridge was formed, which was covered with a free gin-gival graft. To accomplish this, a template was designed according to the recipient site, and a similarly shaped and sized free gingival graft was procured from the right half of the palate using a self-devised 3A-Mucotome (patent application no. 1753/MUM/2011). The free gingival graft was stabilized at the recipient site with the help of 4-0 chromic cat-gut sutures (Figs 4a and 4b). The in-cision at the connective tissue donor

site was sutured, and after achieving complete hemostasis, the acrylic stent was replaced on the palate (Fig 5). Postoperatively, amoxicillin 250 mg tid and diclofenac sodium 50 mg bid were prescribed for 5 days. Postoperative instructions were given, and the patient was re-called after 24 hours for checkup, af-ter 7 days for removal of the acrylic stent and sutures from the donor sites, after 15 days for removal of the sutures from the recipient site, and then after 1, 3, and 6 months for follow-up.

Figs 4a and 4b Sutured free gingival graft. (left) Labial view; (right) occlusal view.

Fig 5 Acrylic stent in place.



107

Results

The patient reported minimal dis-comfort at the donor and recipient sites and attended all follow-up appointments until 3 months post-surgery. The grafts seemed to be well vascularized at 15 days post-operative without any sloughing or necrosis (Figs 6a and 6b). Satis-factory esthetic results and a com-pletely restored grafted alveolar ridge in terms of volume and shape were noted at 3 months postsur-gery (Figs 7a and 7b). The patient was then referred for prosthetic re-placement of her missing teeth.

Discussion

As stated, the ideal treatment of cleft lips, alveoli, and palates in-volves a multidisciplinary team ap-proach.13,21,22 Members include a pediatrician who oversees the development of the child, palatal surgeon (usually a general plastic surgeon, sometimes an otolaryn-gologist), oral and maxillofacial sur-geon for the development of the dentition and palate, otolaryngolo-gist for diseases of the ear, psychol-ogist for both the patient and his or her family, speech and language therapist, and clinical coordinating

Figs 6a and 6b Postoperative healing after 15 days. (left) Labial view; (right) oc-clusal view.

Figs 7a and 7b Postoperative healing after 3 months. (left) Labial view; (right) oc-clusal view.



108

nurse. In the present case, this list would also include a periodontist for reconstruction of alveolar ridge defects by a bone or periodontal plastic surgical procedure.

Although it is possible to have an isolated cleft lip without a cleft alveolus, a cleft alveolus is always associated with a cleft lip.2,3 In the present case, the patient had been operated on previously for cleft lip at the age of approximately 4 to 5 months. She and her family were not aware of/not concerned with the cleft ridge until the time of this report and only took notice since she was to be married in a few months. Since the patients only intention was to improve esthetics at a minimum cost, a combination of free gingival and free connective tissue grafting followed by pros-thetic replacement of the missing teeth was the best alternative for her. Considering the fact that the space available for the two missing teeth was very large and there was significant space between the left canine and first premolar, a prop-erly planned prosthetic reconstruc-tion was of utmost importance. An FPD could have been provided from canine to canine to ensure that color and form were balanced esthetically. Another FPD could have been provided to restore the space between the left canine and first premolar, with full coverage of the first premolar and lock-and-key attachment on the canine.

If the patient would have report-ed in early age, then bone grafting might have been a better alterna-tive at that time. Bone grafting

has become a common procedure in the treatment of cleft ridges and palates. The main difference in the treatment protocols of various re-habilitation centers is the timing of bone grafting. According to its time of occurrence, the bone graft may be considered primary (in early childhood), secondary (during the mixed dentition), or tertiary (in the permanent dentition). Primary bone grafting before the age of 2, which was done routinely during the 1950s and 1960s, has been abandoned by most rehabilitation centers be-cause of the possibility of impaired maxillary growth.23 Robertson and Jolley24 studied the effects of early bone grafting of clefts and found no clear advantages in the grafted groups, but found that there was a significant limitation in anteroposte-rior growth and increased incidence of crossbite in these patients. Occa-sionally, late grafts cause progres-sive root resorption of the teeth adjacent to the cleft, especially the canines.25,26 Today, the most widely accepted procedure is secondary bone grafting.27 Early secondary bone grafting, between the ages of 2 and 6, is done primarily to pro-vide alveolar bone support for the eruption of the lateral incisor. Late secondary bone grafting between the ages of 9 and 11 does not have much effect on midfacial growth and provides bone support for the erupting canine. However, late sec-ondary bone grafting in adults are associated with higher chances of graft failure.13 In addition, the pres-ence of a bony ridge alone for es-thetic prosthodontic reconstruction

is of questionable importance be-cause the height and mass of the ridge are often of no clinical value. However, if implants are a consider-ation or if the bony defect compro-mises the support of the abutment teeth, then the bony ridge is of ut-most importance.

Conclusion

Though bone grafting is considered the primary choice for management of alveolar grafting, it is not without controversy. In an adult patient, as in the present case, a periodon-tal plastic surgical procedure will give satisfactory results with com-paratively less financial or surgical trauma to the patient, so the clini-cian should always keep this option open when dealing with a cleft al-veolar ridge in an adult patient.

References

1. Thornton JB, Nimer S, Howard PS. The incidence, classification, etiology, and embryology of oral clefts. Semin Orthod 1996;2:162168.

2. Habel A, Sell D, Mars M. Management of cleft lip and palate. Arch Dis Child 1996; 74:360366.

3. Marrinan EM, LaBrie RA, Mulliken JB. Ve-lopharyngeal function in nonsyndromic cleft palate: Relevance of surgical tech-nique, age at repair, and cleft type. Cleft Palate Craniofac J 1998;35:95100.

4. Millard DR Jr. Embryonic rationale for primary correction of classical congenital clefts of the lip and palate. Ann R Coll Surg Engl 1994;76:150160.

5. Boyne PJ, Sands NR. Combined orth-odontic-surgical management of residual palato-alveolar cleft defects. Am J Or-thod 1976;70:2037.



109

6. Troxell JB, Fonseca RJ, Osbon DB. A ret-rospective study of alveolar cleft grafting. J Oral Maxillofac Surg 1982;40:721725.

7. Brattstrm V, McWilliam J. The influence of bone grafting age on dental abnor-malities and alveolar bone height in pa-tients with unilateral cleft lip and palate. Eur J Orthod 1989;11:351358.

8. Walle NM, Forbes DP. The effect of size characteristics of alveolar cleft defects on bone graft success: A retrospective study. Northwest Dent Res 1992;3(2):58.

9. Tan AE, Brogan WF, McComb HK, Henry PJ. Secondary alveolar bone graftingFive-year periodontal and radiographic evaluation in 100 consecutive cases. Cleft Palate Craniofac J 1996;33:513518.

10. El Deeb M, Messer LB, Lehnert MW, Heb-da TW, Waite DE. Canine eruption into grafted bone in maxillary alveolar cleft defects. Cleft Palate J 1982;19:916.

11. Enemark H, Krantz-Simonsen E, Sch-ramm JE. Secondary bonegrafting in unilateral cleft lip palate patients: Indica-tions and treatment procedure. Int J Oral Surg 1985;14:210.

12. Bergland O, Semb G, Abyholm FE. Elimi-nation of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 1986; 23:175205.

13. Helms JA, Speidel TM, Denis KL. Effect of timing on long-term clinical success of alveolar cleft bone grafts. Am J Orthod Dentofacial Orthop 1987;92:232240.

14. Long RE Jr, Paterno M, Vinson B. Effect of cuspid positioning in the cleft at the time of secondary alveolar bone grafting on eventual graft success. Cleft Palate Craniofac J 1996;33:225230.

15. Abyholm FE, Bergland O, Semb G. Sec-ondary bone grafting of alveolar clefts. A surgical/orthodontic treatment en-abling a non-prosthodontic rehabilitation in cleft lip and palate patients. Scand J Plast Reconstr Surg 1981;15:127140.

16. Hall HD, Posnick JC. Early results of sec-ondary bone grafts in 106 alveolar clefts. J Oral Maxillofac Surg 1983;41:289294.

17. Eppley BL, Sadove AM. Management of alveolar cleft bone graftingState of the art. Cleft Palate Craniofac J 2000;37: 229233.

18. Jia YL, James DR, Mars M. Bilateral al-veolar bone grafting: A report of 55 con-secutively-treated patients. Eur J Orthod 1998;20:299307.

19. Sindet-Pedersen S, Enemark H. Com-parative study of secondary and late secondary bone-grafting in patients with residual cleft defects. Short-term evalua-tion. Int J Oral Surg 1985;14:389398.

20. Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthet Dent 1980;44:363367.

21. Grayson BH, Santiago PE, Brecht LE, Cut-ting CB. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J 1999;36:486498.

22. Robinson PJ, Lodge S, Jones BM, Walker CC, Grant HR. The effect of palate repair on otitis media with effusion. Plast Re-constr Surg 1992;89:640645.

23. Friede H, Johanson B. Adolescent facial morphology of early bone-grafted cleft lip and palate patients. Scand J Plast Re-constr Surg 1982;16:4153.

24. Robertson NR, Jolley A. Effects of early bone grafting in complete clefts of lip and palate. Plast Reconstr Surg 1968;42: 414421.

25. Gerner NW, Hurlen B, Bergland O, Semb G, Beyer-Olsen EM. External root resorp-tion in patients with secondary bone-grafting of alveolar clefts. Endod Dent Traumatol 1986;2:263266.

26. Rune B, Jacobsson S. Dental replacement resorption after bone grafting to the al-veolar cleft. Plast Reconstr Surg 1989; 83:614621.

27. da Silva Filho OG, Teles SG, Ozawa TO, Filho LC. Secondary bone graft and erup-tion of the permanent canine in patients with alveolar clefts: Literature review and case report. Angle Orthod 2000;70: 174178.


uytr34rftghy

Documents

Transcript of uytr34rftghy