In our study the arch form was improved in 100% cases and occlusal relationship was improved in most of the patients till 24-month follow-up. Abyholm, Bergland and Semb, and L.C. Newlands, demonstrated to stimulate an increase in the height of the hypoplastic cleft area by eruption of the canine on the cleft side through grafted cancellous bone.
Present study comprised 11 individuals having cleft alveolus (including four patients of the last study for long-term follow-up); out of these 4 were unilateral and 7 were bilateral clefts. In our study seven patients were male and remaining four patients were female. Stevenson and Johnson stated that cleft lip with or without cleft palate is more common in males with the ratio of approximately 2:1 over females; our study correlates the above study. In all patients secondary bone grafting of cleft alveolus was performed.
The ribs, iliac crest, calvarium, mandibular symphysis, and tibia are the most common donor sites. Cancellous bone from the iliac crest is generally considered the best material for bone grafting of alveolar clefts.[,] Recombinant human bone morphogenetic protein-2 (rhBMP-2) is now an attractive bony substitute that promotes the differentiation of pluripotential cells into bone-forming cells that lay down new host bone in the site of the defect. Modern studies prove that endochondral concellous specimens have a higher percentage increase in actual bony volume than cortical membranous and cortical endochondral in lay bone grafts.
Finally, the previously raised gingival mucoperiosteal flaps were sutured together and inferiorly to the palatal flaps to provide complete coverage of the bone graft . The flaps were further secured with a few interrupted sutures between the flap and papilla while the area of the back cut posterior was left open to heal secondarily. Corticocancellous graft from iliac crest was harvested by standard surgical methods.
Bone grafts harvested from the posterior iliac crest in general have less morbidity, but depending on the type of surgery, may require a flip while the patient is under general anesthesia.
Bone grafting at the stage of mixed dentition in patients with unilateral or bilateral defect of residual alveolar cleft lip and palate patients were done in this study and it was concluded that in cleft lip and palate patients:
Finkle and Kawamoto reviewed the complication directly related to the harvesting of cranial bone grafts and found over all complication at donor site. In our study there was pain at donor site in 100% cases up to the second postoperative week. This finding correlates with the that of Laurie et al. who stated that all patients experienced moderate postoperative pain lasting 2 weeks to 2 months with an average of 6 weeks.
The palatal mucoperiosteal flaps were then approximated medially with interrupted 4–0 absorbable sutures, thus creating a soft tissue pocket to accommodate the bone graft. The corticocancellous bone graft harvested from iliac crest bone was packed tightly to completely fill the bony cleft and restore the thickness and height of the nasal floor and the maxilla as close to normal as possible. Any permanent teeth erupting through the cleft was covered with bone graft.
Avoidance of heat generation during the harvesting of the graft and storage of bone particles in a saline soaked sponge to avoid desiccation are important in maintaining cell viability before transplantation. In our study paraesthesia over the distribution of the lateral femoral cutaneous nerve of the thigh was not found in any case. This finding correlates with the study of Laurie et al.
Long-term follow-up is required to achieve maximum advantage of secondary alveolar grafting; the age of the patient should be within the mixed dentition period, irrespective of sex, socio-economic status. It may be unilateral or bilateral.
It is evident that secondary alveolar grafting during the mixed dentition period is more beneficial for patients at the donor site as well as the recipient site.
At the time of evaluation teeth were erupted in the area and good alveolar bone levels were present. Premaxilla becomes immobile with a good arch form and arch continuity. There are no major complications in terms of pain, infection, paraesthesia, hematoma formation at donor site without difficulty in walking. There is no complication in terms of pain, infection, exposure of graft, rejection of graft, and wound dehiscence at the recipient site.
Surgical Repositioning of the Displaced Premaxilla in combination with Two-stage Alveolar Bone Grafting in Bilateral Cleft Lip and Palate Patients (共著)