initial treatment of alveolar gaps in cases of labio ... · catherine tomat, brigitte vi-fane,...

Address for correspondence:

A. Picard,Service de Chirurgie maxilla-faciale et plastique,26, avenue du Dr A. Netter,75571 Paris Cedex [email protected].

DOI: 10.1051/odfen/2012303 J Dentofacial Anom Orthod 2012;15:403� RODF / EDP Sciences

1

Conflicts of interest declared by the author: NONEReceived article : 04-2012.Accepted article : 06-2012.

Initial treatment ofalveolar gaps in casesof labio-maxillary-palatalclefts

Arnaud PICARD, Natacha KADLUB, Eva GALLIANI,

Veronique SOUPRE, Sophie CASSIER,

Geoorgiana CONSTANTINESCU, Frederic ZAZURCA,

Catherine TOMAT, Brigitte VI-FANE, Chantal TRICHET-ZBINDEN,

Cecile CHAPUIS-VANDENBOGAERDE, Patrick A. DINER,

Marie-Paule VAZQUEZ

ABSTRACT

Treatment teams use different approaches for correcting the alveolar cleftsector of labio-palatal clefts. Age of patient, whether or not bone grafts are used,and the type of bone grafted are some of the differences. Our team performs agingivoperioplasty with a graft of iliac cancellous bone on patients 4 to 6 years old.This procedure is carried out within the framework of orthodontic treatmentdesigned to restore transverse dimension pre-operatively with a quad helix and toretain the expansion with 6 months of retention. The gingivoperioplasty isaccomplished in a zone free of any scar tissue that might have resulted from aprimary cheiloplasty followed by closure of the palatal cleft. In our view all teamsmust eventually utilize cone beam X-rays for their radiographic evaluationsbecause they are the only tool that provides results of objective analysis that are ofhigh quality and have demanded a very low level of radiation.

KEY WORDS

Labio-palatal cleft,

Bone graft,

Cone beam,

Alveolar cleft,

Gingivoperioplasty.

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2012303

http://www.jdao-journal.org

http://dx.doi.org/10.1051/odfen/2012303

1 – INTRODUCTION

Surgeons should seek to achievethese goals in the primary treatmentof clefts: restore normal morphologyand function. While all treatmentcenters agree on these principles,their management protocols vary fromgroup to group. One European studyshowed that there were 194 differentprotocols for 201 cleft treatmentcenters. The same discordance existsfor gingivoperioplasties to correct al-veolar clefts. There is a great disparityamong the groups in the choice ofchronology, type of bone for graftingand where to harvest it, and evaluationof results. The controversy over gingi-

voperioplasty focuses on many is-sues, when it should be performed,what precisely should be its goals,should grafts be used and if so, withwhat type of bone or bone substitute,what are its effects, if any, on facialgrowth, how to assess its results, andwhat type of rehabilitation to employ.The goal of this article is to use areview of the literature as a frame-work to discuss these various con-troversies and to present themanagement of alveolar clefts thatwe use in our maxillo-facial andpediatric plastic surgery service.

2 – WHAT SHOULD OUR OBJECTIVES BE?

Von Eiselsberg, in 1901, and Lexer,in 1908, are said to have performedthe first maxillary bone grafts. How-ever, it wasn’t until the 1980s that realgraft protocols were established byWitsenbur, then Montoya, andBoldand3,6,26, who defined the objec-tives of osseous grafts in alveolarclefts. Today it is generally agreedthat gingivoperioplasties should havethese objectives:– assure the stability of maxillary

segments;

– close alveolar fistulas;– improve the appearance of the

gingiva;– improve emergence pathways of

teeth and support them aftereruption’;

– restore the alveolus to a normalcondition’;

– provide osseous support to upperlip and wing of the nose’;

– facilitate prosthetic restorations’;– assure rather than impede facial

growth.

3 – WHEN SHOULD WE PLACE GRAFTS?

Graft placements for cleft palatecases are called primary, secondary,or tertiary in accordance with thestage of the dentition in which theyare made:

– a primary bone graft is made in thedeciduous dentition;

– a secondary bone graft is made inthe mixed dentition;

– a tertiary bone graft is made in theadult dentition.

ARNAUD PICARD, NATACHA KADLUB, EVA GALLIANI, VERONIQUE SOUPRE, SOPHIE CASSIER, ET AL.

2 Picard A., et al. Initial treatment of alveolar gaps in cases of labio-maxillary-palatal clefts

Beginning in the early 1970s manyarticles noted an increase in the rate ofmaxillary retrusions following earlyinitial bone grafts18. Following theseobservations Boyne4 introduced thesecondary bone graft that would sub-sequently be adopted in most Eur-opean countries. This procedure,carried out when patients are about 9years old, before eruption of the uppercanines, fulfills desired objectiveswithout interfering with growth ofthe maxilla, which, in most cases, isterminated both in the transverse andantero-posterior senses at thatage9,19.

Other treatment teams proceedwith this bone graft at an earlier stage,

when patients are 4 to 6 years old, inorder to provide patients with enoughbone for eruption of the lateral incisor(Fig. 1a to 1d)13,22. Commentators onthis procedure note that it providesbetter osteointegration and maintainsbone height without altering maxillarygrowth.

In my opinion, the gingivoperio-plasty that Skoog advocates at 3 to 6months bestows no benefits and doesnot obviate the need for a secondgraft15.

The tertiary bone graft carried out atthe end of dental eruption providesinferior osteointegration and should beemployed for dealing with sequelae6.

4 – WHAT TYPE BONE SHOULD BE USED FOR GRAFTS?

Many donor sites are available forharvesting material for grafts includingcancellous bone from the iliac andtibia areas, cortical bone from thecalvarium or the rib, membranousbone from the mandible, and endo-chondral bone from the tibia.

The choice of material for bonegrafts should satisfy the objectives ofachieving a maximum of osteointegra-tion with a minimum morbidity.

A study led by Osaki16 showed thatthe embryonic origin of the graft hadno influence on the quality of osteoin-tegration. Cancellous bone brings thebest results in grafts serving to fillspace. Surgeons most frequently em-ploy cancellous bone to restore alveo-

lar clefts. The prompt revascularizationof cancellous bone and its rich supplyof stem cells stimulate rapid integra-tion at the site of the graft4,9,16.

Iliac sites offer a generous supply ofcancellous bone that has a lowmorbidity rate.

Other suitable sources for harvest-ing bone for grafts include symphysealbone that has a low morbidity rate butvery limited amounts of osseousmaterial23; the tibia where there is arisk of damaging its epiphysis10; andthe ribs, where there is a risk ofcausing pneumothorax while promis-ing only relatively poor osteointegra-tion in the alveolus1.

INITIAL TREATMENT OF ALVEOLAR GAPS IN CASES OF LABIO-MAXILLARY-PALATAL CLEFTS

J Dentofacial Anom Orthod 2012;15:403 3

5 – WHAT TECHNIQUE OF ALVEOPLASTY SHOULD BE USED?

5 – 1 – Periosteal grafts

These have the theoretical goal ofbridging the maxillary osseous cleftwith bone forming tissue so that theosteogenesis thus stimulated willunite the borders of the two separated

maxillary segments. But the amountof bone creation stimulated by thisprocedure varies widely from patientto patient. Depending on the width ofthe cleft the surgeon can utilize aSkoog maxillary periosteal flap, a freeperiosteal graft taken from cranial

Figures 1a to 1dSpontaneous movement of teeth after a gingivoperioplasty and bone graft.

a and b: periapical radiographs showing rotation of an incisor after a bone graft;c and d: panoramic films give another view of rotation of incisor.



tissue as suggested by Beziat, or aperiosteal graft taken from the tibia asStricker has advocated2.

5 – 2 – Sliding muco-periostealflap

Surgeons usually make this type offlap by mesial sliding of the gingivathat covers the smaller segment. Theincision is made further along. Thesliding is made possible by an obliquebuccal muco-periosteal incision in themolar region that has been left to healafter which a papilla can be adjustedmesially. This type of flap has theadvantage of bringing attached gingiva

to the graft and the necks of theadjacent teeth.

5 – 3 – Buccal rotation flap

With this technique, known as afinger flap, surgeons can cover thegraft by rotating a mesial pediclebuccal mucosal tissue segment overit. This covering tissue will be supple,without tension, and will not loseperiosteum from the smaller seg-ment. But its essential disadvantageis adding free mucosa to a zonenormally covered by attached gingivathat might lead to a labio-alveolaradhesion.

6 – EVALUATION METHODS

6 – 1 – Evaluation usingpanoramic andperiapical X-rays

The Bergland scale12 used inmost studies, evaluates the restoredinterdental height (Fig. 2):– grade 1: > 75% of the restored

interdental septal height.– grade 2: 50-75% of the restored

interdental septal height.– grade 3: < 5% of the restored

interdental septal height.– grade 4: absence of osseous

continuity.This scale overestimates the quan-

tity of bone because it is only bidimen-sional and does not take into accountdifferences at the heart of the graft.

Various authors have proposedother scales to improve Bergland’s:– the modified Bergland scale12,

which measures the height of theFigure 2

Diagram depicting the Bergland scale.



graft in relation to the occlusal levelas well as the base level, at thepiriform orifice. A measurement ofthe total height of the graft at thecenter of the alveolar cleft, incomparison with the contralateralside, completes this analysis;

– the Long scale14 evaluates theheight of the bone in the cleft andthe height of supporting bone ofadjacent teeth;

– the Witherow scale25 evaluates theheight of the bone on each side ofthe alveolar cleft.All of the radiological scales over-

estimate the results of bone grafts24,studies having included in this assess-ment the distortions inherent in super-imposing images, and difficulties indiscerning anatomic landmarks, all ofwhich make accurate calculation ofosseous volume impossible.

6 – 2 – Three-dimensionalstudies

Three-dimensional analyses usingscanning or cone beam images,

which, incidentally, emit 15 times lessharmful ionizing radiation than tradi-tional radiography, allow for a betterestimate of residual bone and of itsposition and, in addition, provide valu-able data for rehabilitation with im-plants (Fig. 3a to 3b).

In fact, on the same group ofpatients a bidimensual analysisdeemed 90% of the cases to be grade1 on the Bergland scale while intridimensional analysis only 45% werejudged grade 111.

Overall, tridimensional analysis pro-vides an excellent evaluation of theperiodontal conditions of the teethadjacent to the cleft, of their position,of the height of the bone graft and ofits width, and clearly visualizes the siteof an eventual osseous defect in thegraft, information that can be a usefulguide to later orthodontic treatment aswell as a means of assessing thesupport available for a possible im-plant or the execution of orthognathicsurgery.

7 – MANAGEMENT OF CLEFTS IN THE MAXILLO-FACIAL SERVICE OF THEARMAND-TROUSSEAU CHILDREN’S HOSPITAL

7 – 1 – Review of themanagement schedulefor labio-palatal clefts17

We perform the first surgical proce-dure for cleft palate patients whenthey are 3 to 6 months old by repairingtheir lips, noses, and soft palates.

We use Sommerlad’s technique21

to reconstruct the soft palate and

Millard’s method to carry out thecheilorhinoplasty. The second opera-tion, which is scheduled to take placeone year after the spontaneous partialclosure of the hard palate cleft, allowsfor full closure on two planes of thenasal mucosa and the palatal fibromu-cosa, in the highly vascular zone.During these procedures the alveolarcleft is spared any surgical intervention,awaiting the gingivoperiostoplasty



associated with the graft, the finalprimary surgical intervention.

7 – 2 – Preoperative preparation

After dentofacial orthopedic expan-sion, when patients are 4 to 6 yearsold and in the primary dentition, wecarry out the gingivoperiostoplasty

and graft in a zone free of any scarring,after the primary graft but beforeeruption of permanent incisors.

Orthodontists partially correct theretruded smaller maxillary segmentwith expansion techniques, quadhelix, or expansion screws on cemen-ted bands or a plastic plate (Fig. 4aand 4b).

Figures 3a and 3bRadiological discordance.

The panoramic film (a) shows a right side bone graft of grade 2 on the Bergland scale, while the cone beam classifiesit as grade 3 (b).



After achieving a distance of 32 to35 mm between maxillary canines,orthodontists use a removable quadhelix as a retainer to protect theexpansion gain until the surgical inter-vention can proceed. Cone beam andpanoramic images are taken beforeand after surgery.

7 – 3 – Surgical technique (Fig.5a to 5h)

The surgeon performs a gingivoper-iostoplasty together with a graft.

• Harvesting bone

Surgeons harvest iliac bone bymaking a 3 cm incision parallel to theiliac crest and offset so that the scarwill be masked by even scanty cloth-ing. They remove the bone using localanesthesia under a hinged externalcovering without detaching any ab-dominal muscle insertions.

• Gingivoperiostoplasty

For this, the surgeon makes anincision in the mucosa of the seg-ments bordering the cleft, and thencuts around the necks of the teeth upto the molar region, the length of thesmall fragment. Then the periosteumis elevated carefully so as to avoidinjuring the fine osseous pellicle thatcovers the teeth bordering the cleft.The incision is continued over all theheight of the cleft up to the anteriornasal spine and the piriform orifice.The surgeon then elevates the nasalmucosa along the entire periphery ofthe cleft. On the palatal side thisincision is made at the necks of theteeth. The surgeon then resects ex-cess fibrous tissue as needed andreconstructs the nasal plane incliningthe superior part of the cleft mucosatoward the nasal fossa, all undercarefully controlled dryness.

Before inserting the graft, the sur-geon determines that the closing flaps

Figures 4a and 4bOrthodontists use a quad helix or an expansion screw to correct the position of the smaller maxillary fragment.



Figures 5a to 5gSurgical technique.

a and b: harvesting bone from the ilium where a substantial amount of cancellous bone is available;c and d: sketches depicting the incisions made for the sliding flap;d to g: operative photos of the sliding flap, placement of the graft, and closure in 3 planes protected from blood andsaliva.



are well suited to cover the graftcorrectly and accept sutures that willrequire no tension. The surgeon in-serts the initial sutures near thecheeks and then performs the palatalsuturing. Then cancellous bone isplaced in the cleft to fill any gaps andto obtain proper physiologic osseousvolume. The surgeon then sews upthe two flaps with meticulously placedsutures under no tension. Finally theinterdental papillae are suturedtogether.

• Post-operative care

Patients waken from general an-esthesia the day after their operationand are then perfused with level 1 and2 analgesics like acetaminophen, anti-biotics, and corticoids. They receivecareful nursing care and rinsing of theoral cavity with sterile water, lavage of

the nasal fossas with physiologicserum, and are fed with properlyselected soft aliments. Their hospitalstay usually lasts for four days.

7 – 4 – Post-operative evaluation

The patients are followed by:– the surgeons who evaluate the

healing of the operative site, look-ing for areas of osseous exposureand also monitor the iliac bonedonor area to check for possibledevelopment of hematomas; theorthodontist who assesses stabilityof tooth alignment and monitors thestatus of the quad helix that servesas a retainer for six months;

– cone beam films, cephalograms,and panoramic X-rays 6 and 12months and after the operation(Fig. 6b).

Figures 6a and 6bPreoperative cone beam image (a) then, at 6 months, an image of a left alveolar graft, in the framework of a totallabio-palatal cleft (b).



The cone beam film seems today tobe the instrument of choice for eval-uating the bone graft quantitatively.With it, at very low doses of radiation,practitioners can make a reliable three-dimensional analysis of the status ofthe graft. With it the practitioner canassess movement of dental buds andobjectify the quantitative reinforce-

ment of the graft when the lateralincisor erupts within it.

These secondary surgical proce-dures allow practitioners, in certaincases, to make an objective quantita-tive and qualitative evaluation of thegraft that tissue retraction has madevisible (Fig. 7).

8 – CONCLUSION

The execution of a gingivoperiosto-plasty in a zone free of any scarringreduces complications and allows forestablishment of excellent qualityperiosteum and mucosa.

Placement of a primary graft facil-itates spontaneous movement ofteeth, lessening rotation of buds ofcentral incisors, and eruption of lateralincisors when they are present.

Surgeons can harvest more thanadequate amounts of cancellous bonewith very low morbidity and excellentpotential for osteointegration from iliacdonor sites.

We are in the process of conducting astudy of a large sample of patients withlabio-palatal clefts who had grafts placedwhen they were in the deciduous denti-tion in accordance with our protocol.

Figure 7View of a graft, which a secondary surgical procedure has exposed, demonstrates itsexcellent integration with adjacent bone.



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initial treatment of alveolar gaps in cases of labio ... · catherine tomat, brigitte vi-fane,...

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