The Cleft Palate–Craniofacial Journal 52(5) pp. 614–617 September 2015 Ó Copyright 2015 American Cleft Palate–Craniofacial Association

CASE REPORT Bilateral Alveolar Distraction for Large Alveolar Defects: Case Report Shyam Prasad Aravindaksha, B.D.S., M.D.S., P.G.D.M.L.S., Puneet Batra, R.C.S.(Edinburgh), Partha Sadhu, M.S. (E.N.T.), Mc.H. (Plastic Surgery)

B.D.S., M.D.S., M.Orth.

Distraction osteogenesis has become a very popular technique, as the ability to reconstruct combined deficiencies in bone and soft tissue makes this process unique and invaluable to all types of reconstructive surgeons. We document a case in which an intraoral tooth-borne distractor was designed and segmental alveolar distraction was performed in a large alveolar defect in a patient with bilateral cleft lip and palate. Cosmetic dentistry was performed to attain a pleasing result. This article aims at highlighting the use of distraction in large defects in which bone grafting only is not a suitable procedure. KEY WORDS:

bilateral alveolar distraction, tooth borne distractor, alveolar clefts

Distraction osteogenesis involves gradual, controlled displacement of surgically created fractures, which results in simultaneous expansion of soft and hard tissues with an increase in bone volume (Polley et al., 1997). Distraction osteogenesis establishes the augmentation of the soft tissues simultaneous with bone (histiogenesis). Distraction osteogenesis is versatile, simple, and has the possibility of avoiding bone grafts, infections, blood transfusions, or intermaxillary fixation for long periods of time, making it a good alternative in cases in which conventional techniques are rather difficult to use (Ortiz Monasterio et al., 1997; Vu et al., 2001). Distraction osteogenesis has been widely used for mandibular deficiency, maxillary advancement, temporomandibular joint reconstruction, alveolar augmentation, and mandibular widening in the literature (Liou et al., 2000). Recently, the reconstruction of alveolar deficiency has been managed by the dento-osseous segment using segmental alveolar distraction (Yen et al., 2001; Dolanmaz et al., 2003). Development of miniature, internal distraction devices has made this clinically feasible and practical. We report a case of bilateral cleft lip and palate (BCLP) with a wide alveolar defect in which the segmental distraction histiogenesis lead us to a good esthetic result.

CASE REPORT An 18-year-old female BCLP patient reported to Global Hospital Mount Abu for secondary surgery. Lip repair and palate repair had been done earlier at another center before 2 years of age. On examination, there was a mature scar and slump of the nose as well as alar base deficiency, and intraoral examination revealed a large alveolar fistula and palatal defect in the primary palate (Figs. 1 and 2). Lip rerepair was done followed by intraoral management. The left upper central incisor was in crossbite. There was a rudimentary tooth in the major segment on the left side. The anterior crossbite was corrected with a removable appliance. Orthodontic treatment was started, and on leveling to 0.018 3 0.025, stainless-steel wire was reached (Fig. 4). The patient was planned for bilateral alveolar distraction. An intraoral tooth-borne distractor was designed after tracing the vector (in an anterior semicircle), and the osteotomy was planned in between the first and second premolars bilaterally (Fig. 5). The distractor was cemented (Fig. 6) with hybrid cement, and after a latency phase of 1 week, the distraction was activated. The distraction as carried out at a rhythm of one turn every 12 hours. The appliance was activated again by holding two thin elevators between the premolars and opening the v-shaped screw. The alveolar segments were approximated in 20 days (Figs. 7 and 8). Following this, the consolidation phase lasted 3 months. Orthopantogram x-ray revealed good bone formation (Fig. 9). Subsequently, the patient was advised regarding bone grafting in the approximated segments. However, the patient was happy and did not wish to get bone grafting done. Cosmetic dentistry was done, and composite restoration of the teeth was performed (Fig. 10).

Dr. Aravindaksha is Assistant Professor, Oral and Maxillofacial Surgery, University of Detroit Mercy School of Dentistry, Detroit, Michigan. Dr. Puneet Batra is Professor, Department of Orthodontics, Institute of Dental Studies and Technologies, and Cleft Orthodontist, Global Hospital Mount Abu, Kalkaji, New Delhi. Dr. Partha Sadhu is Director, Smile Train Program, Global Hospital Mount Abu, Rajasthan India. Submitted March 2013; Revised September 2013, February 2014, April 2014; Accepted August 2014. Address correspondence to: Dr. Shyam Prasad Aravindaksha, Oral and Maxillofacial Surgery, University of Detroit Mercy School of Dentistry. E-mail [email protected] and aravinsp@udmercy. edu. DOI: 10.1597/13-058 614

Aravindaksha et al., BILATERAL ALVEOLAR DISTRACTION FOR LARGE ALVEOLAR CLEFTS

FIGURE 1 Intraoral view of the large alveolar fistula and palatal defect in the primary palate.

DISCUSSION The first experimental use of anterior segmental distraction in the maxilla was performed in dogs (Dolanmaz et al.,

FIGURE 2

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2003). It was determined that a tooth-borne distractor caused more dental movement and that relapse tendency was greater in the long run. The process of alveolar distraction osteogenesis involves mobilization, transport, and fixation of a healthy segment of bone adjacent the deficient site (Yen et al., 2001; Dolanmaz et al., 2003). A mechanical device, the alveolar distraction device, is used to provide gradual, controlled transport of a mobilized alveolar segment (Fig. 5). When the desired repositioning of the bone segment is achieved, the distraction device is left in a static mode to act as a fixation device. As a result of the gradual distraction, the alveolar housing, including the osseous and soft tissue components are enlarged in a single, simultaneous process (Fig. 10d). Various authors obtained approximation of wide clefts using tooth-borne devices (Liou et al., 2000; Yen et al., 2001, Dolanmaz et al., 2003). However, additional surgery for alveolar bone grafting was still necessary to close residual fistulae, perform gingivo-periosteoplasty, and graft the empty nasal cleft space above the transported segment.

a: Intraoral preoperative view, frontal. b: Intraoral preoperative view, left lateral.

FIGURE 3 a: Intraoral view after orthodontic crossbite correction: occlusal view, maxilla. b: Intraoral view after orthodontic crossbite correction, frontal view. c: Intraoral view after orthodontic crossbite correction, right lateral. d: Intraoral view after orthodontic crossbite correction, left lateral.

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Cleft Palate–Craniofacial Journal, September 2015, Vol. 52 No. 5

FIGURE 4 a: Alveolar distractor device. b: Alveolar distraction device Illustration.

However, there are some limitations of distraction as well, namely, there must be a minimum quantity of bone, the transport and anchorage segment must have adequate strength to withstand forces of mobilization, expansion must occur only in the direction of transport, and the patient must cooperate with activation process. Complications can also happen with distraction, for example, fracture of transport segment, fracture of anchorage segment, premature consolidation, undesirable transport vector, and compromised wound-healing environment (Moloney et al., 1984; Cheung et al., 1994; Erbe et al., 1996; Jensen et al., 2002; Binger et al., 2003).

CONCLUSION The distraction process may not produce the anatomic objective in a single step. The distraction process results in the substrate, increased bone volume, and expanded soft tissue, which make creation of an appropriate alveolar morphology possible. The resultant increase in alveolar volume is accommodated by the expanded gingiva that gives a near-normal soft tissue. In large cleft defects, segmental distraction can be a very useful adjunct in achieving a good result.

FIGURE 5 Distraction device cemented and in situ.

FIGURE 7 Second activation of the distraction device complete.

FIGURE 6 Intraoral occlusal view showing distraction in progress.

FIGURE 8 Orthopantomogram showing new bone formation in the interpremolar area.

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FIGURE 9 a: Postconsolidation phase: intraoral, frontal. b: Postconsolidation phase: intraoral, right lateral. c: Postconsolidation phase, intraoral, left lateral. d: Postconsolidation phase: intraoral, occlusal view of the maxilla.

FIGURE 10 a: Line diagram of the osteotomy cuts. b: Line diagram of the postdistraction position of the maxillary segments.

REFERENCES Binger T, Katsaros C, Rucker M, Spitzer WJ. Segment distraction to reduce a wide alveolar cleft before alveolar bone grafting. Cleft Palate Craniofacial J. 2003;40:561–565. Cheung LK, Samman N, Hui E, Tideman H. The 3 dimensional stability of maxillary osteotomies in cleft palate patients with residual alveolar clefts. Br J Oral Maxillofac Surg 1994;32:6–12. Dolanmaz D, Karaman AI, Durmus E, Malkoc S. Management of alveolar clefts using dento osseous transport distraction osteogenesis. Angle Orthod. 2003;73:723–729. Erbe M, Stoelinga PJ, Leenen RJ. Long term results of segmental repositioning of the maxilla in cleft palate patients without previously grafted alveolo-palatal clefts. J Craniomaxillofac Surg. 1996;24:109–117. Jensen OT, Cockrell R, Kuhlke L. Anterior maxillary alveolar distraction osteogenesis: a prospective 5 year clinical study. Int J Maxillofac Implant. 2002;17:52–68. Liou EJ, Chen PK, Huang CS, Chen YR. Interdental distraction osteogenesis and rapid orthodontic tooth movement: a novel

approach to approximate a wide alveolar cleft or bone defect. Plast Reconstr Surg. 2000;105:1262–1272. Moloney F, Stoelinga PJ, Tideman H. The posterior segmental osteotomy: recent applications. J Oral Maxillofac Surg. 1984;42:771–781. Ortiz Monasterio F, Molina F, Andrade L, Rosriguez C, Sainz Arregui J. Simultaneous mandibular and maxillary distraction in hemifacial microsomia in adults: avoiding occlusal disasters. Plast Reconstr Surg. 1997;100:852–861. Polley JW, Figueroa AA. Management of severe maxillary deficiency in childhood and adolescence through distraction osteogenesis with an external, adjustable, rigid distraction device. J Craniofac Surg. 1997;8:181–185. Vu HL, Panchal J, Levine N. Combined simultaneous distraction osteogenesis of the maxilla and mandible using a single distraction device in hemifacial microsomia. J Craniofac Surg. 2001;12:253–258. Yen SL, Gross J, Wang P, Yamashita DD. Closure of a large alveolar cleft by bony transport of a posterior segment using orthodontic archwires attached to bone: report of a case. J Oral Maxillofac Surg. 2001;59:688–691.

Bilateral Alveolar Distraction for Large Alveolar Defects: Case Report.

Distraction osteogenesis has become a very popular technique, as the ability to reconstruct combined deficiencies in bone and soft tissue makes this p...
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