Int. J. Oral Maxillofac. Surg. 2014; 43: 428–432 http://dx.doi.org/10.1016/j.ijom.2013.09.007, available online at http://www.sciencedirect.com
Clinical Paper Cleft Lip and Palate
Donor site morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in cleft patients—111 consecutive patients
K. Andersen, S. E. Nørholt, J. Knudsen, A. Ku¨seler, J. Jensen Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark
K. Andersen, S. E. Nørholt, J. Knudsen, A. Ku¨seler, J. Jensen: Donor site morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in cleft patients—111 consecutive patients. Int. J. Oral Maxillofac. Surg. 2014; 43: 428–432. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of this study was to assess the objective and subjective morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in patients with cleft lip and palate. One hundred and eleven patients born between 1995 and 1999, who had undergone chin bone harvesting for alveolar cleft reconstruction in the period from 2000 through 2011, were included. A survey of medical records was conducted. Subjective morbidity after reconstruction was assessed using a questionnaire. Medical records revealed few postoperative incidents; 5.6% reported persistent sensory disturbances in the donor area. Postoperative pain averaged 3.6 2.1 (scale 0–10). The overall satisfaction with the surgical result was 8.7 1.7 (scale 0–10). This study revealed that chin bone harvesting for reconstruction of alveolar defects in patients with cleft lip and palate is a safe and predictable procedure, highly appreciated by the patients, and characterized by only minor postoperative incidents. Patients must be informed of the risk of sensory disturbances in the donor area.
An osseous defect of the alveolar process is an anomaly that affects approximately three out of four patients with cleft lip or cleft lip and palate.1 An untreated alveolar cleft may result in an oro-nasal fistula, speech pathology, dental crowding, 0901-5027/040428 + 05 $36.00/0
antero-posterior and transverse deficiency of the maxilla, fluid reflux, lack of bone support for the anterior teeth, and facial asymmetry.2 Enemark et al.3 advocated that those with a symptomatic oro-nasal fistula or with a lack of bone accommo-
Key words: cleft palate surgery; alveolar osteoplasty; bone grafting. Accepted for publication 10 September 2013 Available online 1 November 2013
dating tooth eruption in relation to an alveolar defect, which could impair orthodontic treatment and prosthodontic rehabilitation in the cleft area, should opt for secondary alveolar bone grafting. This is a widely accepted treatment modality, but
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Mandibular symphyseal bone grafts the type of bone graft and donor site remains controversial. Various bone sources, including anterior iliac crest, tibia, rib, calvarium, and mandible, have been proposed as graft material in the secondary reconstruction of alveolar defects in cleft lip and palate (CLP) patients.4 Most frequently, a graft from the anterior iliac crest has been used, and good outcomes have been reported after secondary reconstruction of alveolar defects in patients with CLP with this graft source.5–8 Donor site morbidity in relation to bone harvesting from the anterior iliac crest includes seroma, fracture, sensory disturbances, disturbances of gait, and hernia through the donor site.9,10 In our institution, reconstruction of alveolar defects in patients with CLP has routinely been performed with a mandibular symphyseal bone graft (MSBG) since 1988.11 An anterior iliac crest graft is used only in selected cases with bilateral cleft lip and palate (BCLP) or a large unilateral cleft lip and palate (UCLP). Good outcomes have been reported after reconstruction of alveolar bone defects with MSBG in patients with CLP.11–14 Few studies have reported the morbidity associated with reconstruction of alveolar bone defects with MSBG in patients with CLP. Sindet-Pedersen and Enemark have stated that an MSBG reduces the operating time, the morbidity of the surgical procedure, and the duration of hospitalization.11 With the MSBG procedure, a cutaneous scar at the iliac crest is avoided. Hoppenreijs et al. revealed a low occurrence of damage to the teeth in relation to harvesting of the MSBG, and minimal postoperative morbidity.13 In a more recent study by Booij et al., it was concluded that the harvesting of an MSBG for reconstruction of alveolar clefts in young patients was a well-accepted procedure characterized by low objective and subjective morbidity.15 The aim of this study was to assess the objective and subjective morbidity after reconstruction of alveolar bone defects with MSBG in patients with CLP.
Presurgical treatment planning
A team consisting of an experienced orthodontist and an experienced maxillofacial surgeon evaluated the indication and proper timing for reconstruction of the alveolar defect, as well as the indication for presurgical extraction of deciduous and supernumerary teeth, type of bone graft, and indication for a splint postoperatively. Treatment was initiated after orthodontic expansion of the upper dental arch was completed, the permanent upper incisors had erupted, and a radiographic examination could verify that the permanent canine on the cleft side had a correct eruption pattern. Deciduous teeth, supernumerary teeth, and malformed permanent incisors in the cleft area were extracted at least 6 weeks before reconstruction of the alveolar defect to allow proper healing of the mucosa before reconstruction. Surgical procedure
The surgical procedure was performed under general anaesthesia after intravenous administration of penicillin according to weight. The mandibular symphyseal region was exposed through an extended labial incision and raising of the mucoperiosteal flap (Fig. 1). A monocortical spongious bone block comprising the outer cortical bone and cancellous part was harvested with a safety margin of approximately 5 mm from the dental apices and the lower border of the mandible. Up until 2005, the graft was harvested with the use of a rotating burr. Since 2005, most
429
procedures have been performed with a piezoelectric device (Piezosurgery, Mectron, Italy). Any sharp bony edges were smoothened, and the wound was closed in two layers with Vicryl 5-0 sutures (Johnson & Johnson, UK). The bone graft was preserved in wet gauze until transplanted into the alveolar cleft defect. Access to the alveolar defect area was gained through a four-flap approach, as described by Aabyholm et al.6 The nasal mucosa was dissected, sutured, and inverted towards the nasal cavity. The defect area was visualized and the block of graft bone adjusted and fitted tightly in the defect area without the use of osteosynthesis. The residual bone graft was particulated using a bone mill (Roswitha Que´tin Dental Products, Germany) with 3-mm perforation to obtain bone graft particles with a size of 0.5–2 mm3. Residual defects were filled with the particulated bone graft. The oral mucosa was sutured with Vicryl 5-0 (Johnson & Johnson). When the alveolar cleft included palatal mucosa, the suture line was protected by use of a custommade surgical splint lined with a gelatine sponge dressing (Curaspon, CuraMedical BV, Netherlands) and fixated with steel wires to the first molars. Elastic tape was routinely placed on the chin to minimize postoperative swelling. Three experienced surgeons performed the surgical procedures.
Postsurgical treatment course
The elastic tape was removed the day after surgery. All patients were discharged the
Materials and methods Patients
The inclusion criteria for this study were: a UCLP or BCLP reconstructed with an MSBG during the period 2000–2011, and a date of birth between 1995 and 1999. Exclusion criteria were: the use of an anterior iliac crest bone graft, or a surgical procedure involving bone grafting and concomitant osteotomy and repositioning of the premaxilla in patients with BCLP.
Fig. 1. The mandibular symphyseal region was exposed through an extended labial incision and raising of the mucoperiosteal flap. A monocortical spongious bone block comprising the outer cortical bone and cancellous part was harvested with a safety margin of approximately 5 mm from the dental apices and the lower border of the mandible.
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Andersen et al.
day after surgery, and were given oral penicillin (50 mg/kg/day) for 5 days and paracetamol for pain control at doses corresponding to weight. The patients were instructed to keep a liquid diet for 5 days, followed by soft diet for another 5 days, and to use chlorhexidine gluconate mouth rinse (0.12%) twice a day. At a follow-up visit 4 weeks after surgery, the postsurgical splint was removed with the use of topical lidocaine gel (SAD, Denmark). Any complications were documented in the records whenever encountered. In some cases the completion of orthodontic treatment was carried out immediately after removal of the postsurgical splint, and in others some years later, depending of stage of eruption of the permanent teeth. Questionnaire
A questionnaire used in previous studies to document complications in relation to reconstruction of alveolar defects with MSBG in patients with CLP was translated from English to Danish by an experienced translator.15 One year or more after surgery, the questionnaire was mailed to the patient with a letter explaining its purpose. After the first deadline had passed, non-respondents received a second questionnaire by mail and a letter explaining the outline and purpose of the questionnaire. The questionnaire contained multiple choice questions regarding perioperative and postoperative pain, as well as its severity and duration. The patients were asked to grade the severity of pain on a visual analogue scale (VAS), with 0 representing no pain and 10 representing severe pain. Another VAS was used to score the appreciation of the MSBG harvesting procedure, with 0 representing ‘not a problem at all’ and 10 representing ‘very annoying’. Moreover, the questionnaire focused on sensory disturbances of the skin and oral mucosa, contour changes of the chin, perception of scarring, and the level of satisfaction and acceptance with the total surgical procedure and outcome.
Table 1. Treatment characteristics. Treatment characteristics Teeth extracted preoperatively Deciduous Supernumerary Permanent Protection splint Teeth extracted intraoperatively Deciduous Supernumerary Permanent Duration of surgery
45 patients (41%) 39 patients 2 patients 4 patients 79 patients (71%) 29 patients (26%) 15 patients 10 patients 4 patients 105 30 min (range 35–205 min)
were extracted according to a standardized scheme, and logged on an Excel spread sheet (Microsoft, USA). Data management and analyses were performed using SPSS 18.0 (SPSS Inc., USA). The patients were homogeneous with regard to diagnoses, treatment, and age, and therefore it was assumed that respondents would not differ systematically from non-respondents. The regional ethics committee in Denmark was consulted regarding ethical issues, and approval of the study design was given. The principles outlined in the Declaration of Helsinki were followed.
Results Surgical records
During the period 2000–2011, 134 patients with CLP born between 1995 and 1999 underwent reconstruction of an alveolar defect at our institution. Of a total of 134 patients, 23 were excluded because of the use of an anterior iliac crest bone graft (19 patients), or a surgical procedure involving bone grafting and concomitant osteotomy and repositioning of the premaxilla in patients with BCLP (four patients). A total of 111 patients, of whom 40 were females (36.0%) and 71 males (64.0%), were included in the study. Ninety patients (81.1%) had a UCLP, while 21 patients (18.9%) had a BCLP. The mean age at surgery was 11.6 2.4 years. Preoperative, intraoperative, and postoperative treatment data are presented in Tables 1 and 2.
The mean duration of the surgical procedure was 105 30 min (range 35– 205 min). In all cases, a sufficient amount of bone could be harvested in the mandibular symphyseal area for reconstruction of the alveolar cleft, and in all cases, the length of the postoperative stay was 1 day. No residual oro-nasal fistulas were detected in the 111 patients. Low postoperative morbidity was revealed, and all incidents were minor and could be addressed with no or minimal intervention. During the postoperative stay, the most frequent incidents were bleeding (seven patients; 6.3%), pain (seven patients; 6.3%), and sensory deficiency (eight patients; 7.2%) (Table 2). All patients showed up for the follow-up examination 30 days postsurgically. In the period between the reconstructive procedure and the follow-up examination, nine patients (8.1%) experienced minor incidents, which could all be addressed with no or minimal intervention. Three patients (2.7%) with an infection were treated successfully with the administration of penicillin according to weight. Two patients (1.8%) with partial loosening of the splint had the splint removed prematurely, and two patients (1.8%) suffering from pain were administered supplementary nonsteroidal anti-inflammatory drugs and paracetamol for pain control at doses corresponding to weight (Table 2). No damage to the developing mandibular canines was observed. In no case was further bone grafting in the cleft area indicated.
Data management
The surgical and orthodontic records were reviewed according to relevant parameters, including presurgical extraction of deciduous or supernumerary teeth, intraoperative extraction of teeth, type of surgical technique used to close the defect, use of a postsurgical splint, duration of the surgical procedure, and length of postoperative stay. Relevant treatment variables and complications
Table 2. Incidents during hospitalization and during the period from discharge to 1-month follow-up. Incident Infection Bleeding Loosening of splint Pain Sensory deficiency Oro-nasal fistula
During hospitalization (111 patients) 0 7 1 7 8 0
(6.3%) (0.9%) (6.3%) (7.2%)
From discharge to 1-month follow-up (111 patients) 3 0 2 2 2 0
(2.7%) (1.8%) (1.8%) (1.8%)
Mandibular symphyseal bone grafts 35 30 25 20 15 10 5 0 No pain
Less than a month
1-6 mths
Sll in pain
Do not remember
Fig. 2. Pain in the mandibular symphyseal region after graft harvest (54 patients).
Questionnaires
All patients were treated 1 year or more before completion of the questionnaire. Fifty-four patients (48.6%) returned the first or second questionnaire. Postoperatively, 24 patients experienced pain in the chin after harvesting of the MSBG. The pain averaged 3.6 2.1 on the VAS. In 17 patients, the pain disappeared within less than a month (Fig. 2). Forty-six patients reported no sensory disturbance in the chin region after surgery, while a total of eight patients (14.8%) reported some kind of sensory disturbance in the chin region. Five patients reported paraesthesia in the donor region, one patient anaesthesia, and two patients indicated dysaesthesia in the donor region (Fig. 3). In two cases, it took less than a month for the patients to consider themselves to be completely recovered. Two patients needed more than a year to recover, while three patients (5.6%) reported persistent sensory disturbances in the donor region. One patient did not remember the duration of the sensory disturbance. Three patients reported that sensory disturbances or pain in the donor region were affected by weather changes. Seven patients (13.0%) reported a slight
contour change of the area of the mandibular symphysis after the operation. The discomfort of the MSBG harvesting had a score of 3.2 2.6 on the VAS. Sixteen patients (29.6%) judged the procedure less uncomfortable than expected and 11 patients (10%) as more uncomfortable than expected. Seventeen patients (31.4%) reported no difference in discomfort between the mandibular symphyseal area and the upper jaw during the postsurgical treatment course, and a fairly even distribution of patients (9.3% and 9.3%) with most discomfort from either the upper jaw or the donor region was revealed. Fifty-two patients (96.3%) were satisfied with the surgical result and two patients (3.7%) were dissatisfied. Neither the surgical records nor the results of the questionnaires indicated any reason for the dissatisfaction of the two patients. On a VAS, the overall satisfaction with the surgical result was 8.7 1.7. Discussion
This study assessed the postoperative morbidity after reconstruction of alveolar bone defects in patients with unilateral or bilateral clefts by the use of MSBG. A ques-
50 45 40 35 30 25
20 15 10 5 0 No sensory disturbances
Paraesthesia
Anaesthesia
Dysaesthesia
Fig. 3. Sensory disturbances after harvest of the mandibular symphyseal bone graft (54 patients).
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tionnaire response rate of 48.6% was achieved. All patients were treated 1 year or more before completion of the questionnaire. This long time interval may have influenced the outcome of the questionnaires. In general, subjective satisfaction with the treatment course was high, and only a few patients experienced a postoperative course worse than expected. Thirteen percent of the patients experienced a slight contour change in the symphysis area. The aspect of bone regeneration in the donor site was not addressed in the current study. Harvesting of two bone grafts in the symphysis with preservation of a central outer cortical bone may theoretically reduce the contour changes in the chin area, but may also to some extent reduce the amount of available bone for the grafting procedure. This may be a viable treatment in patients with small alveolar clefts. The results obtained are comparable to those of previous studies using MSBG15 and iliac crest bone grafts.16 A low level of morbidity was observed after reconstruction of alveolar cleft defects by the use of MSBG. All observed incidents were minor and could be treated with no or minimal intervention. Moreover, no patients required readmission for swelling, respiratory compromise, or bleeding. The longterm need for endodontic surgery was not evaluated in the current study. The level of persistent sensory disturbances was 5.6%, which is comparable to the results of a previously reported study that used a similar treatment modality in a group of young patients with CLP.15 Several studies have described low donor site morbidity after harvesting of an MSBG for alveolar reconstruction in partially edentulous patients with no CLP.17–20 Due to differences in age and the size of the harvested MSBG, the aforementioned studies are not relevant for comparison with studies reporting the outcomes after the use of MSBG in secondary alveolar reconstruction of patients with CLP. In all cases, the postoperative stay lasted a single day, which is shorter than reported in previous studies after reconstruction of alveolar clefts by use of iliac crest bone.21,22 This short postoperative stay is a result of (1) the short duration of the surgical procedure, (2) the minimally invasive surgical procedure, and (3) the low occurrence of postoperative morbidity. The short postoperative stay reported in the current study may permit the treatment of patients, in selected cases, on an outpatient basis as an alternative to inpatient treatment; this is supported by previous studies, although certain medical
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conditions may dictate the need for an inpatient postoperative stay after the repair.23–25 In conclusion, this study revealed that MSBG harvesting for reconstruction of alveolar defects in patients with CLP is a safe and predictable procedure, highly appreciated by the patients, and characterized by only minor postoperative incidents. Nevertheless, the patients must be informed of the risk of sensory disturbances in the donor region. Prospective, randomized controlled studies reporting outcomes and morbidity after reconstruction of alveolar bone defects with MSBG in unilateral cleft patients are indicated. Funding
None. Competing interests
None. Ethical approval
Not relevant. Patient consent
Not required. References 1. Malcolm C, Johnston P, Embryogenesis of cleft lip and palate.McCarty JG, editor. Plastic surgery Cleft lip and palate and craniofacial anomalies, vol. 4. Philadelphia, PA: WB Saunders; 1990. p. 2532. 2. Waite PD, Waite DE. Bone grafting for the alveolar cleft defect. Semin Orthod 1996;2:192–6. 3. Enemark H, Krantz-Simonsen E, Schramm JE. Secondary bone grafting in unilateral cleft lip palate patients: indications and treatment procedure. Int J Oral Surg 1985;14: 2–10. 4. Horswell BB, Henderson JM. Secondary osteoplasty of the alveolar cleft defect. J Oral Maxillofac Surg 2003;61:1082–90.
5. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 1972;70:87–92. 6. Aabyholm F, Bergland O, Semb G. Secondary bone grafting of alveolar clefts. Scand J Plast Reconstr Surg 1981;15:127–40. 7. Enemark H, Sindet-Pedersen S, Bundgaard M. Long-term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg 1987;45:913–9. 8. Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with mandibular or iliac crest bone grafts: a comparative study. J Oral Maxillofac Surg 1990;48:554–8. 9. Kalk WW, Raghoebar GM, Jansma J, Boering G. Morbidity from iliac crest bone harvesting. J Oral Maxillofac Surg 1996;54:1424–9. 10. Schaaf H, Lendeckel S, Howaldt HP, Streckbein P. Donor site morbidity after bone harvesting from the anterior iliac crest. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:52–8. 11. Sindet-Pedersen S, Enemark H. Mandibular bone grafts for reconstruction of alveolar clefts. J Oral Maxillofac Surg 1988;46: 533–7. 12. Koole R, Bosker H, van der Dussen FN. Late secondary autogenous bone grafting in cleft patients comparing mandibular (ectomesenchymal) and iliac crest (mesenchymal) grafts. J Craniomaxillofac Surg 1989;17:28–30. 13. Hoppenreijs TJ, Nijdam ES, Freihofer HP. The chin as a donor site in early secondary osteoplasty: a retrospective clinical and radiological evaluation. J Craniomaxillofac Surg 1992;20:119–24. 14. Enemark H, Jensen J, Bosch C. Mandibular bone graft material for reconstruction of alveolar cleft defects: long-term results. Cleft Palate Craniofac J 2001;38:155–63. 15. Booij A, Raghoebar GM, Jansma J, Kalk WW, Vissink A. Morbidity of chin bone transplants used for reconstructing alveolar defects in cleft patients. Cleft Palate Craniofac J 2005;42:533–8. 16. Swan MC, Goodacre TE. Morbidity at the iliac crest donor site following bone grafting of the cleft alveolus. Br J Oral Maxillofac Surg 2006;44:129–33. 17. No´ia CF, Ortega-Lopes R, Olate S, Duque TM, de Moraes M, Mazzonetto R. Prospective
18.
19.
20.
21.
22.
23.
24.
25.
clinical assessment of morbidity after chin bone harvest. J Craniofac Surg 2011;22: 2195–8. Weibull L, Widmark G, Ivanoff CJ, Borg E, Rasmusson L. Morbidity after chin bone harvesting—a retrospective long-term follow-up study. Clin Implant Dent Relat Res 2009;11:149–57. Raghoebar GM, Louwerse C, Kalk WW, Vissink A. Morbidity of chin bone harvesting. Clin Oral Implants Res 2001;12:503–7. Cordaro L, Torsello F, Miuccio MT, di Torresanto VM, Eliopoulos D. Mandibular bone harvesting for alveolar reconstruction and implant placement: subjective and objective cross-sectional evaluation of donor and recipient site up to 4 years. Clin Oral Implants Res 2011;11:1320–6. McCanny CM, Roberts-Harry DP. A comparison of two different bone-harvesting techniques for secondary alveolar bone grafting in patients with cleft lip and palate. Cleft Palate Craniofac J 1998;35:442–6. Constantinides J, Chhabra P, Turner PJ, Richard B. A comparison of Shepard’s osteotome versus trapdoor flap technique to harvest iliac crest bone for secondary alveolar bone grafting. Cleft Palate Craniofac J 2008;45:347–52. Kim TH, Rothkopf DM. Ambulatory surgery for cleft lip repair. Ann Plast Surg 1999;42:442–4. Rosen H, Barrios L, Reinisch J, McGill K, Meara J. Outpatient cleft lip repair. Plast Reconstr Surg 2003;112:381–7. Izadi N, Haers PE. An investigation into the variables associated with length of hospital stay related to primary cleft lip and palate surgery and alveolar bone grafting. Int J Oral Maxillofac Surg 2012;41:1238–43.
Address: Kristian Andersen Department of Oral and Maxillofacial Surgery Aarhus University Hospital Nørrebrogade 44 8000 Aarhus C Denmark Tel: +45 89482927 E-mail: [email protected]
Clinical Paper Cleft Lip and Palate
Donor site morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in cleft patients—111 consecutive patients
K. Andersen, S. E. Nørholt, J. Knudsen, A. Ku¨seler, J. Jensen Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark
K. Andersen, S. E. Nørholt, J. Knudsen, A. Ku¨seler, J. Jensen: Donor site morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in cleft patients—111 consecutive patients. Int. J. Oral Maxillofac. Surg. 2014; 43: 428–432. # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The aim of this study was to assess the objective and subjective morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in patients with cleft lip and palate. One hundred and eleven patients born between 1995 and 1999, who had undergone chin bone harvesting for alveolar cleft reconstruction in the period from 2000 through 2011, were included. A survey of medical records was conducted. Subjective morbidity after reconstruction was assessed using a questionnaire. Medical records revealed few postoperative incidents; 5.6% reported persistent sensory disturbances in the donor area. Postoperative pain averaged 3.6 2.1 (scale 0–10). The overall satisfaction with the surgical result was 8.7 1.7 (scale 0–10). This study revealed that chin bone harvesting for reconstruction of alveolar defects in patients with cleft lip and palate is a safe and predictable procedure, highly appreciated by the patients, and characterized by only minor postoperative incidents. Patients must be informed of the risk of sensory disturbances in the donor area.
An osseous defect of the alveolar process is an anomaly that affects approximately three out of four patients with cleft lip or cleft lip and palate.1 An untreated alveolar cleft may result in an oro-nasal fistula, speech pathology, dental crowding, 0901-5027/040428 + 05 $36.00/0
antero-posterior and transverse deficiency of the maxilla, fluid reflux, lack of bone support for the anterior teeth, and facial asymmetry.2 Enemark et al.3 advocated that those with a symptomatic oro-nasal fistula or with a lack of bone accommo-
Key words: cleft palate surgery; alveolar osteoplasty; bone grafting. Accepted for publication 10 September 2013 Available online 1 November 2013
dating tooth eruption in relation to an alveolar defect, which could impair orthodontic treatment and prosthodontic rehabilitation in the cleft area, should opt for secondary alveolar bone grafting. This is a widely accepted treatment modality, but
# 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Mandibular symphyseal bone grafts the type of bone graft and donor site remains controversial. Various bone sources, including anterior iliac crest, tibia, rib, calvarium, and mandible, have been proposed as graft material in the secondary reconstruction of alveolar defects in cleft lip and palate (CLP) patients.4 Most frequently, a graft from the anterior iliac crest has been used, and good outcomes have been reported after secondary reconstruction of alveolar defects in patients with CLP with this graft source.5–8 Donor site morbidity in relation to bone harvesting from the anterior iliac crest includes seroma, fracture, sensory disturbances, disturbances of gait, and hernia through the donor site.9,10 In our institution, reconstruction of alveolar defects in patients with CLP has routinely been performed with a mandibular symphyseal bone graft (MSBG) since 1988.11 An anterior iliac crest graft is used only in selected cases with bilateral cleft lip and palate (BCLP) or a large unilateral cleft lip and palate (UCLP). Good outcomes have been reported after reconstruction of alveolar bone defects with MSBG in patients with CLP.11–14 Few studies have reported the morbidity associated with reconstruction of alveolar bone defects with MSBG in patients with CLP. Sindet-Pedersen and Enemark have stated that an MSBG reduces the operating time, the morbidity of the surgical procedure, and the duration of hospitalization.11 With the MSBG procedure, a cutaneous scar at the iliac crest is avoided. Hoppenreijs et al. revealed a low occurrence of damage to the teeth in relation to harvesting of the MSBG, and minimal postoperative morbidity.13 In a more recent study by Booij et al., it was concluded that the harvesting of an MSBG for reconstruction of alveolar clefts in young patients was a well-accepted procedure characterized by low objective and subjective morbidity.15 The aim of this study was to assess the objective and subjective morbidity after reconstruction of alveolar bone defects with MSBG in patients with CLP.
Presurgical treatment planning
A team consisting of an experienced orthodontist and an experienced maxillofacial surgeon evaluated the indication and proper timing for reconstruction of the alveolar defect, as well as the indication for presurgical extraction of deciduous and supernumerary teeth, type of bone graft, and indication for a splint postoperatively. Treatment was initiated after orthodontic expansion of the upper dental arch was completed, the permanent upper incisors had erupted, and a radiographic examination could verify that the permanent canine on the cleft side had a correct eruption pattern. Deciduous teeth, supernumerary teeth, and malformed permanent incisors in the cleft area were extracted at least 6 weeks before reconstruction of the alveolar defect to allow proper healing of the mucosa before reconstruction. Surgical procedure
The surgical procedure was performed under general anaesthesia after intravenous administration of penicillin according to weight. The mandibular symphyseal region was exposed through an extended labial incision and raising of the mucoperiosteal flap (Fig. 1). A monocortical spongious bone block comprising the outer cortical bone and cancellous part was harvested with a safety margin of approximately 5 mm from the dental apices and the lower border of the mandible. Up until 2005, the graft was harvested with the use of a rotating burr. Since 2005, most
429
procedures have been performed with a piezoelectric device (Piezosurgery, Mectron, Italy). Any sharp bony edges were smoothened, and the wound was closed in two layers with Vicryl 5-0 sutures (Johnson & Johnson, UK). The bone graft was preserved in wet gauze until transplanted into the alveolar cleft defect. Access to the alveolar defect area was gained through a four-flap approach, as described by Aabyholm et al.6 The nasal mucosa was dissected, sutured, and inverted towards the nasal cavity. The defect area was visualized and the block of graft bone adjusted and fitted tightly in the defect area without the use of osteosynthesis. The residual bone graft was particulated using a bone mill (Roswitha Que´tin Dental Products, Germany) with 3-mm perforation to obtain bone graft particles with a size of 0.5–2 mm3. Residual defects were filled with the particulated bone graft. The oral mucosa was sutured with Vicryl 5-0 (Johnson & Johnson). When the alveolar cleft included palatal mucosa, the suture line was protected by use of a custommade surgical splint lined with a gelatine sponge dressing (Curaspon, CuraMedical BV, Netherlands) and fixated with steel wires to the first molars. Elastic tape was routinely placed on the chin to minimize postoperative swelling. Three experienced surgeons performed the surgical procedures.
Postsurgical treatment course
The elastic tape was removed the day after surgery. All patients were discharged the
Materials and methods Patients
The inclusion criteria for this study were: a UCLP or BCLP reconstructed with an MSBG during the period 2000–2011, and a date of birth between 1995 and 1999. Exclusion criteria were: the use of an anterior iliac crest bone graft, or a surgical procedure involving bone grafting and concomitant osteotomy and repositioning of the premaxilla in patients with BCLP.
Fig. 1. The mandibular symphyseal region was exposed through an extended labial incision and raising of the mucoperiosteal flap. A monocortical spongious bone block comprising the outer cortical bone and cancellous part was harvested with a safety margin of approximately 5 mm from the dental apices and the lower border of the mandible.
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Andersen et al.
day after surgery, and were given oral penicillin (50 mg/kg/day) for 5 days and paracetamol for pain control at doses corresponding to weight. The patients were instructed to keep a liquid diet for 5 days, followed by soft diet for another 5 days, and to use chlorhexidine gluconate mouth rinse (0.12%) twice a day. At a follow-up visit 4 weeks after surgery, the postsurgical splint was removed with the use of topical lidocaine gel (SAD, Denmark). Any complications were documented in the records whenever encountered. In some cases the completion of orthodontic treatment was carried out immediately after removal of the postsurgical splint, and in others some years later, depending of stage of eruption of the permanent teeth. Questionnaire
A questionnaire used in previous studies to document complications in relation to reconstruction of alveolar defects with MSBG in patients with CLP was translated from English to Danish by an experienced translator.15 One year or more after surgery, the questionnaire was mailed to the patient with a letter explaining its purpose. After the first deadline had passed, non-respondents received a second questionnaire by mail and a letter explaining the outline and purpose of the questionnaire. The questionnaire contained multiple choice questions regarding perioperative and postoperative pain, as well as its severity and duration. The patients were asked to grade the severity of pain on a visual analogue scale (VAS), with 0 representing no pain and 10 representing severe pain. Another VAS was used to score the appreciation of the MSBG harvesting procedure, with 0 representing ‘not a problem at all’ and 10 representing ‘very annoying’. Moreover, the questionnaire focused on sensory disturbances of the skin and oral mucosa, contour changes of the chin, perception of scarring, and the level of satisfaction and acceptance with the total surgical procedure and outcome.
Table 1. Treatment characteristics. Treatment characteristics Teeth extracted preoperatively Deciduous Supernumerary Permanent Protection splint Teeth extracted intraoperatively Deciduous Supernumerary Permanent Duration of surgery
45 patients (41%) 39 patients 2 patients 4 patients 79 patients (71%) 29 patients (26%) 15 patients 10 patients 4 patients 105 30 min (range 35–205 min)
were extracted according to a standardized scheme, and logged on an Excel spread sheet (Microsoft, USA). Data management and analyses were performed using SPSS 18.0 (SPSS Inc., USA). The patients were homogeneous with regard to diagnoses, treatment, and age, and therefore it was assumed that respondents would not differ systematically from non-respondents. The regional ethics committee in Denmark was consulted regarding ethical issues, and approval of the study design was given. The principles outlined in the Declaration of Helsinki were followed.
Results Surgical records
During the period 2000–2011, 134 patients with CLP born between 1995 and 1999 underwent reconstruction of an alveolar defect at our institution. Of a total of 134 patients, 23 were excluded because of the use of an anterior iliac crest bone graft (19 patients), or a surgical procedure involving bone grafting and concomitant osteotomy and repositioning of the premaxilla in patients with BCLP (four patients). A total of 111 patients, of whom 40 were females (36.0%) and 71 males (64.0%), were included in the study. Ninety patients (81.1%) had a UCLP, while 21 patients (18.9%) had a BCLP. The mean age at surgery was 11.6 2.4 years. Preoperative, intraoperative, and postoperative treatment data are presented in Tables 1 and 2.
The mean duration of the surgical procedure was 105 30 min (range 35– 205 min). In all cases, a sufficient amount of bone could be harvested in the mandibular symphyseal area for reconstruction of the alveolar cleft, and in all cases, the length of the postoperative stay was 1 day. No residual oro-nasal fistulas were detected in the 111 patients. Low postoperative morbidity was revealed, and all incidents were minor and could be addressed with no or minimal intervention. During the postoperative stay, the most frequent incidents were bleeding (seven patients; 6.3%), pain (seven patients; 6.3%), and sensory deficiency (eight patients; 7.2%) (Table 2). All patients showed up for the follow-up examination 30 days postsurgically. In the period between the reconstructive procedure and the follow-up examination, nine patients (8.1%) experienced minor incidents, which could all be addressed with no or minimal intervention. Three patients (2.7%) with an infection were treated successfully with the administration of penicillin according to weight. Two patients (1.8%) with partial loosening of the splint had the splint removed prematurely, and two patients (1.8%) suffering from pain were administered supplementary nonsteroidal anti-inflammatory drugs and paracetamol for pain control at doses corresponding to weight (Table 2). No damage to the developing mandibular canines was observed. In no case was further bone grafting in the cleft area indicated.
Data management
The surgical and orthodontic records were reviewed according to relevant parameters, including presurgical extraction of deciduous or supernumerary teeth, intraoperative extraction of teeth, type of surgical technique used to close the defect, use of a postsurgical splint, duration of the surgical procedure, and length of postoperative stay. Relevant treatment variables and complications
Table 2. Incidents during hospitalization and during the period from discharge to 1-month follow-up. Incident Infection Bleeding Loosening of splint Pain Sensory deficiency Oro-nasal fistula
During hospitalization (111 patients) 0 7 1 7 8 0
(6.3%) (0.9%) (6.3%) (7.2%)
From discharge to 1-month follow-up (111 patients) 3 0 2 2 2 0
(2.7%) (1.8%) (1.8%) (1.8%)
Mandibular symphyseal bone grafts 35 30 25 20 15 10 5 0 No pain
Less than a month
1-6 mths
Sll in pain
Do not remember
Fig. 2. Pain in the mandibular symphyseal region after graft harvest (54 patients).
Questionnaires
All patients were treated 1 year or more before completion of the questionnaire. Fifty-four patients (48.6%) returned the first or second questionnaire. Postoperatively, 24 patients experienced pain in the chin after harvesting of the MSBG. The pain averaged 3.6 2.1 on the VAS. In 17 patients, the pain disappeared within less than a month (Fig. 2). Forty-six patients reported no sensory disturbance in the chin region after surgery, while a total of eight patients (14.8%) reported some kind of sensory disturbance in the chin region. Five patients reported paraesthesia in the donor region, one patient anaesthesia, and two patients indicated dysaesthesia in the donor region (Fig. 3). In two cases, it took less than a month for the patients to consider themselves to be completely recovered. Two patients needed more than a year to recover, while three patients (5.6%) reported persistent sensory disturbances in the donor region. One patient did not remember the duration of the sensory disturbance. Three patients reported that sensory disturbances or pain in the donor region were affected by weather changes. Seven patients (13.0%) reported a slight
contour change of the area of the mandibular symphysis after the operation. The discomfort of the MSBG harvesting had a score of 3.2 2.6 on the VAS. Sixteen patients (29.6%) judged the procedure less uncomfortable than expected and 11 patients (10%) as more uncomfortable than expected. Seventeen patients (31.4%) reported no difference in discomfort between the mandibular symphyseal area and the upper jaw during the postsurgical treatment course, and a fairly even distribution of patients (9.3% and 9.3%) with most discomfort from either the upper jaw or the donor region was revealed. Fifty-two patients (96.3%) were satisfied with the surgical result and two patients (3.7%) were dissatisfied. Neither the surgical records nor the results of the questionnaires indicated any reason for the dissatisfaction of the two patients. On a VAS, the overall satisfaction with the surgical result was 8.7 1.7. Discussion
This study assessed the postoperative morbidity after reconstruction of alveolar bone defects in patients with unilateral or bilateral clefts by the use of MSBG. A ques-
50 45 40 35 30 25
20 15 10 5 0 No sensory disturbances
Paraesthesia
Anaesthesia
Dysaesthesia
Fig. 3. Sensory disturbances after harvest of the mandibular symphyseal bone graft (54 patients).
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tionnaire response rate of 48.6% was achieved. All patients were treated 1 year or more before completion of the questionnaire. This long time interval may have influenced the outcome of the questionnaires. In general, subjective satisfaction with the treatment course was high, and only a few patients experienced a postoperative course worse than expected. Thirteen percent of the patients experienced a slight contour change in the symphysis area. The aspect of bone regeneration in the donor site was not addressed in the current study. Harvesting of two bone grafts in the symphysis with preservation of a central outer cortical bone may theoretically reduce the contour changes in the chin area, but may also to some extent reduce the amount of available bone for the grafting procedure. This may be a viable treatment in patients with small alveolar clefts. The results obtained are comparable to those of previous studies using MSBG15 and iliac crest bone grafts.16 A low level of morbidity was observed after reconstruction of alveolar cleft defects by the use of MSBG. All observed incidents were minor and could be treated with no or minimal intervention. Moreover, no patients required readmission for swelling, respiratory compromise, or bleeding. The longterm need for endodontic surgery was not evaluated in the current study. The level of persistent sensory disturbances was 5.6%, which is comparable to the results of a previously reported study that used a similar treatment modality in a group of young patients with CLP.15 Several studies have described low donor site morbidity after harvesting of an MSBG for alveolar reconstruction in partially edentulous patients with no CLP.17–20 Due to differences in age and the size of the harvested MSBG, the aforementioned studies are not relevant for comparison with studies reporting the outcomes after the use of MSBG in secondary alveolar reconstruction of patients with CLP. In all cases, the postoperative stay lasted a single day, which is shorter than reported in previous studies after reconstruction of alveolar clefts by use of iliac crest bone.21,22 This short postoperative stay is a result of (1) the short duration of the surgical procedure, (2) the minimally invasive surgical procedure, and (3) the low occurrence of postoperative morbidity. The short postoperative stay reported in the current study may permit the treatment of patients, in selected cases, on an outpatient basis as an alternative to inpatient treatment; this is supported by previous studies, although certain medical
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conditions may dictate the need for an inpatient postoperative stay after the repair.23–25 In conclusion, this study revealed that MSBG harvesting for reconstruction of alveolar defects in patients with CLP is a safe and predictable procedure, highly appreciated by the patients, and characterized by only minor postoperative incidents. Nevertheless, the patients must be informed of the risk of sensory disturbances in the donor region. Prospective, randomized controlled studies reporting outcomes and morbidity after reconstruction of alveolar bone defects with MSBG in unilateral cleft patients are indicated. Funding
None. Competing interests
None. Ethical approval
Not relevant. Patient consent
Not required. References 1. Malcolm C, Johnston P, Embryogenesis of cleft lip and palate.McCarty JG, editor. Plastic surgery Cleft lip and palate and craniofacial anomalies, vol. 4. Philadelphia, PA: WB Saunders; 1990. p. 2532. 2. Waite PD, Waite DE. Bone grafting for the alveolar cleft defect. Semin Orthod 1996;2:192–6. 3. Enemark H, Krantz-Simonsen E, Schramm JE. Secondary bone grafting in unilateral cleft lip palate patients: indications and treatment procedure. Int J Oral Surg 1985;14: 2–10. 4. Horswell BB, Henderson JM. Secondary osteoplasty of the alveolar cleft defect. J Oral Maxillofac Surg 2003;61:1082–90.
5. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 1972;70:87–92. 6. Aabyholm F, Bergland O, Semb G. Secondary bone grafting of alveolar clefts. Scand J Plast Reconstr Surg 1981;15:127–40. 7. Enemark H, Sindet-Pedersen S, Bundgaard M. Long-term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg 1987;45:913–9. 8. Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with mandibular or iliac crest bone grafts: a comparative study. J Oral Maxillofac Surg 1990;48:554–8. 9. Kalk WW, Raghoebar GM, Jansma J, Boering G. Morbidity from iliac crest bone harvesting. J Oral Maxillofac Surg 1996;54:1424–9. 10. Schaaf H, Lendeckel S, Howaldt HP, Streckbein P. Donor site morbidity after bone harvesting from the anterior iliac crest. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:52–8. 11. Sindet-Pedersen S, Enemark H. Mandibular bone grafts for reconstruction of alveolar clefts. J Oral Maxillofac Surg 1988;46: 533–7. 12. Koole R, Bosker H, van der Dussen FN. Late secondary autogenous bone grafting in cleft patients comparing mandibular (ectomesenchymal) and iliac crest (mesenchymal) grafts. J Craniomaxillofac Surg 1989;17:28–30. 13. Hoppenreijs TJ, Nijdam ES, Freihofer HP. The chin as a donor site in early secondary osteoplasty: a retrospective clinical and radiological evaluation. J Craniomaxillofac Surg 1992;20:119–24. 14. Enemark H, Jensen J, Bosch C. Mandibular bone graft material for reconstruction of alveolar cleft defects: long-term results. Cleft Palate Craniofac J 2001;38:155–63. 15. Booij A, Raghoebar GM, Jansma J, Kalk WW, Vissink A. Morbidity of chin bone transplants used for reconstructing alveolar defects in cleft patients. Cleft Palate Craniofac J 2005;42:533–8. 16. Swan MC, Goodacre TE. Morbidity at the iliac crest donor site following bone grafting of the cleft alveolus. Br J Oral Maxillofac Surg 2006;44:129–33. 17. No´ia CF, Ortega-Lopes R, Olate S, Duque TM, de Moraes M, Mazzonetto R. Prospective
18.
19.
20.
21.
22.
23.
24.
25.
clinical assessment of morbidity after chin bone harvest. J Craniofac Surg 2011;22: 2195–8. Weibull L, Widmark G, Ivanoff CJ, Borg E, Rasmusson L. Morbidity after chin bone harvesting—a retrospective long-term follow-up study. Clin Implant Dent Relat Res 2009;11:149–57. Raghoebar GM, Louwerse C, Kalk WW, Vissink A. Morbidity of chin bone harvesting. Clin Oral Implants Res 2001;12:503–7. Cordaro L, Torsello F, Miuccio MT, di Torresanto VM, Eliopoulos D. Mandibular bone harvesting for alveolar reconstruction and implant placement: subjective and objective cross-sectional evaluation of donor and recipient site up to 4 years. Clin Oral Implants Res 2011;11:1320–6. McCanny CM, Roberts-Harry DP. A comparison of two different bone-harvesting techniques for secondary alveolar bone grafting in patients with cleft lip and palate. Cleft Palate Craniofac J 1998;35:442–6. Constantinides J, Chhabra P, Turner PJ, Richard B. A comparison of Shepard’s osteotome versus trapdoor flap technique to harvest iliac crest bone for secondary alveolar bone grafting. Cleft Palate Craniofac J 2008;45:347–52. Kim TH, Rothkopf DM. Ambulatory surgery for cleft lip repair. Ann Plast Surg 1999;42:442–4. Rosen H, Barrios L, Reinisch J, McGill K, Meara J. Outpatient cleft lip repair. Plast Reconstr Surg 2003;112:381–7. Izadi N, Haers PE. An investigation into the variables associated with length of hospital stay related to primary cleft lip and palate surgery and alveolar bone grafting. Int J Oral Maxillofac Surg 2012;41:1238–43.
Address: Kristian Andersen Department of Oral and Maxillofacial Surgery Aarhus University Hospital Nørrebrogade 44 8000 Aarhus C Denmark Tel: +45 89482927 E-mail: [email protected]
