Prospective evaluation of morbidity associated with iliac crest harvest for alveolar cleft grafting

Anterior Dental Implant in Grafted Cleft Alveolus: A Clinical Comparison Between Intramembranous and Endochondral Bone Graft

BACKGROUND

Alveolar bone graft is usually performed during the early mixed dentition phase, at the chronological age of 6 to 8 years old, to reconstruct the cleft alveolus. As the appropriate time for implant placement is after completion of full growth, it can result in a likelihood of resorption. The aim of this study is to compare the clinical outcomes of anterior dental implants with delayed bone grafting using iliac crest (endochondral) and mandibular ramus or symphysis (intramembranous) bone in adolescents to adulthood patients with cleft alveolus.

MATERIALS AND METHODS

This study included 10 patients with cleft alveolus who underwent delayed bone grafting with autogenous block bone and particulate cancellous bone and marrow (PCBM) from the mandibular ramus and symphysis with dental implant placement, and iliac crest. The success of the treatment was evaluated through clinical and radiographic examination including marginal bone loss measurement of the implants.

RESULTS

All patients underwent delayed bone grafting between the ages of 11 and 21.1 years (mean age: 15.1±4.3 y). The implant diameters ranged from 3.8 to 4.5 mm and the lengths ranged from 8.0 to 11.5 mm. All of the implants were integrated successfully and survived during the 3-year follow-up period.

CONCLUSIONS

Delayed bone grafting followed by implant placement showed long-term stability with satisfactory esthetic and functional rehabilitation. One of the main advantages of delayed bone grafting is to achieve adequate bone support for future dental implant placements with less bone resorption compared with those of primary, early secondary, and secondary bone grafting.

Pain management at iliac donor sites after grafting of alveolar clefts

The aim of this study was to answer the question: which analgesic protocol is most efficient and most effective in overcoming pain and promoting functional recovery after iliac bone grafting in cleft alveolus patients? A systematic review of the literature was performed. The population consisted of cleft lip and alveolus patients with or without cleft palate undergoing iliac crest bone grafting; the outcomes analysed were represented by the duration of hospital stay, subjective pain rating, and degree of impaired mobility. A total of 15 articles were selected for review. The following protocols were subject to comparison in this review: simple classic intravenous/per-oral analgesia, local anaesthetic infiltration in the donor site, anaesthetic-soaked sponge, neural blocks and continuous infusion at the donor site. The results of the included studies were individually reported identifying trends in the efficiency of the different pain-management techniques. Although hospital stay varied from same-day discharge to almost a week, other factors besides pain influenced this outcome. School was resumed after an average of 12.6 days and sport activities after maximum one month regardless of the used protocol. Even though the age of patients had a statistically significant influence on hospital stay durations, it did not determine the latter. The pain management protocols after iliac bone grafting of alveolar clefts selected for analysis have their advantages and drawbacks. All protocols seem effective meaning they reach adequacy in managing pain at the donor site. The efficiency of the protocols could not be assessed due to the lack of data and inconsistency in pain assessment scales. Further investigation through randomized controlled studies is required.

Use of human recombinant bone morphogenetic protein is associated with increased hospital charges in children with cleft lip and palate having bone graft procedures

PURPOSE

There is wide variation in the timing of secondary alveolar bone grafting in patients with cleft lip and palate. The objective of the present study was to examine the timing and hospitalization outcomes of bone grafting procedures in a cohort of 5- to 13-year-old patients with a diagnosis of cleft lip and palate.

MATERIALS AND METHODS

The Nationwide Inpatient Sample for 2004 to 2010 was used. Outcomes examined included complications, disposition status, hospital charges, and length of stay. Multivariable linear regression analysis was used to examine the association between hospital charges and a group of heterogenous patient-level (age, gender, race, comorbid burden, insurance status, and concomitant procedures) and hospital-level variables.

RESULTS

In total, 3,478 patients underwent bone grafting procedures. Excision of bone for grafting was obtained from pelvic bones in 79.4% of cases. Recombinant bone morphogenetic protein (rhBMP) was inserted in 1% of all cases. Nearly 99% were discharged routinely. The overall complication rate was 1.5%. The mean length of hospital stay was 1.3 days and the mean hospitalization charge was $23,852 per case. Those who had insertion of rhBMP had an excess of $14,695 compared with those who did not have rhBMP after adjustment for all other variables (P<.0001).

CONCLUSIONS

Bone grafting procedures are safe when performed in patients 5 to 13 years old. Insertion of rhBMP was performed in nearly 1% of patients undergoing bone grafting procedures. Use of rhBMP was associated with a considerable increase in hospital charges.

Mid versus late secondary alveolar cleft grafting using iliac crest corticocancellous bone graft

BACKGROUND

Mid-secondary alveolar cleft repair performed at ages 9-12, in the mixed dentition stage, prior to eruption of the permanent canine, is generally accepted as the ideal time for residual alveolar cleft closure in cleft lip and palate cases with a cleft alveolus.

METHODS

In our study, four cases of mid-secondary and five cases of late-secondary alveolar cleft grafting were carried out using iliac crest corticocancellous bone graft. Clinical defect closure and radiographic bone fill were compared.

RESULTS

All the nine cases performed in the two different age groups showed excellent results, clinically, with complete closure of the cleft defect and achievement of continuity of the dental arches. One case was planned for a two-stage procedure owing to the large bilateral maxillary defects. Good bone fill was visualized radiographically in all nine cases.

CONCLUSION

Precise timing for undertaking alveolar cleft repair may not be all that crucial for a successful alveolar cleft grafting procedure.

Donor site evaluation: anterior iliac crest following secondary alveolar bone grafting

INTRODUCTION

The use of autogenous bone graft for Secondary alveolar bone grafting is well established in the treatment of cleft lip and palate patients.

AIMS AND OBJECTIVES

To evaluate post-operative morbidity of anterior iliac crest graft after secondary alveolar bone grafting in cleft patients.

MATERIAL AND METHODS

Forty patients during the period from July 2008 to March 2013, who underwent secondary alveolar bone grafting by harvesting graft from anterior iliac crest in Mamata Dental Hospital, Khammam, Andhra Pradesh, India are included in the present study. Unilateral and bilateral cleft patients who had undergone secondary alveolar bone grafting (SABG) with anterior iliac crest as their donor site have been selected and post- operative complications from the surgery were evaluated with the help of a questionnaire which included pain, gait disturbances, numbness and scar problems (infection, irritation).

RESULTS

Patients who were operated gave maximum score for pain as 8 on visual analogue scale. No pain was observed in any of the cases after 8 days, gait disturbances were seen in all patients (limping) for 2-6 days, there was no post-operative numbness with all the patients returning to their routine in 6- 15 days and 90% of the patients gave a satisfied response towards scar.

CONCLUSION

From the results in our study the morbidity after harvesting bone from iliac crest was found to be moderate to low, which had minimal complications and were well tolerated and greater acceptance from the patient.

Review of secondary alveolar cleft repair

INTRODUCTION

The alveolar cleft is a bony defect that is present in 75% of the patients with cleft lip and palate. Although secondary alveolar cleft repair is commonly accepted for these patients, nowadays, controversy still remains regarding the surgical technique, the timing of the surgery, the donor site, and whether the use of allogenic materials improve the outcomes. The purpose of the present review was to evaluate the protocol, the surgical technique and the outcomes in a large population of patients with alveolar clefts that underwent secondary alveolar cleft repair.

MATERIALS AND METHODS

A total of 109 procedures in 90 patients with alveolar cleft were identified retrospectively after institutional review board approval was obtained. The patients were treated at a single institution during a period of 10 years (2001-2011). Data were collected regarding demographics, type of cleft, success parameters of the procedure (oronasal fistulae closure, unification of the maxillary segments, eruption and support of anterior teeth, support to the base of the nose, normal ridge form for prosthetic rehabilitation), donor site morbidity, and complications. Pre- and postoperative radiological examination was performed by means of orthopantomogram and computed tomography (CT) scan.

RESULTS

The average patient age was 14.2 years (range 4-21.3 years). There were 4 right alveolar-lip clefts, 9 left alveolar-lip clefts, 3 bilateral alveolar-lip clefts, 18 right palate-lip clefts, 40 left palate-lip clefts and 16 bilateral palate-lip clefts. All the success parameters were favorable in 87 patients. Iliac crest bone grafts were employed in all cases. There were three bone graft losses. In three cases, allogenic materials used in a first surgery performed in other centers, underwent infection and lacked consolidation. They were removed and substituted by autogenous iliac crest bone graft.

CONCLUSIONS

THE USE OF AUTOGENOUS ILIAC CREST FOR SECONDARY ALVEOLAR BONE GRAFTING ACHIEVES ALL THESE SEVERAL OBJECTIVES: (1) to obtain maxillary arch continuity, (2) to maximize bone support for the dentition, (3) to stabilize the maxillary segments after orthodontic treatment, (4) to eliminate oronasal fistulae, (5) to provide nasal alar cartilage support, (6) to establish ideal alveolar morphology, and (7) to provide available bone with attached soft tissue for future endosteal implant placement in cases where there is a residual dental space. We advocate for the use of a minimal incision to obtain the iliac crest bone graft and for the use of a corticocancellous block of bone in combination with bone chips.

Continuous ropivacaine infusion vs transdermal fentanyl for providing postoperative analgesia following temporomandibular joint interpositional gap arthroplasty

AIM

The purpose of this study was to evaluate the postoperative pain control and mouth opening in patients undergoing temporomandibular joint interpositional gap arthroplasty by either placing an epidural catheter in the incision wound and infusing ropivacaine 0.25% or by using a transdermal fentanyl patch.

MATERIALS AND METHODS

The study was prospective, randomized and double blind. Eighty patients belonging to American Society of Anesthesiologists grade I and II, 18-32 years of age, scheduled for temporomandibular joint interpositional gap arthroplasty were randomized into 2 groups; ropivacaine group (G rop): to receive 0.25% ropivacaine infusion and transdermal fentanyl group (G tf): to receive transdermal fentanyl patch. For postoperative pain (Visual Analog Score [VAS]) and analgesic requirements were assessed 2, 4 and 8 h after surgery and each morning, until and 4 days after surgery.

RESULTS

Time to first analgesic requirement was found to be significantly (P < 0.0001) higher in G rop (49 ± 6.7) as compared with G tf (32 ± 9.1) VAS were also significantly lower in G rop throughout the postoperative period. Postoperatively, mouth opening was better in G rop as compared with G tf, which was statistically significant.

CONCLUSION

It was concluded that by placing an epidural catheter at the incision wound and continuously infusing with ropivacaine 0.25% effectively controls the postoperative pain in patients undergoing temporomandibular joint interpositional gap arthroplasty and provides better postoperative mouth opening.

Maxillonasal osteochondral complex repair in maxillonasal dysplasia

Surgical treatment of maxillonasal dysplasia or Binder syndrome is a challenge for surgeons. Its aim is to replace or substitute the missing or malformed anatomic structures. The authors report a comprehensive analysis for the understanding of the mechanisms resulting in the lack of maxillonasal development observed in Binder syndrome. The evolution of the surgical treatment due to facial function analysis is explained, and the surgical treatment of 20 consecutive cases over the last 20 years is reviewed, illustrated by three-dimensional reconstruction to emphasize the choice made and the results obtained. Bone grafts were always performed, and an arrow-shaped graft for the neospine reconstruction is described. This analysis allowed the authors to ameliorate patient self-image subsequently to facial contour improvement.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Continuous Bupivacaine Infusion Post-Iliac Crest Bone Graft Harvesting in Pediatric Cleft Surgery: Role and Comparison with Ketorolac

Objective

To investigate the use of intravenous ketorolac and iliac crest bupivacaine infusion in the management of iliac crest donor-site pain in the pediatric cleft population. The null hypothesis was there is no difference with respect to pain scores between ketorolac and iliac crest bupivacaine infusion as analgesic adjuncts to intravenous opioids.

Method

A total of 54 children and adolescents (27 boys, 27 girls) undergoing alveolar cleft repair or Le Fort I osteotomy were assigned randomly in a prospective, single-blinded fashion to one of three groups: intravenous ketorolac plus iliac crest normal saline infusion, intravenous ketorolac plus iliac crest bupivacaine infusion, or iliac crest bupivacaine infusion alone. Iliac crest infusions and ketorolac were administered for 48 hours or until discharge, whichever occurred first. All patients received morphine via a patient-controlled analgesia device.

Main outcome Measure(s)

Primary outcome was pain score, and secondary outcomes were morphine consumption and satisfaction scores.

Results

Pain scores, morphine consumption, and satisfaction scores were not significantly different among groups. Estimated costs were significantly higher for bupivacaine infusion than intravenous ketorolac.

Conclusions

Iliac crest donor-site pain is well managed in this patient population. Intravenous ketorolac and iliac crest bupivacaine infusion provide comparable analgesia for iliac crest bone graft donor-site pain in children and adolescents.

Anterior versus posterior approach to iliac crest for alveolar cleft bone grafting

PURPOSE

The goal of this study was to compare perioperative outcomes for the anterior versus posterior approach to the iliac crest for alveolar bone grafting in patients with cleft lip and palate (CLP).

MATERIALS AND METHODS

A retrospective cohort study of patients with CLP who had an anterior or posterior iliac crest bone graft during a 10-year period was performed. Available medical records were reviewed and the outcome variables documented included the operation site for bone graft procurement (anterior or posterior), estimated blood loss, duration of operation, concurrent procedures, and length of hospital stay. The 2 groups were compared by t test, Fisher exact test, and multivariate regression to show differences.

RESULTS

There were 239 patients with CLP who had an iliac crest bone graft to the alveolar cleft; 133 had an anterior and 106 a posterior approach for bone graft procurement. The mean estimated blood loss was significantly less with the posterior approach (85 vs 177 mL; P < .0001). The mean operation duration with the posterior approach was longer (4.6 vs 3.5 hours; P < .0001). Most patients in this group (67%), however, had 2 or more additional procedures during the same anesthetic, whereas only 16% of patients in the anterior group had 2 or more additional procedures. The mean length of stay was significantly shorter for the posterior approach (1.7 vs 2.2 days; P < .0001).

CONCLUSIONS

These results suggest that patients having a bone graft from the posterior iliac crest have a smaller estimated blood loss and a shorter length of stay. In addition, this approach permits repair of the alveolar cleft and additional procedures, including augmentation of the median tubercle and correction of nasolabial distortions, which are often present in patients with CLP.

Morbidity associated with iliac crest harvesting in the treatment of maxillary and mandibular atrophies: a 10-year analysis

PURPOSE

The iliac crest provides an important donor site for cancellous, cortical, and corticocancellous bone because it has the highest concentration of osteocompetent cells, offers sufficient volume, and is readily accessible. Although iliac crest harvesting is considered a common procedure in different medical specialities, donor site morbidity is a subject that requires further discussion. Moreover, the increasing number of bone grafts being undertaken stresses the importance of donor site morbidity in surgical planning and for patient consent. This study evaluated morbidity associated with iliac crest harvesting over a 10-year period and patients' overall satisfaction.

MATERIALS AND METHODS

This prospective study involved 235 patients who were scheduled for iliac harvesting procedures from April 2001 through May 2010. A standardized surgical procedure with an anterior approach was used for the harvesting of all iliac crest grafts. The following variables were considered: pain, discomfort, presence of functional disorders, presence of sensory disturbances, esthetic outcome, and patients' general satisfaction, which were evaluated using specific tests or questionnaires.

RESULTS

Ninety-nine percent of patients complained of mild pain 1 week after intervention but the pain rapidly disappeared after a few weeks. Functional disorders such as alterations in walking and lifting strength were reported by 100% of patients after intervention, but after 5 weeks this percentage had decreased substantially. Sensory disturbances such as hypoesthesia were recognized as transitory complications of iliac crest harvesting. A large percentage of patients were satisfied with the esthetic outcome of the intervention.

CONCLUSIONS

Although the anterior iliac crest is a donor site with low morbidity, many studies have reported contrasting results. These data support the idea that the surgical approach plays a crucial role in decreasing postoperative morbidity. Moreover, this study confirmed that the anterior iliac crest can be considered a first-rate option for bone-defect reconstruction because of its low morbidity. However, future improvements in bone substitutes may well change this situation.

Horizontal Ridge Augmentation Utilizing a Composite Graft of Demineralized Freeze-Dried Allograft, Mineralized Cortical Cancellous Chips, and a Biologically Degradable Thermoplastic Carrier Combined With a Resorbable Membrane: A Retrospective Evaluation of 73 Consecutively Treated Cases From Private Practices

Ridge deficiency is an unfortunate obstacle in the field of implant dentistry. Many techniques are available to rebuild the deficient ridge. Some of these techniques are associated with significant morbidity and often require a second surgical site. With the advent of guided bone regeneration (GBR), one may now graft the deficient ridge with decreased morbidity and without a second surgical site. The purpose of this retrospective consecutive case series from 5 private practices is to report on the outcomes of a composite material of demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically degradable thermoplastic carrier (Regenaform RT) when combined with a resorbable membrane for GBR of lateral ridge defects in human patients. The specific aim was to quantify clinical results through direct measurement. Data were obtained from 73 consecutively treated lateral ridge augmentations performed on 67 partial and/or completely edentate patients. Clinical data (presurgical ridge width, ridge width at implant placement, and bone density at implant placement) were obtained retrospectively from 5 private practices via an exhaustive retrospective chart review, which was pooled and averaged for analysis. The average gain in horizontal ridge width was 3.5 mm (range, 3–6 mm). The density of the bone was noted to be type 2 to 3, with type 3 being the predominant finding. This retrospective case series from 5 clinical private practices suggests that the use of a composite material of demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically degradable thermoplastic carrier, when covered by a resorbable collagen membrane for GBR, is an effective means of horizontal ridge augmentation.

Retrospective review of 99 patients with secondary alveolar cleft repair

PURPOSE

The purpose of the present review was to evaluate the protocol and technique used in a large population of patients with cleft lip and palate when secondary grafting is performed during the early mixed dentition stage, as determined by eruption of the central incisor. In the United States, most investigators have recommended alveolar grafting at the 9- to 11-year age range or before eruption of the permanent canines.

MATERIALS AND METHODS

An institutional review board-approved chart review of 99 patients undergoing alveolar cleft bone grafting during a 7-year period at a single institution was performed. Data were collected regarding demographics, operative time, length of hospitalization, follow-up time, complications, and additional procedures performed. The cases were divided by patient age into 2 groups: group 1, aged 6 to 8 years (n = 61); and group 2, aged 9 years and older (n = 38). Statistical analysis was performed for various comparisons in the study.

RESULTS

The average operative time for groups 1 and 2 was 86 and 103 minutes, respectively. The complication rate, length of stay, and follow-up time between the 2 groups was not statistically significant at the P = .05 significance level.

CONCLUSIONS

We recommend earlier bone grafting at or before the eruption of the central incisor, rather than delaying until the cuspid tooth root is 25% formed. We believe this will provide better bone support for the dentition, a decreased burden of treatment for the patient, and improved quality of life. Performing the procedure at this time can lead to decreased operative times, with comparable postoperative outcomes.

Use of a modified epidural catheter for analgesia after iliac crest bone procurement

BACKGROUND AND OBJECTIVES

Autogenous bone grafting is the gold standard procedure for various maxillofacial defects which needs surgical correction and anterior iliac crest is the most common site of harvest. Immediate postoperative pain at the harvested site is a major morbidity associated with it. The aim of the study was to assess the immediate postoperative pain control at the iliac crest graft harvested site by placing an epidural catheter in the incision wound and continuously infiltrating bupivacaine 0.25% at regular intervals.

MATERIALS AND METHODS

Twenty patients requiring autogenous bone grafting for large maxillofacial defects were chosen for the study. They were divided randomly into two groups of ten each. Group 1 patients were placed with epidural catheter in the incision wound at iliac crest harvested site and group 2 patients did not receive epidural catheter. Continuous infiltration of long acting amide local anesthetic (Bupivacaine) was given to group 1 patients on the postoperative day. Both group 1 & group 2 patients received parenteral analgesic Diclofenac sodium 75mg intramuscularly. Pain at the iliac crest and maxillofacial area was assessed by VAS scale. Also the time of ambulation of the patient was noted. These variables were compared statistically.

RESULTS

The observed findings were statistically analyzed. Group 1 patients showed significant pain relief at the graft harvested site as compared to group 2 patients. Also the patients in group 1 were ambulated early as compared to group 2 patients.

INTERPRETATION AND CONCLUSION

It was concluded that by placing epidural catheter at the incision wound and continuously infiltrating with bupivacaine 0.25% at iliac crest harvested site at regular intervals effectively controls the immediate acute pain postoperatively and the patient can be ambulated and brought back to normal routine early.

A Comparison of Shepard's Osteotome versus Trapdoor Flap Technique to Harvest Iliac Crest Bone for Secondary Alveolar Bone Grafting

Objective:

To compare the postoperative donor site morbidity and alveolar bone graft results following two different techniques for iliac crest bone graft harvest: a closed (Shepard's osteotome) and an open (trapdoor flap) technique.

Design:

A retrospective review of two cohorts of alveolar bone grafts performed from 1998 to 2004 in Birmingham Children's Hospital by two surgeons using different harvest techniques. Medical and nursing anesthetic notes and medication charts were reviewed. Alveolar bone graft results were assessed using preoperative and postoperative radiographic studies.

Patients:

A total of 137 patients underwent an operation. Of these, 109 patients were compatible with the inclusion criteria (data available, first operation, no multiple comorbidities). Sixty-four patients had iliac bone harvested using the open trapdoor technique, while 45 had the same procedure using the closed osteotomy technique.

Results:

Maximum bone graft volumes harvested were similar with both techniques. The mean length of hospital stay was 50.9 hours for the osteotome and 75.5 hours for the open technique group (p < .0001). The postoperative analgesia requirement was higher and the postoperative mobilization was delayed and more difficult for the open technique patients (p < .0005). Kindelan scores performed by two independent orthodontists were similar for both techniques.

Conclusion:

The findings demonstrate that harvesting bone from the iliac crest using an osteotome technique reduces time in hospital, analgesia requirements, and postoperative donor site morbidity with no detrimental outcome.

Bone morphogenetic protein-induced repair of the premaxillary cleft

PURPOSE

The purpose of this study is to evaluate the bony regeneration of premaxillary clefts in humans using recombinant human bone morphogenetic protein type 2 in a collagen sponge carrier.

PATIENTS AND METHODS

Twelve patients with unilateral clefted premaxillas were evaluated preoperatively and 4 months postoperatively. Ten patients were repaired with recombinant human bone morphogenetic protein type 2 while 2 others were grafted with anterior iliac crest particulate marrow cancellous bone. Computed tomographic studies were used to evaluate preoperative alveolar cleft volumes, postoperative bone bridge volumes, and preoperative and postoperative volume ratios.

RESULTS

A preoperative and postoperative volume ratio for patients repaired with recombinant human bone morphogenetic protein type 2 ranged from 24.1% to 90.6% with a mean of 71.7%. Patients who were grafted with particulate marrow cancellous bone had similar preoperative and postoperative volume ratios ranging from 71.3% to 84.9% with a mean of 78.1%.

CONCLUSIONS

Clefts of the anterior maxilla can have complete osseous regeneration induced by recombinant human bone morphogenetic protein type 2 as an effective alternative to conventional anterior iliac particulate marrow cancellous bone grafts.

The Role of Functional Orthodontic Stress on Implants in Residual Alveolar Cleft

BACKGROUND

The most widely accepted protocol for alveolar cleft reconstruction is repair during the mixed dentition stage (age, 9 to 11 years), before eruption of the canine teeth. Alveolar bone grafting should not be considered as an isolated therapy but always as an integrated part of comprehensive orthodontic treatment.

METHODS

The authors evaluate the results of transitional secondary osteoplasty, comparing the use of autogenous cancellous bone versus heterogenetic implants, in patients with unilateral complete clefts who did or did not undergo orthodontic treatment. From 1990 to 1994, 48 patients aged between 9 and 11 years with unilateral alveolar cleft underwent alveolar grafting by transitional secondary osteoplasty. In 30 patients (group A), autogenous cancellous bone was used, and in 18 patients (group B), a heterogenetic implant consisting of demineralized bone powder containing bone morphogenetic protein and hydroxylapatite was used.

RESULTS

Twenty-two patients in group A and 12 patients in group B underwent orthodontic treatment. After 10 to 12 years of follow-up, the clinical and radiographic examinations revealed that the best alveolar bone repair results were obtained using autologous bone graft in association with orthodontic treatment. Also, in the patients who underwent heterogenetic implantation, the orthodontic treatment clearly improved the quality of the osteoplasty.

CONCLUSIONS

The essential conditions for a successful osteoplasty include meticulous operative technique and orthodontic treatment. The latter plays an essential role at several stages of development in children with clefts. The "functional stress" on the autologous or heterogenetic implant exerts a decisive influence on the quality and volume of the osteoplasty, preventing progressive resorption.

Ambulatory in-office anterior iliac crest bone harvesting

OBJECTIVE

A prospective study was performed to evaluate the harvesting of autologous bone within the private practice environment, using either a power-driven trephine or corticocancellous block harvesting, and to assess the clinical safety, postoperative morbidity, and patient satisfaction associated with this application.

STUDY DESIGN

Thirty-nine patients requiring 40 bone harvests from the anterior iliac crest for maxillofacial reconstruction were included for study. The ages ranged from 16 to 73 years (mean 48.4 years). All surgeries were performed by a single surgeon. Patients were recovered and discharged home directly from the office.

RESULTS

Forty iliac crest harvests were performed in the private practice venue from 2001 to 2004, 23 by motorized trephine and 17 by open corticocancellous block harvest. No peri-operative complications were encountered. Postoperative questionnaires were returned by 32 patients. Thirty patients reported that they would undergo hip surgery in an ambulatory environment again if required.

CONCLUSION

Harvesting of bone from the anterior iliac crest is a safe and predictable surgical procedure for the private oral and maxillofacial surgical practice setting in selected cases, resulting in a low complication rate. Patient acceptance of this surgery in the private practice venue is high.

Kombination der Sinusliftoperation mit der lateralen Kieferkammaugmentation

PURPOSE

This paper describes a surgical and prosthetic procedure for treating the extremely atrophic maxilla. It explains a two-staged surgical technique, donor and recipient site morbidity, implant survival, and the implant-retained prosthetic rehabilitation of the patients.

PATIENTS AND METHODS

A total of 57 consecutive patients were treated with a sinus lifting procedure and a simultaneous lateral augmentation using autogenous corticocancellous block and particulate bone grafts from the iliac crest. After a 6-month bone healing period, a total of 284 endosteal Titanium screw implants were inserted. Following a 3-month osseointegration period, the implants were exposed and loaded with either fixed or removable prostheses.

RESULTS

In three cases a partial bone graft loss was observed; however, enosseous implantation was possible as planned. During the observation period none of the 284 implants was lost; 3 implants exhibited treatable peri-implant infection. Complications at the donor and recipient sites were minimal and did not negatively influence the overall clinical result of the treatment.

CONCLUSION

The combination of sinus lift procedure and lateral augmentation for the treatment of the extremely atrophied maxilla proved to be a safe method that produces good and reliable clinical results.

Autogenous Calvarial Bone Graft Harvest: Intraoperational Complications

In the field of maxillofacial reconstructive surgery, the authors take into consideration the autogenous calvarial bone graft harvest technique for the correction of maxilla bone defects and examine some salient aspects such as technical problems and possible surgical complications.

Alveolar Ridge Augmentation: A Comparative Longitudinal Study Between Calvaria and Iliac Crest Bone Grafts

Insertion of endosseous implants is often difficult because of lack of supporting bone. In the case of severe atrophy of the jaws, a large volume of autogenous bone can be harvested from the iliac crest and calvaria. Both grafts undergo partial resorption with time, but the rate of bone loss has not been fully elucidated. The aim of this study was to evaluate the alveolar bone height gain (ABHG) obtained with iliac crest and calvaria bone grafts. Twenty-five patients had mandibular bone grafts, 32 had maxillary bone grafts, and 11 had both mandibular and maxillary bone grafts. Measures were made on preoperative, postoperative, and follow-up radiographs. A general linear model was used to evaluate the rate of ABHG plotted against months elapsed from the time of the operation to the time of follow-up. General linear model output showed a statistically significant effect for only the type of donor bone graft (P = .004), with a better ABHG for calvaria. The iliac crest bone grafts lost most of the ABHG in the first 6 months, whereas calvaria bone grafts lost ABHG over a greater interval of time. The type of bone graft is the strongest predictor of ABHG, and calvaria bone graft had a higher stability than did iliac bone graft. However, the gap in ABHG between the 2 grafts tended to decrease over time.

Management of alveolar clefts

Treatment philosophies in the management of alveolar clefts have changed greatly over the years. Currently. the most widely accepted protocol is for repair using autologous cancellous bone from the iliac crest during the stage of mixed dentition. Preliminary data suggest that the appropriate age for surgical repair during the secondary phase can be decreased without evidence of limitation of facial growth. Further long-term studies are necessary to support this protocol, however. With a multidisciplinary approach between the various medical and dental specialties, it is now commonplace to achieve normal dentofacial aesthetics and function. The continued advances in medical and dental technology have further contributed to the excellent outcomes that are now achieved.

Morbidity of harvesting of bone grafts from the iliac crest for preprosthetic augmentation procedures: A prospective study

It has been the aim of the present prospective clinical study to assess the morbidity following the harvest of bone from the anterior and posterior ilium in elective preprosthetic augmentations. Fifty consecutive healthy patients (30 female, 20 male, mean age 52.5+/-9.3 years, range 31 years to 65 years) underwent augmentations of implant sites by iliac crest bone grafts. The bone harvest was carried out in 25 cases from the anterior and in 25 cases from the posterior ilium. The superficial sensory function of the skin was determined quantitatively preoperatively, 7 and 30 days after surgery with the 'Pain and Thermal Sensitivity' Test (PATH Test). On the same occasions subjective pain on a visual analogue scale (VAS) and gait disturbances were documented. In the PATH Test, for the innervation areas of the lateral femoral cutaneous nerve (LFCN) and the superior and middle cluneal nerves (SMCN) a significant impairment of the superficial sensory function could be found after 1 week and a significant tendency towards recovery after 1 month (warm stimulus(FCNpreop) 37.9+/-3.0 degrees C, warm stimulus(LFCNday7): 38.6+/-3.2 degrees C, warm stimulus(LFCNday30): 37.9+/-2.9 degrees C, P(LFCNwarmpreop/day7)=0.023,P(LFCNwarmpreop/day30) =0.886, warm stimulus(SMCNpreop): 36.1+/-2.4 degrees C, warm stimulus(SMCNday7): 36.6+/-2.3 degrees C, warm stimulus(SMCNday30): 36.3+/-4.0 degrees C,P(SMCNwarmpreop/day7) <0.0005,P(SMCNwarmpreop/day30) =0.086). Gait disturbances were seen in seven patients after anterior and in three patients after posterior bone harvest 7 days after surgery (P(gaitdisturbanceanterior/posterior)=0.123). After 1 month none of the patients of both groups showed gait disturbances any longer. The maximum subjective pain level was found on the second postoperative day in both groups. It was significantly higher for the anterior approach (VAS(anteriorday2) 7.0+/-1.5, VAS(posteriorday2) 5.5+/-1.8,P(VASanterior/posteriorday2) =0.004). At day 7 and at day 30, the pain levels did no longer differ significantly (VAS(anteriorday7) 3.7+/-1.4, VAS(posteriorday7) 3.2+/-1.6,P(VASanterior/posteriorday7) =0.165, VAS(anteriorday30) 1.4+/-0.7, VAS(posteriorday30) 1.4+/-0.8,P(VASanterior/posteriorday30) =0.724). Because of the lower morbidity of bone harvest from the posterior ilium in the early postoperative phase compared to the anterior approach it seems that it should be preferred in elective augmentation procedures.

Canine eruption into grafted alveolar clefts: A retrospective study

BACKGROUND

The contemporary treatment of cleft lip and palate involves a sequence of surgical procedures and orthodontic management. Alveolar bone grafting (ABG) is usually undertaken after orthodontic expansion of the maxillary segments between the ages of eight and 12 years. Two of the important goals of alveolar bone grafting are the provision of bony support for the eruption of the canine and the closure of residual oro-nasal fistulae. The purpose of this study was to retrospectively evaluate the root development and eruption of the canine following ABG.

METHODS

Group 1: radiographic and clinical records of a sample of 19 cleft patients who underwent alveolar bone grafting procedures, performed between 1996 and 1999 were reviewed. Group 2: a random sample of 15 cleft patients attending for routine dental review were clinically examined. The age of patient, degree of root development and eruption status of the canine, and presence of oronasal fistulae pre and post alveolar bone grafting were evaluated.

RESULTS

Most cleft canines had continued root development and descended in the alveolus towards eruption following ABG. Four canine teeth (8 per cent) were impacted and required surgical exposure and orthodontic treatment following failure of eruption. Closure of anterior oro-nasal fistulae at the time of grafting was maintained post-operatively.

CONCLUSIONS

This study demonstrated that canine root development and eruption continued satisfactorily through grafted alveolar clefts in most cases and closure of anterior oro-nasal fistulae was achieved in all cases.

Cancellous bone grafting in alveolar cleft repair: new experience

Bone grafting plays an important role in the dental rehabilitation of patients with alveolar cleft. During the period between 1993 and 2001, 12 patients with alveolar clefts have been treated in our clinic. Cancellous iliac bone grafts were used in all 12 patients. Seven patients had left and five patients had right complete unilateral cleft lip and complete cleft palate operations. All patients had palatal fistulas. The ages were between 4 and 18 years (mean age, 10.5 y). Seven of them were female (58.4%) and 5 were male (41.6%). All the cancellous grafts survived. Enough filling and the closure of the fistulas were achieved except one patient who had wound dehiscence and partial graft loss. The patients experienced a limp for 2 days (mean time) because of the donor site. This surgical procedure achieves successful results if it is used with the proper indication in suitable cases.

Iliac crest donor site morbidity following open and closed methods of bone harvest for alveolar cleft osteoplasty

Donor site morbidity after bone harvesting still remains a crucial problem in alveolar cleft osteoplasty. This study focuses on ilium donor site morbidity comparing two different techniques. A series of 52 consecutive patients was divided in half. All had anterior iliac crest bone grafts. In the study group the harvesting was performed with a closed osteotomy using a cylindrical Shepard osteotome. The control group underwent the traditional open osteotomy. In the open osteotomy group the short-term morbidity at the donor site was slightly greater than in the closed harvesting group. The low short-term morbidity in the closed harvesting group was reflected in the analgesic consumption which was three times higher in the open osteotomy group (p < 0.008). The most striking difference occurred in the appearance of the mature scar: a length of 24.2 mm (mean) in the closed harvesting group against 60.3 mm in the open osteotomy group (p < 0.0001), and a width of 4.9 mm (mean) versus 7.7 mm, respectively (p < 0.003). The long-term morbidity was negligible in both groups. Based on these findings we suggest that bone harvesting from the anterior iliac crest remains the preferred method, provided that closed harvesting is undertaken.

Iliac crest bone graft harvesting techniques: a comparison

This study was undertaken to compare the morbidity of traditional iliac bone graft harvesting techniques for grafting alveolar clefts to minimally invasive techniques. Fifty-five age-matched patients, ages 6.5 to 16 years (mean, 11.2 years), 22 girls and 33 boys, were divided into three groups. The traditional bone window open harvesting technique served as the control group. Two different minimally invasive techniques, one that used a bone grinder and another that used a trephine, for bone harvesting were compared with the control. Both invasive techniques were statistically superior, p < 0.05, in terms of total time pain medication was necessary (mean of 12.0 hours for bone grinder, 17.6 hours for trephine, 26.0 hours for control), operative time for bone harvest (mean of 11 minutes for bone grinder and trephine, 20 minute for control), and mean incision length (2 cm for bone grinder and trephine, 5 cm for control). Patients exposed to the minimally invasive techniques had fewer complications, a trend toward earlier ambulation, and shorter hospital stays when compared with the bone grinder technique. The patients exposed to the bone grinder demonstrated earlier ambulation and fewer requirements for analgesia when compared with the trephine technique, although these results did not reach statistical significance. The trephine technique was useful when maxillary osteotomies were combined with alveolar bone grafting, because it provided structural bone grafts and cancellous bone. On the basis of these findings, the bone grinder is the preferred technique for harvesting alveolar bone grafts when no structural support is required. These authors no longer use the traditional bone window open harvesting technique.