Reconstruction of secondary alveolar cleft (very late secondary osteoplasty) with iliac graft and protein rich fibrin - A Case Report

Dr. Divya James¹, Dr. M. R. Muthusekhar²

¹Postgraduate Student, Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha University, Chennai

²Professor and HOD, Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha University, Chennai

*Corresponding Author E-mail: muthusekhar55@gmail.com

Abstract:

Cleft of the palate and lip have intrigued the clinician for a very long time. Commonest congenital anomaly to affect the orofacial region and since the time of Veau (1931), and at various times efforts have been made to classify and repair these anomalies. Conflicting claims have been made with regard to success and time of surgery in this area. Prominent among these have been the studies of Bohn, Bjork and Skieller, Waite and Kersten and Boyne and Sands. The ilium bone is used most commonly as it is easy to access and large amount of bone can be obtained from the area.

KEY WORDS: Orofacial, regurgitation, distortion.

INTRODUCTION:

In children with cleft lip and palate, cleft within the region of the alveolar process is commonly left untreated, with cosmetic repair of the lips and nasal deformities and useful repair of the palate taking precedence. However, alveolar cleft repair is crucial for closure of an oronasal communication/fistula, thereby eliminating liquid regurgitation into the nose; and for achieving continuity and stability of the alveolar process. It additionally helps in providing support to the alar base of the nose and establishment of a correct alveolar contour and a normal dental arch preventing vital maxillary segmental collapse, constriction and arch distortion. The graft aditionally provides bone volume for tooth eruption, also orthodontic movement of teeth by establishing a favorable osseous environment that encourages canine eruption into the arch and provides good periodontal support for teeth adjacent to the cleft [1].

The objectives of alveolar bone grafting includes:

1 To restore function and form by stabilizing the maxillary segments to form a continuous arch form.

2 For provision of an osseous environment which is responsive to orthodontic movement of teeth.

3 For prosthodontic rehabilitation.

The secondary objectives include: elimination of oronasal fistulae; provision of greater periodontal support for teeth adjacent to the cleft and augmentation of bony support for the lip and alar base [2]. Although the objectives of surgery have been unanimous, the ideal timing for alveolar cleft grafting still remains rather controversial.

The timing of graft placement is based more on dental development and may be classified as follows [3]:

A. Primary osteoplasty [3, 5].

B. Secondary osteoplasty, which can further be divided into:

a. Early secondary, performed between 2 and 8 years of age

b. Mid-secondary, performed at chronological age of 9–12,

c. Late secondary, performed between 12 and 16 years of age

d. Very late-secondary, performed later than 16 years of age [3,6,7].

Of these, ‘mid-secondary repair’ performed between the age of 9 and 12 has been shown by several studies to be ideal [1–4]. This article presents four cases of ‘very late secondary repair’ of alveolar clefts performed in a 29 year old patient.

The outcome was based on:

Radiographic appearance of the bone fill and the occlusal level as well as basal of the newly formed interdental bone at the grafted cleft site, at 3 months post-op.

Case Report:

A 29 year old female patient, reported to the department of oral and maxillofacial surgery with an ongoing orthodontic treatment since 2 years. History of surgeries performed earlier for repair of cleft lip and palate. Intraoral examination showed congenitally missing 12, 22.

Radiographic examination showed bone defect seen in the labial region of anterior teeth and in the palatal region. Impacted teeth present in relation to 23.

Treatment plan- Alveolar bone grafting with iliac graft and protein rich fibrin.

Local anaesthesia in filtrated in the right iliac region. Incision placed in the anterior iliac crest. Subcutaneous tissue elevated, iliac bone exposed. Iliac bone harvested. Crevicular incision placed from 21 to 23 region and 11 to 13 region. Mucoperiosteal flap elevated and nasal mucosa was separated. Iliac bone graft and protein rich fibrin placed in the alveolar cleft region. Incision was sutured.

Patient was followed up till 3 months and bone fill was checked radiographically.

RESULTS:

The case performed in the very late age group showed excellent results, clinically, with complete closure of the cleft defect and achievement of continuity of the dental arches.[8-12] Radiographic bone fill was checked post - operatively. Good bone fill was visualized radiographically also.[13-20]

CONCLUSION:

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

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Received on 10.03.2018 Modified on 22.04.2018

Research J. Science and Tech. 2018; 10(4):233-236.

DOI: 10.5958/2349-2988.2018.00033.5