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. An untreated alveolar cleft may result in an oro-nasal fistula, speech pathology, dental crowding, antero-posterior and transverse deficiency of the maxilla, fluid reflux, lack of bone support for the anterior teeth, and facial asymmetry. Enemark et al. advocated that those with a symptomatic oro-nasal fistula or with a lack of bone accommodating 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 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. 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. 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.
In our institution, reconstruction of alveolar defects in patients with CLP has routinely been performed with a mandibular symphyseal bone graft (MSBG) since 1988. 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.
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. 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. 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.
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.
Materials and methods
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.
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.
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 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. 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 Quétin Dental Products, Germany) with 3-mm perforation to obtain bone graft particles with a size of 0.5–2 mm 3 . 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 custom-made 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 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.
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. 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.
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 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.
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 .
|Teeth extracted preoperatively||45 patients (41%)|
|Protection splint||79 patients (71%)|
|Teeth extracted intraoperatively||29 patients (26%)|
|Duration of surgery||105 ± 30 min (range 35–205 min)|
|Incident||During hospitalization (111 patients)||From discharge to 1-month follow-up (111 patients)|
|Loosening of splint||1 (0.9%)||2 (1.8%)|
|Pain||7 (6.3%)||2 (1.8%)|
|Sensory deficiency||8 (7.2%)||2 (1.8%)|