Abstract
Bone grafting is a successful protocol for cleft repair but it is very challenging to close large gaps using local gingival tissue. In the last decade, interdental distraction osteogenesis has been introduced as a successful treatment protocol for repairing such large clefts. In this article a new method for closing the alveolar cleft is introduced and one case is presented. A tooth supported distractor which was specially designed to be inserted on to the main arch wire was used for the distraction. The aim was to distract the tooth segments through the curve of the dental arch and achieve complete closure of the gaps. The distractor introduced had several advantages: it is simple to apply, activate and remove; there is no need for a second operation; it is an outpatient procedure. In the case reported, a very large gap was successfully closed using this protocol whilst maintaining the ideal arch form and generating new bone behind the distracted segments.
Surgical closure of cleft defects is a challenging procedure for the clinician. Bone grafting is the usual, and successful, procedure, which has been carried out for many years . During bone grafting, the graft area should be covered properly by the neighbouring gingival tissue. When there is not enough gingival tissue around the defect for restoration, surgeons tend to use a buccal soft tissue graft or tongue tissue graft to cover the bone graft. Both tissues have a rich blood circulation, so are successful for the primary maintenance of the bone graft tissue, but it is not possible to move teeth along these tissues.
If the cleft is very large it is difficult to close the gap using local gingival tissue. Recently, interdental distraction osteogenesis has been introduced for repairing clefts larger than a canine tooth . The method was used to decrease the size of the gap before grafting and performing gingivoperiosteoplasty.
In this article, a new method for closing the alveolar cleft is introduced by describing one case. A tooth supported distractor, specially designed for distraction through the curve of dental arch is introduced and the clinical results of the procedure discussed.
Case 1
The patient was a 22-year-old female who had double jaw surgery 3 months previously. She had Class I dental relationship, normal overjet and overbite and a unilateral residual alveolar cleft on the left side. Upper left incisors and canine (21, 22 and 23) were congenitally absent on the clefted side and the gap was very large, extending towards the nasal floor ( Fig. 1 a and b ). The surgeon had concerns about the success of the grafting protocol and he proposed two interventions to achieve a better result. This led the authors to consider closing the gap using alveolar distraction and the protocol was designed accordingly. The upper arch was banded and bonded with 22 slot brackets. Other than first molars, bands were adjusted and bonded for 12 and 13 to avoid bracket failure on these teeth. The upper teeth were realigned and relevelled until 19 × 25 SS wires could be fully inserted in the slots. An archwise distractor designed by Erverdi (Tasarım Med, Istanbul, Turkey) was used for moving the alveolar segments. The body of the distractor was made of titanium and the rods were made of stainless steel. Every half turn (180) of the screw equals 0.5 mm activation and the maximum opening was 13 mm. It was possible to achieve larger amounts of distraction with the same device simply by closing the screw then adding crimpable tubes on the sides of the distractor and then reactivating the screw.
Two distractors were placed on the archwire between teeth 12 and 13 and 25 and 26 ( Fig. 2 a ). The plan was to distract the alveolar segment containing upper right central and lateral and the segment containing upper left bicuspids towards the cleft area until the segments were in contact. The patient was operated on under general anaesthesia for the osteotomy of alveolar segments. The miniplates that were close to the osteotomy lines (that remained from previous surgery) were removed during the surgical intervention. The osteotomy was performed by making vertical cuts distal to 12 and 25 on the vestibular buccal bone and extended until the palatal cortical bone and these vertical cuts were connected with a horizontal cut above the apices of the teeth. Piezo surgery was used to avoid injury to the palatal periosteum during the surgical procedure. Mobility of the segments was monitored by activating the screw several times, and then the screw was deactivated to the original position.
