Subido por Elizabeth Cruz

1-s2.0-S1010518215003224-main

Anuncio
Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 21e26
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery
journal homepage: www.jcmfs.com
Evaluation of success of alveolar cleft bone graft performed at 5 years
versus 10 years of age*
de
ric Bodin a, Bruno Grollemund a, Thomas Bridonneau a,
Caroline Dissaux a, *, Fre
Isabelle Kauffmann a, b, Jean-François Mattern c, d, Catherine Bruant-Rodier a
a
Cleft Competence Center, Maxillofacial and Plastic Surgery Department (Head: Catherine Bruant-Rodier, MD, PHD), Strasbourg University Hospital,
^pital, 67091 Strasbourg, France
1 place de l'Ho
b
^pital de Hautepierre, Avenue Moli
Pediatric Surgery Department, Strasbourg University Hospital, Ho
ere, 67200 Strasbourg, France
c
^pital de Hautepierre, Avenue Moli
Imaging Department, CBCT Department, Strasbourg University Hospital, Ho
ere, 67200 Strasbourg, France
d
Cabinet de radiologie et d'imagerie m
edicale de Bischwiller, 13 rue Poincar
e, 67240 Bischwiller, France
a r t i c l e i n f o
a b s t r a c t
Article history:
Paper received 17 March 2015
Accepted 17 September 2015
Available online 19 October 2015
Background and purpose: Although alveolar cleft bone grafting is the most widely accepted approach,
controversies remain on the operative timing.
Methods: A consecutive retrospective series of 28 patients who received alveolar bone grafting was
examined and divided into 2 groups depending on the age at the time of bone graft. Group A (14 patients) was operated at a mean age of 5.2 years [range, 4e7] and Group B (14 patients) at a mean age of
10 years [range, 8.5e13].
All the children were assessed clinically and by Cone Beam Computed Tomography (CBCT) before
bone grafting and 6 months post-operatively. Cleft and bone graft dimensions, volumes were assessed
using Osirix v.3.9.2. Residual bone graft coefficient (Bone Graft Volume on 6-months Postoperative CBCT/
Alveolar Cleft Volume) was calculated. Complications, tooth movement or dental agenesis were also
reported.
Results: The sample was uniform within both groups, considering cleft forms, pre-surgical fistula rate
and cleft volume. Residual bone graft coefficient reached 63.3% in Group A and 46.2% in Group B
(p ¼ 0.012). Results of residual bone graft are also influenced by tooth eruption through the graft
(p ¼ 0.007 in Group A and p ¼ 0.02 in Group B).
Conclusions: This 3D analysis highlighted higher success of alveolar bone grafts when children are
operated earlier around 5 years.
Level of evidence: Therapeutic study. Level III/retrospective comparative study.
© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.
Keywords:
Cleft lip and palate
Alveolar bone grafting
Treatment outcome measures
1. Introduction
In patients with cleft lip and palate, managing residual alveolar
cleft is essential to restore maxillary segment union and stability,
allow tooth eruption, close alveolar fistula, and provide support to
the lip and the nose (Witsenburg, 1985).
*
Reference institution of the study: Maxillofacial and Plastic Surgery Depart^pital,
ment, Cleft Competence Center, Strasbourg University Hospital, 1 place de l'ho
67091 Strasbourg, France.
* Corresponding author. Maxillofacial and Plastic Surgery Department, Stras^ pital Civil, 67091 Strasbourg, France.
bourg University Hospital, 1 place de l'Ho
Tel.: þ33 6 59433615.
E-mail
addresses:
carodissaux@gmail.com,
caroline.dissaux@nck.aphp.fr
(C. Dissaux).
However, different modalities may be used. Before the 1970s,
primary osteoplasty was routinely performed until Robertson
(Robertson and Jolleys, 1968) and Rherm (Rherm et al., 1969)
showed its adverse developmental effect on maxillary growth.
Secondary alveolar bone grafting has since been developed and is
now well established following the original work of Boyne and
Sands (1972). The bone that is most commonly used is the
cancellous iliac bone, but the tibial shaft, mandible, rib, and calvaria
may also be used.
The procedure is usually performed when the patient is between 9 and 12 years old, in a mixed dentition, before eruption of
the canines so that they may erupt through the grafted site.
More recently, other authors (Borstlap et al., 1990; Lilja et al.,
2000; Talmant et al., 2002) have advocated that alveolar bone
http://dx.doi.org/10.1016/j.jcms.2015.09.003
1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
22
C. Dissaux et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 21e26
Table 1
Patient characteristics and distribution of cleft forms.
Age at time of alveolar
bone graft (years)
Number of patients
UCLA
UCLP
BCLP
Number of grafts
Sex ratio
Retro-alveolar fistulas
Orthopedic maxillary
expansion
Group A
Group B
5.2 (4; 7)
10 (8.5; 13)
14
2
10
2 (1 only grafted
on 1 side)
15
4 F/10 M
3
13
14
2
9
3 (1 only grafted
on 1 side)
16
3 F/11 M
3
13
UCLA ¼ unilateral cleft labio-alveolar; UCLP ¼ unilateral cleft lip and palate;
BCLP ¼ bilateral cleft lip and palate.
grafting be performed before the eruption of maxillary lateral incisors, when the patient is between 4 and 6 years old. The graft
allows the lateral incisor to erupt through the grafted bone, and
these authors reported better results in terms of residual bone
height.
The primary aim of this study was to compare the results of
bone grafts performed in patients at 5 and 10 years of age. The
secondary aim was to show the value of Cone Beam Computed
Tomography (CBCT) in bone graft assessment.
2. Material and methods
Twenty-eight consecutive pediatric patients received secondary
alveolar bone grafts between January 2012 and February 2013 at
our institution.
Inclusion criteria were as follows: (a) Children had to have undergone operation by the same surgeon; (b) Children had residual
alveolar clefts. The same operations were performed during the
first year of life (3 months: Millard lip closure without gingivoperiosteoplasty; 6 months: one-stage palatoplasty using
VeaueWardill flaps); (c) No patients belonged to a syndrome; (d)
No attempt at previous grafting had been done.
Patients were divided into two groups. Group A (14 patients)
received secondary bone graft at a mean age of 5.2 years (range:
4e7 years); and Group B (14 patients) underwent operation at a
mean age of 10 years (range: 8.5e13 years). Patient characteristics
and distribution of cleft forms within both groups are presented in
Table 1. Fistulas located right behind the maxillary arch, also known
as retroalveolar fistulas, were also recorded.
In each group, 13 patients required maxillary transversal
expansion before grafting.
Secondary alveolar bone grafting was performed following
previously described principles (Boyne and Sands, 1972; Abyholm
et al., 1981; Bergland et al., 1986), and the cancellous bone harvested from the iliac crest was used.
Patients were asked to begin to brush their teeth 1 day after
surgery and to have a full liquid diet for 10 days and then to eat food
that did not need to be chewed for an additional 3 weeks.
All children were assessed clinically and by CBCT (QR Newtom
5G, 1 slice/0.15 mm) the day before bone grafting and 6 months
after surgery. Tooth movements were recorded on clinical examination and CBCT images. Early and late complications were also
reported.
2.1. Data acquisition
Preoperative CBCT was used to assess cleft volume and dimensions, whereas postoperative CBCT allowed estimating the residual graft volume.
All data recorded in Digital Imaging and Communications in
Medicine (DICOM) format were transferred to Osirix v.3.9.2
software.
On preoperative CBCT images, the maximal height, maximal
width, and maximal length of the cleft were measured using the
rulers along the edges. On postoperative CBCT images, the same
dimensions were reported for the graft.
Maximal graft dimensions are expressed as a percentage of
maximal cleft dimensions.
Alveolar clefts and bone grafts were delimited on each slice
using the drawing tool. The X, Y, and Z planes, as well as scanning
information, were used to delineate the measurement areas for the
alveolar cleft and the graft. This way, the alveolar cleft volume was
measured on transversal areas between two sagittal planes and two
coronal planes (an upper area on the nasal floor and a lower area on
the tooth cervix). These planes were based on the limit between the
bone and the air on the noncleft side. Multiplanar views or a single
plane in the full-screen window could be selected to facilitate graft
edge location, as well as the corresponding preoperative image
superimposition. Collection of these slices was stacked to produce a
3D volume (Fig. 1). The volume of the entire structure was calculated and shown by the system.
The residual bone graft coefficient (%) was calculated using the
following formula: Bone Graft Volume on CBCT image 6 months
post surgery/Alveolar Cleft Volume.
Fig. 1. Example of bone graft volume acquisition. The alveolar bone grafts were delimited on each slice using the drawing tool. Transversal areas were superimposed to produce a
3D volume using Osirix v.3.9.2 software.
C. Dissaux et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 21e26
Table 2
Preoperative alveolar cleft dimensions and volume.
Height (cm)
Width (cm)
Anteroposterior length (cm)
Volume (cm3)
Group A
Group B
1.10 (0.8; 1.5)
1 (0.65; 1.2)
0.9 (0.7; 1.1)
0.965 (0.7; 1.3)
1.22 (0.9; 1.5)
1 (0.7; 1.3)
0.9 (0.7; 1.1)
1.03 (0.7; 1.5)
Volumetric measurements were performed twice by one
observer in the horizontal dimension on the same day and once by
another observer.
palate (UCLP), and two patients with total bilateral cleft lip and
palate (BCLP; one grafted on only one side), corresponding to a total
of 15 bone grafts. Group B included two patients with UCLA, nine
with UCLP, and three with BCLP (1 grafted on only one side), corresponding to a total of 16 grafts.
Three retroalveolar fistulas were found during the preoperative
clinical examination in each group.
On preoperative CBCT images, the dimensions of the alveolar
cleft in both groups were comparable, as well as the cleft volumes,
with respectively 0.965 cm3 (range: 0.7e1.3) in Group A and
1.03 cm3 (range: 0.7e1.5) in Group B (Table 2).
3.2. Postoperative complications
2.2. Statistical analysis
A Student t test was used to compare Groups A and B for
quantitative values. A P-value of 0.05 or less was considered statistically significant. The impact of dental agenesis and dental
eruption was studied using a Fisher exact test.
Only one graft exposure was observed 3 weeks after surgery in
Group B. No complication of the graft occurred in Group A.
No donor site complications (iliac crest) were observed in either
group.
3.3. 2D evaluation (Table 3)
2.3. Ethics considerations
The study was conducted in accordance with the tenets of the
Declaration of Helsinki (2004) and was approved by Strasbourg
University Hospital Ethical Commission.
3. Results
3.1. Patient and cleft characteristics
The study sample was homogeneous within both groups in
terms of cleft form, presurgery fistula rate (Table 1) and cleft volume (Table 2). Group A included two patients with unilateral cleft
labio-alveolar (UCLA), 11 patients with total unilateral cleft lip and
Table 3
2D evaluation.
Max BG width/Max CA width (%)
Max BG height/Max CA height (%)
Max anteroposterior BG length/
Max anteroposterior CA length (%)
23
Group A
Group B
P
100
64.3
85.3
94
53.3
78.5
NS
0.14
0.44
Maximal dimensions of the bone graft are expressed as a percentage of maximal
alveolar cleft dimensions. No statistically significant differences were revealed in
this analysis.
Max ¼ maximal; BG ¼ bone graft; CA ¼ alveolar cleft; NS ¼ not significant (no
statistically significant difference).
In all cases, the maxillary union was obtained with a sufficient
bony bridge on the transversal plane (Fig. 2), except in the case of
graft exposure in Group B.
The mean maximal height of the bone graft reached 64.2% of the
maximal height of the alveolar cleft in Group A and 53.3% in Group
B.
The mean maximal anteroposterior length of the graft reached
85.3% of the maximal anteroposterior length of the alveolar cleft in
Group A and 78.5% in Group B.
Intergroup differences were not statistically significant.
3.4. 3D evaluation
The mean bone graft volume was of 0.6 cm3 (range: 0.36e1.1) in
Group A and 0.45 cm3 (range: 0e0.7) in Group B.
The residual bone graft coefficient was of 63.3% in Group A and
46.2% in Group B (P ¼ 0.012). The intergroup difference was statistically significant, with a higher residual bone graft in Group A
(Fig. 3).
3.5. Dental evaluation
In Group A, the assessment performed 6 months after surgery
showed that the lateral incisor had erupted through the bone graft
in four cases (four of 15). These four cases obtained the best results
Fig. 2. Bony bridge observed 6 months after the alveolar bone graft. A. Image obtained one day before surgery. B. Bony bridge observed 6 months after surgery.
24
C. Dissaux et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 21e26
Fig. 3. Distribution of the residual bone graft coefficients within both groups. Mean residual bone graft coefficients were statistically different between Groups A and B (p ¼ 0.012).
In Group A, most coefficients were greater than 50% (red line), while in Group B, most of them were less than 50%. Residual bone graft coefficient was calculated using the formula:
Volume of alveolar bone graft 6 months after surgery/Volume of alveolar cleft.
in terms of residual bone graft 6 months after surgery, with a residual bone graft coefficient ranging between 69% and 90% (Fig. 4).
In Group B, the eruption of the maxillary canine through the
bone graft was observed in four cases (four of 16). These 4 cases also
had the best bone graft results, with a coefficient ranging between
51.4% and 83% (Fig. 4).
In both groups, the results of the residual bone graft 6 months
post surgery were influenced by the tooth eruption through the
graft (P ¼ 0.007 in Group A and P ¼ 0.02 in Group B).
The influence of dental agenesis on bone graft results was also
investigated (Table 4). Lateral incisor agenesis was shown to influence bone graft results only in Group B (P ¼ 0.002).
4. Discussion
Since alveolar bone grafting performed in patients between 9
and 12 years old has been established as the “gold standard”
technique, many studies have confirmed its success rate (Bergland
et al., 1986; Hynes and Earley, 2003; Schultze-Mosgau et al., 2003;
Boland et al., 2009). This study focused on grafts performed at an
earlier age, before maxillary lateral incisor eruption. This assessment, which strictly compared results of alveolar bone grafts performed at two different ages before canine eruption (the gold
standard) or before lateral incisor eruption, was original. Indeed,
major studies have evaluated subjects at different ages without
individualizing and comparing these two distinct groups.
This study was based on a homogeneous population with an
equal distribution of cleft forms, fistulas and comparable sex ratio
in both groups. The cleft volume calculated based on CBCT data is
comparable to cleft volumes reported in the literature assessed
using CT scans. Feichtinger et al. (2008) reported a mean cleft
volume of 1.2 cm3 (range: 0.7e1.7) in a series of 20 patients at 11
years of age.
Compared to CT, the CBCT device (Arai et al., 1999) allows one to
perform an assessment using a very low radiation dose and a higher
resolution on a limited area. This way, the volume analysis obtained
by adding areas is highly accurate because slices are performed
every 0.15 mm.
The 2D evaluation overestimated results compared to the 3D
evaluation. For instance, results relating to the maximal height or
width in this study could appear satisfactory in both groups with no
statistically significant difference. This is the reason why most 2D
evaluations (Newlands, 2000; Matic and Power, 2008; Boland et al.,
2009) based on the Bergland scale (Bergland et al., 1986) provide
excellent results with Bergland scores I or II (graft height >50% of
cleft height). However, based on the sagittal dimension or the 3D
evaluation at 6 months, alveolar bone grafts did not seem to be
associated with such good results. Van der Meij (2001), Feichtinger
(Feichtinger et al., 2008), and Hamada (Hamada et al., 2005) have
already pointed out that the 2D evaluation overestimated results
compared to 3D evaluation. Feichtinger et al. also showed that graft
resorption takes place mostly in the sagittal dimension, although it
seems stable on coronal views. As previously reported (Zhang et al.,
2012), we also noticed that a significant bone resorption took place
preferentially at the nasal floor (Fig. 5), mostly affecting the graft
height dimension.
The 3D evaluation also allowed detection of a statistically significant difference between groups. Indeed, the assessment of the
Fig. 4. Eruption of the lateral incisor (Group A) and canine (Group B) through the
alveolar bone graft. Best results in terms of residual bone graft 6 months after surgery
were obtained when the tooth erupted through the graft.
C. Dissaux et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 21e26
Table 4
Impact of dental agenesis on alveolar bone graft outcomes.
Residual BG
coefficient
Lateral incisor
agenesis
No lateral incisor
agenesis
P
Group A
Group B
61.75%
32.5%
63.5%
54.5%
NS
P ¼ 0.002
BG ¼ bone graft; NS ¼ not significant (no statistically significant difference).
25
in patients who experienced eruption of the cleft-adjacent tooth. As
in Lilja et al. (2000), the question of determining the indication of
the graft depending on the eruption status of the adjacent tooth
should be raised, especially in the case of lateral incisor agenesis.
Thus, if we considered Group B (grafts performed at 10 years), an
agenesis of the lateral incisor was shown to have a negative impact
on bone graft outcome. Although the presence of a larger bone gap
was assumed in the case of lateral incisor agenesis, the practice of
waiting for canine eruption in this group did not seem to guarantee
good outcomes.
Finally, the growth and early secondary bone grafting at the age
of 5 may be questioned. The impact on the maxillary growth remains unknown but, thanks to improvements in dentofacial orthopedics, the impaired growth did not seem to be more
problematic than for grafting performed at the age of 10.
5. Conclusion
In conclusion, CBCT is a key imaging modality for the 3D
assessment of alveolar bone grafting using a low radiation dose and
a high resolution when the analysis is limited to the maxilla area.
This 3D analysis showed a higher success rate of bone grafts when
the children underwent operation earlier (around 5 years of age).
The impact of the adjacent tooth was primordial and directly
influenced the success rate of the bone graft regardless of age. The
maxilla growth and evolution of the newly formed bony bridge
over the years should be monitored and could give rise to another
study, especially if the implant placement, in the case of agenesis, is
scheduled at the end of the child growth period.
Fig. 5. Significant bone resorption at the nasal floor.
maximal dimensions provided only an approximation of the results. The accurate estimation of volumes showed better outcomes
for the bone grafts performed earlier (mean residual bone graft
coefficient of 63% in Group A versus 46% in Group B).
Captier et al. (2003) and Borba et al. (2013) pointed out that the
age and graft success were correlated, but they did not include
grafts performed in patients at such a young age (i.e., 5 years old) in
their analysis.
The bone graft volume 6 months after surgery and the residual
bone graft coefficient found in our study are similar to those reported by Feichtinger and Van der Meij (2001), whose analyses
were based on CT scans of grafts performed in patients of 10 years
old (Group B; mean graft volume of 0.45 cm3 and coefficient of 46%)
(Table 5), and we obtained better outcomes when Group A (grafts
performed at a mean age of 5 years) was considered.
When the tooth eruption was included in the analysis, we
observed a significant impact of the tooth eruption through the
bone graft on its stability. Zhang et al. (2012) and Borba et al. (2013)
reported that the resorption rate of the graft was significantly lower
Table 5
3D evaluation of alveolar bone graft in literature.
Study
Residual bone
graft coefficient
Volume of
alveolar cleft
Volume of
alveolar
bone graft
Van der Meij et al. (2005)
10-year-old patient; CT scans
Feichtinger et al. (2008)
11-year-old patient; CT scans
70% UCLP
55% BCLP
50% UCLP
1.1 cm3
0.45 cm3
3D evaluation of the alveolar bone graft found in the literature. These 2 studies of
grafts have been performed using CT scans on children aged 10 years. Both studies
showed that the 2D evaluation overestimated outcomes compared to the 3D
evaluation.
Funding
The authors declare no source of support for this study.
References
Abyholm FE, Bergland O, Semb G: Secondary bone grafting of alveolar clefts: a
surgical/orthodontic treatment enabling a non-prosthodontic rehabilitation in
cleft lip and palate patients. Scand J Plast Reconstr Surg 1(2): 127e140, 1981
Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K: Development of a compact
computed tomographic apparatus for dental use. Dentomaxillofac Radiol 28:
245e248, 1999
Bergland O, Semb G, Abyholm FE: Elimination of the residual alveolar cleft by
secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J
23: 175e205, 1986
riostoplasties
Boland FX, Drikes S, Persac S, Peron JM, Delcampe P: Gingivope
es a
une greffe osseuse: e
valuation radiologique. Rev Stomatol Chir
associe
Maxillofac 110: 193e197, 2009
Borba AM, Borges AH, Vilarinho da Silva CS, Borozoski MA, Naclerio-Homen MG,
Miloro M: Predictors of complications for alveolar bone graft. Br J Oral Maxillofac Surg 52: 174e178, 2013
Borstlap WA, Heidbuchel KL, Freihofer HPM, Kuijpers-Jagtman AM: Early secondary
bone grafting of alveolar cleft defects: a comparison between chin and rib
grafts. J Craniomaxillofac Surg 18: 201, 1990
Boyne PJ, Sands NR: Secondary bone grafting of residual alveolar and palatal clefts.
J Oral Surg 3: 87e92, 1972
Captier G, Bigorre M, Mattei L, Delestan C, Montoya P: La greffe osseuse secondaire
s techniques et indans les fentes labio-maxillo-palatines totales: modalite
dications a propos de 62 greffes. Ann Chir Plast Esthet 48: 20e30, 2003
€ ck R, K€
Feichtinger M, Zemann W, Mossbo
archer H: Three-dimensional evaluation of
secondary alveolar bone grafting using a 3D navigation system based on
computed tomography: a two-year follow-up. Br J Oral Maxillofac Surg 46:
278e282, 2008
Hamada Y, Kondoch T, Noguchi K, Iino M, Isono H, Ishii H, et al: Application of
limited cone beam computed tomography to clinical assessment of alveolar
bone grafting: a preliminary report. Cleft Palate Craniofac J 42: 128e137, 2005
Hynes PJ, Earley MJ: Assessment of secondary alveolar bone grafting using a
modification of the Bergland grading system. Br J Plast Surg 56: 630e636, 2003
Lilja J, Kalaaji A, Friede H, Elander A: Combined bone grafting and delayed closure of
the hard palate in patients with unilateral cleft lip and palate: facilitation of
lateral incisor eruption and evaluation of indicators for timing of the procedure.
Cleft Palate Craniofac J 37: 98e105, 2000
Matic DB, Power SM: Evaluating the success of gingivoperiosteoplasty versus secondary bone grafting in patients with unilateral clefts. Plast Reconstr Surg 121:
1343e1353, 2008
26
C. Dissaux et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 21e26
Newlands LC: Secondary alveolar bone grafting in cleft lip and palate patients. Br J
Oral Maxillofac Surg 38: 488e491, 2000
Rherm AH, Koberg WR, Koch H: Long term postoperative results of primary and
secondary bone grafting in complete clefts of the lips and palate. Cleft Palate J 7:
206e212, 1969
Robertson NRE, Jolleys A: Effects of early bone grafting in complete clefts of the lip
and palate. Plast Reconstr Surg 42: 414e420, 1968
Schultze-Mosgau S, Nkenke E, Schlegel AK, Hirschfelder U, Wiltfang J: Analysis of
bone resorption after secondary alveolar cleft bone grafts before and after
canine eruption in connection with orthodontic gap closure or prosthodontics
treatment. J Oral Maxillofac Surg 61: 1245e1248, 2003
Talmant JC, Lumineau JP, Rousteau G: Prise en charge des fentes labio-maxilloquipe du Dr Talmant a
Nantes. Ann Chir Plast Esthe
t 47:
palatines par l'e
116e125, 2002
Van der Meij AJW: Bone volume after secondary bone grafting in unilateral and
bilateral clefts determined by computed tomography scans. Oral Surg Oral Med
Oral Path 92: 136, 2001
Witsenburg B: The reconstruction of anterior residual bone defects in patients with
cleft lip, alveolus and palateda review. J Maxillofac Surg 13: 197e208, 1985
Zhang W, Shen G, Wang X, Yu H, Fan L: Evaluation of alveolar bone grafting using
limited cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral
Radiol 113: 542e548, 2012
Descargar