Vol 3, No 1 (2015) ISSN 2167-8677 (online) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu Pilot study of pre-maxilla replacement and bone graft in a patient with lip and palate clefts: transforaminal relationship between up- per canines and bone graft João Luis Carlini1, Danielle Del Santo2, Kesia Keiko Asami2 1Oral and Maxillofacial Surgery, Chief of Stomatology Departament, Professor at Federal University of Paraná, Staff of CAIF – Center for Integral Assistance of Cleft Lip and Palate Patients, Curitiba, Paraná, Brazil 2Dental Surgeon, School of Dental Medicine at Federal University of Paraná, Curitiba, Paraná, Brazil Abstract Objective: The aim of this study was to assess patients subjected to replacement surgery of the pre maxilla with bone graft, having as donor area the iliac crest and chin, and the relation with upper canines erupted in grafted areas. Materials and Methods: 54 records were eval- uated from cleft patients that were under treatment at CAIF - Center of Attention to Clefts in Curitiba, PR, Brazil, both sexes, with unilateral and bilateral lip and palate clefts. Patients younger than fourteen years old, both sexes, that lost the surgical segment or did not con- tinue the treatment at same welcoming institution, were excluded. The surgical segment average was 5.72 years. Results: Using both descriptive and chi-square statistics, we ob- served a statistically significant distinction regarding the eruption of upper canines in the re- gion of secondary bone grafts when using iliac crest and chin grafts, which 62.8% of the sam- ple that was treated with chin grafts happened to have an eruption of upper canines, and 37.2% were successful with iliac crest grafts (value-p 0.028). Conclusions: It is necessary to carry out a study with a larger sample size and where the samples are paired in order to confirm the superiority the iliac crest donor area as the gold standard for this surgical proce- dure. Citation: Carlini J, Del Santo D, Asami K. (2015) Pi- lot Study of Pre Maxilla Replacement and Bone Graft in a Patient with Lip and Palate Clefts Trans- foraminal– Relationship between Upper Canines and Bone Graft. Dentistry 3000. 1:a001 doi:10.5195/d3000.2015.36 Received: July 24, 2015 Accepted: September 1, 2015 Published: September 29, 2015 Copyright: ©2015 Carlini J, Severo D, Asami K. This is an open access article licensed under a Creative Commons Attribution Work 4.0 United States License. Email: kka12@pitt.edu Introduction Among congenital anoma- lies of the mouth, oral clefts stand out, ranging from those that may occur as an isolated or associated disorder to anomalies of varying de- grees. During January, 1975 until December, 1994, we recorded 16,853 new cases of oral clefts in Brazil, having the southeast region contributed with 61% these news cases [1]. The clefted individuals have several problems associated with facial deformity including malocclu- sion, nasal deformity, problems with feeding, listening and speak- ing, and the association between clefts with other anomalies is evi- dent. These abnormalities affect the midface, occurring because the upper jaw bones do not fuse during the sixth and tenth week of intrau- terine life [2]. Currently the classifi- cation of Spina is the most used to typify the lip and palate clefts [3]. After the primary recon- structive surgeries, lip repair and palatoplasty, becomes necessary http://dentistry3000.pitt.edu/ Familial aggregation of anxiety associated with bruxism Vol 3, No 1 (2015) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu 2 surgery for correction the cleft alve- olar ridge through bone grafts [4]. For the unilateral cleft pa- tient, the secondary bone grafting surgery has been well described in the literature [5,6]. Clefts trans- foraminal patients are the most se- verely affected due to the absence of alveolar bone support in pre maxilla region, and absence of bone and soft tissue in hard palate region, leading to the projection of the pre maxilla, absence of eruption of the upper permanent canines, and ab- sence of sealing lip [7,8]. Having had a bone graft, or with the assistance of bone graft, changes in upper jaw growth are minimized because the majority of bone growth in the time of reposi- tioning of pre maxilla, is already complete [9]. Treatment of pre max- illa in patients with bilateral clefts there are surgical procedures, such as complete refurbishment of the pre maxilla, promoting a better sealing lip [10], and the reposition- ing of pre upper jaw with autoge- nous bone graft [11]. Surgical treatment in bilat- eral clefts patients can have serious implication, because manipulating the pre maxilla can result in changes of bone growth in the re- gion. There are controversies if the surgical intervention in pre maxilla should be performed before or after the complete facial growth [11]. Hedbuchel, Kypers-Jagtman, and Freihofer (1993) studies, demonstrated success with bone graft associated to upper jaw oste- otomy and repositioning of pre maxilla, resulting in a well aligned and stabilized dental arch with a significant improvement in incisor inclination. SUBJECTS AND METHODS This study was experimental unit with 54 patients, unilateral or bilateral cleft lip and palate accord- ing to the classification of Spina [12], who were in treatment at Cen- ter of Attention to clefts lip and pal- ate-CAIF, Curitiba-PR- Brazil. Clini- cal data were collected through medical and dental records, pano- ramic radiographs, in profile, upper occlusal and periapical the region of cleft. Selected patients were older than 14 years old, an age that al- ready set the functional position of the maxillary canines, and both sexes. Patients younger than 14 years age, both sexes, that lost the surgical segment or did not con- tinue the treatment at same wel- coming institution, were excluded. The patients were submitted to treatment protocol of CAIF es- tablishing assessment throughout the areas of dentistry, such as speech therapy, psychology, nurs- ing, plastic surgery and pediatrics. In orthodontic intervention breakers appliances were placed in the upper jaw to promote correc- tion of atresia of upper jaw, and to improve the position of the pre maxilla. With this first step per- formed, the patient was referred to a team of Oral and Maxillofacial Surgery, where the molds of lower and upper arch were made. From the plasters models, surgery mod- els with correct position of the pre maxilla were performed and the confection of surgical guides in au- topolymerizing acrylic resin, for this new position. The surgeries were per- formed under general anesthesia and tracheal intubation. After in- duction of anesthesia, lidocaine 2% with epinephrine 1:100.000 was infiltrated in the region to be surgi- cally manipulated. 15 scalpel blades was used to vertically incise the margins of the cleft, extending laterally with intrasulcular incision one or two teeth apart from the area of the cleft, where alleviating incisions were made toward the back of the vestibule. The same procedure was performed on the opposite side, followed by the de- tachment of the mucoperiosteal flap. Vertical incisions were also made in the pre maxilla, followed by the detachment of the perios- teum on the lateral and palatine portions on both sides. With the as- sistance of a reciprocating saw the bone situated on the posterior por- tion of the pre maxilla was seg- mented. The pre maxilla was ante- riorly dislocated; the nasal mucus membrane was separated from the oral mucus membrane and the na- sal floor was closed bilaterally us- ing absorbable thread (polyglactin 4.0). Once the nasal floor was closed, the palatine mucus mem- brane was sutured with the re- maining palatine mucus membrane existing in the pre maxilla, using absorbable thread (polyglactin 4.0). Next, the surgical guide was placed with steel thread nº 0 on the screws that were placed on the pre maxilla and bilaterally on the area of the molars to reposition the pre maxilla. In the donor area, the graft was removed from the iliac crest by the plastic surgeon. The chosen area is the internal (medial) of the crest. The removed block was mon- ocortical, and with the use of a bone scoop, a large quantity of medul- lary bone was collected. After con- trolled the bleeding, a suture was performed as planned. The graft block was then prepared. The whole medullary part of the block was removed. The area corre- sponding to the bilateral cleft was totally filled in with medullary bone, which was collected through curettage and removed from the bone block. The remaining cortical bone plate of the iliac crest was http://dentistry3000.pitt.edu/ Familial aggregation of anxiety associated with bruxism Vol 3, No 1 (2015) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu 3 then used for the placement of the pre maxilla on the stumps of the re- maining upper jaw and supplying the containment of the particulate medullary bone in the area of the clefts. The edges of the cortical block were placed on the distal ex- tremity, corresponding to the alve- olar process, with a 1.5 x 7.0mm screw and on the medial extremity, corresponding to the pre maxilla, with a 1.5 x 7.0mm screw. All the cutting edges that could traumatize the mucus membrane were re- moved with a spherical diamond drill bit in low revolution. The whole grafted area was then covered with the mucoperios- teal flap with the assistance of alle- viating incisions in the periosteum. The suture was performed without tension over the flap using a 4.0 nylon thread. In the symphysis donor area, the incision was initiated 1.5cm be- low the red line of the lower lip, cutting the mucus mem- brane and muscles, immedi- ately directing the scalpel to the jaw bone. After detach- ing the periosteum, the os- teotomy was performed with an appropriate design to adapt to the jaw defect with a number 701 conical tronca drill in low revolu- tion. The suture of the do- nor area was performed in anatomic plans with polygalatine 4-0, keeping the exter- nal compressive dressings in the chin area to avoid labial ptosis and to offer the patient greater comfort. The placement of the graft was made through miniplates and 1.5mm titanium screws promoting the stability of the graft. A compres- sive dressing was placed over the area to reduce edema and control possible active bleeding points, kept for a minimum of three days. A regimen of intravenous antibiotics was performed with Cefazolin until the release of the patient (that oc- curs on the first day after the oper- ation) and continued orally until the tenth day after the operation. Analgesia was done with Dipyrone and supplemented with Ceto- profeno. Post-operation care included rigorous hygiene of the surgical area with brushing and use of mouth wash with Chlorhexi- dine 0.12%. The follow up was done clinically and the sutures were re- moved after two weeks. Two months after the opera- tion the surgical guide was re- moved and the stability of the pre maxilla was checked. The screws used in the placement of the graft were removed six months after the operation and, only after this pro- cedure the patients were once again referred for orthodontic treatment. The parameters used to eval- uate the success of the treatment were based on periapical x-rays, done six months after surgery, the period during which the filling of the cleft with bone and the immo- bility of the pre maxilla are ob- served with a clinical exam. After six months the removal of the placement screws was scheduled, under local anesthetics, and the pa- tient was referred to resume ortho- dontic treatment. RESULTS Fifty-four patients with an average age of 19.54 years old were selected based on inclusion criteria presenting a standard de- viation of 6.790. The time elapsed from the surgery until the analysis of the medical-dental records had an average of 5.72 years, a stand- ard deviation of 1.867. For the eval- uation of the results, the non-pa- rameter Chi-squared and the Fisher Test were used. 33.3% of the patients were female, and 67.4% were male. In 33 Table 1. Descriptive analysis of the number of patients and region of the donor area Frequency Percentage Iliac Crest 24 44.40% Chin 30 55.60% Total 54 100.00% Table 2. Comparative analysis between time of surgery and bone graft donor area Surgical Follow-up Donor Area Frequency Average Standard Devia- tion P-value Iliac Crest 24 5.1 1.4 0.033 Chin 30 6.2 2.1 Total 24 5.7 1.9 http://dentistry3000.pitt.edu/ Familial aggregation of anxiety associated with bruxism Vol 3, No 1 (2015) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu 4 patients it was verified that the type of cleft was the labiopalatal bi- lateral type, and 21 possessed uni- lateral lip and palatal cleft. Through the evaluation of the panoramic and profile x-rays, six of the 54 patients evaluated presented with at least one of the permanent upper canines before the surgical procedure, corre- sponding to 88.9% of the presence of the same teeth included after the evaluation of the pre-surgery x- rays. Besides the 6 aforementioned patients, 3 of the 54 patients, pre- sented with the absence of both permanent canines, being that 94.4% of the sample presented with two included permanent up- per canines in the area of the cleft subsequently operated. In relation to the area origi- nating from the bone graft, 44.4% iliac crest was used, and in 55.6% of the patients chin graft was used (Table 2). After the operation, pa- tient check-up and the evaluation of the post-procedure panoramic and profile x-rays, 11.1% of the pa- tients maintained one of the ca- nines included, 11.1% of the sam- ple remained with both of the up- per canines enclosed. In relation to the percentage of erupted upper canines in the area of the cleft, after the procedure of the placement of the bone graft and the replacement of the pre maxilla, 14.8% of the pa- tients had at least one erupted ca- nine, and 64.8% of the patients had both upper canines erupted in the area of the cleft. In this way, a suc- cession was observed of approxi- mately 80% of the patients of the sample. Beginning with the statisti- cal analysis carried out through the test of averages, 24 patients re- ceived an autogenous graft origi- nating from the iliac crest donor area, obtaining a standard devia- tion of 1.4, and 30 patients had the chin as the donor area, obtaining a standard deviation of 2.1 (Table 3). The P value for this case was 0.033, concluding that there was signifi- cant statistical evidence of differ- ences between the donor areas. The group of patients that presented with eruption of the up- per canines, the proportional test Qui-squared was applied, making it possible to verify statistical evi- dence between the percentages ob- tained. Among the patients that were subjected to the reposition of the pre maxilla, and the filling in of the clefted area with iliac crest bone graft, 34.3% of the patients had upper canines, right and left, erupted. For the patients in whom autogenous bone graft was used, having the chin as the donor area, 65.7% of the patients presented with, after the abovementioned surgical segment, the two upper canines erupted (p≤0.028) (Table 4). DISCUSSION The rupture of the alveolar bone, exactly at the height of the upper lateral incisors persists after the initial repair surgeries, main- taining the discontinuity of the up- per arch [13]. This study of retro- spective character evaluated the eruption of the upper canines in ar- eas with an alveolar cleft, in carrier patients with unilateral and bilat- eral alveolar clefts, treated with chin and iliac crest bone grafts. Many studies presented di- verse techniques for the recon- struction of alveolar bone defects for these patients, autogenous bone or allogeneous sources being able to be used to provide a bone outline for the reparation of the de- fect. Among the autogenous donor areas most used are the iliac crest, chin, shin, costal arch and skullcap. The benefits of the bone graft in the treatment of cleft pa- tients were well described, mainly when it concerned unilateral clefts. In the bilateral cleft patients, sev- eral particularities are noted, such as significant bone and soft tissue deficiency, exaggerated protrusion of the pre maxilla, frequent devia- tion of the upper dental midline, present malocclusion due to atresia of the upper jaw segments, mobil- ity of the pre maxilla, pronounced buconasal fistulas. These factors damage the aesthetics and social inclusion, phonation and alimenta- tion of these patients, limiting the orthodontic and prosthetic rehabil- itations [5 ,14 -16] . From an x-ray point of view, the periapical and occlusal x-rays allow the evaluation of the level of neoformation of the bone in the area of the bone graft [13], as they also allow the visualization of the upper canine eruption process. Starting the surgery with bone graft in the area of the cleft, as much for patients with unilateral or bilateral clefts, it is expected that the upper canine erupts in the grafted bone, inducing the deposi- tion of bone in the alveolar crest and increasing the vertical height of the upper jaw [16,17]. In our study we did not contemplate vertical height gain of the upper jaw; we limited ourselves verifying the via- bility of the eruption of the upper canines in the clefted area. According to Cohen et al, the success or failure of the final result of the bone graft in the area of the cleft does not depend specifically on the donor area. Other factors in- fluence the final result of the treat- ment, such as: morbidity, the viabil- ity of the autogenous bone, the type of bone, if it is cortical or spongy, and the biological behavior of the graft [5]. The iliac crest is the gold standard for grafts in cleft patients http://dentistry3000.pitt.edu/ Familial aggregation of anxiety associated with bruxism Vol 3, No 1 (2015) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu 5 since it is a spongy bone which pro- vides advantages, such as: the con- stant tissue growth of that bone, being remodeled more quickly than the cortical bone, rendering more viable the eruption of the teeth in the area of the cleft. The chin graft also possesses advantages well described in liter- ature, for example: easy access, less morbidity, similar embryonic origin, and quicker revasculariza- tion, with a tendency to keep greater post-operation bone vol- ume when compared with the iliac crest graft [18]. Mish (2000) affirmed that autogenous bone grafts are osteo- genic and capable of forming bone in the absence of undifferentiated mesenchymal cells. The grafted bone forms new bone in three dif- ferent phases: osteogenesis, oste- oinduction, and osteoconduction. He also observed that for the fact of the symphysis area having the same origin intramembranous as the upper jaw, there exists a quicker revascularization than the one of endochondral origin, as in the case of the iliac crest, having the advantage of minimal reab- sorption and mobility of the graft, more premature vascularization, ambulation closer to the patient, no visible scar, abundant mate- rial, no secondary de- formity and reduction of post-operation pain. In our study, we did not evaluate the post-operation condi- tions of the patients in agreement with the grafted area. Regard- ing the type of graft used and the eruption of the upper canines, we obtained better re- sults with a patient on whom an intramembranous bone graft was used, the chin, possibly due to all the features of that type of bone origin and the receptor lo- cation. Hedbuchel, Kuijpers-Jag- tman and Freihofer performed a study in 1993 with 22 patients who presented with bilateral lip and palate cleft. In all their patients up- per jaw osteotomy was performed with the stabilizing of the pre max- illa being that they used various types of grafts, such as: rib, iliac crest, chin, bone bank, and jaw bone. The average age of the pa- tients of the study was 13.3 years old. The results obtained were sat- isfactory only having suffered the loss of one of the grafts. In our study, the patients were subjected to replacement of the pre maxilla with subsequent bone graft and we only used two types of bone, and the study group was composed of patients with both bilateral and unilateral transformed clefts. We also obtained satisfactory results in both groups, but with a greater sta- tistical value for the group with chin bone graft. Silva Filho and colleagues (2000), presented a study involv- ing 50 patients (32 men and eight- een women) all with palatine gap and aged from eight to fifteen years old. All the patients were subjected to iliac crest bone graft for the fill- ing of the palatine gap, and they were observed through x-rays for a period of one to five years. In 72% of the cases there was spontane- ous eruption of the canines, in 6% of the cases there was a need for orthodontic traction, in the other 22% of cases there was movement of the teeth in question, but they had not erupted yet. Our study included 54 pa- tients, a sample similar to the pre- viously cited study, being that 33.3% of the sample composed of male patients and 66.7% of female patients. Our patients were moni- tored through panoramic, profile, upper occlusal and periapical x- rays of the upper canine area, in a period of seven days, three months, six months and twelve months fol- lowing the operation. We obtained both of the erupted upper canines in 34.3% of the cases treated with iliac crest, and 65.7% of the cases treated with a chin graft. Cohen and colleagues (1991) performed a study based on the experience of two plastic sur- geons of the University of Illinois Hospital, Chicago. The patients were between nine and eleven Table 3. Comparative analysis between the number of erupted canines regarding the type of donor area Erupted Canine 1 2 Total Donor area Fre- quency Col- umn % Fre- quency Col- umn% Fre- quency Col- umn% P- value Iliac Crest 4 50% 12 34.30% 16 37.20% 0.028 Chin 4 50% 23 65.70% 27 62.80% Total 8 100% 35 100% 43 100% http://dentistry3000.pitt.edu/ Familial aggregation of anxiety associated with bruxism Vol 3, No 1 (2015) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu 6 years old at the time of the surgery, this age being similar to the age in our study, which was from eight to twelve years of age. The surgical technique used was similar in all the patients, only the type of graft being different: iliac crest or skull- cap. The patients were monitored between 18 and 60 months and the results were satisfactory and with- out a significant difference be- tween the two types of grafts [18]. In our study we compared two types of grafts, iliac crest and chin, with an average of 5.72 years of surgical follow-ups, being that we obtained satisfactory results in both groups, but not in all the cases, which affirms the objective of this research: eruption of the upper ca- nines in the area of the bone graft bilaterally or unilaterally. For our research, we obtained a 37.2% suc- cess rate for the patients grafted with iliac crest, and a 62.8% suc- cess rate for the patients grafted with chin bone. http://dentistry3000.pitt.edu/ Familial aggregation of anxiety associated with bruxism Vol 3, No 1 (2015) DOI 10.5195/d3000.2015.36 http://dentistry3000.pitt.edu 7 References 1. 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