Alveolar cleft grafting | |
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![]() CBCT scan of the maxilla in an 11 year old showing a left alveolar cleft. | |
Other names | Alveolar grafting, cleft grafting, bone grafting |
ICD-10-PCS | Q35.1, Q35.9, Q37 |
Alveolar cleft grafting is a surgical procedure, used to repair the defect in the upper jaw that is associated with cleft lip and palate, where the bone defect is filled with bone or bone substitute, and any holes between the mouth and the nose are closed. [1]
An alveolar cleft is a failure of the premaxilla to fuse with the upper jaw leaving a defect in the bone. It is common in people with cleft palate and is also associated with holes between the mouth and the nose that affects speech, and allows fluid to move into the nose when eating and drinking.[ citation needed ]
Surgeries on the roof of the mouth early in life typically close the larger hole between the mouth and the nose (caused by the cleft in the palate) but do not repair the defect in the bone, or any holes further forward between the palate and the upper lip. About the age of 8, just before the eye teeth are about to erupt into the bone defect (the cleft), braces are used to first widen the upper jaw, and position the premaxilla. Then, a surgery places bone or a bone substitute in the defect to allow the premaxilla to fuse to the rest of the maxilla, provide bone for eruption of the canine, and close any remaining holes between the mouth and nose. If completed early, the canine teeth will erupt into the mouth with good bone support and remain healthy.
Alveolar cleft grafting is used primarily to allow the eruption of the maxillary canines into the mouth between the ages of 8 and 13 years old. It is also used to close oranasal fistulas, stop fluid reflux into the nose, improve speech, support the maxillary lateral teeth, and stabilize the jaw for orthodontics or orthognathic surgery.[ citation needed ]
In cleft palate patients bone grafting during the mixed dentition has been widely accepted since the mid-1960s. The goals of surgery are to stabilize the maxilla, facilitate the healthy eruption of teeth that are adjacent the cleft, improving the esthetics of the base of the nose, create a bone base for dental implants, and to close any oro-nasal fistulas. [2]
One of the most controversial topics in alveolar cleft grafting is the timing of treatment, however, most centres recommend grafting around the ages of 6–8 years old as the lateral incisor and maxillary canine near the cleft site. [3] This is referred to as secondary grafting during mixed dentition (after eruption of the maxillary central incisors but before the eruption of the canine). [4] A smaller proportion recommend primary grafting around the age of 2, but success rates are lower, and fewer patients are good candidates. Late secondary grafting (after eruption of the canine) has also been advocated but has been largely abandoned due to the loss of tooth support. [4]
In secondary grafting, the dental age of the patient needs to be closely monitored for the eruption of the first maxillary molars in unilateral cases around the age of 6, and in bilateral cases the eruption of central incisors about the age of 8. This timing is used because there is minimal growth of the upper jaw after ages 6–7, the patient is more compliant with orthodontics that is required prior to surgery for expansion, the donor site is better developed, and the grafting precedes the eruption of teeth into the site. [4]
In cases with a single cleft, 35-60% of lateral incisors are congenitally missing, [4] and cannot be relied on for timing. Instead, the eruption of the incisors and first molars is used as a queue to begin assessments. With bilateral cases, the premaxilla must be repositioned before grafting and special consideration must be given. During this time, the orthodontist must be wary of rotating teeth into the cleft site. Last, the size of the patient, defect, and social issues must all be taken into consideration and is best assessed with a CBCT scan as the patient enters the mixed dentition phase of dental development. [5]
In cleft lip and palate cases, the maxilla is typically narrow compared to the lower jaw and must be expanded outward. An expansion appliance is placed in the maxilla 6–9 months prior to correct any crossbite or upper arch constriction. [3] This will widen the cleft size, and so that parents and patients need to be warned the symptoms such as fluid reflux may worsen, although some centres will expand the jaw after surgery is complete. In the case of double clefts, expansion is typically before surgery because the premaxilla needs to be repositioned forward, which cannot occur until the upper jaw is widened to allow room. [4]
The goals of the surgery are to: [4]
At surgery, the gingiva is incised along the cleft margin to allow creation of pocket of tissue up towards the nose (recreating a nasal floor), and down towards the mouth (recreating a palate, and closing the palatal opening). The bony edges of the cleft are cleaned, and any extra teeth in the cleft are removed. The gingiva along the outside part of the upper jaw is raised, so that it can be drawn forward to close the cleft. [ citation needed ]
After creation of the pocket, but before suturing closed the gingiva a bone graft is placed into the bony defect. This is most commonly harvested from the anterior hip but can also be obtained from other sites, donor bone, or bioactive materials such as bone morphogenic proteins. Once packed the cleft is filled with bone material the gingiva is sutured closed to create a water tight closure between the mouth and the nose. [4]
The most common source of the bone graft is from the iliac crest, [6] harvested at the time of the cleft closure. Other sources such as the chin, and posterior iliac crest, or skull can also be used. Artificial grafts such as demineralized bone, recombinent bone morphogenic protein or a mix of harvested bone and artificial grafts have also been used. Insufficient data exists to show that one is beneficial over the other. [1]
The mouth wounds recover in 7–10 days with precautions for fluid only diet for 5 days, and not to increase pressure in the nose or sinuses for 2–3 weeks. Evidence that the bone graft is forming will be seen on x-ray at about 8 weeks. Movement of teeth into the graft can begin at 3 months once bone graft consolidation is seen on xray. [4] Recovery from the bone harvest will vary depending on the site (if harvested) with the anterior iliac crest being sore for 2–3 weeks.[ citation needed ]
Success of the bone graft with the first surgery are approximately 85% [7] but may vary with technique and bone grafting material. [1]
Orthodontics after surgery can close the space between the central incisor and maxillary canine in 50-75% of cases, and for those who can't have the space closed the gap can be filled with a dental implant once growth has finished. [8]
The first attempts at bone grafting cleft patients were made by Lexer (1908) and Drachter (1914). Between 1921 and 1952 various attempts were made to graft patients using the turbinate, rib and other harvest sites. Schmid (1954) at meetings in 1951 and 1952 reported on the treatment of patients using iliac crest bone grafts but stated, "The procedure has merely been presented for discussion". By 1964 the iliac crest bone graft had gained popularity and was presented at multiple meetings. [9]
Human teeth function to mechanically break down items of food by cutting and crushing them in preparation for swallowing and digesting. As such, they are considered part of the human digestive system. Humans have four types of teeth: incisors, canines, premolars, and molars, which each have a specific function. The incisors cut the food, the canines tear the food and the molars and premolars crush the food. The roots of teeth are embedded in the maxilla or the mandible and are covered by gums. Teeth are made of multiple tissues of varying density and hardness.
A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate contains an opening into the nose. The term orofacial cleft refers to either condition or to both occurring together. These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.
The maxilla in vertebrates is the upper fixed bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The two maxillary bones are fused at the intermaxillary suture, forming the anterior nasal spine. This is similar to the mandible, which is also a fusion of two mandibular bones at the mandibular symphysis. The mandible is the movable part of the jaw.
Incisors are the front teeth present in most mammals. They are located in the premaxilla above and on the mandible below. Humans have a total of eight. Opossums have 18, whereas armadillos have none.
Orthognathic surgery, also known as corrective jaw surgery or simply, jaw surgery, is surgery designed to correct conditions of the jaw and lower face related to structure, growth, airway issues including sleep apnea, TMJ disorders, malocclusion problems primarily arising from skeletal disharmonies, and other orthodontic dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics and self esteem.
In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855-1930), the "father of modern orthodontics", popularised it. The word "malocclusion" derives from occlusion, and refers to the manner in which opposing teeth meet.
The alveolar process or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones. The structures are covered by gums as part of the oral cavity.
Permanent teeth or adult teeth are the second set of teeth formed in diphyodont mammals. In humans and old world simians, there are thirty-two permanent teeth, consisting of six maxillary and six mandibular molars, four maxillary and four mandibular premolars, two maxillary and two mandibular canines, four maxillary and four mandibular incisors.
Veterinary dentistry is the field of dentistry applied to the care of animals. It is the art and science of prevention, diagnosis, and treatment of conditions, diseases, and disorders of the oral cavity, the maxillofacial region, and its associated structures as it relates to animals.
In human anatomy of the mouth, the palatine process of maxilla, is a thick, horizontal process of the maxilla. It forms the anterior three quarters of the hard palate, the horizontal plate of the palatine bone making up the rest.
Tooth eruption is a process in tooth development in which the teeth enter the mouth and become visible. It is currently believed that the periodontal ligament plays an important role in tooth eruption. The first human teeth to appear, the deciduous (primary) teeth, erupt into the mouth from around 6 months until 2 years of age, in a process known as "teething". These teeth are the only ones in the mouth until a person is about 6 years old creating the primary dentition stage. At that time, the first permanent tooth erupts and begins a time in which there is a combination of primary and permanent teeth, known as the mixed dentition stage, which lasts until the last primary tooth is lost. Then, the remaining permanent teeth erupt into the mouth during the permanent dentition stage.
Dental anatomy is a field of anatomy dedicated to the study of human tooth structures. The development, appearance, and classification of teeth fall within its purview. Tooth formation begins before birth, and the teeth's eventual morphology is dictated during this time. Dental anatomy is also a taxonomical science: it is concerned with the naming of teeth and the structures of which they are made, this information serving a practical purpose in dental treatment.
This is a list of definitions of commonly used terms of location and direction in dentistry. This set of terms provides orientation within the oral cavity, much as anatomical terms of location provide orientation throughout the body.
A Le Fort fracture of the skull is a classic transfacial fracture of the midface, involving the maxillary bone and surrounding structures in either a horizontal, pyramidal or transverse direction. The hallmark of Lefort fractures is traumatic pterygomaxillary separation, which signifies fractures between the pterygoid plates, horseshoe-shaped bony protuberances which extend from the inferior margin of the maxilla, and the maxillary sinuses. Continuity of this structure is a keystone for stability of the midface, involvement of which impacts surgical management of trauma victims, as it requires fixation to a horizontal bar of the frontal bone. The pterygoid plates lie posterior to the upper dental row, or alveolar ridge, when viewing the face from an anterior view. The fractures are named after French surgeon René Le Fort (1869–1951), who discovered the fracture patterns by examining crush injuries in cadavers.
Dental pertains to the teeth, including dentistry. Topics related to the dentistry, the human mouth and teeth include:
The premaxilla is one of a pair of small cranial bones at the very tip of the upper jaw of many animals, usually, but not always, bearing teeth. In humans, they are fused with the maxilla. The "premaxilla" of therian mammal has been usually termed as the incisive bone. Other terms used for this structure include premaxillary bone or os premaxillare, intermaxillary bone or os intermaxillare, and Goethe's bone.
A jaw abnormality is a disorder in the formation, shape and/or size of the jaw. In general abnormalities arise within the jaw when there is a disturbance or fault in the fusion of the mandibular processes. The mandible in particular has the most differential typical growth anomalies than any other bone in the human skeleton. This is due to variants in the complex symmetrical growth pattern which formulates the mandible.
Maxillary hypoplasia, or maxillary deficiency, is an underdevelopment of the bones of the upper jaw. It is associated with Crouzon syndrome, Angelman syndrome, as well as Fetal alcohol syndrome. It can also be associated with Cleft lip and cleft palate. Some people could develop it due to poor dental extractions.
A facial cleft is an opening or gap in the face, or a malformation of a part of the face. Facial clefts is a collective term for all sorts of clefts. All structures like bone, soft tissue, skin etc. can be affected. Facial clefts are extremely rare congenital anomalies. There are many variations of a type of clefting and classifications are needed to describe and classify all types of clefting. Facial clefts hardly ever occur isolated; most of the time there is an overlap of adjacent facial clefts.
In human anatomy, the mouth is the first portion of the alimentary canal that receives food and produces saliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth.
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