bone grafting, fixed with micro plates. ... Creating interdental edentulous space for maxillary dental crowding. ... from the interdental attached gingiva a horizontal ...
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Bali et al
Review Article DISTRACTION OSTEOGENESIS IN CLEFT PALATE CASES - A REVIEW Shweta Bali*, Priyanka Thukral**, Deepa Verma***, Nidhi Gupta ****, Vaibhav Joshi***** ABSTRACT Severe maxillary deficiency can be caused by cleft lip and palate which is said to be second most common birth deformity. Patients having maxillary deformity present difficult treatment challenge. Traditionally this deformity has been treated using le-fort one osteotomy and skeletal repositioning. The drawback of this method limited anterior maxillary advancement and potential of relapses in larger advancements. The alternative method of osteodistraction offers promising results for successfully treating these patients while [2,3] potentially minimizing the risk of relapse. . KEY WORDS : osteodistraction, cleft palate, INTRODUCTION Cleft palate is the second most frequent kind of deformity which occurs in 1:500 cases ,and has doubled within last fifty years. It develops within fourth and fifth embryonic week. Various studies have shown that from 1/2 to 1/3 of all cleft palate patients have familial history of this deformity [1]. When this deformity occurs, the parents of these unfortunate children search eagerly for some way to prevent the mental anguish, the misery and distortion of personality, the facial deformity, malocclusion and pathetic functional inadequacy that can be associated with cleft lip and palate. Histologically with all forms of surgery, maxillofacial techniques have undergone fads and fashions. Traumatic uranoplasty procedures closed clefts by molding the separated parts together. But what was a surgical success at two years of age when judged by an esthetic and functional yardstick became a complete failure by the time patient was 20 year old or even younger.
deformities but at the same time, non traumatic procedures no longer can duplicate the early uranoplasty results. As per Enlow the best results can be achieved when surgical procedures are developed to coincide with the most favorable growth periods and orthodontic therapy and speech therapy can be properly timed. Treatment of cleft palate individual is no longer left to any single specialist, pediatrician, prosthodontist, orthodontist or speech therapist [4]. CLASSIFICATION International classification of facial clefts (4th Congress of Plastic Surgury, Rom 1967) •
Harelip cleft •
Studies by authors have indicated that treatment of cleft should be multifocal approach. Too early surgical interference can produce bizarre Address For Corresspondence: Dr Shweta Bali Professor, Dept of Periodontics, Santosh Dental College, Ghaziabad.
Group 1:lip right, and/or left jaw right, and/or left
Group 2:lip right, and/or left jaw right and/or left hard palate right and/or left soft palate, medial Lip- jaw- palate –cleft
•
Group3:hard palate and soft palate
•
Group 4:rare facial clefts, f.e. medial,
*Professor, ***** Assistant Professor, Dept of Periodontics, Santosh Dental College, Ghaziabad **Professor, Dept of Prosthodontics, Santosh Dental College, Ghaziabad ***Professor, Dept of Orthodontics Santosh Dental College, Ghaziabad ****Associate Professor, Dept of Pedodontics, Santosh Dental College, Ghaziabad.
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BUJOD •
lateral, oblique, nasal cleft Bilateral lip-jaw-palate
INDICATIONS
Treatment Plan
drinking and retention plate
0-0,5
surgery lip
0,5-1
surgery soft palate
2 3 4 5
surgery hard palate
•
Wide alveolar cleft or oral nasal fistula in bilateral cleft lip and palate patients.
•
Maxillary alveolar bony defect due to trauma or tumor .
•
Creating interdental edentulous space for maxillary dental crowding.
•
Maxillary lengthening for maxillary hypoplasia with/without dental crowding, and with/without alveolar cleft.
6 7 treatment with changeable prothesis
8 9 10
jaw-cleft-osteoplasty
11 discontinuance of permanent dentition
The segment of new alveolar bone and gingiva will provide extra dental space for the relieve of dental crowding.
12
CONTRAINDICATIONS •
Patients with systemic disease, like diabetes.
•
Cases of in-adequate bone volume and with danger of fractures.
•
Osteoporosis.
•
Care must be taken to preserve 0.5-1.0 mm thickness of alveolar bone adjacent to the dental roots.
13 14 15 16
orthodontics
17
surgery
18
final correction
speech therapy
age
ADVANTAGES Traditional Apporoach Of Alveolar Cleft Reconstruction
•
Closure of the cleft with autologoues bone material instead of grafting.
•
Sealing by primary or secondary autogenous bone grafting, fixed with micro plates.
•
No need for substitution with buccal mucosa or tongue flaps.
•
Palatal expansion and later orthodontic tooth alignment are always necessary to align the collapsed dental arches.
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Usage of local attached gingiva for essential tooth eruption.
•
Relieve of dental crowding.
•
Buccal mucosa or tongue flaps as a substitute for the attached gingival.
•
Technically impossible to minimize the size of the fistula.
Concept Loui Cleft Palate Distractor5 •
Reconstructing the dental arch on the basis of distraction osteogenesis .
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Lengthening of the dental arch while minimizing the alveolar cleft .
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Simultaneous growth of the attached gingiva .
INTRA OPERATIVE APROACH 1.
lateral segment = dental arch.
2.
Horizontal intraoral incision along the buccal vestibule of the maxilla.
3.
Mucoperiosteal flaps are reflected, exposing at the site of horizontal osteotomy on the buccal side.
4.
Mucoperiosteal tunnel, extending upward from the interdental attached gingiva a horizontal incision is made, to expose the site
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BUJOD of vertical osteotomy. 5.
Estimating on the x- ray or stereolithographic model, the anatomical position of the dental roots.
6.
Sites of the osteotomy are positioned with a surgical marking pen.
7.
Horizontal osteotomy with a oscillating saw, 3 to 5mm away from the dental root apex and tooth buds.
8.
Interdental osteotomy with a small round burr and a thin osteotome, cutting through buccal and palatal cortical layers respectively.
9.
Also cutting carefully through the interdental cancellous bone, buccolingually .
10.
Before completing the osteotomy, the distraction device is mounted and screwed across the interdental osteotomy line.
11.
Functional check of the device.
12.
Irrigation and closure of the wound with absorbable sutures.
13.
latency period ( 5 - 7 days), distraction (0.9 mm per day = 3 turns ).
14.
The distracted segment runs along an orthodontic arch wire in a curved direction (optional), consolidation period (2 – 3 month).
15.
Po s t - d i s t ra c t i o n : o r t h o d o n t i c to o t h movement is initiated 2 to 3 weeks after distraction .
DISCUSSION Patients with severe maxillary clefts are difficult to treat with standard surgical and orthodontic approaches [1,3]. These patients present with maxillary hypoplasia, residual palatal or alveolar fistulas, absent or aberrant dental conditions and pharyngeal flaps. Traditional protocols for treatment of maxillary hypoplasia in cleft patients rely on a combined surgical-orthodontic approach which includes a le-fort 1 maxillary advancement with simultaneous fistula closure and maxillary and alveolar bone grafting. This surgical technique
Bali et al
requires rigid internal fixation for stabilization of the repositioned maxilla. The long term results of cleft patients with maxillary deficiency treated with this traditional approach have been disappointing and an increased relapse tendency has been reported. Mollina and Ortiz monasterio originally presented the concept of gradually distracting the maxilla after le-fort one osteotomy . In their technique elastic and orthodontic face masks were utilized to distract the maxilla .Their technique was further modified by use of red device. Rigid external distractor or Polleys device utilizes a skeletally fixed distraction device that is fully adjustable and offers the ability to change vertical and horizontal vector ay any time without patient discomfort during distraction process.[4,5] With further advancements to reduce patient discomfort intraoral cleft palate distracters have also been used loui cleft distractor being one of them. The main principle behind maxillary distraction osteogenesis is that the patient creates stable autogenous bone in the location where it is needed for stability, in the pterygomaxillary region. CONCLUSION One premise for successful bony reconstruction is the gap between the bony structures heals with bone that has the same properties as the host 5 bone. This occurs if the space is protected with the in growth of fibrous tissue. Various methods exist to protect such spaces, including bone grafting and creation of a protective periosteal sleeve. Distraction osteogenesis is a relatively new technique in craniofacial region and is based on the principle of applying tensile forces to separate two bony elements in such a way that a periosteal sleeve develops. The newly created space is thus filled with loose connective tissue, blood vessels, growth factors, and other molecules associated with bone formation. The gap is eventually filled with new bone that gradually matures and ossifies in a manner consistent with host bone. A combined treatment approach using distraction and orthodontic therapy is highly recommended to
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BUJOD produce excellent functional and esthetic results in patients with mid face deformities and clefts. Distraction Osteogenesis Using Loui Cleft Palate Distractor
Fig 1 showing cleftfig 2 cleft palate
overdentures.:A 1-7 year follow up study,Int j oral Maxillofac Surg 26:358, 1997. 2.
Oda T,Sawaki Y,Fukuta K,Ueda M:Segmental mandibular reconstruction by distraction osteogenesis underskin flaps,Int J oral maxillofac Surg27:9,1998.
3.
3 Ueda M:Maxillofacial bone distraction processes using osseointegated intraoral implants :International Satow congress on cranial and facial bone distraction.
4.
Polley JW, FiguerraAA,: Management of severe maxillary deficiency in childhood and adolosence through Distraction Osteogenesis with an adjustable Rigid ExternalDistractor Device. The Journal of Craniofacial Surgery,8,181-185,May1997.
5.
5 LouiEJ,ChenPKT,Huang CS,Chen YR: Interdentaldistraction osteogenesisand rapid orthodontic tooth movement :a novel approach to approximate a wide alveolar cleft o r b o ny d e fe c t . P l a s t re co n s t r Su rg 105:1262,2000
fig 3 osteotomy segment fig4 loui palatal distractor
fig 5 Distraction complete
fig 6 occlusal veiw
References 1.
S, Slagter AP,Stoelinga PJW,Habets LLMH: Interposed bone grafts to accommodate enosteal implants for retaining mandibular
Source of Support :
NIL
Conflict of Interest :
NOT DECLARED
Date of Submission :
07-03-2014
Review Completed :
02-06-2014
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Vol. 5 Issue-1 January 2015
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