secondary alveolar cleft repair
TRANSCRIPT
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SECONDARY ALVEOLAR CLEFT REPAIR
Natarajan.c
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Any patient born with complete cleft should be considered for alveolar grafting.
Cardinal rule
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Classification
Based on the timing of grafting , Primary - less than 2 yrs. Early secondary - 2-5 years. Secondary - 6-15 years. Late secondary - >15 years.
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Primary repair – before palatal closure. Secondary repair – after palatal closure.
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Pitfalls of primary repair……
“….a surgery that is needless and sometimes barbaric……”
-Pruzansky In , 1963 Convention of American
Cleft Palate Association.
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Robertson and Jolly (1968) –first to report
mid-face deficiency and malocclusion due to primary repair.
Transverse maxillary arch collapse is not
completely prevented by primary repair.
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Koberg states that, “……most severe maxillary deformities
are to be expected as late results of primary bone grafting , so that late secondary osteoplasty remains the only justifiable form of bone transplantation in cleft surgery……”
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Secondary repair -Objectives
.
Max arch stabilization, Bony support to teeth adjacent to cleft, Provision of bone for tooth eruption &
ortho movement, Ridge height for prosthetic rehabilitation, Obliteration of oro-nasal fistula, Support for alveolar base.
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Untreated cleft results in…
Palatally displaced alv.ridge on cleft side wit tooth malalingment.
Deficient bone support. Inadequate oral hygiene, due to oro-nasal
fistula. Segmental mobility. Effects on speech.
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Various methods of repair.
Grafting. 1.autogenous 2.allogenous 3.alloplastic
Orthognathic surgery.
Intradental distraction osteogenesis.
Periosteoplasty.
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Secondary bone grafting of residual alveolar clefts
Phillip J. Boyne & Ned R. Sands journal of oral surgery feb1972, vol 30, 87-92.
CLASSIC ARTICLE. Prefered time for surgery-btwn 9 and 12
years.
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But , dental developmental age, and not the chronological age is the foremost consideration.
grafting is done → canine root is 1/4th to 2/3rd
complete.
“delaying grafting beyond the point of canine root development → increased incidence of periodontal defects and fistula.”
Sindet – Pederson - Enmark
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But…
When orthognathic surgery is planned …
Secondary grafting is delayed.
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Grafting….
In autogenous group , bone is deposited in 2 to 6wk . At 6th mo complete bone fill.
In allogenous group , host bone
induction was not there till 7th wk .At 6 mo only 30% bone filling was evident.
-Marx .et al, JOMS 42 ; 3 ,1984.
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Currently alloplasts are indicated for only ridge contouring & not indicated in growing individuals & wit unerupted tooth adjacent to cleft & only wen endosteal implants are not planned.
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Optimal sequence…
Transverse expansion of maxilla (in late mixed dentition)
Followed by bone grafting
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Graft procurement site selection is based on …
Primarily , size of the defect. Age of the patient. Operator preference. Patients desire.
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“best inductor agent…..is natural human bone of cancellous structure in finely divided form , and that the most responsive tissue is the connective tissue closely related to living bone…”
-Collins ,Pathology of Bone.
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Various cancellous graft procurement sites …
Illium. Calvarium. Mandibular symphysis.???? Rib. Proximal tibia.
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But…
Best cancellous grafts obtained from Trochanter major(femur) -Spiessl, oral & maxillofacial bone
surgery.
PCBM – Particulate Cancellous Bone Marrow
grafts, obtained from illiac crest is the donor material of choice.
-Boyne & Sands 1972
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Requisites of ideal bone graft…
Existence in unlimited supply. Provision for immediate osteogenesis for
rapid consolidation. No adverse host rxn. immed. revascularization Osteoinduction Adaptability . No impediment in growth. Framework for osteoconduction. Completely replaceable by bone.
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Functions of successful bone graft
Restores normal continuity & functions. Restores appearance and facial esthetics. Forms allostructural framework for new
bone formation. Furnishes osteogenic cells. Precursor for bone induction principle.
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Rules for bone grafting-Kazanjian 1952
Adequate blood supply of recipient site. Bone to bone contact ,CREEPING
SUBSTITUTION. Rigid fixation of fragments. Grafts to be placed into only healthy
tissue..
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Bone storage-Marx 1994
Cell viability Best maintained in culture media/N.S. 95% viability at room temp for 4 hrs. temp of solution death rate of cells. Temp cooler than room temp small in
cell survival. Avoid hypotonic sols.
10cc loose uncompressed cancellous bone for every 10mm length of reconstruction.
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