|Year : 2017 | Volume
| Issue : 1 | Page : 22-25
Comparative efficacy of autologous alveolar bone grafting with autologous platelet-rich plasma and without platelet-rich plasma in cleft alveolus patients
Rohan Suhas Deshpande1, Abhilasha Omprakash Yadav1, Rajiv Mukund Borle1, Atul Vijay Kala1, SN Jajoo2, Deep Thakkar1
1 Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Sawangi (M), Wardha, Maharashtra, India
2 Department of Plastic Surgery, Jawaharlal Nehru Medical College, Sawangi (M), Constituent Colleges of Datta Meghe Institute of Medical Sciences, Sawangi (M), Wardha, Maharashtra, India
|Date of Web Publication||2-May-2017|
Abhilasha Omprakash Yadav
Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Sawangi (M) Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The aim of this longitudinal study was to evaluate the efficacy of alveolar bone grafting with autologous platelet-rich plasma (PRP) over cancellous bone grafting alone in cleft alveolus patients.
Materials and Methods: A total of 30 patients were evaluated, out of which 15 patients were subjected to alveolar bone grafting with cancellous bone and 15 patients underwent alveolar bone grafting with autologous PRP along with cancellous bone graft. Autologous PRP was extracted using a plasma centrifuge machine. Chi-square test was used for statistical analysis, which revealed statistically significant (P < 0.05) in the study group and control group.
Results: Radiographic evaluation was done on the amount of graft resorption at the end of 6 months postoperatively. Success of the graft was assessed with the help of Bergland scoring criteria.
Conclusion: Results obtained from our study suggested that resorption of bone graft was comparatively less in the study group as compared to control group.
Keywords: Alveolar bone grafting, cleft alveolus, platelet-rich plasma
|How to cite this article:|
Deshpande RS, Yadav AO, Borle RM, Kala AV, Jajoo S N, Thakkar D. Comparative efficacy of autologous alveolar bone grafting with autologous platelet-rich plasma and without platelet-rich plasma in cleft alveolus patients. J Cleft Lip Palate Craniofac Anomal 2017;4:22-5
|How to cite this URL:|
Deshpande RS, Yadav AO, Borle RM, Kala AV, Jajoo S N, Thakkar D. Comparative efficacy of autologous alveolar bone grafting with autologous platelet-rich plasma and without platelet-rich plasma in cleft alveolus patients. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2017 Jun 23];4:22-5. Available from: http://www.jclpca.org/text.asp?2017/4/1/22/205415
| Introduction|| |
A cleft is a congenital abnormal space or a gap in the upper lip, alveolus, or palate. Any disturbance during the embryonic formation, development, and growth of orofacial region will result in the formation of orofacial clefts. The orofacial clefts are congenital deformities which manifest at birth. Facial esthetics, speech, mastication, deglutition can be impaired because of orofacial clefts with a significant impact on the psychosocial aspect of the patient's life during his/her life. The main basis for closure of alveolar clefts has been well supported and includes , stabilizing and providing continuity to the maxillary arch, permitting support for tooth eruption, eliminating oronasal fistulae, providing an improved esthetic result, and providing bone for tooth movement.
Bone grafting of the cleft maxilla before eruption of the permanent cuspid has become an accepted part of the management of patients with clefts involving the maxillary alveolus. The reasons for performing a bone graft are to stabilize the maxillary segments and provide bony support for the teeth adjacent to the cleft. Boyne and Sands reported bone grafting for alveolar cleft between ages of 9 and 11 years before the canine teeth had fully erupted.
Platelet-rich plasma (PRP) extracted from autogenous blood contains many growth factors, such as platelet-derived growth factor (PDGF), vascular endothelial growth factor, and transforming growth factor-beta, which can accelerate bone regeneration and enhance bone formation by accompanying autogenous bone graft or bone substitutes.,
In this study, secondary alveolar bone grafting was performed, it is the most popular treatment modality, and it is typically performed in patients between the ages of 9 and 12 years during the period of mixed dentition in alveolar cleft patients using autologous anterior iliac crest corticocancellous bone with and without PRP and the early results were evaluated with the purpose to evaluate the effectiveness of PRP for autogenous bone graft in the alveolar cleft, in patients who underwent autogenous bone graft for cleft alveolus.
| Materials and Methods|| |
After approval from the Ethics Committee of Institutional Ethical Board, longitudinal comparative study was planned in two patient groups who underwent iliac cancellous bone grafting. They were divided into two groups of 15 patients each. Fifteen patients underwent only alveolar bone grafting and 15 patients underwent alveolar bone grafting with autologous PRP along with cancellous bone. All patients' parents or guardians provided written informed consent before the procedure.
Evaluation of the early results was done with the help of intraoral periapical radiographs with grids for the measurement, and also evaluation was done using maxillary occlusal radiographs and orthopantomogram (OPG) for both the groups. Bergland Scoring Criteria was used to assess the success of bone grafting after 6 months in control group and study group.
- Normal interdental alveolar height
- >75% normal interdental alveolar height
- 50%–75% interdental alveolar height.
- <50% normal interdental alveolar height.
Out of 15 patients in the control group, ten patients had left unilateral cleft lip and palate (ULCP) and five had right ULCP. In the study group, nine patients had left ULCP while five patients had right ULCP and one patient had bilateral cleft palate.
In the study group, five patients were in preteen group while six patients in control group were in preteen group. Mean age of the patients was 14.26 ± 4.04 years.
Under all aseptic precautions, oro-endotracheal intubation was done for all patients using south pole or RAE endotracheal tube. Crevicular incision was given along the cleft alveolus (at least 4 teeth on either side of cleft). If a fistula was present, then after giving a peri-fistular incision, the nasal and oral layers were separated. The nasal layer was sutured using a 4-0 vicryl to form the bed for the bone graft.
The incision on the anterior iliac crest was marked with the overlying skin retracted superior-medially to prevent the surgical scar from lying directly over the crest of the ridge and causing irritation from clothing resting on the crest of the ridge. A 4–6 cm incision was performed starting 2 cm inferior to the anterior superior iliac spine to prevent unsightly scar and also to avoid damage to the lateral femoral cutaneous nerve. Dissection was carried through the skin and subcutaneous tissue down to the muscles. The dissection continued through the aponeurosis between the external oblique and tensor fasciae latae muscles; the Scarpa's fascia was incised. The periosteum was sharply elevated off the crest of the ridge and the iliacus muscle retracted medially in a subperiosteal plane. A cancellous bone graft was then harvested from the medial aspect of the crest by either a trap door technique or a trephine depending on the amount of bone graft required [Figure 1]a. The bone graft was harvested using bone gouge and curettes and was then transferred to the recipient site of cleft alveolus directly without storing it in isotonic saline [Figure 1]c. After bone graft harvest, hemostasis was achieved. Closure achieved with multilayered closure of the periosteum, muscular aponeurosis, and skin. The periosteum and the muscle were closed using 2-0 resorbable sutures, whereas the skin was closed using 3-0 nonresorbable suture.
|Figure 1: (a) Iliac crest bone graft, (b) recipient site for grafting, (c) autologous platelet rich plasma placed in recipient site|
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For the control group, the cancellous bone graft was gently packed in the cleft defect and the closure of the recipient site was done (a water tight closure) using a resorbable suture. For the patient of test group intraoperatively, 10 ml of patient's blood was withdrawn and collected in sterile glass test tubes containing 1.5 ml of anticoagulant citrate phosphate dextrose adenine. The blood-containing test tubes were shaken gently to enhance complete mixing of the blood with anticoagulant. Then, it was kept at room temperature for a minimum of 10 min to minimize the complement activity. Later, blood-containing test tubes were centrifuged using refrigerated centrifugal machine at 3000 rpm for 10 min. PRP and the bone graft were together placed in the trapdoor prepared for receiving the bone graft in the cleft alveolus area [Figure 1]b. The patient was then reversed and extubated and monitored in the Intensive Care Unit for next 24 h.
| Results|| |
Chi-square test revealed statistical significance (P < 0.05) in study group and control group.
All patients had an uneventful course postoperatively. In the control group, out of 15 patients, 20% patients (three patients) had Bergland Scoring I. Fifty-three percent of patients (eight patients) had Bergland Scoring II which can be considered as successful bone grafting. Twenty-six percent (four patients) had graft failure. In the study group, out of 15 patients, 66% (ten patients) had Bergland Scoring I, 20% (two patients) Bergland Scoring II, while only two cases had failure of graft [Table 1].
|Table 1: Distribution of patients according to Bergland scoring in test and control group|
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Patients in whom bone grafting along with PRP was done within the age group of 12–22 years, six patients out of nine (66.6%) had Bergland Scoring Criteria I [Figure 2]a and [Figure 2]b, two patients out of 9 (22.2%) had Bergland Scoring Criteria II, and 1 case (11.1%) had Bergland Scoring Criteria III. In all eight out of nine patients (88.8%), cases showed successful results with least bone resorption at the end of 6 months postoperatively [Table 2] and [Table 3].
|Figure 2: (a) Preoperative radiograph occlusal view, (b) postoperative radiograph occlusal view|
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|Table 2: Correlation of age with Bergland scoring (alveolar bone grafting)|
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|Table 3: Correlation of age with Bergland scoring (alveolar bone grafting with platelet.rich plasma)|
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| Discussion|| |
It is gathered that PRP could enhance the osteogenesis of alveolar bone grafting, reduce resorption of graft in cleft lip and palate patients, and may be useful for subsequent orthodontic therapy. The result of our study is in accordance with previous studies.,, During follow-up of these patients who were concomitantly undergoing orthodontic therapy, it was noted that group of patients in which bone grafting was done with PRP showed enhanced tooth movement through the graft and stable results orthodontically as well as compared to patients in whom only bone grafting was done.
Alveolar bone grafting is a significant treatment for cleft lip and palate. It may not only induce the tooth eruption but also stabilize the alveolar arch of maxilla. Iliac cancellous bone is a preferable grafting material because it can be harvested easily and sufficiently and has high osteoinductive potential compared with the other materials. However, even with iliac bone marrow, partial absorption and shortage of reconstructed alveolar height or width may develop postoperatively. One of the important factors for successful osteogenesis is the patient's dental age. Secondary bone grafting is considered to be preferable to tertiary grafting, because the older the patients are, lower the osteogenic activity. It is assumed that PRP might enhance the osteogenesis of autologous bone and lessen postoperative bone resorption.
Bone morphogenic proteins have the ability to enhance the chemotaxis and mitogenesis of osteoblast precursors and to stimulate osteoblast deposition in the collagen matrix of wound healing in bone.
Various evaluation methods for the postoperative course of grafted bone have been reported: dental X-rays, occlusal X-rays, and computed tomography (CT).
Feichtinger et al. and Rosenstein et al. have recommended using three-dimensional CT (3D CT) to obtain specific results on the volume and width of the bone bridge. Radiation exposure of pediatric patients with CT scan is much higher as compared to intraoral radiographs and the costs of 3D CT are greater than for other examinations. In this study, we used multiple radiographs which have several benefits: radiation exposure to patients is less than for other radiographic examination methods; longitudinal changes in grafted bone are correctly compared.
Marx has demonstrated that the maturity of grafted bone combined with PRP is significantly greater than that without PRP and that grafted bone combined with PRP shows a mature Haversian system and a greater proportion of lamellar phase bone  Marx noted that there is massive initial secretion of growth factors by platelet on activation and the effect continues but to a lesser extent until the platelets die off after 9 days when the secretory role of platelet is taken over by other chemical mediators 
Different opinions have been expressed by other authors; Schmitz and Hollinge  doubt the effects of PRP because PDGF is inhibitory to osteoblastic cells if delivered in a continuous form and increases bone resorption. In the present study, it was revealed that PRP could enhance osteogenesis much more than osteoresorption in a remodeling phase within 6 months after the operation. PRP served as an adjunct to promote osseous bone regeneration. However, it is unknown for how long (6 months) PRP exerts an influence on the bone volume in this study.
| Conclusion|| |
Secondary bone grafting is suitable for reconstruction of cleft alveolar defects. Secondary bone grafting facilitates eruption of unerupted canines, irrespective of the use of autologous PRP. Autologous PRP reduces the rate of bone resorption; also, corticocancellous bone graft's efficacy is increased if used with autologous PRP.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
McCarthy JG. Plastic Surgery, Vol 4. Philadelphia: W.B Saunders; 1990. p. 2753-70.
Bajaj AK, Wongworawat AA, Punjabi A. Management of alveolar clefts. J Craniofac Surg 2003;14:840-6.
Murthy AS, Lehman JA. Evaluation of alveolar bone grafting: A survey of ACPA teams. Cleft Palate Craniofac J 2005;42:99-101.
Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 1972;30:87-92.
Mohan S, Baylink DJ. Bone growth factors. Clin Orthop Relat Res 1991;263:30-48.
Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:638-46.
Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.
Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 1986;23:175-205.
Dempf R, Teltzrow T, Kramer FJ, Hausamen JE. Alveolar bone grafting in patients with complete clefts: A comparative study between secondary and tertiary bone grafting. Cleft Palate Craniofac J 2002;39:18-25.
Marukawa E, Oshina H, Iino G, Morita K, Omura K. Reduction of bone resorption by the application of platelet-rich plasma (PRP) in bone grafting of the alveolar cleft. J Craniomaxillofac Surg 2011;39:278-83.
Sakio R, Sakamoto Y, Ogata H, Sakamoto T, Ishii T, Kishi K. Effect of platelet rich plasma on bone grafting of alveolar clefts. J Craniofac Surg 2016. doi: 10.1097/SCS.0000000000003345. [Epub ahead of print].
Kassolis JD, Rosen PS, Reynolds MA. Alveolar ridge and sinus augmentation utilizing platelet-rich plasma in combination with freeze-dried bone allograft: Case series. J Periodontol 2000;71:1654-61.
Feichtinger M, Mossböck R, Kärcher H. Evaluation of bone volume following bone grafting in patients with unilateral clefts of lip, alveolus and palate using a CT-guided three-dimensional navigation system. J Craniomaxillofac Surg 2006;34:144-9.
Rosenstein SW, Long RE Jr., Dado DV, Vinson B, Alder ME. Comparison of 2-D calculations from periapical and occlusal radiographs versus 3-D calculations from CAT scans in determining bone support for cleft-adjacent teeth following early alveolar bone grafts. Cleft Palate Craniofac J 1997;34:199-205.
Marx RE. Platelet rich plasma: A source of multiple autologous growth factors for bone grafts. In: Lynch SE, Genco RJ, Marx RE, editors. Tissue Engineering: Application in Maxillofacial Surgery and Periodontics. Chicago: Quintessence;1999. p. 71-82.
Schmitz JP, Hollinger JO. The biology of platelet-rich plasma. J Oral Maxillofac Surg 2001;59:1119-21.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]