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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 113-118

A retrospective study of tibial cancellous bone grafting in the management of alveolar clefts


1 Department of Plastic and Reconstructive Surgery, Saifee Hospital, Mumbai, Maharashtra, India
2 Department of General Surgery, Saifee Hospital, Mumbai, Maharashtra, India
3 Consultant Orthodontist, Private Practice, MGM Dental College and Hospital, Mumbai, Maharashtra, India
4 Department of Oral and Maxillofacial Surgery, MGM Dental College and Hospital, Mumbai, Maharashtra, India
5 Department of Plastic Surgery, Jaslok Hospital, Mumbai, Maharashtra, India

Date of Web Publication26-Jul-2018

Correspondence Address:
Dr. Abbas Asgharali Mistry
1001, Rekab Towers, E. S. Patanwala Marg, Ghorapdev, Mumbai - 400 033, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_13_18

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  Abstract 


Introduction: This is a retrospective study to assess the outcomes of tibial bone grafts in secondary grafting of alveolar clefts. Tibial cancellous bone harvested from upper-end diaphysis is believed to be qualitatively similar to iliac bone without the known morbidities of the donor site. Patients and Methods: The study comprises of 54 patients with complete alveolar clefts treated at our institute. The quality of graft take was graded radiologically using Bergland's criteria. The patients were followed up for complications, longest follow-up being 10 years. Results: The success rate was 96.3% for the sample. There were two cases, one of complete and one of partial bone loss each with recurrence of fistulae. A single case of wound infection at donor site was seen. On long-term evaluation, we had one case of slight hypertrophic scarring. Conclusion: Tibial cancellous bone graft provides good quality of viable bone for alveolar bone grafting without the accompanying morbidity. Hence, it is an excellent alternative to iliac crest bone grafting.

Keywords: Alveolar bone graft, alveolar cleft, tibial bone graft, tibial bone harvest


How to cite this article:
Mistry AA, Mistry YA, Kale C, Mistry TA, Goleria DK, Samudre BA. A retrospective study of tibial cancellous bone grafting in the management of alveolar clefts. J Cleft Lip Palate Craniofac Anomal 2018;5:113-8

How to cite this URL:
Mistry AA, Mistry YA, Kale C, Mistry TA, Goleria DK, Samudre BA. A retrospective study of tibial cancellous bone grafting in the management of alveolar clefts. J Cleft Lip Palate Craniofac Anomal [serial online] 2018 [cited 2019 Jan 20];5:113-8. Available from: http://www.jclpca.org/text.asp?2018/5/2/113/237632




  Introduction Top


An alveolar cleft is the result of abnormal primary palate formation during weeks 4–12 of gestation.

The rationale for its closure includes the following:[1]

  1. Stabilizing the maxillary arch, especially in bilateral clefts with mobile premaxillae
  2. To consolidate the maxilla to facilitate secondary surgery
  3. Permitting support for tooth eruption
  4. Providing support for adjacent teeth
  5. To treat oronasal fistulae
  6. To provide support for alar base
  7. For subsequent osseointegrated implant placement and
  8. To improve dental and facial esthetics.


Methods for closure of the alveolar cleft have been solidified during the last century with the use of autogenous bone grafting because it supplies living, immunocompatible cells that integrate fully with the maxilla and are essential for osteogenesis.[2]

Secondary bone grafting is now the preferred method of treatment, because early grafting has proven detrimental to midfacial growth.[2] This is typically done between 8 and 10 years. By 8–9 years, sagittal and transverse growth has virtually ceased thus chances of interfering with maxillary growth are minimal after this age. However, vertical growth continues until adolescence and is affected by the secondary bone grafting.[3]

Various sites for bone graft harvesting have been proposed, including the iliac crest [2] cranium,[4] tibia,[5] rib, and mandibular symphysis.[6]

Although literature demonstrates 83.7%–93% success rates for iliac bone graft, morbidity associated with it is sometimes significant; and therefore, other sites are sought for bone grafts. We have chosen tibial cancellous bone harvested from the upper end diaphysis because of its easy accessibility,[7] qualitative similarity to iliac graft,[8] and less morbidity of donor site. We would, therefore, like to report our experience with the tibial bone grafting.


  Patients And Methods Top


This retrospective study was undertaken to assess the outcome of use of tibial bone grafts for closure of alveolar defects performed at our institute from January 2005 to December 2015. The study included all patients between 6 and 10 years of age, who underwent surgery for repair of complete alveolar clefts and had complete records including pre and postoperative radiographs with at least 1year follow-up. Both unilateral and bilateral cases were included in the study. Patients with associated syndromes, previous surgery for alveolar bone graft, or patients with incomplete clefts were excluded from the study. Fifty-four patients were selected during this period. Forty patients had unilateral (31 left and 9 right) and 14 had bilateral clefts. The mean age at the time of operation was around 9.0 ± 1.1 years.

Orthodontic expansion and arch alignment were carried out in all cases with Quad-Helix device before grafting [Figure 1]. Twelve weeks after the grafting operation, a final long-term active orthodontic treatment was performed to restore dental intraarch and interarch relationships.
Figure 1: Quad-Helix appliance placed to achieve proper arch form

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Procedure

Regardless of the timing and materials used, the main principles in approaching alveolar clefts have been well described. They include (1) appropriate flap design, (2) wide exposure, (3) nasal floor reconstruction, (4) closure of oronasal fistula, (5) packing bony defect with cancellous bone, and (6) coverage of bone graft with gingival mucoperiosteal flaps.

While the technique for the recipient site remains the same, the donor site harvesting technique used by us is briefly described. Under tourniquet, a 3 cm straight or oblique incision is taken through the skin and subcutaneous tissue. The periosteum is incised on three sides a little beyond the planned bony window [Figure 2]. Osteotomy is performed on three sides and the fourth side is fractured leaving the bone attached to the periosteum [Figure 3]a. Bone is harvested from the diaphysis of tibia using a scoop. The bony window is closed by repositioning of the periosteo-osseous flap with the attached bone and sutured [Figure 3]b. Skin is closed. A crepe bandage dressing with posterior slab is given and tourniquet released.
Figure 2: (Green-dotted line) Outline of Tibia. (Red line) Skin incision. (Purple-dotted line) Periosteal incision on three sides. (Purple solid line) Osteotomies

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Figure 3: (a) The bony window is made by fracturing the fourth side but hinged to the periosteum. (b) The osteoperiosteal flap is repositioned and sutured after bone harvest.

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Both sites are operated simultaneously thus saving time which is approximately 60 min.

Patient is discharged the same evening.

Usually, up to 10 cc of cancellous bone graft can be harvested. The alveolar defect varied from 0.8 to 8 cc. The volume of bone graft needed to fill the alveolar defects was measured using bone wax to fill in the alveolar defect and then calculating its volume by displacement technique using a 5 ml syringe [Figure 4].
Figure 4: (a) The alveolar defect (b) Defect filled with bone wax (c) The actual volume of the defect (d and e) Measurement of volume using displacement method

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Radiographic assessment

Orthopantomograms (OPGs) and intraoral periapical (IOPA) X-rays were taken pre- and post-operatively. Postoperative X-rays were taken at 6 months and at 12 months. Since the last few years, we are taking cone-beam computed tomography (CBCT) scans in addition to OPG and IOPA.

The quality and success as assessed radiographically was done using Bergland's criteria,[2] on IOPA at the end of 6 months or later. The interdental septum height was measured and recorded as follows:

  • Type 1 – Bone height at the level of cementoenamel junction (CEJ) of adjacent tooth
  • Type 2 – Bone height below level of CEJ but reaching up to 3/4th height of CEJ of adjacent tooth
  • Type 3 – Bone height <3/4th height of CEJ of adjacent tooth
  • Type 4 – Absence of bony bridge.


Type 1 and Type 2 [Figure 5] were considered as successful bone graft and Type 3 and 4 were considered failure of bone grafting.[9]
Figure 5: Pre- and post-operative radiograph showing Type 1 graft uptake in a unilateral cleft according to Bergland's criteria

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The IOPA's were randomized and shown to the blinded observer and he was asked to rate the defect according to Berglands' criteria. The assessment was performed by the orthodontist. In case of bilateral clefts, the lower score was considered as score for that patient.

CBCT scan is a better tool to accurately assess the defect in terms of volume and is useful if done postoperatively in assessing the developing bone graft on follow-up [Figure 6]. However, CBCT assessment was not used in this study as very few patients had a CBCT.
Figure 6: A case of unilateral cleft lip and palate. Postoperative cone-beam computed tomography and orthopantomograms show excellent bone fill (Bergland's Type 1)

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  Results Top


The results of this study were based on the assessment that was carried out at 1-year postsurgery and subsequently thereafter, the longest follow-up being 10 years.

The average amount of bone that could be harvested was 11 ± 2.6 cc (maximum = 17 cc and minimum = 8 cc).

Radiographic assessment using Bergland's criteria was as follows: Type 1, n = 40 (74.1%); Type 2, n = 12 (22.3%); Type 3, n = 1 (1.8%); and Type 4, n = 1 (1.8%).

A success rate of 96.3% (Type 1 + 2) was seen in the whole sample [Figure 7].
Figure 7: Graph showing graft take according to Bergland's criteria

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The separate assessment of unilateral cases (n = 40) and bilateral cases (n = 14) is shown in [Table 1].
Table 1: Assessment of unilateral cases and bilateral cases separately

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There were more cases of Type 1 graft take in unilateral than bilateral cases which was statistically significant (P < 0.001). However, statistically, there was no significant difference between the overall success rate of unilateral and bilateral cases (P = 0.064) as determined by Fisher's exact tests. A representative case of bilateral CLP is shown in [Figure 8].
Figure 8: Clinical photos of a case of bilateral cleft lip and palate showing excellent bone uptake done using tibial bone graft

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Complications were divided into those at the recipient site and those at the donor site.

As far as the donor site complications are concerned one case of superficial skin wound infection of the donor leg (1.8%) was seen. This was treated conservatively with dressings only and healed with hypertrophic scarring [Figure 9].
Figure 9: Hypertrophic scarring on the tibial site

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As regards complications at alveolar bone grafting sites, we had:

  1. A case of wound breakdown with complete loss of graft and resultant postalveolar fistula. This patient followed up almost after 6 months and refused further treatment
  2. A case of wound breakdown with partial loss of bone graft. This was treated with strict oral hygiene and antibiotics and fortunately for us and the patient the wound healed though approximately there was 50% bone loss.



  Discussion Top


Iliac cancellous bone graft is still the first choice for secondary alveolar bone grafting for many surgeons. However, harvest of iliac crest bone carries with it, complications, such as haematoma, seroma, nerve injury, gait disturbances, and persistent pain.[10]

The reasons for not using tibial cancellous bone graft may be from fear of injuring the epiphyseal plate and potential growth disturbances in growing patients, the expectation of lesser quantity and quality of bone graft and possibly, in the authors' opinion, unawareness of the simplicity, and low morbidity of the technique.

The amount of bone harvested in each case in our sample was 11 ± 2.6 cc. This was in agreement with other studies in literature where 14–25 cc bone graft has been reported.[11],[12] This proved to be adequate in all cases. There was no case in which the opposite or other sites were required to be harvested.

As a method to quantify the bone graft uptake and success or failure of the procedure radiographic assessment using Bergland's criteria. The results showed that out of the 54 patients, 52 had either Type 1 or Type 2 uptake at 6 months (Type 1, n = 40 (74.1%); Type 2, n = 12 (22.3%); Type 3, n = 1 (1.8%); and Type 4, n = 1 (1.8%). That is, in 96.3% cases, an adequate bony bridge was formed between the two ends of the cleft. The alveolar bone grafting resulted in an alveolar process of sufficient volume. The orthodontist had sufficient bone to be able to move teeth into the new bone for functional loading and to upright them in overcorrection.

On comparing the results between unilateral and bilateral clefts, it was seen that a significantly better score was seen in unilateral clefts than bilateral clefts. This is in perfect agreement with our expectations as the mobile premaxilla and larger defect in a bilateral scenario does contribute to graft loss. Even though every attempt was made to stabilize the segments and reduce the defect size in a bilateral cleft, the results, as expected, were still poorer when compared to unilateral clefts. This was similar to reports in literature where unilateral cases had better results than bilateral clefts.[13]

We undertook this study to assess the outcomes of alveolar bone grafting using tibial cancellous bone graft because we feel it is qualitatively same as iliac bone graft with additional advantages of shorter operating time, minimal scarring, early mobility, and a short stay in hospital. It is done as a day-care procedure for all our patients. Since it is performed as a day-care procedure, the cost is also less.

All of our cases underwent preoperative orthodontic arch alignment and expansion. The rationale for expansion and alignment of arches was that it not only helps in maintaining the future intermaxillary transverse relationship but also stabilizes the alveolar segments, approximates them, thus making the surgery easier, and in some cases facilitates access into the cleft. The authors believe that preoperative alignment of the arch and postoperative stabilization with archwire significantly improves outcomes of bone grafting as evidenced by the high success rate in our study.

As regards to the complications at donor site, we had one case of superficial wound infection which healed by locally managing the wound with antibiotic cream. The patient had scar hypertrophy which is being managed by pressure therapy and silicone gel. Other major complication which has been mentioned in literature is fracture of the tibia.[14],[15] However, we have never encountered this. Long-term follow-up of potential damage to the growth center after proximal tibial grafting in patients with clefts has also not been reported.[16],[17]

Many studies have been performed using Bergland's classification to assess the integration of grafted bone in the past. The subjective nature of evaluation using Bergland's criteria is the shortcoming of this study. CBCT scan, as mentioned before, is a much better tool to accurately assess the defect in terms of volume and is useful if done postoperatively in assessing the developing bone graft on follow-up. However, to get an adequate sample size, we included older patients who did not have a CBCT. However, we have based our conclusions on the final functional outcome as regards occlusion and esthetics.

As regards recipient site complications, we had 2 cases of wound breakdown with exposure of the bone graft with resultant loss; one complete bone loss with fistula and other partial loss. Both the complications could be attributed to poor oral hygiene with subsequent infection. In the first case, it was poor follow-up also.

Contrary to our expectation, there has been no significant late resorption of alveolar bone graft in any of the patients. This is probably because of retaining the arch width with orthodontic treatment postoperatively.


  Conclusion Top


We present here 52 out of 54 cases of successful alveolar bone grafting using tibial cancellous bone graft. It is our opinion that it provides good quality of viable bone like that of iliac cancellous bone without the accompanying morbidity.

We had 96.3% of success which is comparable to other reported articles irrespective of site of donor site. Complications were few. Hence, we conclude that the tibial bone graft is an excellent alternative for alveolar bone grafting.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Collins M, James DR, Mars M. Alveolar bone grafting: A review of 115 patients. Eur J Orthod 1998;20:115-20.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
Enemark H, Sindet-Pedersen S, Bundgaard M. Long-term results after secondary bone grafting of alveolar clefts. J Oral Maxillofac Surg 1987;45:913-9.  Back to cited text no. 3
    
4.
Sadove AM, Nelson CL, Eppley BL, Nguyen B. An evaluation of calvarial and iliac donor sites in alveolar cleft grafting. Cleft Palate J 1990;27:225-8.  Back to cited text no. 4
    
5.
Lilja J, Möller M, Friede H, Lauritzen C, Petterson LE, Johanson B, et al. Bone grafting at the stage of mixed dentition in cleft lip and palate patients. Scand J Plast Reconstr Surg Hand Surg 1987;21:73-9.  Back to cited text no. 5
    
6.
Sindet-Pedersen S, Enemark H. Mandibular bone grafts for reconstruction of alveolar clefts. J Oral Maxillofac Surg 1988;46:533-7.  Back to cited text no. 6
    
7.
Catone GA, Reimer BL, McNeir D, Ray R. Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: A preliminary report. J Oral Maxillofac Surg 1992;50:1258-63.  Back to cited text no. 7
    
8.
Sivarajasingam V, Pell G, Morse M, Shepherd JP. Secondary bone grafting of alveolar clefts: A densitometric comparison of iliac crest and tibial bone grafts. Cleft Palate Craniofac J 2001;38:11-4.  Back to cited text no. 8
    
9.
Jia YL, James DR, Mars M. Bilateral alveolar bone grafting: A report of 55 consecutively-treated patients. Eur J Orthod 1998;20:299-307.  Back to cited text no. 9
    
10.
Zouhary KJ. Bone graft harvesting from distant sites: Concepts and techniques. Oral Maxillofac Surg Clin North Am 2010;22:301-16, v.  Back to cited text no. 10
    
11.
Al Harbi H, Al Yamani A. Long-term follow-up of tibial bone graft for correction of alveolar cleft. Ann Maxillofac Surg 2012;2:146-52.  Back to cited text no. 11
    
12.
Vittayakittipong P, Nurit W, Kirirat P. Proximal tibial bone graft: The volume of cancellous bone, and strength of decancellated tibias by the medial approach. Int J Oral Maxillofac Surg 2012;41:531-6.  Back to cited text no. 12
    
13.
Goudy S, Lott D, Burton R, Wheeler J, Canady J. Secondary alveolar bone grafting: Outcomes, revisions, and new applications. Cleft Palate Craniofac J 2009;46:610-2.  Back to cited text no. 13
    
14.
van Damme PA, Merkx MA. A modification of the tibial bone-graft-harvesting technique. Int J Oral Maxillofac Surg 1996;25:346-8.  Back to cited text no. 14
    
15.
Chen YC, Chen CH, Chen PL, Huang IY, Shen YS, Chen CM, et al. Donor site morbidity after harvesting of proximal tibia bone. Head Neck 2006;28:496-500.  Back to cited text no. 15
    
16.
Ilankovan V, Stronczek M, Telfer M, Peterson LJ, Stassen LF, Ward-Booth P, et al. A prospective study of trephined bone grafts of the tibial shaft and iliac crest. Br J Oral Maxillofac Surg 1998;36:434-9.  Back to cited text no. 16
    
17.
Besly W, Ward Booth P. Technique for harvesting tibial cancellous bone modified for use in children. Br J Oral Maxillofac Surg 1999;37:129-33.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

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