齿槽裂修复方法的研究进展

目的探讨齿槽裂修复治疗的目的、方法以及治疗时机的选择。方法查阅1950年至2006年有关齿槽裂修复的文献,归纳文献中报道的不同方法,并评价其各自的优缺点。结果齿槽裂修复的主要目的:关闭口鼻瘘;建立稳定、连续的上颌骨牙弓;为牙齿萌出提供基础;为上唇和鼻底提供稳定支架。主要治疗方法:植骨术;牵引成骨技术;组织工程骨和生长因子应用;引导骨再生技术。患者最佳的手术治疗时机是9~11岁时混合牙列期。结论在9~11岁混合牙列期手术,以髂骨松质骨为移植材料被认为是修复齿槽裂的主要手段。牵引成骨技术、组织工程技术和引导骨再生技术,将是齿槽裂修复的新方向。     

扩弓后单侧完全性牙槽突裂的骨移植修复

目的:研究单侧完全性牙槽突裂畸形患者扩弓后骨移植修复的效果,为唇腭裂序列治疗后期正畸和正颌外科治疗提供临床基础。方法:对23例恒牙期单侧完全性唇腭裂术后伴发牙弓狭窄的牙槽突裂畸形患者进行快速扩弓并保持半年后,采用自体髂骨松质骨颗粒移植修复进行研究,对术后随访的X线片进行效果评价。结果:临床应用该方法治疗23例牙槽突裂患者,术后随诊3个月以上,临床观察牙槽突裂已修复,X线片显示骨密度接近正常骨质,移植骨块清晰可见,有较好的术后愈合效果。结论:正畸扩弓技术牙槽突裂骨移植修复术是唇腭裂序列治疗的重要组成部分,对于矫治伴有牙槽突裂的上牙弓缩窄畸形的唇腭裂患者,应在植骨手术前行扩弓治疗。     

Secondary Bone Grafting of Alveolar Clefts: A Surgical/Orthodontic Treatment Enabling a Non-prosthodontic Rehabilitation in Cleft Lip and Palate Patients

A procedure combining grafting of cancellous bone to the residual cleft of the primary palate with subsequent orthodontic movement of teeth into the former cleft area is described. The preliminary results from the first 80 patients (89 clefts) are presented. The age of the patients at the bone grafting ranged from 8 to 18 years, and the observation time from 17 to 44 months. The results have been assessed 1) on the basis of dental radiographs and 2) clinically, by the response of the grafted area to the orthodontic movement of adjacent teeth. In 69 clefts in which the cleft side canine had been brought into its final position at the time of evaluation, the height of the interal-veolar septum was assessed to be approximately normal in 38% and slightly less than normal in 44%. A septum of insufficient height (less than 3/4 of the normal) had formed in 5 clefts (7%). Even in these cases, the main objects of the operation were fulfilled: The maxillary segments were stabilized, the teeth adjacent to the cleft had better bone support, and the gap in the dental arch could be closed orthodontically in four of the five clefts. Failures, i.e. no continuous bone bridge across the alveolar cleft, were recorded in 8 instances (9%) of the total material. When failures were disregarded, the gap in the dental arch was closed orthodontically in 90%, while prosthodontic closure was deemed necessary in 10% of the cases. Optimal results were obtained when bone grafting was performed prior to the full eruption of the cleft side canine. In this situation, the known potential of an erupting tooth to induce alveolar bone generation proved to be of great advantage. By deliberately guiding the erupting canine through the grafted area close to the incisor, a nearly normal interalveolar septum was formed, and the gap in the dental arch was closed orthodontically in 23 out of 26 clefts. When fissural teeth were present, they were in most cases integrated in the dental arch. Approximate incisor symmetry could thus be obtained. In the remaining 20 clefts, the ipsilateral canine had not reached its final position at the time of evaluation, and the end results could not be assessed. However, bone formation in the defect was good in 19 of the 20 clefts, and a fully satisfactory result is expected in the majority of these cases. Further advantages were obtained by this procedure: 1) The maxillary segments were stabilized, particularly important in bilateral clefts in which the premaxilla was movable. 2) Oronasal fistulae were effectively closed and mucosal recesses eliminated. 3) The grafted bone provided support for the receded alar base, reducing the nasal asymmetry and improving the facial contour. 4) The postoperative orthodontic treatment could be brought to an end at approximately the same age as for patients with a non-cleft malocclusion. The only significant complication in this series was infection of the grafted area, causing loss of the bone grafts in two cases, and possibly contributing to the failure in some other patients. The experience gained with this treatment permits the conclusion that a full osseous and dental rehabilitation can be achieved in the great majority of patients with cleft lip and palate without any prosthodontic reconstructive work.     

The use of free-periosteum for secondary bone grafting to the maxillary alveolar clefts

Some modification on the surgical technique for bone grafting to the alveolar clefts has been required. Secondary bone grafting was performed with and without free-periosteum on 34 (mean age, 9.8 +/- 1.1 years) and 44 (mean age, 10.7 +/- 1.2 years) alveolar clefts, respectively. Vertical bone formation which scored 3 or 4 was obtained in 97.1% of free-periosteum grafted clefts, while it was obtained in 79.5% of the control group. The rate of postoperative wound dehiscence in free-periosteum grafted clefts (20.6%) was not significantly different from the control group (11.4%). In the wound dehiscence cases, however, the grafted periosteum covered the grafted bone and prevented bone exposure. The score of bone formation in the free-periosteum grafted clefts (3.57 +/- 0.79) was significantly higher than that of the control group (2.60 +/- 1.34). Thus, free-periosteum grafting in secondary bone grafting is useful for bone formation in alveolar clefts.     

Reconstruction of Previously Failed Alveolar Bone Grafts with Medial Femoral Condyle Flap in Pediatric Cleft Lip and Palate Patients

Alveolar cleft reconstruction is important to increase the quality of life of cleft lip and palate patients. Usually, alveolar clefts can be reconstructed using bone grafts. However, bone grafting can be insufficient, and other alternatives may be necessary in wide and recalcitrant clefts. The medial femoral condyle (MFC) flap may be the solution for alveolar clefts that are impossible to reconstruct with bone grafting. In this study, the reconstruction of alveolar clefts in the pediatric cleft lip and palate population, using the MFC flap, is described.This study examined 9 pediatric patients whose alveolar clefts were reconstructed prospectively using MFC flap in 2015 and 2019. The age, gender, follow-up times, independent parameters, and existence of concomitant vestibulonasal fistulas of the patients were recorded. Computerized tomography images of the patients were evaluated to detect defect characteristics and evaluate the volume of flap postoperatively. Flap viability was confirmed with bone scintigraphy, and donor area morbidity was evaluated with the Dynamic Gait Index (DGI) in the postoperative period.The study included 7 male and 2 female patients. The mean age of the patients was 13. In addition to an alveolar cleft, 6 patients also had vestibulonasal fistula. It was observed that the volume of the flaps had not changed one year after the operation. The DGI score of all the patients was 24.Existing techniques may be inadequate in the reconstruction of wide and recalcitrant alveolar clefts. MFC flap may be the start of a new era for the treatment of alveolar clefts.     

Assessment of secondary alveolar bone grafting using a modification of the Bergland grading system.

Although the management of the alveolar cleft remains controversial secondary alveolar bone grafting is the most widely accepted approach. The results of a series of 71 secondary alveolar bone grafts performed between 1990 and 2001 on 58 patients with complete cleft lip and palate 13 of which were bilateral are presented. Bone grafts were assessed when the canine tooth had fully erupted using periapical dental radiographs.The occlusal level of the newly obtained interdental bone of each grafted cleft was recorded and categorised in accordance with the Oslo grading system as described by Bergland. In addition the basal level of each bone graft was recorded. In this way total bone graft height was measured and each graft was categorised with respect to the desired normal height of noncleft interdental alveolar bone. This modified analysis grades more precisely the efficacy of secondary alveolar bone grafting and helps to identify and categorise those patients with insufficient bone for dental, orthodontic and orthognathic rehabilitation and those who may require further investigation and regrafting.     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16-19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16-19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16-19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

不同术式的双侧牙槽嵴裂植骨术对唇、颊龈沟深度的影响

目的　研究不同术式的双侧牙槽突裂植骨术对唇、颊龈沟深度的影响。方法　对我科 1992年 4月至 2 0 0 2年 3月间采用 :①提袋手柄式瓣牙槽突裂修复术 ;②双颊瓣牙槽突裂修复术 ;③双颊瓣加鼻中隔犁骨凿断牙槽突裂修复的 4 2例牙槽突裂患者进行分析。结果　将术后唇颊龈沟变浅分为Ⅳ级 ,结果 4 2例中 ,0级 2 0例 ,占 4 7 6 % ;Ⅰ级 10例 ,占 2 3 8% ;Ⅱ级 10例 ,占 2 3 8% ;Ⅲ级2例 ,占 4 7%。采用提袋手柄式瓣和双颊瓣加犁骨凿断牙槽突裂修复术的 6例中 ,唇颊龈沟变浅 2 3者有 4例 ,唇颊龈沟消失者 2例 ,可见这两种术式均可使唇颊龈沟变浅。结论　三种术式均有使唇颊龈沟变浅之可能 ,术中应注意预防之     

自体髂软骨及松质骨移植在牙槽突裂同期行鼻畸形整复术中的应用

目的　探索牙槽突裂与鼻畸形同期整复的新方法。方法　对 4 2例牙槽突裂患者采用自体髂骨及松质骨充填牙槽裂隙 ,髂嵴软骨片覆盖并充垫塌陷的梨状孔外缘及鼻侧区 ,同时利用鼻前庭黏膜软骨复合组织瓣V Y推进法整复鼻畸形。结果　 9～ 11岁患者牙槽突高度恢复平均为86 7% ,厚度恢复平均为 89 6 % ,牙槽突外形和功能为Ⅰ、Ⅱ级 ,尖牙在骨移植区萌出 ,梨状孔外缘鼻侧区低陷处高度恢复 ,鼻翼塌陷畸形恢复 ,鼻孔形态对称 ;12岁以上患者牙槽突高度恢复平均为70 1% ,厚度恢复平均为 71 7% ,牙槽突外形和功能为Ⅱ级、Ⅲ级 ;2例 18岁患者鼻背长轴、鼻端偏斜未能改善。结论　利用自体松质骨和软骨来修复牙槽突裂并同时进行鼻畸形整复 ,既能保证牙槽突高度、牙弓连续性的恢复 ,鼻畸形的改善 ,又能防止鼻背、鼻端长期畸形发展而造成难以矫正的偏斜 ,同时也能尽早消除因畸形给患者带来的心理障碍 ,是一种比较理想的整复方法     

牙槽骨扩展增加骨量后的植牙术

目的观察运用致密羟基磷灰石(HA)微粒,在颌骨萎缩患者牙槽嵴上行牙槽骨扩展术后行人工种植牙的临床效果。方法使用HA颗粒采用牙槽骨扩展术和粘骨膜下隧道法,对26例颌骨萎缩患者增加牙槽骨骨量后行人工种植牙。结果牙槽骨扩展术后置入HA颗粒不移位不弥散,与基骨牢固相接,人工种植牙时间为术后3.2个月,26例全部成功;粘骨膜下隧道术6例置入HA颗粒都有不同程度移位、弥散,与基骨大多为纤维性包裹及部分新骨长入,人工种植牙时间为术后4.8个月,1例失败。结论运用牙槽骨扩展术大大地扩大了人工种植牙的适应证、缩短疗程和提高成功率。     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract

This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16–19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16–19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16–19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

The percutaneous trephine technique for harvesting iliac crest bone graft in alveolar clefts and its effect on donor site morbidity and quality of bone graft

The percutaneous trephine technique uses a bone marrow biopsy needle to harvest cancellous bone graft from the anterior iliac crest. The subjects of this study were 41 patients with 47 alveolar clefts who underwent secondary bone grafting over a period of 5 years, using the above technique. The donor site morbidity was evaluated retrospectively by means of a postal questionnaire and case note survey. Patients were questioned about severity of pain, duration of pain and duration of limping. None of the patients had donor site pain or limping for more than 2 weeks. No patient had severe donor site pain. Case note surveys revealed no donor site complications of haematoma, sensory disturbance, wound breakdown or contour abnormality. In 85.10% (n=40) of the alveolar clefts where the canine tooth had reached its final position at the bone grafted site, dental radiographs were used to assess the interalveolar septal height. In 82.5% (n=33) the interalveolar septal height was more than three quarters of normal i.e. a successful result. In conclusion the percutaneous technique causes minimal donor site pain and gait disturbance. It is a simple and safe technique, easy to learn and quick to perform leaving the patient with an imperceptible donor site scar. The results of clinical and radiological assessment of the quality of the bone graft also compare favourably with the conventional open technique of harvesting iliac crest graft in cases of alveolar clefts. Received: 31 December 1997 / Accepted: 20 July 1998     

Dressing for alveolopalatal wounds after alveolar bone grafting

Cotton gauze with alpha cyanoacrylate was used for alveolopalatal wound dressing after alveolar bone grafting to treat 93 alveolar clefts in 74 cleft patients to reduce mechanical injuries, tension for wound dehiscence, and adhesion of food remnants. T-shaped cotton gauze was put on the gingivoperiosteal flaps and was impregnated with cyanoacrylate. The procedure required no preoperative preparation and its intraoperative execution took less than 5 minutes. The gauze with cyanoacrylate was removed approximately 1 week after surgery. No infection was observed at any of the operational sites, but tiny fistulas developed at four of them. The mean bone graft score was 1.4 point. No complications such as thermal injury resulted from the use of cyanoacrylate. Gauze impregnated with cyanoacrylate proved to be a convenient and dependable dressing for alveolopalatal wounds resulting from gingivoperiosteoplasty for alveolar bone grafting.     

Early cheiloplasty : its effects on alveolar cleft

Summary Early cheiloplasty is performed within the first ten days of life in healthy new borns. Sixteen unilateral and six bilateral cleft lip patients were operated on. All had alveolar and palatal clefts. Pre- and postoperative maxillary models were taken and compared with those obtained from late repaired clefts in which an extraoral traction (EOT) device was used preoperatively. Early operation had a significant occlusive effect on alveolar arch, but there was no alteration of the palatal clefts and palatal shelves.Presented at the Sixth Congress of the European Section of the International Confederation for Plastic and Reconstructive Surgery (September 3–6, 1989, Istanbul, Turkey)     

Long-term outcome of secondary alveolar bone grafting in cleft lip and palate patients: A 10-year follow-up cohort study

Abstract

The objective was to assess the long-term outcome of secondary alveolar bone grafting (SABG) in cleft lip and palate patients and to examine relationships between preoperative and postoperative factors and overall long-term bone graft success. The records of 97 patients with cleft lip and palate, who had secondary alveolar bone grafting of 123 alveolar clefts, were examined. Interalveolar bone height was assessed radiographically a minimum of 10 years after grafting using a 4-point scale (I–IV), where types I and II were considered a success. After an average follow-up of 16 years after SABG (range = 10.2–22.7 years), 101 of the 123 grafts (82%) were categorised as successes. Mean age in the success group was 12.1 years and 13.6 years in the failure group (p = 0.03). It was found that the success rate was significantly lower (p = 0.02) if SABG was performed after eruption of the tooth distal to the cleft. No significant differences were found with regard to the other parameters investigated. The timing of secondary alveolar bone grafting is critical with regard to the age of the patient and the stage of eruption of the tooth distal to the cleft.     

Iliac bone for secondary grafting in residual alveolar clefts

Iliac cancellous bone has proven efficacy as a bone-graft donor. This study analyses the success of iliac bone autografts in secondary alveolar clefts. The study group was 30 patients with clefts with complete clinical charts and occlusal radiographs with surgery did in Cleft Unit Temuco Regional Hospital (Chile) between 1990-1996. The quality of graft "take" was measured radiologically and clinically. The results were named "excelent-good-regular-bad" and were studied by statistic methods. We did not find complications in donor site. We only had two partial dehiscences in recipient site. In 29 grafts, we feel "bone consistence" in clinical examination. We had one "nontake" graft. 80% of alveolar bone grafts showed similar bone density with respect normal bone. 80% of same grafts had similar height of interdental septum. We had 22 cases with "good result" and 3 cases with "regular result". All of them statistically significant. In our experience, iliac bone graft for alveolar clefts is a good technique for this difficult problem.     

Tibia as donor site for alveolar bone grafting in patients with cleft lip and palate: long-term experience.

Tibial bone grafts were studied in 137 patients with clefts of the lip and palate. Twenty-one had clefts of the lip and primary palate and 116 had complete unilateral clefts of the lip and palate. Bone grafting was performed secondarily or late secondarily. Bone was harvested from the proximal part of the tibia distal to the tuberosity through an incision about 15 mm long. The mean follow-up time after bone grafting was 5.5 years (range 2-11). There were no operative, or early or late postoperative complications reported (such as haematoma, fracture, or shortening of the limb). Harvesting time was about 15 minutes. The possibility of operating with two teams makes the total operating time shorter. Bleeding was negligible (less than 15 ml) and the amount of bone obtained was always sufficient. Patients were mobilised the next day and were back to full physical activity by one month. Indications for tibial bone grafting included facilitation of tooth eruption into the graft, giving bony support to the neighbouring teeth, making it possible to insert a titanium fixture, raising the alar base of the nose, and closing an oronasal fistula. Compared with iliac, cranial, mandibular, and costal donor sites, using the tibia took less time, gave less bleeding, made it possible for two teams to operate simultaneously, gave a smaller scar, and there were minimal complications and satisfactory quantity and quality of bone in all cases. The results suggested that the tibia is an excellent choice of graft for residual alveolar clefts in patients with cleft lip and palate.     

牙槽裂植骨同期鼻中隔骨支架植入鼻整形术

目的　研究在牙槽裂植骨修复的同时 ,利用自体髂骨皮质板块 ,修复单侧唇腭裂鼻畸形。方法　 10岁以后的单侧完全性唇腭裂患者 ,采用自体髂骨松质骨移植修复牙槽裂 ,同时采取髂骨内侧骨皮质修整后植入两侧鼻翼软骨内侧脚之间 ,形成鼻中隔前下部的骨性基础支架 ,将分离复位的鼻翼软骨内侧脚提升 ,使软骨穹窿顶超过骨性支架的上缘约 3mm ,将软骨缝合固定于骨性支架。结果　本组 2 4例患者均一期痊愈出院 ,患侧鼻翼基部凹陷、鼻小柱偏斜、鼻尖低平等畸形得到良好的矫正。结论　牙槽裂植骨与鼻畸形整复同期进行互不干扰。鼻中隔前骨性支架对鼻的外形结构有良好的支持作用 ,可以有效地矫正唇腭裂鼻畸形 ;与牙槽裂植骨同期进行 ,取材方便 ,减少了手术及麻醉的次数。     

Late management of cleft lip and palate problems: a joint orthodontic/surgical approach

Three patients are presented from a larger case series of adolescent cleft lip and palate patients to illustrate a combined approach to the treatment of severe facial and dentoalveolar discrepancy. The following treatment regime was employed: orthopaedic expansion of the maxillary dentoalveolus; tertiary bone grafting of the alveolar cleft; upper and lower dental arch alignment and decompensation; and orthognathic surgery to correct the skeletal defect by means of a maxillary single unit advancement. The advantages of tertiary grafting (when secondary grafting has not been carried out) in the orthodontic and surgical management of these patients is discussed.     

高位Le Fort Ⅰ型截骨同期牙槽嵴裂植骨矫治唇腭裂术后面中部畸形

目的 探讨联合应用高位Le Fort Ⅰ型截骨同期牙槽嵴裂植骨矫治唇腭裂术后面中部畸形的可行性。方法2002年1月～2005年1月，共收治10例唇腭裂术后面中部畸形患者，男4例，女6例。年龄16～32岁。单侧唇腭裂8例，双侧2例。影像学检查均有继发面中部畸形的主要表现。均采用高位Le Fort Ⅰ型截骨和牙槽嵴裂自体髂骨游离移植一期手术矫正。高位Le Fort Ⅰ型截骨的截骨线在上颌骨前壁比常规Le Fort Ⅰ型截骨线高，最高可达眶下孔下5mm左右，水平截开至颧牙槽嵴处再弧形转向下后方。结果术后伤口均I期愈合。复查头部X线片，所有患者上颌骨位置均得到明显改善。随访6～24个月，牙弓外形良好，X线片示无明显骨质吸收，植骨区密度与周围接近。10例均获得满意面容，其中9例获得良好的牙骀关系。结论高位Le Fort Ⅰ型截骨术不仅可前移上颌骨，还可前移部分眶下区及整个鼻旁区和鼻底，更明显地改善畸形。同期行牙槽嵴裂自体髂骨游离移植，可减少手术次数、降低费用、获得理想效果，是矫治唇腭裂术后面中部继发畸形的一种有效方法。