Alveolar cleft reconstruction with vomerine bone: two surgical procedures in one step: a case series

Abstract

Aim: Iliac crest (IC) is the most common source of bone for alveolar cleft repair, as it allows for harvesting a large amount of cancellous bone with a high rate of favorable outcomes. Its drawback is the donor-site morbidity. We propose a new technique for alveolar cleft grafting using vomerine bone (VB), which, through bone grafting, reconstructs the alveolus with the VB and simultaneously corrects the nasal septum deviation.

Method: We performed 18 alveolar reconstructions with VB in patients with a small bony defect and septal deviation, which would benefit from septoplasty. A matched control group with IC bone grafting was selected. Panoramic X-rays were used for vertical assessment of ossification with the Bergland scale and CT scans for the evaluation of the thickness of the grafted area in the VB and IC groups and compared with an independent samples T-test. A paired T-test compared angular measurements of the septal deviation pre- and post- vomerine grafting.

Results: All grafts healed uneventfully, with no complications at the donor site and respiratory function was improved. There was no statistically significant difference in ossification height between VB and IC, the alveolar thickness at the occlusal and middle third was higher with IC. Septal deviation was reduced significantly.

Conclusion: Alveolar graft from VB seems to be a viable alternative to IC in patients who present with a mild bony alveolar defect in addition to septal deviation, allowing combined procedures while reducing the morbidity of the donor site.

Keywords

Alveolar cleft / bone graft / vomerine bone / septoplasty

References

[1] Brusati R.The early gingivoalveoloplasty. Preliminary results.Scand J Plast Reconstr Surg Hand Surg1992;26:65-70

[2] Boyne PJ.Secondary bone grafting of residual alveolar and palatal clefts.J Oral Surg1972;30:87-92

[3] Dempf R,Kramer FJ.Alveolar bone grafting in patients with complete clefts: a comparative study between secondary and tertiary bone grafting.Cleft Palate Craniofac J2002;39:18-25

[4] Mølsted K,Prahl-Andersen B,Semb G.The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 3: dental arch relationships.Cleft Palate Craniofac J2005;42:78-82

[5] Bergland O,Abyholm F,Eskeland G.Secondary bone grafting and orthodontic treatment in patients with bilateral complete clefts of the lip and palate.Ann Plast Surg1986;17:460-74

[6] Lilja J.Alveolar bone grafting.Indian J Plast Surg2009;42 Suppl:S110-5 PMCID:PMC2825060

[7] El-Deeb M,Lehnert MW,Waite DE.Canine eruption into grafted bone in maxillary alveolar cleft defects.Cleft Palate J1982;19:9-16

[8] Lilja J,Friede H,Petterson LE.Bone grafting at the stage of mixed dentition in cleft lip and palate patients.Scand J Plast Reconstr Surg Hand Surg1987;21:73-9

[9] Abyholm FE,Semb G.Secondary bone grafting of alveolar clefts. A surgical/orthodontic treatment enabling a non-prosthodontic rehabilitation in cleft lip and palate patients.Scand J Plast Reconstr Surg1981;15:127-40

[10] Coots BK.Alveolar bone grafting: past, present, and new horizons.Semin Plast Surg2012;26:178-83 PMCID:PMC3706037

[11] Andersen K,Knudsen J,Jensen J.Donor site morbidity after reconstruction of alveolar bone defects with mandibular symphyseal bone grafts in cleft patients-111 consecutive patients.Int J Oral Maxillofac Surg2014;43:428-32

[12] Zeltner M,Hämmerle CH,Benic GI.Volumetric analysis of chin and mandibular retromolar region as donor sites for cortico-cancellous bone blocks.Clin Oral Implants Res2016;27:999-1004

[13] Hudak KA,Denny AD.Cranial bone grafting for alveolar clefts: a 25-year review of outcomes.Plast Reconstr Surg2014;133:662e-8e

[14] Bajaj AK,Punjabi A.Management of alveolar clefts.J Craniofac Surg2003;14:840-6

[15] Ruppel JK,Oliver DR.The Americleft Project: a comparison of short- and longer-term secondary alveolar bone graft outcomes in two centers using the standardized way to assess grafts scale.Cleft Palate Craniofac J2016;53:508-15

[16] Meazzini MC,Morabito A,Brusati R.Alveolar bone formation in patients with unilateral and bilateral cleft lip and palate after early secondary gingivoalveoloplasty: long-term results.Plast Reconstr Surg2007;119:1527-37

[17] Meazzini MC,Novelli G.Long-term computed tomographic evaluation of alveolar bone formation in patients with unilateral cleft lip and palate after early secondary gingivoalveoloplasty.Plast Reconstr Surg2016;137:365e-74e

[18] Chi SI,Joo LA,Kim HJ.Identifying the more suitable nostril for nasotracheal intubation using radiographs.J Dent Anesth Pain Med2016;16:103-9 PMCID:PMC5564078

[19] Tessier P,Posnick J,Tulasne JF.Taking calvarial grafts-tools and techniques: VI. The splitting of a parietal bone “flap”.Plast Reconstr Surg2005;116:74S-88S

[20] Hussain S.Evaluation of alveolar grafting with tibial graft in adolescent patients.Indian J Dent Res2013;24:659-63

[21] Weibull L,Ivanoff CJ,Rasmusson L.Morbidity after chin bone harvesting-a retrospective long-term follow-up study.Clin Implant Dent Relat Res2009;11:149-57

[22] Carlsen A,Jensen T.Donor site morbidity associated with autogenous bone harvesting from the ascending mandibular ramus.Implant Dent2013;22:503-6

[23] Xie K,Wang L,Wu G.One-stage repair of alveolar cleft and nasal deformities using grafts from nasal septum: application of vomer, ethmoid, and septal cartilage.J Craniofac Surg2022;33:1869-74

[24] Taub PJ,Silver L.Vomer bone graft to augment the deficient cleft maxilla.J Craniofac Surg2009;20 Suppl 2:1882-5

[25] Lawrence R.Pediatric septoplasy: a review of the literature.Int J Pediatr Otorhinolaryngol2012;76:1078-81

[26] Calvo-Henríquez C,Arancibia-Tagle D.Does pediatric septoplasty compromise midfacial growth?.Eur Arch Otorhinolaryngol2020;277:1565-74

[27] Manteghi A,Bundogji N.Pediatric septoplasty and functional septorhinoplasty: a quality of life outcome study.Int J Pediatr Otorhinolaryngol2018;111:16-20

[28] Muthubabu K,Thejas SR,Vinayak R.Quality of life in patients with nasal septal deviation after septal correction.Indian J Otolaryngol Head Neck Surg2019;71:2219-24 PMCID:PMC6848472

[29] Zins JE.Membranous versus endochondral bone: implications for craniofacial reconstruction.Plast Reconstr Surg1983;72:778-85

[30] Feichtinger M,Kärcher H.Assessment of bone resorption after secondary alveolar bone grafting using three-dimensional computed tomography: a three-year study.Cleft Palate Craniofac J2007;44:142-8