| Abstract|| |
Background: In a resource-limited setting, use of advanced reconstruction procedures for cleft patient is unaffordable. The autogenous graft sites such as iliac or rib are not favored owing to socio-ethno-economic and cosmetic reasons. In such situations, tibial graft is an excellent alternative. There is limited literature on the use of tibial graft from India and this manuscript attempts to address this lacuna.
Materials and Methods: Archives of a single department on cleft palate cases treated with tibial graft were collected. Cases fulfilling the inclusion and exclusion criteria were selected. The efficiency of treatment was evaluated from the orthopantomogram (OPG) and/or computed tomogram (CT) imaging using previously described methodology. All the data collected were analyzed using Microsoft Excel.
Results: The mean age of the patients was 17.78 ± 3.29 years with a range of 13-23 years. Three patients had been treated with secondary bone grafting, while the remainder had been treated with tertiary bone grafting. The median age of the study population was 17.39 years, while the mode was 17 years. The mean efficiency in terms of preoperative and post-operative size of defects as measured in OPG was 74.32 ± 7.31, while it was 73.15 ± 9.9 as measured in CT. All the patients were comfortable with closure of the defect. Patients treated with secondary bone grafting had a mean efficiency was 79.53 ± 9.07, while for tertiary grafting, it was 71.72 ± 4.86.
Conclusion: The tibial graft offers an excellent alternative to the conventional standard grafts such as iliac crest or rib grafts. The efficiency of the treatment measured at 6 months period on standard OPG or CT is comparable to the results obtained with the rib/iliac crest.
Keywords: Cleft palate, reconstruction, tibial graft
|How to cite this article:|
Hussain S. Evaluation of alveolar grafting with tibial graft in adolescent patients
. Indian J Dent Res 2013;24:659-63
In a resource-limited setting, treatment of cleft lip and palate (CLP) is very challenging. CLP causes significant morbidity in terms of abnormal physical, psychological, and social well-being. In such situations, the treatment-seeking behavior is often diverse and patients seek treatment for CLP often at late stages. Often presenting at late mixed dentition with the residual alveolar cleft, the cases often turn challenging.  The procedure that could be offered at that stage is alveolar bone grafting (ABG). The main function of any treatment at such stage would be to stabilize the maxillary arch, facilitate eruption of the canine (if unerupted), provide bony support to the adjoining teeth, lift the alar base of the nose, assist closure of an oronasal fistula, prepare the bed for dental implants, as well as to ensure satisfactory periodontal health of the teeth within and adjacent to the cleft. The timing of the ABG surgery is determined by the eruption of the canine, especially restricted at a time when there is thin rim of bone covering the tooth adjacent to the cleft. 
|How to cite this URL:|
Hussain S. Evaluation of alveolar grafting with tibial graft in adolescent patients
. Indian J Dent Res [serial online] 2013 [cited 2019 Oct 17];24:659-63. Available from: http://www.ijdr.in/text.asp?2013/24/6/659/127604
The use of bone grafts is essential for ABG surgery. Use of tissue-engineered products such as recombinant human bone morphogenetic protein-2 (rhBMP-2) has been proven to reduce unnecessary surgery, reduce hospital stay, and provide better benefits. However, despite being beneficial, the cost of rhBMP-2 is still alarmingly high to be used routinely in resource-limited settings.  Alternative standard accepted methods such as iliac crest graft or rib grafts provide good quantity of bone graft but produce unesthetic scar. Owing to local ethno- socio-cultural reasons, female cleft patients, particularly during adolescence, have reservation for such scar. 
Alternate donor sites have been considered. Among the options available, tibia has been demonstrated to be a good source of bone graft. In 1914, Drachter was the first to report the closure of a cleft with tibial bone and periosteum.  Though the technique has been refined over the years, the issue of potential complications as well as availability of other options favored the use of other sites. A recent literature report indicates the safety of this graft.  However, the safety profile of this graft and its efficacy in ABG has not been assessed in Indian patients . To address the lacunae, this study was designed to find the efficacy of the tibial bone as a source for ABG in late mixed dentition or in adult patients who could not afford rhBMP-2 and were not willing for rib or iliac.
| Materials and Methods|| |
This retrospective, evaluative study was performed with the details of cases from the archives of the department within the past 5-year period. All the surgeries were performed by a single surgeon using the technique mentioned below. The inclusion criteria for the study were: cleft patients aged between 13 and 22 years who had complete details and undergone ABG using tibial graft. The exclusion criteria were: patients with systemic problem, those who had undergone alveolar grafting, and those without complete documentation [pre- and postoperative orthopantomogram (OPG) with or without computed tomogram (CT)].
Under general anesthesia, after adequate preparation of the donor site, a vertical line was drawn parallel to the long axis of tibia from the articulating margin, which bisected tibia into two halves, including tibial tuberosity. From this vertical line, another horizontal line was drawn 5 cm away from the articulating margin, which formed a point angle. From this point angle, another line was drawn in between the anterior margin and the medial border of tibia. On this straight line, a 1 cm incision was made at a distance of 7 cm away from the point angle; dissection was carried over the skin, periosteum along with the medial quadriceps muscle overlying the medial condyle. The tibial bone was exposed. At this point, 6-8 mm trephine was passed perpendicular to the medial surface along the metaphyseal area. Through this, sufficient quantity of corticocancellous bone was obtained. On exposing the medial head of the tibia, bone graft can be harvested by using trephine or bone scoop. After harvesting adequate amount of bone, a two-layer closure was done. Medial quadriceps along with periosteum was closed, over which the skin was closed separately. This will avoid postoperative stiffness or contraction [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
After obtaining the bone graft, the cleft was examined and compared intraoperatively with the CT scan images. The procedure began with infiltration of 2% lidocaine with 1/100,000 epinephrine into both the palatal mucoperiosteum and the vestibular sulcus on both sides of the cleft. Full-thickness mucoperiosteal flaps were raised on both sides of the palatal aspect of the cleft using straight incisions that extended from the tuberosity region around the cervical portion of the teeth to meet the cleft in the anterior maxilla.This broad dissection allowed accurate exploration of the palatal-nasal defect and its continuation toward nasal mucosa. A horizontal incision was made on the vestibular side approximately 5 mm above the attached gingiva and extended medially just short of the bony margin of the cleft defect. The lateral aspect of the maxilla was exposed widely to include the lateral aspect of the cleft. The dissection was carried on the inner aspect of the maxilla into the nasal region toward the apex of the alveolar cleft, so that a vertical sheet of nasal mucosal aspect was developed that was continuous with the palatal dissection already carried out [Figure 6].
On the medial aspect of the cleft, a similar horizontal vestibular incision was made that allowed complete exposure of the lateral nasal margin of the noncleft nostril, the anterior nasal spine, and the medial margin of the cleft alveolus. The nasal mucosa on the medial aspect of the cleft was developed in such a way that this dissection also was continuous with the palatal dissection. A small vertical releasing incision was made in the attached gingiva, so that the entire cleft alveolar defect was clearly visible [Figure 7] and [Figure 8].
The palatal mucosa was reconstructed from posterior to anterior by suturing posterioanteriorly. From the vestibular side, the nasal mucosa was reconstructed in such a way that the height of the nasal floor was equal to or slightly superior to that on the noncleft side. This was an important technical point because unless there is adequate space for bone between the palatal and nasal layers, long-term bone stock quantity will be insufficient. Part of the nasal mucosal suturing was carried out through the access created by palatal dissection.
A thin piece of cortical bone was fashioned to fit snugly in the nostril defect. The cortical side of this piece of bone was placed against the nasal mucosa and the medullary side faced the graft. Particulate marrow was packed into the defects with pressure. The vertical incision over the attached gingiva was closed such that the reconstructed gingiva rested on the newly grafted bone. The palatal flap was then repositioned to its ideal position and stay sutures were placed around at the anterior and lateral aspects of the flap. The vestibular horizontal incisions were closed. At the end of the procedure, palatal mucosa was on the palate, nasal mucosa formed the nasal floor, the attached gingiva covered the teeth, the graft was at the alveolar margin, and the maxillary vestibule was covered by alveolar mucosa [Figure 9] and [Figure 10].
No splints were used postoperatively to accommodate natural healing process. Standard drugs including nonsteroidal anti-inflammatory drugs and extended spectrum antibiotics were used. Clear liquid diet and proper oral hygiene were maintained, and the average hospital stay was around 1 week.
Details of grafting procedure along with preoperative and postoperative size of the defects were collected from OPG of the hospital records as described in previous reports. , In cases where CT was available, the volume of the defect, pre- and postoperatively at 6 months period, was assessed as described in the literature.  CT scan (SIEMENS SOMATAM Espirit) were acquired. Spiral images were generated at 130 kV and 100 mA X-ray as well as a 3 mm rotation. The slice thickness of the reconstructed images was 3 mm with 1.5 mm overlap. The image matrix size was 512 Χ 512 pixel and each of the pixel size was approximately 0.3 mm. For examination purpose of CT, the occlusal plane served as a reference line. However, the Frankfort horizontal plane also was used to orient the images. The resulting image slice data were stored on a magneto-optical disk and then used to convert into the 3D CT images. The point of evaluation was employed (a) for identification of the alveolar cleft defect and (b) to find the location of the bone graft. The images of the bone graft were outlined with optical mouse. ,
Inbuilt software was used to analyze the irregularly outlined shape, and the actual volume of the bone graft was determined from each of the individual images.
The efficiency of the technique using area or volume of the defect was measured by the formula used previously: ,[Table 1].
| Results|| |
A total of nine patients' records fulfilled the inclusion and exclusion criteria of the study. All the nine patients were females in late mixed dentition or adolescent stage. They were of low socioeconomic status, and had postponed the treatment owing to their restricted financial background. The subjects had sought opinion from several centers and had reservations for scars along rib or the iliac region. Preoperatively, they had been clearly briefed of the potential issues involved with tibial grafts and the choice of alternatives.
The mean age of the patients was 17.78 ± 3.29 years with a range of 13-23 years. Three patients had been treated with secondary bone grafting, while the remainder had been treated with tertiary bone grafting. The median age of the study population was 17.39 years, while the mode was 17 years. The mean efficiency in terms of preoperative and post-operative size of defects as measured in OPG was 74.32 ± 7.31, while it was 73.15 ± 9.9 as measured in CT. All the patients were comfortable with closure of the defect. Patients treated with secondary bone grafting had a mean efficiency of 79.53 ± 9.07, while for tertiary grafting, it was 71.72 ± 4.86 [Table 1].
| Discussion|| |
Tibial graft offers a convenient source of bone graft without the issue of scar or postoperative morbidity that is seen in iliac crest or rib graft. Tibial graft has been recently used as a potential graft source for placement of dental implants in India.  Females, particularly young adolescents, do not prefer to have long scars owing to several socio-cultural and ethnic beliefs. When this is coupled with limited resources or the patients are with limited resources that include financial aspects, the timing of the surgery is often postponed. In my personal observation, such parents seek treatment for their female cleft child in and around puberty or when they attain legal age of marriage. Hence, this bimodal treatment-seeking behavior occurs around two peaks - one in 12-14 years of age and another in 18-20 years of age. This trend is unique to the area of surgical practice and hence lacks prior documentation.
Better results of ABG grafting were obtained in cases of secondary grafting (circum-eruption period of canine). When the treatment was performed around eruption of lateral incisor or canine, the tooth later grew into the transplant and led to a functional stress of the transplanted bone. Equivalent good results were also obtained in tertiary grafting when the transplanted bone had been stressed functionally as observed in young adults in the study group. On comparing secondary with tertiary grafting, there was a trend of lower resorption seen in secondary grafting. This was observed in our study too where three females aged below 15 years showed a bone graft uptake of 80% while young adults had a graft uptake of only 72%. This indicates that age is a crucial determinant for the success while the area or volume of the defect is not a serious deterrent for the uptake of the tibial graft. The same trend has been reported in literature. 
The graft harvest procedure is simple as the area of the bone is subcutaneous and no other vital structures are there in the adjoining sites. This is a major merit of this technique patients can resume normal activities including walking 1 day postoperatively. Complications of iliac graft including excessive postoperative pain, bleeding, difficulty in walking, and limping can easily be overcome by tibial grafting.  However, care should be exercised to avoid damage to the tibial articulating margin. If not attended or cared, it may lead to hemarthrosis, delayed wound healing, pain, and secondary arthrosis of the knee joint. The amount of bone available in tibia is sufficient for procedures like secondary alveolar grafting and filling of the large cystic cavities.  The common side effect of any arch expansion is acute exacerbation of the oronasal fistulae. Even if the fistulae appear during the pre-bone grafting stage of arch expansion, it could be appropriately handled at the time of the bone grafting procedure. Though the sample size is limited, this study documents the results of this less-considered technique. The graft offers an excellent alternative for the unique condition faced in the area of the center.
| Conclusion|| |
Unique prevalence of non-acceptance of iliac rib graft and the limited resources compelled us to prefer tibial graft in young female patients. The success of this graft is in par with the other traditional grafts. In the present series, cancellous bone from tibia was used and all the conditions for a successful bone grafting were achieved, making this an acceptable alternative.
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Director and Consultant Maxillofacial Surgeon, Abdul Kadir Hospital, Elankadai, Kottar, Nagercoil, Tamilnadu
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]