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A Comparison of Two Different Bone-Harvesting Techniques for

Secondary Alveolar Bone Grafting in Patients with Cleft Lip and Palate
C.M. MCCANNY, B.D.S., M.DENT.SCI., F.D.S.R.C.S. (ED.), M.ORTH. R.C.S.(ED.)
D.P. ROBERTS-HARRY, B.D.S., M.SC., F.D.S.R.C.P.S. (GLAS.), D.ORTH. R.C.S. (ENG.), M.ORTH. R.C.S (ENG.)

Objective: To compare the outcome of the trephine with open hip surgery
for alveolar bone grafting in cleft lip and palate surgery.
Design: The study was retrospective. The radiographs were assessed blindly
and on two separate occasions 1 week apart.
Setting: University Teaching Hospital.
Patients, Participants: In one group (group A), a trephine was used; in the
other (group B), open hip surgery was employed. Group A was comprised of
16 patients (nine with unilateral and seven with bilateral clefts of the lip and
palate) and group B, 13 patients (eight unilateral and five bilateral). The prime
entry criterion for inclusion in the study was that the canine tooth had erupted
into the graft site.
Interventions: A long cone periapical radiograph was taken of the erupted
canine tooth in the graft site.
Main Outcome Measure: The radiographs were graded from type I to type IV,
as described by Bergland et al. (1986a). A comparison was also made of the
eruption of the canine, postoperative morbidity, and length of stay in hospital
for each group.
Results: There was no statistically significant difference in the interdental
bone height (p 5 .61, MannWhitney U test). In group A, all patients had a
satisfactory clinical outcome (type I or II), and in group B, only one patient had
an unsatisfactory result (type III). The spontaneous eruption of the canine and
the number of nights spent in the hospital were also similar for both groups.
However, no patients in group A suffered postoperative complications, where-
as three patients in group B reported either a limp or postoperative infection
of the hip.
Conclusion: Both techniques produced satisfactory repair of the bony de-
fect, but the open hip surgery resulted in greater postoperative morbidity.

KEY WORDS: alveolar bone grafting, cleft lip and palate, open hip surgery, tre-
phine

Secondary alveolar bone grafting was introduced in 1972 subsequent favorable effect on speech if the fistula is large
by Boyne and Sands. The main objectives of it include the (Enemark et al., 1985), (4) to provide bone into which the
following: (1) to stabilize the maxillary segments, especially canine and other adjacent teeth could erupt or be moved or-
the mobile premaxilla in bilateral cleft cases (Turvey et al., thodontically and, in addition, give the adjacent teeth bony
1984), (2) to eliminate the need for a prosthesis or at least support (Johanson et al., 1974; Boyne and Sands, 1976), (5)
improve the vestibular soft tissue relationship and alveolar to restore the canine eminence, thus providing bone support
contour and thus facilitate the final prosthetic restoration (Jo- for the alar base and possibly helping to eliminate nasal asym-
hanson et al., 1974; Abyholm et al., 1981), (3) to close an metry and relieve obstructed airways (Boyne and Sands, 1972;
oronasal fistula if present and eliminate irregularities in mu- Bergland et al., 1986a), and (6) to consolidate the maxilla so
cosal contour (Abyholm et al., 1981; Paulin et al., 1988), with as to facilitate secondary corrective surgery, such as orthog-
nathic surgery (Amanat and Langdon, 1991).
Fresh autogenous bone is the ideal bone graft material be-
Dr. McCanny is Registrar in Orthodontics, Leeds Dental Institute, Leeds, cause it supplies living, immunocompatible bone cells essential
U.K. Dr. Roberts-Harry is Head of Department of Orthodontics and Consultant to osteogenesis (Albrektsson, 1980). The bone can be har-
Orthodontist, Leeds Dental Institute, Leeds, U.K. vested from several sites. The ilium is used most frequently,
Submitted March 1997; Accepted January 1998.
as access is easy and a large amount of bone can be obtained
This paper was presented verbally at the British Orthodontic Society Meet-
ing, Scarborough, September 22, 1997. from the area (Boyne and Sands, 1972; Johanson et al., 1974;
Reprint requests: Miss C.M. McCanny, 18 Eden Drive, Leeds, West York- Abyholm et al., 1981).
shire, LS4 2TN, U.K. This study assessed two different surgical techniques for

442
McCanny and Roberts-Harry, BONE-HARVESTING TECHNIQUES 443

harvesting bone from the ilium. Specifically, this study was months) for group A and 61 months (range, 13 to 95 months)
designed to compare differences in outcome between trephine for group B.
and open hip surgery for secondary alveolar bone grafting in
patients with cleft lip and palate. Radiographic evidence of Assessment of Outcome
bone height, eruption of canine teeth through bone grafts, post-
operative morbidity, and length of hospital stay were the out- The assessment of treatment outcome was evaluated from
come measures utilized. radiographic examination. Those patients with suitable radio-
graphs in the hospital notes were not recalled. For the others,
MATERIALS AND METHODS an appointment and explanatory leaflet was posted.
The following criteria were assessed: (1) radiographic signs
Sample Selection of bony infill as observed on a postoperative periapical radio-
graph, using the long cone technique, when the canine tooth
Prior to the study, ethical approval was sought and obtained. had fully erupted. In patients with unilateral clefts of the lip
The two experimental groups were drawn from two different and palate, the contralateral tooth acted as a control. In two
centers. Forty-seven consecutively treated patients who had al- cases, however, the canines had been extracted, so the upper
veolar bone grafts between 1986 and 1993 were identified for first premolar was used instead. For bilateral cases, the inter-
consideration in this study. Group A consisted of 25 patients dental bone height between the adjacent teeth was used for
from St. James University Hospital, where the trephine tech- comparison; (2) the position of the canine, whether this was
nique is utilized. Group B consisted of 21 patients from The reached spontaneously or required surgical exposure; (3) post-
General Infirmary at Leeds, where open hip surgery is the operative morbidity and postoperative complications. As most
technique utilized. patients were unsure about some aspects, this was determined
The prime entry criteria for inclusion in the study was that from the hospital notes; and (4) length of stay in the hospital.
the canine tooth was erupted in the graft site. From this initial The bone levels were assessed according to the method out-
sample, 17 patients were excluded, nine from group A and lined by Bergland et al. (1986a). This involves the measure-
eight from group B. In group A, three patients were too young, ment of interseptal bone height, mesial to the cleft canine, from
as the canine teeth had not erupted; one patient had the op- periapical radiographs and is categorized into the following
eration carried out at another hospital; and in one, implants groups: I septum height approximately normal, II septum
had been placed into the graft. Three patients had moved from height at least three quarters of normal, III septum height less
the area, and one could not be contacted. In group B, one than three quarters of normal, and IV failures if no continuous
patient was too early, three had moved from the area, and four bone bridge crossing the cleft could be identified even if sig-
could not be contacted. nificant bone formation had taken place.
The final study population included 16 patients in group A Each radiograph was assigned a randomly allocated number,
(seven males and nine females) and 13 patients in group B by an independent person, to be used for patient identification
(eight males and five females). There were nine unilateral at a later stage. One of the authors (C.M.C.) assessed the ra-
cases and seven bilateral in group A, giving a total of 23 cleft diographs blindly, on two separate occasions, 1 week apart.
sites. As one of the canines in a bilateral case had not erupted, For two patients, it was difficult to take long cone periapical
it was not included, giving 22 cleft sites in this group. Group radiographs because of the anatomy of the palate, and an upper
B had eight unilateral cases and five bilateral, a total of 18 anterior oblique occlusal radiograph was taken instead.
cleft sites.
RESULTS
Operative Details
The results are as follows.
All the bone grafts were taken from the iliac crest. Two
surgeons were involved: one surgeon performed all the tre- Radiographic Assessment
phine operations for the patients in group A, and one surgeon
performed the open hip grafts in the group B patients. The Trephine Technique (group A)
trephine technique used was based on that described by
McGurk et al. (1993), and the open hip technique was similar There was a successful outcome (type I or II) in 100% of
to that described by Boyne and Sands (1972). For the bilateral the alveolar grafts. Normal bone height (type I) was recorded
cleft patients in group A, the two sides were grafted approxi- in 16 out of 22 (72.7%) cleft sites. Type II was seen in 6 out
mately 6 months apart, whereas with the open hip technique, of 22 (27.3%) sites (Fig. 1).
both sides were grafted at the same operation. This was due
to preference of the operator. Open Hip Technique (group B)
The mean age at operation was 14 years (range, 9 to 30
years) in group A and 14.3 years (range, 7 to 25 years) in There was a successful outcome (type I or II) in 94.7% of
group B. The mean follow-up was 43 months (range, 23 to 62 these grafts (Fig. 1). Twelve out of 18 (66.7%) had type I, 5
444 Cleft PalateCraniofacial Journal, September 1998, Vol. 35 No. 5

FIGURE 1 Graphical representation of the percentages of patients in each type from group A and group B.

out of 18 (28%) had type II, and 1 out of 18 (5.5%) had type duce an unnecessary bias for this group. As this was a retro-
III. The results are quoted in percentages to allow comparison spective study, it was not possible to calculate the length of
with other studies. operation for each technique.

Eruption of the Canine STATISTICAL ANALYSIS

In group A, nine (39.1%) canine teeth had erupted prior to


A Kappa statistic (Cohen, 1960) was used to assess intraex-
the bone graft, and 10 (43.5%) erupted spontaneously through
aminer reliability in examining radiographs. There was no sig-
the graft. Two (8.7%) canines had to be exposed, one (4.35%)
nificant difference between the two readings done 1 week apart
was extracted because of its unfavorable position, and one
by the author (k 5 0.83).
(4.35%) remained unerupted at the time of this study.
A MannWhitney U revealed that there was no significant
In group B, eight (44.5%) canines had erupted before graft-
difference between groups A and B for the type of alveolar
ing, and eight (44.5%) erupted into the graft. One (5.5%) ca-
bone height.
nine was extracted, and one (5.5%) needed surgical exposure.
The two canines that were extracted were not included in the
radiographic assessment. DISCUSSION

Postoperative Morbidity The results of this study showed that secondary alveolar
bone grafting for cleft lip and palate patients, as measured by
In group A, one patient had dehiscence of the wound at the bony infill of the cleft, produced a clinically satisfactory out-
recipient site but no morbidity of the donor site. In group B, come in 39 of 40 patients (97.5%). There are no reports in the
3 out of 13 (23%) experienced problems with the hip. One literature comparing the success of the trephine method to
patient (7.6%) reported a limp, and two (15.4%) had infected open hip surgery. Additionally, there are no studies docu-
hematomata of the hip, which resulted in a longer stay in the menting clinical and radiographic results of the trephine meth-
hospital for one of the patients. The other patient developed od.
an infection after being discharged from the hospital. The results of this study compare favorably with those of
Abyholm et al. (1981), who studied 69 clefts where the canine
Length of Stay in the Hospital had erupted into its final position after secondary alveolar bone
grafting. The height of the interseptal bone was assessed to be
The average number of nights in the hospital was five for type I in 26 (38%) and slightly less than normal (type II) in
group A (trephine), ranging from 4 to 15 for each hospital 30 (44%). A septum of insufficient height (type III) had
admission. For group B patients, the mean hospital stay was formed in five (7%) clefts. Failures (type IV) were recorded
five nights (range, 3 to 10). The upper range for group A was in eight (11%).
for a patient who had to undergo several procedures at the Bergland et al. (1986a) examined 292 grafted clefts (using
same time (including lip revision). It was decided to exclude the open hip technique) and found that 50% of these were type
this patient in calculating the mean because this would intro- I, 40% type II, 7% type III, and 3% type IV. Better results
McCanny and Roberts-Harry, BONE-HARVESTING TECHNIQUES 445

were obtained (i.e., a higher percentage in types I and II) when 11 patients, in which the trephine technique was used for bone
the graft was placed prior to the eruption of the canine. grafting, 81.6% of patients walked with a slight limp but with-
Bergland et al. (1986b) looked at 82 bilateral alveolar cleft out assistance on the first day after grafting, and all patients
sites, 43 of which were grafted before and 39 after eruption were walking with ease by the fourth day. The patient in the
of the canine. Again, they reported a high success rate before current study in which the open hip technique was used, re-
the canine had erupted, with 98% of the sample in type I or ported a limp that lasted 4 to 6 weeks. No postoperative com-
II and only one in type III. Surgery carried out after the canine plications were observed in the trephine group. The number
had erupted produced 80% in types I and II, 10% in type III, of patients in each group was too small to apply statistics in a
and 10% in type IV. meaningful way.
The results of the present study showed that only 2 of 23 A reduction in postoperative morbidity has also been de-
(8.7%) canines, related to the cleft, required surgical exposure scribed by Caddy and Reid (1985) when the trephine was used.
in the trephine group. Ten of 23 (43.5%) canines erupted spon- They reported no problems with blood loss, hematomata,
taneously, nine erupted before the graft, one was extracted, wound infections, or other complications. All of the patients
and one remained unerupted. For the open hip group, 1 of 18 were able to walk within 24 hours and some even on the eve-
(5.5%) required exposure, 8 of 18 (44.5%) erupted into the ning of the operation. The main benefit of the trephine tech-
graft, eight erupted before the graft, and one was extracted. nique is that it avoids muscle stripping, thus making early am-
These results compare favorably with those obtained by bulation possible (Tilley and Davis, 1984).
Bergland et al. (1986a), who reported that 15% of their patients The mean number of nights in the hospital for each of the
required surgical exposure of the canine. A further study by two groups was the same (five). The patients with bilateral
Bergland et al. (1986b) found that four patients (10.2%) re- clefts in group A (trephine) had two separate hospital admis-
quired surgical exposure on one side. El-Deeb et al. (1982) sions. This is not a deficiency of the technique itself, but rather
observed that 17 of 64 (27%) canines on the cleft side erupted the particular surgeons preference. The in-patient stay for both
spontaneously, 11 of 64 (17%) required exposure alone, and groups was similar to that reported by Bergland et al. (1986a,
36 of 64 (56%) required surgical exposure and orthodontic b), whose patients were usually discharged after 6 days, but it
alignment to be in occlusion. was slightly longer compared to the study by Grillon et al.
A later study by El-Deeb (1986) found that surgical expo- (1984), in which the average stay in hospital was 3 days
sure was required in 20 of 34 (59%) cleft canines. Seventeen (range, 2 to 6 days). Kortebein et al. (1991) reported an av-
of 34 (50%) of these required orthodontic alignment, and the erage stay of 3.1 days for iliac or calvarial grafts, which they
remaining 14 (41%) aligned spontaneously. have currently reduced to 2 days. Caddy and Reid (1985) re-
The study by El-Deeb et al. (1982) indicates that the mean ported an operative time between 15 and 25 minutes for tre-
time between bone grafting and eruption of the canine was 3.4 phining. There have been no equivalent reports on the oper-
years 6 1.6, which was significantly greater than a control ating time required for open hip surgery.
group (mean, 2.2 years 6 1.9). Hinrichs et al. (1984) reported
on 18 patients followed up for 2 to 8 years and found that CONCLUSIONS
56% of the cleft-associated canines required surgical exposure
and 44% also required orthodontic assistance to erupt to a (1) When the interdental bone height mesial to the cleft
functional occlusion. In the other studies, no indication is giv- canine was used as a means of assessing the outcome of the
en of the time interval between bone grafting and the decision graft, a MannWhitney U test revealed no statistically signif-
to surgically uncover the tooth. Bergland et al. (1986b) re- icant differences between the two surgical techniques.
ported waiting 1 to 3 years until the premolars and canines (2) The morbidity of the two techniques would suggest that
had erupted before recommencing orthodontic treatment. the open hip technique had more postoperative complications,
Postoperative complications (infection of the hip or post- including gait disturbance and wound infection.
operative limp) were recorded in 3 of 13 (23%) patients in (3) The average number of nights in the hospital was five
whom the open hip technique was used. In one of the cases, (range, 4 to 15) for the patients in group A and five (range, 3
this was determined from the hospital notes, and the two other to 10) for group B. For the bilateral cases in the trephine group,
patients recalled their experiences. This is not a very scientific this involved two admissions, two anesthetics, and two over-
method of assessing the morbidity, and it is probable that a night stays in the hospital.
large number of patients could not recall their experiences be- (4) Satisfactory eruption of the canine was observed in both
cause of the time interval between the operation and the time groups. Only two (8.7%) canines in group A and one (4.35%)
of examination. in group B had to be exposed.
Details of pain should have been recorded contemporane- In conclusion, both techniques produced satisfactory repair
ously using, for example, a visual analog scale or by recording of the bony defect, but the open hip surgery resulted in greater
the amount and type of analgesia required. Restriction of mo- postoperative morbidity. This preliminary study would there-
bility, determined by an independent observer, as described by fore suggest that the trephine is the preferred technique for
McGurk et al. (1993) would have provided a more accurate secondary alveolar bone grafting in patients with cleft lip and
record of postoperative gait disturbance. In their pilot study of palate.
446 Cleft PalateCraniofacial Journal, September 1998, Vol. 35 No. 5

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