Key Words: Cleft palate, alveolar distraction, secondary alveolar bone grafting.

Transkript

1 Page 184 OLGU SUNUMU / CA SE RE PORT Tek TarafT rafl Genifl Alve veol Yar r Bulu lunan Eriflkin Bir Hasta tada Alve veol Distrak siyo yonu: Olgu Sunu numu In ter den tal Al veo lar Dis trac ti on in an Adult Pa ti ent with a Uni la te ral Wi de Al veo lar Cleft: Ca se Re port Yrd.Doç.Dr. Asl han UZEL * Doç.Dr. Mehmet KÜRKÇÜ ** Çukurova Üniv. Diflhek. Fak. *Ortodonti A.D., **A z Difl ve Çene Hastal klar A.D. Adana / Çukurova Univ. Faculty of Dentistry Dept. of *Orthodontics and **Maxillofacial Surgery, Adana, Turkey Yaz flma adresi: Corresponding Author: Dr. Asl han Uzel Çukurova Üniversitesi Diflhekimli i Fakültesi Ortodonti A. D Balcal Adana TÜRK YE Tel: Faks: E-posta: asliuzel@cu.edu.tr 184 ÖZET Amaç: Bu çal flman n amac, tek tarafl tam dudak-damak yar bulunan eriflkin bir hastada, greft uygulamas öncesi genifl alveol yar n daraltmak için hyrax vida kullanarak yap lan alveol distraksiyonunu sunmak ve sonuçlar n tart flmakt r. Bireyler ve Yöntem: Hastam z tek tarafl tam dudak-damak yar ile birlikte III. S n f kapan fl iliflkisi, üst çene darl ve premaksilla gerili i bulunan 18 yafl nda bir erkek bireydir. Üst çene geniflletmesi ve difllerin s ralanmas n takiben alveol yar n n baflar l greft uygulamas için fazlas yla genifl oldu u ortaya ç km flt r. Yan segmentin lokal anestezi alt nda cerrahi olarak distraksiyon yoluyla mezialize edilmesi planlanm fl, bu amaçla difl destekli hyrax vidas kullan lm flt r. Üç haftal k aktivasyon ve 12 haftal k retansiyon süresi sonras nda alveole ilyak kemik grefti uygulanm flt r. Bulgular: Alveol greft uygulamas sonras yar k bölgesinde yeterli yumuflak doku kapat m ve kemikleflme sa lanm flt r. Ancak, debonding sonras al nan tomogra görüntülerinde yar k hatt na komflu köpek diflin kökünün kemik d fl na itildi i tespit edilmifltir. Sonuç: Alveol distraksiyonu genifl alveol yar bulunan eriflkin hastalarda yar k bölgesini daraltmak için iyi bir tedavi seçene i olabilir ve difl destekli hyrax vida bu amaçla etkili olarak kullan labilir. Ancak, uygulanan kuvvet vektörleri dikkatli ayarlanmal d r (Türk Ortodonti Dergisi 2010;23: ) Anahtar Kelimeler: Damak yar, alveolar distraksiyon, ikincil alveol kemik grefti. Gönderim Tarihi: Kabul Tarihi: SUMMARY Aim: To demonstrate treatment of an adult patient with a wide unilateral cleft by segmental alveolar distraction using a hyrax screw. Subjects and Methods: An 18 year-old boy presented with a right complete cleft lip and palate; collapsed lateral segments; a retruded position of the premaxilla; and a Class III relationship. Following orthodontic expansion and alignment of the upper teeth the residual width of the cleft was too wide to successfully grafting and it was decided to mesialize the right buccal segment surgically by means of callus distraction using an intraoral tooth-anchored hyrax screw under local anesthesia. After three weeks of activation and a 12 weeks retention period bone grafting was performed. Results: After alveolar grafting the cleft was found to have an osseous closure with adequate soft tissue coverage and the integrity of the maxilla was provided. However, as the skeletal relation was not appropriate for the space closure of the missing lateral incisor the disuse atrophy of the grafted bone could not be prevented. Conclusion: Segmental alveolar distraction can be a good choice in the treatment of adult patients with wide residual alveolar clefts. But, teeth movement is the most important factor in the long term success of the grafted bone. (Turkish J Orthod 2010;23: ) Key Words: Cleft palate, alveolar distraction, secondary alveolar bone grafting. Date Submitted: Date Accepted:

2 Page 185 Tek Tarafl Genifl Alveol Yar Bulunan Eriflkin Bir Hastada Alveol Distraksiyonu: Olgu Sunumu Interdental Alveolar Distraction in an Adult Patient with a Unilateral Wide Alveolar Cleft: Case Report G R Alveol kemikteki yar k bölgesinin onar l-mas amac yla ikincil alveolar kemik grefti uy-gulanmas, dudak-damak yar na sahip hasta-lar n tedavi süreçlerinin vazgeçilmez bir par-ças olarak kabul görmektedir (1-9). Bu hasta-larda baflar l alveol kemik grefti uygulanmas -n n faydalar pek çok araflt rmac taraf ndan ortaya konmufltur. Bu faydalar: Yar k bölgesine komflu difllere kemik deste i sa lanmas ; diflle-rin yar k hatt na do ru sürebilmeleri için ke-mik matriks oluflturulmas ; üst çenede kemik devaml l ve yeterli alveoler kemik kontürü-nün oluflturulmas ; üst çenede ark geniflli inin korunmas ; yan segmentlerin stabilize edilme-si; oronazal stüllerin kapat lmas ; burunun si-metrisinin sa lanmas ; a z ve burun taban -n n birbirinden ayr lmas yla a z hijyeninin sa lanmas, olarak s ralanabilir (2-16). Kolay ulafl lmas ve yeterli miktarda kan-sellöz kemik elde edilebilmesi nedeniyle en fazla kullan lan ve baflar s kan tlanm fl olan greft maddesi hastan n kendi iliak kemi idir (1,4,7,11). kincil alveoler kemik greftlemesi, hasta karma difllenme döneminde iken, yar k bölgesine komflu daimi kanin difl sürmeden hemen önce, üst çenenin ortodontik olarak geniflletilmesini takiben yap l r. Daimi kanin sürdükten sonra yap lan greft uygulamas n n baflar oran daha düflüktür (14,17-22). Özel-likle genifl alveol yar na sahip hastalarda üst çene geniflletmesini takiben oronazal s-tüller daha da genifller. Bu durum, alveol ke-mik grefti uygulamas n ve stülün tamam y-la kapat lmas n zorlaflt r r. Literatürde, du-dak-damak yar kl hastalarda a z içi difller aras distraksiyon osteogenezisinin farkl amaçlarla uygulanmalar rapor edilmifltir (2325). Genifl alveol yar n daraltmak ve yeter-li miktarda sa l kl difl eti ile baflar l kemik greftlemesi yapabilmek amac yla uygulanan farkl distraktor tipleri sunulmufltur (23,24). Bu olgu sunumunun amac, tek tarafl tam dudak-damak yar bulunan eriflkin bir has-tada, greft uygulamas öncesi genifl alveol ya-r n daraltmak için hyrax vida kullanarak IN TRODUC TION Secondary alveolar bone grafting, has be-come a well-accepted treatment modality for the residual alveolar defect repair in patients with cleft lip and palate (1-9). Its benets re-ported in the literature include; bone support for teeth adjacent to the cleft site ; bony mat-rix for the eruption of the teeth in the line of the cleft site; bony continuity in the maxillary arch and creation of satisfactory alveolar bone contour ; support of the arch width and pre-vention of maxillary arch collapse ; stabilizati-on of maxillary segments ; elimination of oro-nasal stulas ; improved facial symmetry, alar base support, and nasolabial contour ; and improved status of oral hygiene by separating the nasal cavity from the oral cavity (2-16). The anterior iliac crest is the most com-mon donor site for retrieving the bone graft because of easy access and availability of suf-cient amount of cancellous bone (1,4,7,11). Alveolar bone grafting is typically performed after orthodontic palatal expansion in mixed dentition stage just before the eruption of the permanent canine. Success rate of grafting is reduced when performed after eruption of the canines (14,17-22). Especially in patients with a wide alveolar cleft, the cleft or oronasal s-tula becomes wider with expansion. Thus, this makes alveolar bone grafting and comp-lete closure of the stula much more infeasib-le. The use of interdental distraction osteoge-nesis for different purposes in patients with cleft palate has been reported in the literature (23-25). Different types of intraoral distrac-tors have been used as an effective treatment modality to narrow wide alveolar clefts for the success of the bone grafting with sufcient amount of healthy attached gingiva.(23,24). The aim of this case report was to demonstra-te the results of segmental alveolar distraction by using a hyrax screw in the treatment of an adult patient with a wide unilateral cleft. eekil 1. Olgunun tedavi bafllang c ndaki a z içi radyograsi. Figure 1. Initial intraoral radiograph of the case. Turkish Journal of Orthodontics 2010;23:

3 Page 186 Uzel, Kürkçü eekil 2. Olgunun üst çene geniflletmesi ve difl s ralanmas sonras a z içi radyograsi. Figure 2. Intraoral radiograph of the case after yap lan segmental alveol distraksiyonunun sonuçlar n sunmakt r. expansion and alignment of the upper teeth. OLGU SUNUMU his Teflflh Tek tarafl, sa bölgede tam dudak-damak yar ile birlikte III. S n f kapan fl iliflkisi, üst çene darl ve premaksilla gerili i bulunan 18 yafl nda bir erkek birey sunulacakt r (ekil 1). CASE REPORT Diagnosis An 18 year-old boy with a right complete cleft lip and palate; collapsed lateral segments; a retruded position of the premaxilla; and a Class III relationship was presented (Figure 1). Treatment Progress Following orthodontic expansion and eekil 3.Olgunun distraksiyon vidas ile çekilmifl a z içi radyograsi. Figure 3. Intraoral radiograph of the case with the distraction screw in place. eekil 4. Olgunun distraksiyon sonras a z içi foto raflar ve panoramik radyograsi. Tedavi Seyri Üst çene geniflletmesini ve difllerin s ralan-mas n takiben hastan n alveol yar n n ba-flar l greft uygulamas için fazlas yla genifl ol-du u ortaya ç km flt r (ekil 2). Sa kanin ve birinci küçük az n n bir segment halinde dis-traksiyon yoluyla öne do ru hareket ettiril-mesi ve yar n daralt lmas planlanm flt r. Distraksiyon ayg t olarak difl destekli hyraks vidas (17 mm) kullan lm flt r (ekil 3,4). Lokal anestezi alt nda, palatal mukoperi-ostun tafl nacak segmentteki ba lant s koru-nacak flekilde mukoperiosteal bir flep kald -r lm flt r. Küçük az difllerinin kökleri aras n-dan ve kanin kök ucunun üzerinden burun bofllu unun yan duvar na uzanan bir kemik kesi hatt belirlenmifltir. Kesi reciprocating testere ile yap lm flt r. Kesi derinli i diflaras osteomu ile artt r lm flt r. Daha sonra, kesi hatt nda osteotomlarla ilerleyerek ve kaninin kök ucundan dama a do ru uzat larak kemik alignment of the upper teeth the residual width was too wide for successful grafting procedure for the cleft repair (Figure 2). It was decided to mesialize the right canine and the rst premolar surgically as a segment by cal-lus distraction to narrow the cleft. An intraoral tooth-anchored hyrax screw (17 mm) was used as a distraction device (Figure 3,4). A mucoperiosteal flap was raised under local anesthesia maintaining the attachment of the palatal mucoperiosteum to the transport seg-ment. An osteotomy line was determined bet-ween the roots of the premolars above the ca-nine apex to the lateral wall of the nasal ca-vity. Osteotomy was performed by using re-ciprocating saw. The osteotomy depth was in-creased with interdental osteotomes. After-wards, the osteotomy procedure was continu-ed by advancing through the osteotomy line with osteotomes then nal osteotomy comp-- Figure 4. Intraoral radiograph of the case when the distraction was completed. 186

4 Page 187 Tek Tarafl Genifl Alveol Yar Bulunan Eriflkin Bir Hastada Alveol Distraksiyonu: Olgu Sunumu Interdental Alveolar Distraction in an Adult Patient with a Unilateral Wide Alveolar Cleft: Case Report eekil 5. Olgunun kemik grefti uyguland ktan iki ay sonra al nm fl olan a z içi foto raflar, oklüzal ve panoramik radyograleri. Figure 5. Intraoral photograph, occlusal and kesisi tamamlanm flt r. Hareket ettirilecek olan segment sadece damaktaki mukoperios-teuma ba l kalacak flekilde tamamen hare-ketli hale getirilmifltir. Distraksiyon vidas cer-rahi sonras yedinci günde günlük 0,5 mm lik aktivasyon olacak flekilde çevirilmeye bafl-lanm flt r. Üç haftal k aktivasyon ve 12 hafta-l k retansiyon süreci sonras nda, alveol yar genel anestezi alt nda ilyak kemik grefti ile onar lm flt r. Greftlemeden iki hafta sonra ha-f kuvvetlerle difl hareketleri bafllat lm flt r. leted by extending coronally from the apical region of the canine to the palatal side. The transport segment was totally mobilized alt-hough remained attached to the palatal mu-coperiosteum. Activation of the distraction device was started on the seventh day after surgery, with a daily distraction of 0.5 mm. After three weeks of activation and a 12 we-eks of retention period, the alveolar cleft was repaired by using iliac graft under general anesthesia. Teeth movement was started with light forces two months after grafting. panoramic radiographs of the case two months after bone grafting. eekil 6. Olgunun debonding sonras a z içi foto raflar ve panoramik radyograsi. Figure 6. Intraoral radiograph of the case two months after debonding. Tedavi Sonuçlar Alveol kemik grefti sonras, yar k bölgesinin yeterli yumuflak doku örtüsü ve kemikleflme sa lanarak kapand tespit edilmifltir. (ekil 5). Ancak, iskeletsel iliflki eksik kesici difllerin yerinin kapat lmas için uygun olmad ndan kemik grefti bölgesine do ru yeterli difl hare-keti yapt r lamam fl ve greft kemi inin dik yön-deki atrosine engel olunamam flt r. Bilgisa-yarl tomogra görüntüleri üst sa kanin kökü-nün yanak taraf na do ru e ildi ini ve kemik deste ini kaybetti ini göstermifltir. Bu duru-mun distraksiyon kuvvet vektörlerine ba l or-taya ç kt düflünülmektedir (ekil 6,7). Treatment Outcome After alveolar grafting, the cleft was found to have an osseous closure with adequate soft tissue coverage and the integrity of the maxil-la was provided (Figure 5). However, as the skeletal relation was not appropriate for the space closure of the missing incisors, adequa-te tooth movement couldn t be done through the grafted bone and the vertical atrophy of the grafted bone could not be prevented. The CT images showed that the right canine root was tilted buccally and loosed its bone sup-port. This was probably due to the vectors of the distraction forces (Figure 6,7). eekil 7. Olgunun debonding sonras üç boyutlu tomogra görüntüleri. Figure 7. 3D images of the case after debonding. Turkish Journal of Orthodontics 2010;23:

5 Page 188 Uzel, Kürkçü SONUÇ Difl destekli hyraks vida kullan larak uygulanan segmental alveol distraksiyonu, genifl alveol yar bulunan eriflkin hastalarda yar k bölgesini daraltmak için iyi bir tedavi seçene- i olabilir. Ancak distraksiyon ayg t n n kuvvet vektörleri difl köklerini kemik d fl na itmeyecek flekilde dikkatle ayarlanmal d r. Greft bölgesi içine do ru yapt r lan difl hareketinin greft kemi inin uzun dönemli stabilitesi aç - s ndan çok önemli oldu u unutulmamal d r. CONCLUSION Segmental alveolar distraction with hyrax screw can be a good choice for treatment of adult patients with wide residual alveolar clefts. However, the force vectors of the distraction device should be adjusted carefully to prevent the roots to tilt out of the bone. The importance of teeth movement for the long term success of the grafted bone should be kept in mind. KAYNAKLAR/REFERENCES 1. Berkowitz S. Cleft Lip and Palate. 2nd ed Springer-Verlag Berlin Heidelberg, Germany. 2. Bergland O, Semb G, Abyholm F. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate-Craniofacial Journal. 1986;23: Watson ACH, Sell DA, Grunwell P. Management of Cleft Lip and Palate Whurr Publishers. London, Philadelphia. 4. Murthy AS, Lehman Jr. J A, Evaluation of alveolar bone grafting: A survey of ACPA teams. Cleft Palate-Cran J 2005;42: Aurouze C, Moller KT, Bevis RR, Rehm K, Rudney J, The presurgical status of the alveolar cleft and success of secondary bone grafting. Cleft Palate-Cran J 2000;37: Feichtinger M, Mossböck R, Karcher H. Assessment of Bone Resorption After Secondary Alveolar Bone Grafting Using Three-Dimensional Computed Tomography: A Three-year study. Cleft Palate-Cran J 2007;44: Aksu M. Sekonder Alveolar Kemik Greftlemesi. Cumhuriyet Üniv Difl Hek Fak Derg 2007; 10 : ençimen M, Gülses A, Özkaynak Ö,Varol A, Okçu KM, Do an N. Trombositten Zengin Fibrin Membran Kapl Otojen Kemik Grefti ile Tek Tarafl Alveol Yar Onar m. Hacettepe Difl Hek Fak Derg 2009; 33: Goudy S, Lott DG, Burton R, Wheeler. Canady J. Secondary Alveolar Bone Grafting: Outcomes, Revisions, and New Applications. Yay n aflamas nda. Cleft Palate- Cran J Daskalogiannakis J, Ross R.B. Effect of alveolar bone grafting in the mixed dentition on maxillary growth in complete unilateral cleft lip and palate patients. Cleft Palate-Cran J 1997;34: Eppley BL, Sadove AM, Management of alveolar cleft bone grafting-state of art. Cleft Palate-Cran J 2000;37: Tai C-C E, Sutherland I.S, McFadden L. Prospective analysis of secondary alveolar bone grafting using computed tomography. J OralMaxillofacial Surg 2000; 58: Kawakami S, Hura K, Yokozeki M, Takahashi T, Seike T, Nakanishi H, Moriyama K. Longitudinal evaluation of secondary bone grafting into the alveolar cleft. Cleft Palate-Cran J 2003;40: Ozawa T, Omura S, Fukuyama E, Matsui Y, Torikai K, Fujita K. Factors influancing secondary alveolar bone grafting in cleft lip and palate patients: prospective analysis using CT image analyzer. Cleft Palate-Cran J 2007;44: Craven C, Cole P, Holier Jr L,Stal S. Ensuring Success in alveolar bone grafting: A three-dimensional approach. J Craniofac Surg 2007; 18: Kindelan J., Roberts-Harry D. A 5-year post-operative review of secondary alveolar bone grafting in the Yorkshire region. Br J Orthod 1999; 26: Mclntyre GT, Devlin MF. Secondary Alveolar Bone Grafting (CLEFTS S) Cleft Palate-Cran J 2010;47: Keskin A, Tuncer N, A lkan A. Kortikokansellöz Blok Greftler le Rezidüel Alveol Yar klar n n Rekonstrüksiyonu. T Klin J Dental Sci 1999;5: Global strategies to reduce the health-care burden of craniofacial anomalies. Report of WHO meetings on International Collaborative Research on Craniofacial Anomalies. Human genetics programme, WHO, 2002,Geneva, Switzerland. 20. Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Ofcial Publicaton of the American Cleft Palate-Craniofacial Association 2000, Cleft Lip and Palate. Critical elements of care. Funded by the Washington State department of Health Division of Community and Family Health Ofce of Children with Special Health Care Needs. Produced by Children s Hospital and Regional Medical Center, Seattle, WA Kortebein MJ, Nelson CL, Sadove AM: Retrospective analysis of 135 secondary alveolar cleft grafts using iliac or calvarial bone.j Oral Maxillofac Surg 1991;49: Liou EJ, Chen PK, Huang CS, Chen YR. Interdental distraction osteogenesis and rapid orthodontic tooth movement: a novel approach to approximate a wide alveolar cleft or bony defect. Plast Reconstr Surg 2000;105: Binger T, Katsaros C, Rücker M, Spitzer WJ. Segment distraction to reduce a wide alveolar cleft before alveolar bone grafting. Cleft Palate-Cran J 2003;40 : Nalçac R,Topbafl S, Orhan M, Doruk C. Dudak damak yar kl bireylerde konuflma bozukluklar n n önemi, konuflma terapisi ve distraksiyon osteogenezisin de erlendirilmesi: ki olgu nedeniyle. Türk Ortod Derg 2009;22: