With regard to bilateral maxillary alveolar clefts, early grafting has generally fallen out of vogue. Today cleft grafting is reserved as a secondary reconstructive procedure, and adequate bilateral buccal mucosal flaps and upper lip flaps are used to cover grafted bone.1–3 These flaps may result in secondary loss of the vestibule and shortening and inversion of the upper lip. The purpose of this communication is to summarize our experience with changes in vestibular depth after use of three different methods to cover grafted bone, from April of 1992 to March of 2002.
Forty-two patients with bilateral alveolar clefts were treated in the Department of Oral and Maxillofacial Surgery of Xiang Ya Hospital, Central South University. The study group included three patients with a bilateral alveolar cleft and a bilateral cleft lip and 39 patients with a bilateral alveolar cleft and a complete bilateral cleft lip and cleft palate. Three different soft-tissue closure techniques were used to repair the bilateral alveolar clefts: the bucket-handle mucosal flap, bilateral buccal mucosal flaps, and bilateral buccal mucosal flaps with premaxillary separation and bone grafting. Postoperatively, the depth of the sulcus was evaluated using following four grades:
- Grade 0: no change in the depth of the labiogingival and buccogingival sulcus of the anterior portion of the maxilla
- Grade I: depth of the labiogingival and buccogingival sulcus of the anterior portion of the maxilla compared with the depth of the buccogingival sulcus in the malar areas is reduced by about one-third
- Grade II: the labiogingival and buccogingival sulcus of the anterior portion of the maxilla compared with the buccogingival sulcus in the malar areas is reduced by about two-thirds
- Grade III: Loss of depth of the labiogingival and buccogingival sulcus of the anterior portion of the maxilla
Forty-two bilateral alveolar clefts were repaired with the above-mentioned techniques. There were 20 grade 0 patients (47.6 percent), 10 grade I patients (23.8 percent), 10 grade II patients (23.8 percent), and two grade III patients (4.7 percent). In six patients who underwent the bucket-handle mucosal flap technique and bilateral buccal mucosal flaps with premaxillary bone grafting, the depth of the vestibular sulcus was reduced to two-thirds in four patients and the vestibular sulcus totally disappeared in two patients (Table 1 and Figs. 1 and 2).
According to our clinical experience, closure of the buccal and palatal sides or the buccal side of the bone graft almost always requires the addition of more tissue to the area. A variety of flaps can be used for this purpose, but each has its own indications and potential pitfalls. In our clinical practice, we have found that the bucket-handle mucosal flap can obviously reduce the depth of the labiogingival sulcus of the anterior portion of the maxilla. The change in depth of the vestibular sulcus of the maxilla was also obvious, after the bilateral buccal mucosal flaps associated with resection of the vomer with the osteotome placed through the cleft and palatal flaps were rotated to close the buccal and palatal defects.
The above-mentioned techniques could reduce the depth of the vestibular sulcus; therefore, surgeons should notice this complication and prevent it during operative planning and the operation.
Xin-chun Jian, D.D.S., M.D.
Yong-hua Lei, Ph.D.
Miqdadi Miqduti, D.D.S., B.D.
Department of Oral and Maxillofacial Surgery
Xiang Ya Hospital
Central South University
Changsha, Hunan, People’s Republic of China
1. Troxell, J. B., Fonseca, R. J., and Osbon, D. B. A retrospective study of alveolar cleft grafting. J. Oral Maxillary Surg.
40: 721, 1982.
2. Hall, D. H., and Posnick, J. Early results of secondary bone grafts in 106 alveolar clefts. J. Oral Surg.
41: 289, 1983.
3. Erol, O. O., and Agaoglu, G. Reconstruction of the superior labial sulcus in secondary bilateral cleft lip deformities: An inverted U-shaped flap. Plast. Reconstr. Surg.
108: 1871, 2001.
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