“COMPARATIVE AND QUANTITATIVE STUDY OF TITANIUM

MESH REINFORCED ALVEOLAR BONE GRAFT WITH

STANDARD BONE GRAFTING TECHNIQUE ON CLEFT
PATIENTS”

By
Dr. VENUGOPAL S .S

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
In partial fulfillment
Of the requirements for the degree of

Master Of Dental Surgery

In
ORAL AND MAXILLOFACIAL SURGERY

Under the guidance of

PROF. (Dr.) MUSTAFA .K

Department of Oral and Maxillofacial Surgery

A.J. Institute of Dental Sciences
Kuntikana, Mangalore
2008-2011

1
 Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “COMPARATIVE AND

QUANTITATIVE STUDY OF TITANIUM MESH REINFORCED

ALVEOLAR BONE GRAFT WITH STANDARD BONE

GRAFTING TECHNIQUE ON CLEFT PATIENTS” is a bonafide and

genuine research work carried out by me under the guidance of DR. MUSTAFA K,

M.D.S, Professor Department of Oral and Maxillofacial Surgery, A.J Institute of

Dental Sciences, Kuntikana, Mangalore.

DATE:

PLACE: Manglore Dr VENUGOPAL S.S

2
 CERTIFICATE BY THE GUIDE

A. J. Institute of Dental Sciences, KUNTIKANA,

MANGALORE-575018,
KARNATAKA, INDIA.

CERTIFICATE

This is to certify that the dissertation entitled “COMPARATIVE AND

QUANTITATIVE STUDY OF TITANIUM MESH REINFORCED

ALVEOLAR BONE GRAFT WITH STANDARD BONE

GRAFTING TECHNIQUE ON CLEFT PATIENTS” is a bonafide

research work done to my satisfaction by Dr. VENUGOPAL S .S in

partial fulfillment of the degree of Master of Dental Surgery in Oral

and Maxillofacial Surgery of Rajiv Gandhi University of Health

Sciences, Bangalore.

____________________
Date: Prof. (Dr.) Mustafa. K
Place: Mangalore Post Graduate Guide
Professor,
Department of Oral &maxillofacial Surgery
3
 ENDORSEMENT BY THE H.O.D &
PRINCIPAL OF THE INSTITUTION

A. J. Institute of Dental Sciences,

KUNTIKANA - 575004, MANGALORE,
KARNATAKA,INDIA

CERTIFICATE

This is to certify that the dissertation entitled “COMPARATIVE

AND QUANTITATIVE STUDY OF TITANIUM MESH

REINFORCED ALVEOLAR BONE GRAFT WITH STANDARD

BONE GRAFTING TECHNIQUE ON CLEFT PATIENTS” is a

bonafide research work done by Dr. VENUGOPAL S .S under the

guidance of Prof. (Dr.) MUSTAFA K, Prof.

___________________ ___________________
Prof. (Dr.) B. Sureshchandra
Prof. (Dr.) Nandesh Shetty
Principal,
Head of the Department,
A.J. Institute of Dental Sciences
Department of Oral & Maxillofacial
Mangalore
surgery
Date:
Date:
Place: Mangalore
Place: Mangalore

t
4
 COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation / thesis in print or electronic format for academic / research

purpose.

Date: Dr. Venugopal S .S

Place: Mangalore

© Rajiv Gandhi University of Health Sciences, Karnataka

5
 Acknowledgements
I express my dearest gratitude and indebtedness to my guide Dr. Mustafa k,
M.D.S, Professor, Department of Oral and Maxillifacial Surgery, A.J. Institute of
Dental Sciences, Kuntikana, Mangalore, for his relentless encouragement and most
valuable guidance which has made this study possible.

I would like to thank to Dr. Nandesh Shetty Professor and Head of the
Department, Oral and Maxillofacial Surgery, A.J. Institute of Dental Sciences,
Kuntikana, Mangalore, for his sincere support throughout the period of my study.

My special thanks to our Dean Dr.B.Sureshchandra for his support and

guidance. I am also grateful to Dr.ShehzanaFfatima, Dr Shreyas Soraka.,
Dr.Naveen Rao and Dr. Subeen for their continuous support and help to make this
study possible.

I am deeply thankful to Jyothi Shalini Mascharenhas, Oral medicine and

Radiology technician and entire staff members and post graduates of Oral medicine
and Radiology department for rendering the much needed help in radiographic work
for my study.

I am grateful to Mr. M.S.Kotian, Assistant Professor, Kasturba Medical

College for rendering his valuable help in compiling the statistical data for my study.

Warmest thanks to M/s. Kohinoor Computer Zone, Mangalore, for bringing

out my dissertation in this form.

I gratefully acknowledge the help and co-operation offered to me by the non

teaching staff and fellow colleagues of my department.

Last, but not the least, I would like to dedicate my thesis to GOD almighty, my wife
Dr Ranjitha for her support and strength, my parents, other family members and friends
without whose support, blessings and inspiration I would not have come this far.

2008-2011 Dr. Venugopal S. S

6
 LIST OF ABBREVIATIONS

IOPA - Intraoral Periapical Radiograph

OPG – Orthopantomograms

ACPA – American cleft and palate association

3-D radiographs – three dimensional radiographs

Ti- Mesh – Titanium mesh

a X2= Chi – Square Test

P = Probability

N = number of cases

NS = P > 0.05 = Not Significant

S =P < 0.05 = Significant

HS = P < 0.01 = Highly Significant

VHS = P < 0.001 = Very Highly Significant

7
 ABSTRACT

BACKGROUND AND OBJECTIVES

Bone grafting has become essential in treating patients with alveolar defect.

However, in some cleft patients it is difficult to augment the bone defect to desired

degree due to the cleft width and gap between the two maxillary segments. In recent

years titanium mesh has been used for reconstruction of large or small osseous defects

in oral and maxillofacial surgery.The purpose of the study is to compare the

conventional alveolar bone graft technique with titanium mesh fixed alveolar bone

graft technique. To assess clinically and radiograpically the amount of bone formation

in conventional bone grafting with titanium mesh grafted procedure.

METHODOLOGY

The present study was conducted on 20 patients who were selected randomly

for alveolar bone grafting with cleft alveolus. 10 patients were divided into

conventional bone grafting and 10 patients for titanium mesh used bone graft groups.

The post operative radiographic assessment was done by Chelsea scale, and divided

accordingly to their scores.

RESULTS

It was found that in Titanium mesh group 80% of clefts were rated category A, 10%

category C, and 10% category D, were as B, E and F were nil. Conventional bone

grafted group showed 60% of clefts were rated as category A, 20% category C and

20% and category D were as B, E, and F were nil. The above mentioned categories

A and C had a satisfactory radiological result as mentioned by Chelsea scale.

According to same scale the category D was consider as failure rate.

8
INTERPRETATION AND CONCLUSION

The bone grafting procedure provides adequate bone support to the teeth adjacent to

the cleft site. In all cases it was seen that bony bridge was well established across the

cleft area. The Titanium Mesh was best utilized for wider clefts. It helped in securing

the corticocancellous bone particle in cleft site and reduces the amount of resorption.

The nature of its biocompatibility, minimal thickness and easy handling helps in

proper contouring of the alveolus and establishing functional and aesthetic forms of

the lip and nasal form.

KEYWORDS

Titanium mesh; alveolar bone grafting; Chelsea scale; mixed dentition; iliac crest

bone grafts; Canine eruption; periodontal support.

9
 Contents
PAGE NO.

1. INTRODUCTION 1-2

2. AIMS AND OBJECTIVES 3

3. REVIEW OF LITERATURE 4-17

4. METHODOLOGY 18-26

5. RESULTS 27-48

6. DISCUSSION 49-54

7. CONCLUSION 55-56

8. SUMMARY 57

9. BIBLIOGRAPHY 58-63

10. ANNEXURES 64-66

10
 LIST OF TABLES

Page No:

Table 1: Master chart 28

Table 2: results chart – 1 29

Table 3: Result chart – 2 32

Table 4: Scores According to Chelsea scale 40

Table 5: Age Distribution 41

Table 6: sex Distribution 42

Table 7: cleft category 42

Table 8: values of mesh and conventional groups 43

Table 9: group statistics 43

11
 LIST OF FIGURES
Page No:

Figure 1: Armamentarium 20

Figure 2: Titanium Mesh 20

Figure 3: Investigation design 21

Figure 4: Iliac bone region – donor site 25

Figure 5: Cortico-cancellous bone particles 25

Figure 6: Titanium mesh used for bone grafting technique 26

Figure 7: Conventional bone grafting technique 26

Figure 8: Frontal picture of case – 1 31

Figure 9: Subnasal picture of case – 1 31

Figure 10: Case 1- Pre Operative Radiograph 32

Figure 11: Case 1- Post Operative Radiograph 32

Figure 12: Frontal picture of case – 2 33

Figure 13: Subnasal picture of case – 2 33

Figure 14: Case 2- Pre Operative Radiograph 34

Figure 15: Case 2- Post Operative radiograph 34

Figure 16: Frontal picture of case – 3 35

Figure 17: Subnasal picture of case – 3 35

Figure18: Case 3- Pre Operative Radiographs 36

Figure 19: Case 3- Post Operative Radiograph 36

Figure 20: Frontal picture of case – 4 37

Figure 21: Subnasal picture of case – 4 37

Figure 22: Case 4- Pre Operative Radiograph 38

Figure 23: Case 4- Post Operative Radiograph 38

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Figure 24: Frontal picture of case – 5 39

Figure 25: Subnasal picture of case – 5 39

Figure26: Case 5- Pre Operative Radiograph 40

Figure 27: Case 5- Post Operative Radiograph 40

Figure 28: Frontal picture of case – 6 41

Figure 29: Subnasal picture of case – 6 41

Figure 30: Case 6- Pre Operative Radiograph 42

Figure 31: Case 6- Post Operative Radiograph 42

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 LIST OF GRAPHS

Page No:

1. Bar chart figure -1: age distribution 47

2. Bar chart figure – 2: sex distribution 47

3. Bar chart figure – 3: category 48

4. Bar chart figure – 4: value 48

14
 Introduction

Autogeneous bone graft has become essential in treating patients with cleft lip, palate

& alveolar defects. Primary & early autogenous bone graft is performed in first 18

months of life and reconstruction of cleft alveolus in such patients has been

demonstrated to fall short of desired therapeutic results¹.

The cleft alveolus patients do have insufficient bone at the time of eruption of

maxillary permanent incisor & canine teeth. It’s generally agreed that these bone graft

do not preclude the need for early secondary alveolar bone grafts. Early secondary

bone graft shows clinical evidence of acceptable vascular supply to both buccal &

palatal dentoalveolar soft tissues & with no disruption of premaxillary segments.

The ideal and most accepted bone grafting procedure is Secondary bone graft. This is

performed at mixed dentition stage. It is widely accepted to be performed before

eruption of canine. Best results for canine tooth eruption is seen when surgical

procedure is performed around 10 years of age & evaluating canine eruption between

ages of 7 to 11 years.

Tertiary bone grafting procedure is done in permanent dentition stage. Lower age

limit involves those patients in whom cleft alveolus involves canine & lateral incisors.

Hence, considered age should be dental age rather than chronological age.

Main goal of treating a cleft alveolus includes:

- Closure of oronasal fistula,

- Establishing continuity between the cleft segments,

- Constructing proper alveolar contour,

- Preventing tooth loss caused due to lack of periodontal bone support,

- Provide bone support for eruption of teeth & aid in orthodontic tooth movement,

- And creating firm support for nasal floor.

15
This goal should be achieved to provide tremendous enhancement of oral aesthetics

for the cleft patients².

Even today the widely accepted gold standard of bone grafting is the autogenous

bone, rather than using allogenic bone, xenogenic bone, bone substitute & alloplasts.

Autogenous bone remains superior with function, form & adaptability.

Autogenous bone graft amounts to transplanted osteogenesis in which osteocompetent

cell transplanted from one body site to another which contains osteocompetent cells.

Greater the cellular density of transplanted osteocompetent cells greater the new bone

formation.

The goal of autogenous bone harvesting is the acquisition of specific quantity, contour

& quality of bone required for construction. Donor site should not import much blood

loss, least overall morbidity & least function impairment. Ilium is most preferred

donor site; it contains greater absolute cancellous bone volume & has highest

canelleous bone to cortical bone ratio³.

In recent years titanium mesh has been used for various reconstructive procedures in

maxillofacial surgeries. Titanium mesh usage has been utilized in wide cleft, closure

of alveolar defect, to increase the vertical height of the ridge & other reconstructive

procedure. In cases of wide cleft, where there is improper support for cleft premaxilla,

lack of stability, difficulty to achieve proper ridge form and to over come the bone

graft resorption at the cleft sites, in all such cases the Titanium mesh was used in

alveolar bone grafting procedure to get a better and successful results4.

16
 AIMS & OBJECTIVES:

Bone grafting has become essential in treating patients with alveolar defect. However,

in some cleft patients it is difficult to augment the bone defect to desired degree due to

the cleft width and gap between the two maxillary segments, which do result of bone

resorption near the adjacent teeth. Stability is one of the major successes for bone

graft to be taken up, which do lacks in wide clefts and thin premaxillary segments.

In recent years titanium mesh has been used for reconstruction of large or small

osseous defects in oral and maxillofacial surgery. It’s widely accepted for its

biocompatibility, and ease of handling properties with minimal complications has

been an advantage for material choice.

The purpose of the study is to compare the conventional (standard) alveolar bone graft

technique with titanium mesh fixed alveolar bone graft technique. The normal closure

of alveolar cleft with palatal & labial mucoperiosteum flap compared with titanium

mesh fixed to hold the bone particles & normal closure. Bone formation Assessment

is done radiographically and its overall clinical outcome is calculated statistically.

To assess radiograpically the amount of bone formation in conventional (standard)

bone grafting with titanium mesh grafted procedure and the amount of bone graft

intake.

To evaluate the overall clinical out come of above mentioned two bone grafting

procedures.

To evaluate and compare statistically results between conventional and Titanium

Mesh alveolar bone grafting procedure.

17
 Review of literature:
Boyne PJ, Sands NR (1976)⁵. Conducted a study on 15 patients and suggested that,

Late or secondary bony reconstruction of the osseous alveolar and anterior palatal

clefts may be accomplished with either an essentially nonviable autogenous graft or

an autogenous particulate marrow and cancellous bone graft. It was thought that the

use of rib, solid one-piece grafts from the iliac and other types of nonviable graft was

warranted only after major growth and development of the premaxillary region. The

secondary grafting with such grafts would restrict to patients over 15 years of age.

The prognosis of dental rehabilitation without appropraite bone-grafting procedures of

the alveolar and prepalatal cleft was unfavourable

El Deeb M. et al(1982)6. Conducted study on Forty-six patients with clefts of the

alveolus who had received alveolar bone grafts at ages 7-14 years. A total of 64

affected canines from 18 bilateral and 28 unilateral alveolar cleft patients were

recorded. All canines erupted through the graft. Spontaneous eruption occurred for

27% of test canines, 17% required surgical uncovering (either bony or soft tissue),

and 56% required surgical uncovering and orthodontic assistance to accomplish

eruption. All patients required orthodontic treatment to accomplish arch alignment.

The prognosis for canine eruption through a graft site is most favourable if the graft is

performed at 1/4-1/2 canine root formation and when the patient is aged 9-12 years.

18
Turvey TA et al(1984)⁷. Conducted study on delayed bone-grafting procedures in a

group of twenty-four cleft patients. All patients benefited from closure of their

fistulas.

The need for prosthesis was eliminated in twelve patients, and eight of the remaining

twelve patients required only a three-unit bridge. . In seventeen patients, the graft was

placed prior to canine eruption, and in sixteen of these patients, the canine erupted

passively into the arch. Not every patient with a cleft is a candidate for delayed bone

grafting, but the procedure has been found to be beneficial in selected persons.

Hans Enmark, DDS, et al(1987) ⁸. In Cleft palate institute & Aarhus university

hospital, Aarhus, Denmark did a longitudinal study to evaluate the treatment results

after secondary bone grafting in 224 cleft patients. The evaluation of treatment results

included longitudinal comparison of marginal bone level, periodontal status in cleft

related teeth, and dental status in bone grafted region. The study demonstrated that

significantly better results were achieved with secondary bone grafting if the

treatment is performed before the canine eruption.

Sindet-Pedersen S, Enemark H(1990) 9. In Aarhus University Hospital, Denmark,

they conducted a comparative study on 40 patients with unilateral cleft lip palate. 20

patients were randomly selected for mandibular bone graft and 20 patients for iliac

crest bone graft. Age group was considered to be 8 to 13 years. Marginal bone level in

cleft related teeth was similar in both groups. The results of this study demonstrated

that reconstruction of alveolar clefts with mandibular bone graft had several

advantage compared to iliac crest bone graft. Which included operation time, reduced

morbidity, reduced hospitalization time and scar at iliac crest is avoided.

19
Amanat N, Langdon JD(1993) 10. In a short review of the literature outlined the role

of alveolar bone grafting in cleft patients. An analysis of a series of 47 secondary

alveolar bone grafts in 34 patients was presented. The age range was 7-24 years. At

the time of evaluation, 30 canines were in final occlusion and good alveolar bone

levels were present in 83% of patients. The 13 bilateral cases (26 clefts), 14 canines

were in final occlusion and all cases had good alveolar bone levels.10

Bart Witsenburg et al(1993) ¹¹. In Medisch Spectrum Twente hospital Netherlands

conducted study on 40 patients with two groups of patients before 12years and

patients after 12years of age. Bone grafting was done by both anterior iliac crest and

mandibular symphyseal autogenous graft. It was evaluated both clinically &

radiograpically. The study indicated that the best grafting results were achieved when

grafting is performed before 12 years of age. Radiographic results showed mandibular

symphyseal bone graft to be better than anterior iliac bone graft. Iliac graft was a

better choice when larger residual defects were repaired.

A. J. W. Vander Meij, et al(1994)¹². Conducted study in free university hospital

Amsterdam during 1983-1991, on 8 patients with right unilareral cleft lip and palate.

Early, secondary bone grafting was done with iliac crest graft. Axial CT scan were

made with 1.5 mm slice parallel to occlusal plane. It was impossible to assess quantity

and quality of graft with conventional radiographs. A major problem existed in

follow- up studies of bone grafts; the outline was indistinguishable from its

surrounding alveolar bone. The CT scan gives the advantage of quantity of bone

amount grafted and remained after 1 year follow ups.

20
Eduard Keese, Raines Schmelzle(1995)¹³. Published a study conducted in

University of Humberg in maxillo facial surgery unit investigated in 148 cleft lip and

palate patient from 1959-1969. Patients had regularly visited up to 1994. They

recorded age at surgery, cleft form (unilateral, bilateral) pre operative cleft width was

measured on original cast. Assessment of long term results of primary bone grafting

was based on relevant radiograph of permanent dentition in terms of Bergland index.

Influential factor, neither age at surgery, dental hygiene, cleft form, Aplasia or loss of

teeth near the cleft nor the surgeon was found to influence the success of primary

bone grafting procedure. It was significant correlation of cleft width and Bergland

index. In small cleft upto 4mm wide Bergland index 4 that is ≤ 25% was found and in

no cleft larger than 8mm developed a Bergland index that is ≤ 100% interdental

septum.

Von Arx T, Hardt N, Wallkamm B(1996)14. They conducted study in Lucerne,

Switzerland, evaluated 20 patients who had insufficient bone volumes for primary

placement of dental implants. The Use of stable Titanium Mesh guaranteed ridge

augmentation in vertical and buccal directions. The integration of autogenous bone

grafts was excellent with only minimal bone resorption because the Mesh protected

the graft from exterior trauma and non functional forces. The Titanium augmentation

Micro Mesh made of pure Titanium had extra ordinary tissue compatibility and

especially suited for long-term bone graft stabilization.

21
Diane V. dado et al(1997) 15. In Loyola university medical centre Texas, conducted

study on 15 patients with unilateral cleft lip and palate, mean age around 12 years.

Keeping maxillary alveolar crest parallel to the plane of the scan, 1.5 mm cuts were

made. It helped in examining the position, size, and spatial relationship of grafted area

and quantification of amount of bone coverage of roots, bone height adjacent to graft

site. The vertical bone height was measured by counting the number of scan slices

from apex towards the crown to include the last slice of alveolar bone. Primary

alveolar bone graft placement resulted in bony continuity of the cleft alveolar arch

with enough bone present which allowed orthodontic tooth movements, functional

and aesthetic arch alignment was important.

16
C.M. MCCANNY et al(1998) . Conducted study in year 1986 to 1993 on 47

patients who had alveolar bone defects. They operated on 25 patients from St. James’

University with trephine technique and 21 patients from General Infirmary at Leeds,

by open hip surgery technique. The assessment of treatment was done by radiographic

examination. They concluded that interdental bone height mesial to the cleft canine

was used as a means of assessing the outcome of the graft. Statistically it showed no

significant difference in both procedures. The morbidity of the two techniques

suggests that the open hip technique had more postoperative complications, including

gait disturbance and wound infection. Satisfactory eruption of the canine was

observed in both groups. Preliminary study would therefore suggest that the trephine

was the preferred technique for secondary alveolar bone grafting in patients with cleft

lip and palate.

22
Joachim Hartel et al(1999) 17. Conducted a study from 1994 -1998 in Rostock cleft

center Germany, and evaluated in 15 patients who received 23 implants in bone

grafted clefts. Age of patients was 14 to 27 years. Clinical and radiographic follow-

ups were performed. The results of this study showed that implants succeeded in

grafted bone without bone resorption in those cases where time between bone grafting

and implant placement was only 6-8 weeks. Tension exerted by a scar following

osteoplasty led to pressure atropy of the grafted bone and aseptic bone resorption.

There study concluded that implants should not be placed with in 6-8 weeks followed

by osteoplasty. Delayed implants or static and functionally unfavourable implantation

may lead to loss of bone grafts in alveolus. Trapiziodal mucosal flaps used for

coverage of bone graft quite often led to scarring and consequently to pressure

atrophy of transplanted bone.

Eric J. W. Liou et al (2000)18. In chang gung hospital they performed interdenal

distraction on 10 patients with dentoalvleolar cleft/defects. They reported that the

alveoli & gingivae on both ends of clefts were approximated after distraction

osteogenesis. It eliminated the extensive alveolar bone grafting & also allowed rapid

tooth movement orthodontically into newly formed alveolar bone.

Yasunori Sumi. et al (2000)19. conducted study on 3 patients, 2 men and 1

women,aged 17,28 and 28 years respectively, they all had inadequate bone volume for

implants placement. The latest surgical procedure for localized ridge augmentation

was based on guided bone regeneration by using barrier membrane. Ridge

augmentation was sufficient upto half the space between Mesh and subjacent cortical

bone filled with bone chip graft. Autografts also served as osteconductive scaffold for

23
deposition of bonematrix during healing. They provided osteoindutive properties with

regard to osteogenic transfer. Bone graft provided osteoblast, osteoblast precursor

cells and grafted bone matrix resulting in new bone formation in augmented site.

M. Fukuda, T. Takahashi, T. Yamaguchi (2000) 20. In National Sendai Hospital,

Sendai, Japan, placed 14 implants in 9 patients. One of the main problems with

endosseous implant was insufficient width or height or both of the alveolar ridges at

the implantation site. Several techniques were used to solve bone grafting problems.

Chin bone onlay grafting was a well established way of widening the narrow

maxillary ridge, which was used to increase interdental alveolar bone height. A

technique was used to increase bone height by chin bone onlay grafting in conjunction

with placement of the implant. Appropriate alveolar bone height was achieved by

onlay grafting in patients with local alveolar bone Defects. Chin bone onlay grafting

combined with insertion of the fixture is a simple, one-step procedure to increase

alveolar bone height without support, such as the titanium miniplate system.

Advantages of the chin bone as a donor site were its topographic accessibility,

reduced morbidity, and absence of visible scars and less resorption of grafted bone

when compared with that harvested extraorally

21
Amin kazemi et al(2002) . In Philadelphia, Hospital of the University of

Pennsylvania suggested that controversies did exist regarding timing of surgery,

choice of graft material, flap design & surgical technique in treating cleft patients. It

was surgeon’s obligation to plan operations carefully and provide individualized

treatment that allowed best results for individual patients.

24
Timothy A. Turvey et al(2002)22.They observed in a study conducted in university

of North Carolina at Chapel Hill suggested that patients who had undergone cleft

palate surgery during infancy often exhibited some degree of maxillary growth

restriction. Addressing midface deficiency in the presence of cleft malformation

represented only one stage reconstruction of the defect. Facial skeleton disproportion

may be addressed either by Osteotomy or by bone grafting procedures. Three

important reasons for using bone graft in performing midfacial advancement is that it

maintained the position of maxilla during healing, encouraged healing and reduces

risk of fibrious union and its also helped in maintaining contour.

Development of more rigid fixation improves better results of cleft surgeries. Earlier

they used stainless steel plates and screws and then Titanium alloys were used. The

use of rigid fixation benefits reduced time for intermaxillary fixation and assured

position of midface during healing.

23
H. Witherow et al(2002) . In Chelsea, Westminster Cleft Lip and Palate Unit.

London, England. There they conducted study on Seventy-six patients (87 clefts)

operated on in one unit between 1985 and July 1999. All patients required secondary

alveolar bone grafting using cancellous iliac bone. The preoperative radiograph was

taken within 1 month of surgery. The postoperative film used for assessment was a

standardized upper anterior occlusal taken through the cleft line, 70% to the

horizontal and was taken at least after 6 months postoperatively. The cleft was

bisected vertically by an imaginary line and the roots of the teeth adjacent to the cleft

are divided into four. The distal tooth within the cleft could be either the erupted

canine or the most distal cleft tooth if the canine was unerupted. It allowed the

position of the bone within the cleft to be determined in the mixed dentition.

25
Depending on the positions of the bony bridge spanning the cleft, the radiographs

were placed into one of six groups that reflect the position of the bone related to the

cleft teeth. Category A also requires 75% or more of the root surface to be covered

with spanning bone from the amelocemental junction, and category B at least 25%

from the ACJ. Category C has only 25% of the coronal root deficient of bone,

category D, 50% of the coronal root deficient of bone. Category E does not have bone

bridging at either the apical or the amelocemental levels but has bridging between

both the intermediate levels. Category F has 75% or greater of the coronal root

deficient in bone. The new scale was developed to provide an accurate description of

the position of bone in the alveolar cleft after secondary grafting. It also enabled the

bony in-fill within the alveolar cleft to be measured in the mixed dentition before

eruption of the canine. It allows the significance of these different positions to be

determined in conjunction with long-term clinical trials.

A.J.W. Vander Meij, et al(2003)24. In medical centre Amsterdam, year 1983-1991,

determined the relation of cleft width and residual amount of bone after bone grafting

in 53 unilateral cleft lip and palate patients. CT scan was made with axial cuts of 1.5

mm thickness, parallel to occlusal plane. Direct relation was seen between width of

cleft and fate of bone graft. Revascularization of centre of the graft in wider clefts was

probably more likely to fail. Other problems such as unfavourable loading of bone

graft and collapse of mucogingival flaps with subsequent loss of stability and possible

exposure of graft are more frequent in wider clefts.

26
Mario Roccuzzo et al(2004)25. Torino Italy, studied on eighteen partially

edentulous patients who needed fixed partial denture or single crown with insufficient

corono-apical height defect of alveolar process. Surgical procedure was done by using

0.2mm thick Titanium Mesh system which used along with bone particle. Excellent

biocompatibility, easy handling and three dimensional reconstructions of large bone

defects were noted with no major complication

Ananth S. Murthy, James A. Lehman Jr(2005)26. They conducted an anonymous

survey by mailing 240 ACPA teams across North America regarding alveolar bone

grafting. The questionnaire included multiple questions about each team's approach to

alveolar bone grafting and options for the missing tooth. 90% of centers performed

secondary alveolar bone grafting, 78% performed grafting between ages 6 and 9

years, and iliac crest donor site was the most popular site (83%). There was no

consensus with respect to dental criteria for the timing of grafting, follow-up x-rays,

or the use of a grading system for evaluating results. They also found that only 14%

routinely followed the alveolar bone graft patients with postoperative periapical x-ray

evaluation. Sixty-two percent used postoperative x-rays occasionally and 24% never

used follow-up x-rays. There study concluded by saying wide acceptance of

secondary alveolar bone grafting in the management of the cleft alveolus, and there

was a consensus for the age of grafting and donor site. The disturbing finding of this

survey was the lack of postoperative x-ray evaluation of the grafted alveolus, which

could be best determined by radiographs at 6 months following surgery, the use of a

routine, standardized scale to measure postoperative results could allow for better

outcome studies in alveolar bone grafting.

27
Yoshiro Matsui,DDS, PHD, et al(2006) )4. Yokohama Japan, studied on 15 cleft

lip/palate patients. They required tertiary bone grafting with implant therapy.

Titanium mesh was adapted and filled with bone particles. It was seen that alveolar

ridge augmentation with titanium mesh and autogenous bone particles from the iliac

crest has high predictability as a preimplant procedure in patients with cleft lip/palate.

Tension exerted by scars, which led to pressure atrophy in the grafted Bone, may also

be minimized by the titanium mesh. The fact that all Placed implants exhibite signs of

osseointegration and had functioned well for substantial durations indicated that

alveolar ridge augmentation with titanium mesh had very high predictability as a pre-

implant procedure in patients with cleft lip/palate.

Periklis Proussaefs, Jaime Lozada,(2006)27. Conducted study on Seventeen

consecutively treated patients. For all patients titanium mesh was used during the

bone grafting procedure in conjunction with intraorally harvested intramembraneous

bone graft and inorganic bovine mineral. The autogenous graft particles were mixed

in equal portions with Bio-Oss particles. The recipient site was perforated to induce

bleeding and promote the incorporation of the graft. The particulate graft was then

loaded on the titanium mesh and placed at the recipient site. All patients received pre-

and postoperative panoramic radiographs. In addition, periapical radiographs were

made before the bone grafting procedure and before implant placement. The

impressions were taken before bone grafting & after implant placement. Postoperative

stone casts were used to quantitatively assess the volume of the alveolar ridge. A

custom tray was fabricated by photopolymerized acrylic resin. During implant

surgery, a biopsy was taken from the grafted area & subjected for histomorphometric

evaluation and light fluorescent microscopy. The current study provided histologic

28
evidence in humans that using a titanium mesh in conjunction with autogenous bone

graft and Bio-Oss particles could result in new bone formation. Exposure of the

titanium mesh was observed in 6 cases in the current study. Despite the exposure, no

infection was noticed in any of the patients. The augmented alveolar ridge had a solid

consistency, and no sign of inflammation or resorption. No further resorption

occurred after implant placement.

Thomas Bayerlein et.al(2006)28. in Germany at the University,Clinic of Greifswald

conducted retrospective analytical study on 46 childrens. Cleft osteoplasty was carried

out and followed-up under reproducible circumstances. Iliac crest cancellous bone

was exclusively used for autogenous grafting. Bone in the cleft area was determined

radiographically using digitized orthopantomograms and dental X-ray films.

intraalveolar bone height was classified in 4 grades with respect to optimal height of

the interdental bony septum. 76% of 46 cleft children could be assigned to the

successful groups I and II, while 24% were assigned to the unfavourable and

insufficient groups III and IV. The Cleft-adjacent lateral incisor was present in 18 out

of the 46 patients treated, while it was absent in the remaining 28 patients due to

congenital absence or extraction of teeth unworthy of preservation. They concluded

that Osteoplasty provides a basis for shaping a closed dental arch with an intact

periodontium in the cleft area. It also provides the preconditions of creating optimal

functional and aesthetic results not only with respect to chewing function, but also by

natural upper lip and symmetrical nose positions. They also recommended that the

therapy should be commenced preferably during an early phase of the mixed dentition

with respect to surgical success in terms of alveolar bone height, and that the

existence or presence of the lateral incisor was favourable.

29
 29
Y.L. Jia , M.K. Fu, L. Ma(2006) . At the Peking University School of

Stomatology in 1992 to 2001, they recorded 202 patients with clefts who had

secondary alveolar bone grafting. In all patients, alveolar bone grafting was done by

one surgeon by a standardised method. An anterior occlusal radiograph was used to

evaluate the long-term results of the alveolar bone grafting. Successful grafting

allowed eruption of teeth into the cleft and the achievement of Orthodontic movement

of teeth adjacent to the cleft site, to obtain non-prosthodontic rehabilitation. The

height of the interdental septum after the operation was the main indication of

successful of bone graft. Long-term follow-up is needed to establish the final

condition of the bone associated with fully erupted canines. They suggest that in

unilateral and bilateral cleft lip and palate, the success rate was higher when the cleft

was grafted before the eruption of the canine at the cleft. The shortage of tissue to

cover the transplant was one of the variables that affected the success of bone

grafting. Loss of the graft was usually the result of dehiscence of the wound and

breakdown of the flap in the area of the cleft, leading to exposure and contamination

of the graft.

Roccuzzo, M., Ramieri, G., Bunino, M. and Berrone, S.(2007) 30. They conducted

study in Italy on a group of 23 partially edentulous patients. The aim of clinical trial

was to evaluate alveolar ridge augmentation using an autogenous onlay bone graft

alone or associated with a titanium mesh. During First surgery in control group, an

autogenous bone graft was harvested from the mandibular ramus and secured by

means of titanium screws. . Particulate bone was added. In patients assigned to the

test group only, a titanium mesh was used to stabilize and protect the graft. They

30
concluded the study by suggest that an onlay osseous graft protected by a Titanium

mesh demonstrated significantly less bone resorption when compared with an onlay

bone graft alone. This benefit was reduced in case of short-term mesh exposure, with

limited drawbacks.

Bernd Lethaus et al(2010) 31. In Maastricht University Medical Centre, Netherlands,

reported a case of maxillary and orbital floor reconstruction with a microvascular

fibula graft and an individualized titanium mesh. A 25-year-old female was diagnosed

by ossifying cementoblastoma of maxilla at age of 17 years and patient underwent

hemimaxillectomy. The orbital floor next to the maxilla was removed, which resulted

in an enophthalmus and a collapse of cheek. To reduce the defect and to reconstruct, a

microvascular fibula flap was selected for transfer. An individually premolded

titanium mesh was used to reconstruct the floor of the orbit. The position of the

mandibula was predefined as the ideal position for the implants, which then

predefined the ideal position for the transferred bone. computertomography scan of

both legs was performed, and the necessary bony shape was virtually matched with

the patient's left fibula. They demonstrated that CAD/CAM techniques were of

greater value in planning and executing the reconstruction of defects. It gave a better

impression of the anatomical situation, the actual amount of bone and the demands on

the reconstruction, which resulted in a safer operation. Models also helped in

explaining and discussing the operation with patients.

31
 METHODOLOGY

The purpose of the study is to compare the conventional alveolar bone graft technique

with titanium mesh fixed alveolar bone graft technique, and to analyse the bone

volume by radiographic assessment. Also to compare clinically the various treatment

outcomes in comparison of above mentioned two methods.

Twenty patients with cleft alveolus, requiring for alveolar bone grafting was randomly

selected, from department of oral & maxillofacial surgery at A.J. institute of Dental

science, Mangalore.

Method of collection of data:

Among the patients with age group of 7 years to 25 years who have reported to

department of oral and maxillofacial surgery to A J institute of dental science and

Unity smile train centre Mangalore, for alveolar bone defect in cleft alveolus and

associated problems in cleft cases.

Selected patients met with the following criteria:

Inclusion criteria:

- Age group of 7-25 years

- Pre - Operative radiographic Width assessment of the cleft defects.

- No history of earlier surgical complication

Exclusion criteria:

Age group before 6 years

Age group above 25 years

32
a. A detailed case history was obtained and recorded in a proper format.

(Appendix I).

b. Preoperative photographs and Intraoral, occlusal, OPG radiogrphs were taken.

c. Patients/Parents consent was taken for surgical procedure. (Appendix II)

d. Investigation design.

Armamentarium for surgery: picture -1

• Iliac Bone graft harvesting set

• Cleft & palotoplasty set

• 4-0 vicryl suture material

• 5-0 proline suture material

• Titanium mesh 0.2mm (micro mesh): picture - 2

• 1.5mm 4-6mm length titanium screws

• Titanium plating set.

• Micromotor handpeice and drills

Maufactured and distributed by:

Stryker,lebinger GmbH & Co.KG

Freiberg/ Germany.

Indication and handling instruction of Titanium Mesh:

Stryker implants made of pure titanium Ti6A14v alloy. The implants are intended

for Osteotomy, stabilization and fixation of fractures and reconstruction. It is a

biocompatible material with corrosion resistant and non-toxic in the biological

environment. It produces negligible artifacts by X-ray, CT scan & MRI.

33
 Picture 1 - Armamentarium

Picture 2 - Titanium mesh: 0.2mm

34
 Picture – 3 investigation design

INVESTIGATION DESIGN

Patients with alveolar cleft defect

Pre Operative Radiographs taken for Radiograpic assessment of alveolar

bone defects

CONVENTIONAL GROUP TITANIUM MESH GROUP

10 patients with standard alveolar 10 patients with Titanium Mesh

bone grafting with autogeneous alveolar bone graft with
Bone autogeneous Bone

Post operative Radiodigraphs were taken after 6 months. Assessment was

done for both groups by Chelsea alveolar bone graft scale.

Results calculated according to

stastics

Data were analyzed and compared by using stastical values

35
 Surgical procedure:

The study was conducted on 20 patients who were selected randomly for alveolar

bone grafting with cleft alveolus. Routine case history and preoperative photographs

and radiographs were taken. All routine lab investigation was done and fitness for

surgery was cleared from consent departments.

All patients were operated under general anaesthesia. Patient preparations were done,

that includes face, the oral cavity and iliac bone for harvesting graft as donor site. The

cleft area is widely exposed through incisions along the edges of the cleft. The

incision on the vestibular side is made along the gingival border; circumferential

incision was given all along the interdental gingival which preserve the gingival

attachment, so as to contour and cover later at the time of closure of flap. Posteriorly,

the incision is extended to the first permanent premolar or molar depending on flap

mobility for watertight closure. It is necessary to cut through the periosteum at the

base of the flap. Anteriorly, the incision is extended along the gingival border to the

center of the cleft side central incisor. Vertical incisions are made along the edges of

the cleft. On the palatal side, mucoperiosteal flaps are raised along the edges of the

cleft. A wide exposure and visibility of the cleft area is achieved with these incisions.

During the exposure of the cleft, care is taken not to traumatize the thin bone lamellae

that cover the dental roots adjacent to the cleft.

Once the proper flap was raised and cleft was exposed, the nasal floor was

reconstructed. On the palatal side, the mucoperiosteal flaps are sutured together with

everting inverted mattress sutures which gives a base for bone graft particles to be

placed.

36
The surgeon simultaneously harvests cancellous marrow from the anterior iliac crest.

A trap door of cortical bone is raised, hinged on the inner edge of the iliac crest.

Chunks of cancellous bone are removed by a bone scoop, leaving the inner and outer

cortex of the iliac bone intact. Once the sufficient graft is harvested, complete wash

was given with betadine. Layered closure is done with vicryl suture material. The skin

closure is done with 5-0 proline suture materials. A tight pressure dressing is given

over the harvested donor site to minimize haematoma.

Once the autogenous bone is harvested from the iliac graft the alveolar cleft is filled

with chunks of cancellous bone chips. To improve the nasal symmetry, sufficient

bone chips must be placed under the alar base. The alveolar crest must be formed up

to the normal height and thickness.

Once the cleft is filled with sufficient bone graft, lateral mucoperiosteal flap is

advanced to cover the cleft and is sutured to the smaller medial flap and to the palatal

flaps to give a water tight seal. In titanium mesh covered bone graft the alveolar cleft

is filled with bone particles, and titanium mesh is cut into proper shape and contoured

to alveolar defect. The titanium mesh is fixed with mono cortical screws to the edges

of the sound alveolar bone sparing the tooth structures. The bone graft is secured

inside the mesh with proper contour of alveolus and achieving good stability to

premaxilla. Once the mesh is secured and fixed with 2 to 3 mono cortical screws, the

flaps is covered over it and sutured in a water tight closure. The closure of flap was

done with resorbable suture material.

37
After the surgical procedure patient was kept under observation for 1 week to 10 days

postoperatively. All postoperative care and medication including antibiotics and

analgesics were followed for the patients. Postoperative oral hygiene care was

maintained by chlorhexidene mouth wash usage every 6th hourly.

The Suture over iliac donor site was removed after 10-12days of post operative

period. Radiographs were taken at regular intervals of 1st month 3rd month and 6th

month respectively to monitor acceptance of bone graft and post operative

complications and clinical out comes of the bone grafting procedure.

38
 Figure – 4: Iliac bone region – Donor site

Figure – 5 : Cortico-cancellous bone particles

39
Figure 6: Titanium mesh used for bone grafting technique

Figure 7: Conventional bone grafting technique

40
 Master chart of both titanium mesh group and conventional bone graft group

Cleft
SL NO AGE/SEX PROCEDURE DONE POSTOPERATIVE RADIOGRAPH Category SCORE
1
12/F Right side titanium mesh, left side normal grafting Radiographs taken on 3rd & 6th month A 6

2
8/M Left sided cleft, Titanium Mesh bone grafting Radiographs taken on 3rd & 6th month C 6

3
7/M Left side Titanium Mesh bone grafting, right side normal grafting Radiographs taken on 3rd & 6th month A 6

4
7/F Left sided Titanium Mesh Bone grafting Radiographs taken on 3rd & 6th month A 6

5
22/F Left sided Titanium Mesh Bone grafting Radiographs taken on 3rd &6th month A 6

6
7/F Left side Titanium Mesh bone grafting Radiographs taken on 3rd & 6th month D 4

7
8/ M Right side Titanium Mesh & left side normal bone grafting Radiographs taken on 3rd& 6th month A 6

8
7/F left side alveolus left Titanium Mesh bone grafting done Radiographs taken on 3rd & 6th month C 6

9
23/F right side Titanium Mesh bone grafting over fixed partial denture Radiographs taken on 3rd& 6th month D 4

10
13/F right side titanium mesh grafting, left side normal grafting Radiographs taken on 3rd & 6th month A 6

1
8/F left side alveolus normal bone grafting Radiographs taken on 3rd & 6th month A 6

2
7/F right side alveolar defect, normal bone grafting done Radiographs taken on 3rd& 6th month D 4

3
21/M right side alveolar defect, normal bone grafting done Radiographs taken on 3rd & 6th month C 6

4
7/M left side alveolus, normal bone grafting Radiographs taken on 3rd & 6th month A 6

5
7/M left side alveolar defect, normal bone grafting done Radiographs taken on 3rd& 6th month A 6

6
8/M left side alveolar defect, normal bone grafting done Radiographs taken on 3rd& 6th month D 4

7
7/M left side alveolar defect, normal bone grafting done Radiographs taken on 3rd& 6th month A 6

8
7/M left side alveolar defect, normal bone grafting done Radiographs taken on 3rd& 6th month A 6
9
21/M right alveolar cleft, normal bone graft Radiographs taken on 3rd& 6th month A 6

10
13/F bilateral alveolus cleft, normal bone grafting done Radiographs taken on 3rd& 6thmonth C 6

41
 RESULTS:

A total of 20 patients were operated in our unit with details given as in master chart.

10 patients with Titanium Mesh used bone grafting technique. Master chart -1

10 patients with conventional bone grafting technique. Master chart - 2

Out of 10 patients operated with Titanium Mesh 4 cases were bilateral clefts operated.

One side it was grafted by normal bone grafting procedure and opposite side with

titanium mesh.

In Titanium Mesh used group, out of 4 bilateral alveolar defects 1 case was grafted

simultaneously in single operative procedure for both sides, right side with Titanium

Mesh and left side without Mesh. 3 other patients were treated with 6 months interval

between operative procedures.

In 1 patient Titanium Mesh was used over 20 mm alveolar cleft defect with 4 units

fixed partial denture over the cleft.

In all 10 patients with titanium Mesh used, there was no post operative complication

or infection near the operated site. In 3 patients it was seen that mesh was exposed at

superior part of mucogingival junction and attached gingival.

The amount of bone graft taken and post operative radiographic assessment is given

in result chart - 1.

In 10 patients of normal bone grafted technique showed a excellent graft acceptance.

In 1 patient premaxillary osteotomy was performed along with bilateral grafting. The

premaxilla was stabilized with wires and self cure acrylic material.

In all 10 patients, No postoperative complication or graft failure was noticed.

The amount of bone graft taken and post operative radiographic assessment is given

in result chart - 2

42
 RESULT CHART – 1

Titanium Mesh used group – alveolar bone graft scale- Results

SL NAME Age/ Cleft Category Values

No: sex
1 Anitha George 12/F Right side Cleft – A 6
Titanium Mesh

2 Jinan 8/M Left side Cleft - C 6

3 Shamil 7/M Left side Cleft -- A 6

Titanium Mesh

4 Marium farzina 7/ F Left side Cleft – A 6

5 Sujitha 22/F Left side Cleft – A 6

6 Bagya 7/F Left side Cleft - D 6

7 Mohammed Nabil 8/M Right side Cleft –A 6

Titanium Mesh

8 Shabana 7/F Left side Cleft - C 6

9 Zapeera 23/F Right side Cleft – D 4

10 Vidya 13/F Right side Cleft – A 6

Titanium Mesh

Total 58

Percentage 96.66%

43
 RESULT CHART – 2

Normal Bone Grafting Group: alveolar bone graft scale- Results

SL NAME Age/ Cleft Category Values

No: sex
1 Aishwarya 8/F Left side Cleft – A 6

2 Aswathy 7/F Right side Cleft - D 4

3 Akshay 7/M Left side Cleft – C 6

4 Ahath 7/M Left side Cleft – A 6

5 Basith 8/M Left side Cleft – A 6

6 Safath 7/F Left side Cleft – D 4

7 Mohammed Thaha 7/M Left side Cleft – A 6

8 Seema 13/F Right side Cleft - A 6

9 Rohith 21/F Right side Cleft - A 6

10 Deepthi 13/F Right side Cleft - C 6

Total 56

93.33%
percentage

44
Figure 8: Frontal picture of case – 1

Figure: 9 Sub nasal picture of case-1

45
 RADIOGRAPHS OF TITANIUM MESH USED

Figure10: Case 1- Pre Operative Radiograph

OCCLUSAL
IOPA

Figure 11: Case 1- Post Operative Radiograph

OCCLUSAL
IOPA

46
Figure12: Frontal picture of case – 2

Figure:13 Sub nasal picture of case-2

47
 RADIOGRAPHS OF TITANIUM MESH USED

Figure 14: Case 2- Pre Operative Radiograph

OCCLUSAL IOPA

Figure 15: Case 2- Post Operative radiograph

OCCLUSAL IOPA

48
Figure 16: Frontal picture of case – 3

Figure: 17 Sub nasal picture of case-3

49
RADIOGRAPHS OF TITANIUM MESH USED

Figure18: Case 3- Pre Operative Radiographs

Figure 19: Case 3- Post Operative Radiograph

50
Figure :20 Frontal picture of case – 4

Figure: 21 Sub nasal picture of case-4

51
RADIOGRAPHS OF CONVENTIONAL BONE GRAFTED TECHNIQUE

Figure 22: Case 4- Pre Operative Radiograph

Figure 23: Case 4- Post Operative Radiograph

52
Figure:24 Frontal picture of case –5

Figure: 25 Sub nasal picture of case-5

53
RADIOGRAPHS OF CONVENTIONAL BONE GRAFTED TECHNIQUE

Figure 26: Case 5- Pre Operative Radiograph

Figure 27: Case 5- Post Operative Radiograph

54
Figure 28: Frontal picture of case – 6

Figure: 29 Sub nasal picture of case-6

55
RADIOGRAPH OF CONVENTIONAL BONE GRAFTED TECHNIQUE

Figure 30: Case 6- Pre Operative Radiograph

Figure 31: Case 6- Post Operative Radiograph

56
 RESULTS

The radiographic assessment and scores of both Titanium mesh group & conventional

group was categorised accordingly to Chelsea scale.

Comparision of both groups were tabulated and stastically mentioned as given below

STATISTICAL ANALYSIS:

According to the results analyzed:-

TABLE III – Scores of the cleft according to Chelsea scale for titanium group and

conventional bone grafting group.

TABLE IV – age distribution according to Chi- Square – Test. Results showed that

there was no significance difference among the age groups who were operated for

cleft alveolus.

TABLE V – Indicates the sex distribution according to Chi – Square Test. The results

showed that there was no significant difference among both sex groups.

TABLE VI – Indicates the category distribution according to Chi – Square Test. The

results showed that there was no significant difference among both sex groups.

TABLE VII – Indicates the values of mesh and conventional grafting procedure

according to Mann – Whitney U Test. The results showed that there was no

significanct difference among the both bone grafted group.

TABLE VIII – Indicates the group statistics between Titanium Mesh and normal

bone grafting according to Mann –Whitney ‘U’ Test. The overall clinical out come

shows no significance difference among the both groups.

57
 TABLE III

Scores According to Chelsea scale

TITANIUM MESH CONVENTIONAL BONE GRAFT

GROUP GROUP

CATEGORY CATEGORY SCORE

SCORE
1 CATEGORY 48 1 CATEGORY A 36
A
2 CATAGORY 0 2 CATAGORY B 0
B
3 CATAGORY 6 3 CATAGORY C 12
C
4 CATAGORY 4 4 CATAGORY D 8
D
5 CATAGORY 0 5 CATAGORY E 0
E
6 CATAGORY 0 6 CATAGORY F 0
F

TOTAL 58 56

58
 STATASTICAL RESULTS

TABLE IV- AGE DISTRIBUTION

Std.
MESH N Mean Deviation Z
AGE TITANIUM MESH
10 11.4000 6.23966 .55800

CONVENTIONAL 10 9.8000 4.61399 P=.577 NS

P = 0.577 NS

TABLE V SEX DISTRIBUTION

MESH Total
TITANIUM
MESH CONVENTIONAL
SEX M Count 3 4 7
% 30.0% 40.0% 35.0%
F Count 7 6 13
% 70.0% 60.0% 65.0%
Total Count 10 10 20
% 100.0
100.0% 100.0%
%

a X2=0.22 P=0.639 NS

TABLE VI – CLEFT CATEGORY

MESH Total
TITANIUM
MESH CONVENTIONAL
CAT A Count 8 6 14
% 80.0% 60.0% 70.0%
C Count 1 2 3
% 10.0% 20.0% 15.0%
D Count 1 2 3
% 10.0% 20.0% 15.0%
Total Count 10 10 20
% 100.0
100.0% 100.0%
%

a X2=0.952 P=0.621 NS

59
 TABLE VII - VALUE OF MESH AND CONVENTIONAL GROUP

MESH Total
TITANIUM
MESH CONVENTIONAL
VALUE 4.00 Count 1 2 3
% 10.0% 20.0% 15.0%
6.00 Count 9 8 17
% 90.0% 80.0% 85.0%
Total Count 10 10 20
% 100.0
100.0% 100.0%
%

a X2=0.392 P=0.531 NS

TABLE VIII - Group Statistics

Std.
MESH N Mean Deviation Z
VALUE TITANIUM MESH
10 5.8000 .63246 .61000

CONVENTIONAL 10 5.6000 .84327 P=.542

NS

P = 0.542 NS

a X2= Chi – Square Test

P = Probability

N = Number of cases

NS = P > 0.05 = Not Significant

S =P < 0.05 = Significant

HS = P < 0.01 = Highly Significant

VHS = P < 0.001 = Very Highly Significant

60
Bar chart figure -1

Bar chart figure - 2

61
Bar chart figure - 3

CONVENTIONAL

Bar chart figure - 4

62
 DISCUSSION

Bone grafting procedures has become one of the essential treatment aspects for cleft

patients, its one of the challenging task for the surgeon to fulfil the needs of these

patients to get back their proper functional and aesthetic form. It requires lot of skills

and experience to treat such patients. This study was conducted to compare between

the Conventional bone graft and Titanium Mesh used bone grafting technique in 20

patients.

In a study conducted by Mario Roccuzzo et al(2004)25 showed that, excellent

biocompatibility of Titanium Mesh and the easy handling of the titanium micro- mesh

systems allowed their application for three – dimensional reconstruction of larger

bony defects. The apparent benefits of titanium mesh lies in its probable protective

effect during the healing time followed by bone grafting. The mesh gave the flap

sufficient retention to prevent dehiscence. They recommended the use of 0.2 mm

thickness mesh which represents the best compromise between the necessary stiffness

for flap support and graft protection. It gives an essential flexibility to reduce the risk

of mucosa perforation and soft tissue dehiscence. They also suggested that the vertical

ridge augmentation with Ti- Mesh and autogenous bone was predictable, even if

titanium mesh exposure occurs which does not go through major resorption. A second

surgery was done to the recipient site to remove mesh after 4- 6 months while placing

an implant. In our study we noticed that use of titanium mesh had an excellent usage

for wide alveolar cleft, its nature of easy handling and three dimensional contour of

bone was very useful in bone grafting procedure. It was seen that the use of 0.2 mm

thickness mesh helped in proper adaptability of flap and secured the grafted

63
cancellous bone particles preventing graft displacement. In our study it was noticed

that there were 3 cases with minimal exposure of titanium mesh, but yet the bone graft

take was quiet successful. In 2 bilateral cleft cases the mesh was removed after 6

months, while treating for the opposite cleft site. In 1 patient the mesh was removed

under local anaesthesia procedure. In our study the consideration for mesh removal

were younger age group between 7 – 14 years that is maxillary growth period, in case

of flap dehiscence, or implant exposure, and in case of implant interfering with

erupting tooth buds. So, the ideal time for implant removal in our study is 6 months

after postoperative period. In case of age group above 15 years the removal is

considered on above mentioned factors. In a study by Yoshiro Matsui,DDS, PHD, et

al(2006)4 reported that during bone grafting, the titanium mesh was trimmed and

shaped to obtain sufficient bone volume for implant placement with an adequate

occlusal relationship with the opposite jaw. In case of pre operated cleft lip, the

tension exerted by fibrous tissue and scars leads to pressure atrophy in the grafted

bone, which will be minimized by the titanium mesh. In our study we followed in the

same way that mesh was trimmed to proper shape and adapted anatomically over the

cleft area to contour the ridge form and countering forces. In our study we used

titanium mesh for all 10 cases which was more useful since the tension exerted by

scar tissue of the lip was avoided by use of titanium mesh especially in bilateral lip

cases and adult patients. Honma et al(1999)³³ reported that the wider the gap between

the teeth, the more alveolar bone loss occurs. In all cleft cases the stability acts as a

main key role in success of bone graft. So, in our study it was seen that the cleft

segments were more mobile especially in bilateral cases which lack bridging between

the premailla and distal segments. So, we had fixed the titanium mesh to distal ends of

clefts and to premaxilla which gave stability for the entire segment. In most of our

64
cleft cases the isolated palatal segments, that is greater segment and lesser segment

were varying in there levels and arch form, so, in such situations mesh acts as an

anchor for these segments to bridge and secure the graft material to desired shape and

contour of alveolus. In a study by Thomas Bayerlein et al(2006) 28 suggested that

alveolar bone graft provides a basis for shaping a closed dental arch with an intact

periodontium in the cleft area. Such procedures within the cleft area can be achieved

under optimal circumstances which provide the preconditions of creating optimal

functional and aesthetic results. Hence, they not only recover good functional results,

but also improve the symmetry of upper lip and nasal form. The alveolar bone

grafting is credited with great significance for rehabilitation of the cleft patient. As

mentioned above it was seen in our study that, both titanium group and conventional

group provided optimal functional and aesthetic results for both upper lip and nasal

floor. The bone availability was assessed using two-dimensional radiographs that

were OPG and dental X-ray films. The disadvantage was that they do not provide the

evidence of the volumetric changes in case of bony bridge as reported by Van der

Meij et al(1994)34. The three dimensional computed tomography despite being

superior in bone imaging was not used during routine diagnosis of cleft patients due to

higher radiation exposure and expense. In our study we used the dental X-ray,

Occlusal radiograph and OPG for pre- operative and post operative bone volume

assessment. Thomas Bayerlein et al(2006)28 suggested that the extent of interdental

height of alveolar ridge obtained with respect to dentition at the time of surgery does

not show significantly higher success rates. Hence, considering the range of variation

during early mixed dentition, that is between 6 and 10 years of age, than late mixed

dentition. Gundlach et al(1987)35 considered cancellous bone grafting in the cleft area

between 7 to 8 years as the most favourable age interval, because the alveolar ridge

65
has largely completed its final height by then and both maxillary development and

growth itself is hardly disturbed. Boyne and Sands(1972)36. Recommend that

secondary osteoplasty is carried out between 7 and 14 years of age in order to avoid

disturbed growth. As stated above considering the age for surgery in our study in most

of the cases were at age group of 7 to 14 years. It was considered that permanent

canine eruption time is the ideal time for bone grafting procedure. But, in our study

few patients visited at later age group for profile correction and orthognathic surgeries

so, we had to take up for bone grafting procedure prior or simultaneous along with

premaxillary osteotomies.

As mentioned by Ross E. Long JR et al(1995)37 the bone graft provides a viable tissue

for establishment of a morphologic and functional normal alveolar process. It’s an

inert bone structure, which also unites and stabilizes the maxillary segments. The

grafted site has the capacity to permit eruption of teeth, support normal tooth bearing

function, and undergo remodelling to allow orthodontic tooth movement. In our study

as mentioned above the bone grafting procedure helped in good functional and

structural changes, which established good alar base and nasal floor support. In our

study Patient treated prior to the eruption of canine teeth showed an excellent

remodelling and allowed post operative orthodontic tooth movement. It was reported

by Hinrichs et al (1984)38, Enemark et al (1987)8 Teja et al (1992)39 that there was

satisfactory Postoperative periodontal support for cleft associated teeth after

secondary alveolar grafting. In our study it was noticed that, most of the cleft teeth

had an excellent periodontal support after bone grafting. Post operative radiograph

showed a well formed peridontium, which was clearly noticed in all cleft associated

teeth.

66
In a study conducted by Bart Witsenburg et al(1993)¹¹ indicates that surgical

reconstruction of residual alveolo – palatal defects with autogenous bone grafts

usually leads to successful closure of oronasal communications in the cleft region. In

addition, good radiographic results of bone incorporation were observed. In our study

it was noticed that the greater success of bone graft resulted in a good clinical seal and

closure of oronasal communication. H. Witherow et al(2002)23 developed the Chelsea

scale to provide an accurate description of the position of bone in the cleft after bone

grafting. Inter and intraobserver reproducibility is satisfactory with values for 8- point

matrix indicating moderate to substantial agreement. In our study the description

position after bone grafting was categorized by the 8-point matrix scale as mentioned

above in the postoperative radiograph. Using Chelsea scale, in our study the two

groups, Titanium Mesh group and conventional bone grafting group were categories

into category A, B, C, D, E and F depending on the bony bridge in the cleft. All

patients Radiographs were placed into one of the six groups that reflect the position of

the bone related to the cleft teeth. It was found that in Titanium mesh group 80% of

clefts were rated category A, 10% category C, and 10% category D, were as B, E and

F were nil. In case of conventional bone grafted group 60% of clefts were rated as

category A, 20% category C and 20% and category D were as B, E, and F were nil.

When the results were analysed statistically and compared between both groups it was

seen that overall total of 70% of clefts in category A, 15 % category C, and 15%

category D. according to Chi – Square Test(a X2) The Titanium Mesh group had a

category a X2 = 0.952 , which gave a probability value P = 0.621 which was clinically

not significant. When the values were calculated for both Titanium Mesh and

conventional bone grafted group it showed a result of a X2 = 0.392 and probability of

67
0.531 which was not significant. The group statistics of over all results of both group

showed as, titanium mesh mean value of 5.800 and standard deviation of 0.63246,

where as conventional bone grafted group showed a mean value of 5.600 and standard

deviation of 0.84327. The probability of these above said group statistics were P=

0.542 which was clinically not significant. The above mentioned categories A and C

had a satisfactory radiological result as mentioned by Chelsea scale. According to

same scale the category D was consider as failure rate. As mentioned by the study

H. Witherow et al(2002)23 the Chelsea scale had an advantage to enable the bony in-

fill within the alveolar cleft to be measured in the mixed dentition before eruption of

canine. It can be also used in recording the position of the bony bridge, which helps in

determine the positions in conjunction of long term clinical trials. They have

mentioned in their study that, it’s theoretically possible to use the above scale for any

radiograph provided that the roots can be divided into four and X- ray directed

through the cleft line. In our study this scale was considered as relevant scale as most

of our patients were of mixed dentition and to be determined further in long term

studies, and the radiographic scale was appropriate to be used in cleft line. As

mentioned in there study regarding category B, that it was the group which had a

clinical implication for orthodontics and long term periodontal condition. They were

not quiet sure of its stability at the time of orthodontic application and deficient alar

base support. In our study the category B was not reported in any of the above

mentioned groups.

68
 Conclusion

The findings of this study indicate the following:

The positive outcomes of Alveolar bone grafting is formation of viable, functional

alveolar process bridging the maxillary cleft and eliminating oronasal fistula in

most of the cases.

In all cases it was seen that, the bone grafting procedure provides adequate bone

support to the teeth adjacent to the cleft site and well establishes bony bridge

across the cleft area. It also gives good skeletal support to the alar base on the cleft

side.

The bone grafting procedure when done at mixed dentition, helped in bone

formation, bridging the tooth in the cleft line, helped in good post operative

orthodontic application, aids in proper arch alignment and restoring better

occlusion.

The tooth which is in the line of clefts once restored into proper occlusal form

restores a satisfactory periodontal support.

The Titanium Mesh used in our study was best utilized for wider clefts. It helped

in securing the corticocancellous bone particle in cleft site and reduces the amount

of resorption. The nature of its biocompatibility, minimal thickness and easy

handling helps in proper contouring of the alveolus and three dimensional

reconstructions.

69
The success of bone grafting depends on the stability, hence in cleft cases

particularly where premaxillary segments was unstable the use of Titanium Mesh

helped in maintaining stability of the entire arch and secure the graft material in

proper place and form.

The titanium mesh helped in protecting the bone graft at the time of healing, it

also minimises the amount of pressure exerted by the scar tissue of previously

operated cleft lip and palate patients.

70
 SUMMARY

Alveolar Bone grafting procedure is an important step in managing cleft lip and

palate patients. It’s difficult to achieve grafting success in patients with improper

stability of premaxilla and wider cleft area. The use of Titanium mesh has given

advantage in overcoming such problems. Titanium mesh usage has given both

clinically and radiographically advantages in overcoming various factors.

Compared with conventional bone grafting procedure Titanium Mesh has slightly

better overall results. In addition to analyzed long term study and usage of

titanium mesh in cleft alveolus patients, longer duration and larger sample would

give a much more conclusive inference.

Thus the usage of Titanium mesh in alveolar bone grafting procedure, should be

considered ad important tool.

71
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77
 ANNEXURES
Appendix 1

Sl . No: OP.NO: Date:

1. Name :

2. Age / Sex :

3. Address :

4. Occupation :

5. Chief complaint :

6. History of present illness :

7. Past Medical Surgical & History:

8. Personal History :

9. Family History :

10. General Examination :

11. Extra oral Examination :

12. Intra oral Examination :

a) Hard Tissue Examination :

b) Soft Tissue Examination :

13. Routine Investigation :

14. Radiographic Assessment :

15. Diagnosis :

16. Treatment Plan :

17. Follow ups :

18. Post Operative Findings :

78
 Appendix II

Informed consent / Parent Consent Form

Name of the patient :

Hospital no :

Father/ husband’s name :

Age/ sex :

I here by authorize Dr________________ of A J Institute of Dental Science,

Manglore, to perform upon the following Surgical Operation

procedure_________________________________________ .

It has been explained to me that during the course of the operation/ procedure,

the necessity thereof, possible alternate options, risk involved, possibility of

complications and the prognosis has been explained to me in the language that I

understand.

Date: Signature of patient/ thumb impression

When patient is a minor or unable to affix signature due to mental or physical

disability.

Date: Signature of parents/ relative/ thumb impression

79
 CONSENT FOR PARTICIPATION IN RESEARCH

TITLE OF RESEARCH
“COMPARATIVE AND QUANTITATIVE STUDY OF TITANIUM

MESH REINFORCED ALVEOLAR BONE GRAFT WITH

STANDARD BONE GRAFTING TECHNIQUE ON CLEFT
PATIENTS”

INVESTIGATORS:

Dr Venugopal S S

Post Graduate Resident,

Department of Oral & Maxillofacial surgery

A.J Institute of Dental Sciences.

INTRODUCTION

I, Dr Venugopal S S will be doing my dissertation to assess the clinical and

radiological changes after alveolar bone grafting procedure in cleft patients. The

objective of my study is to determine the clinical and radiological outcomes after

alveolar bone graft using Titanium Mesh, with the age group of 7 years to 25 years.

Assessment will be done radiographically and.

PRIVACY AND CONFIDENTIALITY

80