Protocol and Evaluation of 3D-Planned Microsurgical and Dental Implant Reconstruction of Maxillary Cleft Critical Size Defects in Adolescents and Young Adults.

Krzysztof Dowgierd,Maciej Borowiec,Martyna Dowgierd,Łukasz Krakowczyk,Rafał Pokrowiecki,Zuzanna Sokolowska,Jan Wos,Marcin Kozakiewicz

doi:10.3390/jcm10112267

Abstract

Functional and esthetic final reconstruction of the cleft maxilla is still challenging. Current reconstructive and augmentation techniques do not provide sufficient bone and soft tissue support for the predictable rehabilitation with dental implants due to presence of maxillary bone critical size defects and soft tissue deficiency, scaring and poor vascularity. In this article the protocol for the use of 3D virtual surgical planning and microvascular tissue transfers for the reconstruction and rehabilitation of cleft maxilla is presented. Twenty-five patients (8 male/17 female) aged 14–41 years old with cleft-associated critical size defects were treated by 3D-virtual planned microvascular tissue transfers taken either from fibula, iliac crest, radial forearm, or medial femoral condyle. Follow-up lasted 1–5 years. No significant bone resorption (p > 0.005) nor volume loss of the graft was observed (p = 0.645). Patients received final permanent prosthetic reconstruction of the anterior maxilla based on 2–5 dental implants, depending on the defect severity. This is the first study presenting the use of virtual planning in the final restoration of the cleft maxilla with microvascular tissue transfers and dental implants. Presented protocol provide highly functional and aesthetic results.

Highlights

Reconstructive treatment of the cleft maxilla is even more complicated, and the outcomes are frequently unsatisfactory. This is due to secondary deformations, malocclusion, bone loss induced by improper orthodontic treatment based on teeth and maxilla expansion leading to the formation of critical size defects and oro-nasal fistulas that cannot be reconstructed by simple grafting or augmentation procedures
fibula free flap (FFF) is helpful in the reconstructions where subsequent Le-Fort 1 type maxillary osteotomy (LF-1) osteotomy, distraction, or orthognatic surgery is planned, as this graft serves as interposition, stabilizing element
Microvascular tissue transfers do not exhibit significant bone resorption what distinguishes them among contemporary reconstructive and bone augmentation procedures

Summary

Introduction

Cleft lip and palate (CLP) is a birth defect that disturbs the continuity of the upper lip, gingiva, alveolus, and palate tissues. The aim of primary palatoplasty and cleft lip reconstruction, which are performed in the early months/years of the child’s life, is to restore proper function to these orofacial structures, critical for food intake, breathing and speech development. The major objectives of the primary closure of the cleft are to provide anatomical closure of the defect, to create an apparatus for the development of normal speech and to minimize maxillary growth disturbances and dento-alveolar deformities [1]. Regardless of the operative technique and positive outcomes, primary surgery always results in the development of tissue scarring and subsequent deformation of the lip and alveolus, which are enhanced by the child’s growth

Results

Discussion

Conclusion