Enxerto autógeno de crista ilíaca na reconstrução do processo alveolar em portadores de fissura labiopalatina: estudo de 30 casos

Carlini, João Luiz; Zétola, André Luís; Souza, Ricardo Pires de; Denardin, Odilon Victor Porto; Rapoport, Abrão

doi:10.1590/S0100-69912000000600006

Resumos

A reconstrução do processo alveolar em pacientes portadores de fissuras labiopalatais (FLP) é fundamental para erupção de dentes permanentes e para o restabelecimento estético através de implantes osteointegrados. Assim, considerado o alto grau de reabsorção do enxerto de osso autógeno puro e triturado, optou-se no Centro de Atendimento Integral ao Fissurado Labiopalatino, Curitiba, Paraná (1997 a 1999), pelo estabelecimento de dois grupos de 15 pacientes. No primeiro, foi utilizada crista ilíaca triturada e no outro combinada com hidroxiapatita biorreabsorvível. Ao fim de seis meses, os resultados cirúrgicos foram avaliados através de radiografia periapical digital, determinando quatro linhas limites para a reconstrução óssea. A primeira linha foi traçada na região cervical do dente adjacente à fissura que apresentava menor distorção. As outras linhas foram traçadas paralelamente à linha 1, distando 3mm entre cada uma delas. O espaço entre as linhas 1 e 2 foi denominado de A, entre 2 e 3 de B e 3 e 4 de C. Para critérios de avaliação, quando o enxerto permaneceu no espaço A, foi considerado de sucesso, em contraposição aos espaços B e C, quando foram denominados de procedimentos malsucedidos. Como resultados finais, o espaço A foi constatado em 46,7% dos pacientes submetidos ao procedimento controle com crista ilíaca e 80% para o grupo experimental, quando o enxerto ósseo foi empregado conjuntamente com o material aloplástico (hidroxiapatita).

Enxerto; Osso; Autógeno

The reconstruction of alveolar process in cleft lip palate patients is mandatory to enable the eruption and movement of permanent teeth through the clefted area by orthodontic procedure, beside the establisment of aesthetics with prostetic procedure by osteointegrated implants. Considering that autogenous bone grafts provide a high reabsortion level determining a reduction of orthodontic movement or making impossible to place implants, to minimize this problem, we developed a protocol by which the bone (anterior iliac crest) is mixed with alloplastic material (hydroxyapatite) to keep the bone matrix framework, reducing the absotion degree at the clefted area. We selected 30 patients at the Centro de Atendimento Integral ao Fissurado Lábio-Palatino (Center of Integral Care of Cleft Lip and Palate Patients), in Curitiba, Paraná (from 1997 to 1999). The patients were divided in two groups: at the first one, we utilized grated autogenous iliac crest and in the last one, the same bone combined with bio-reabsorbable hydroxyapatite. After 6 months, we compared for both procedures, the results through digital periapical X ray, concerning the height of the alveolar bone of the adjacent teeth, and 4 limiting lines for bone reconstruction as follow: line 1 was drawn at the cervical region of the adjacent tooth to the less distorted cleft and lines 2,3 and 4, parallel to line 1, being 3mm apart from each other. It was successfull considered the grafts whose greatest concavity was between lines 1 and 2 (space A) and for grafts between lines 2 and 3 (space B) or 3 and 4 (space C), surgical failure. The control group (grated bone) had 46,7% of the patients in space A while the study group (bone plus alloplastic material) 80% of patients in this space, being the determining factor of sucess the patient age.

Bone; Graft; Autogenous

ARTIGO ORIGINAL

Enxerto autógeno de crista ilíaca na reconstrução do processo alveolar em portadores de fissura labiopalatina - estudo de 30 casos

Iliac crest autogenous graft in reconstruction of alveolar process in cleft patients - study of 30 cases

João Luiz Carlini^I; André Luís Zétola^II; Ricardo Pires de Souza^I; Odilon Victor Porto Denardin^III; Abrão Rapoport, TCBC-SP^IV

^IMestres em Cirurgia de Cabeça e Pescoço do Hospital Heliópolis, Hosphel, SP

^IIMestrando em Cirurgia de Cabeça e Pescoço do Hospital Heliópolis, Hosphel, SP

^IIIDoutor em Medicina pela UNIFESP

^IVCoordenador do CPG, Hosphel, SP

^{Endereço para correspondência} Endereço para correspondência: Prof. Dr. Abrão Rapoport Pça. Amadeu Amaral, 47 cj. 82 - Paraíso 01327-010 São Paulo SP E-mail: cpgcp.hosphel@attglobal.net

RESUMO

A reconstrução do processo alveolar em pacientes portadores de fissuras labiopalatais (FLP) é fundamental para erupção de dentes permanentes e para o restabelecimento estético através de implantes osteointegrados. Assim, considerado o alto grau de reabsorção do enxerto de osso autógeno puro e triturado, optou-se no Centro de Atendimento Integral ao Fissurado Labiopalatino, Curitiba, Paraná (1997 a 1999), pelo estabelecimento de dois grupos de 15 pacientes. No primeiro, foi utilizada crista ilíaca triturada e no outro combinada com hidroxiapatita biorreabsorvível. Ao fim de seis meses, os resultados cirúrgicos foram avaliados através de radiografia periapical digital, determinando quatro linhas limites para a reconstrução óssea. A primeira linha foi traçada na região cervical do dente adjacente à fissura que apresentava menor distorção. As outras linhas foram traçadas paralelamente à linha 1, distando 3mm entre cada uma delas. O espaço entre as linhas 1 e 2 foi denominado de A, entre 2 e 3 de B e 3 e 4 de C. Para critérios de avaliação, quando o enxerto permaneceu no espaço A, foi considerado de sucesso, em contraposição aos espaços B e C, quando foram denominados de procedimentos malsucedidos. Como resultados finais, o espaço A foi constatado em 46,7% dos pacientes submetidos ao procedimento controle com crista ilíaca e 80% para o grupo experimental, quando o enxerto ósseo foi empregado conjuntamente com o material aloplástico (hidroxiapatita).

Descritores: Enxerto; Osso; Autógeno.

ABSTRACT

The reconstruction of alveolar process in cleft lip palate patients is mandatory to enable the eruption and movement of permanent teeth through the clefted area by orthodontic procedure, beside the establisment of aesthetics with prostetic procedure by osteointegrated implants. Considering that autogenous bone grafts provide a high reabsortion level determining a reduction of orthodontic movement or making impossible to place implants, to minimize this problem, we developed a protocol by which the bone (anterior iliac crest) is mixed with alloplastic material (hydroxyapatite) to keep the bone matrix framework, reducing the absotion degree at the clefted area. We selected 30 patients at the Centro de Atendimento Integral ao Fissurado Lábio-Palatino (Center of Integral Care of Cleft Lip and Palate Patients), in Curitiba, Paraná (from 1997 to 1999). The patients were divided in two groups: at the first one, we utilized grated autogenous iliac crest and in the last one, the same bone combined with bio-reabsorbable hydroxyapatite. After 6 months, we compared for both procedures, the results through digital periapical X ray, concerning the height of the alveolar bone of the adjacent teeth, and 4 limiting lines for bone reconstruction as follow: line 1 was drawn at the cervical region of the adjacent tooth to the less distorted cleft and lines 2,3 and 4, parallel to line 1, being 3mm apart from each other. It was successfull considered the grafts whose greatest concavity was between lines 1 and 2 (space A) and for grafts between lines 2 and 3 (space B) or 3 and 4 (space C), surgical failure. The control group (grated bone) had 46,7% of the patients in space A while the study group (bone plus alloplastic material) 80% of patients in this space, being the determining factor of sucess the patient age.

Key words: Bone; Graft; Autogenous

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido em 21/2/2000

Aceito para publicação em 5/9/2000

Trabalho realizado no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Heliópolis Hosphel São Paulo-SP.

1. Ellis III, E.. Management of patients with orofacial clefts. In: Contemporary Oral and Maxillofacial Surgery Peterson, L..J.; Ellis III,E.; Hupp,J.R. et al.. 2° ed. St.Louis: Mosby Year Book, Inc.,1988, p.657-681.
2. Sicher, H. & Tandler, J. Anatomia para Dentistas Ed. Atheneu, Săo Paulo,1981, p.283-309.
3. Spina,V. A proposed modification for the classification of cleft lip and palate. Cleft Palate J , 1973, 10:2512-2516.
4. Witsenburg, B. The Reconstruction of Anterior Residual Bone Defects in patients with Cleft Lip, Alveolus and Palate. J. Max-Fac. Surg, 1985, 13:197-208.
5. Boyne, P. J. & Sands, N.R. Secondary bone grafting of residual alveolar and palated clefts. J. Oral Surg, 1972, 30:87-92.
6. Boyne, P.J. Osseous Reconstruction of the Maxilla and the Mandible Surgical Techniques Using Titanium Mesh and Bone Mineral. Editora Quintessence books, 1997, cap. 1 e 2, p. 3-15.
7. Shafer, D. M. Secondary Bone Grafting for Unilateral Alveolar Clefts: A Review of Surgical Techniques. Oral Max Surg N Amer, 1995, 1:29-42.
8. Enemark, H.; Pedersen-Sindet, S. ; Bundgaard, M. Long-Term Results after Secondary Bone Grafting of Alveolar Clefts. J.Oral Maxillofac.Surg., 1987, 45:913-918.
9. Paulin,G. ; Astrand, P. ; Rosenquist et al. Intermediate Bone Grafting of Alveolar Clefts. J. Cranio-Max.- Fac. Surg., 1988, 16:2-7.
10. Kortebein,M. J.; Nelson , C. L. ; Sadove, M. A. . Retrospective Analysis of 135 Secondary Alveolar Cleft Grafts Using Iliac or Calvarial Bone. J. Oral Maxillofac. Surg., 1991, 49:493-498.
11. Amanat,N. & Langdon, J. D. Secondary Alveolar Bone Grafting in Clefts of the Lip and Palate. J. Cranio-Max.Fac.Surg, 1991, 19:7-14.
12. Schultz,R. C. . Free Periosteal Graft Repair of Maxillary Clefts in Adolescents. Plastic and Reconstructive Surgery, 1984, 73:556-563.
13. Takahashi,T.; Fukuda,M. ; Yamaguchi,T. et al.. Use of Endosseous Implants for Dental Reconstruction of Patients with Grafted Alveolar Clefts. J. Oral Maxillofac. Surg, 1997, 55:576-583.
14. Koole,R.; Bosker,H ; Van Der Dussen, N. Late Secondary Autogenous Bone Grafting in Cleft Patients Comparing Mandibular (Ectomesenchymal) and Iliac Crest (Mesenchymal) Grafts. J. Cranio-Max-Surg., 1989, 17:28-30.
15. Turvey,T. A. ; VIG, K. ; Moriarty et al.. Delayed bone Grafting in the Cleft Maxilla and Palate: A Retrospective Multidisciplinary Analysis. Am.J. Orthod, 1984, 86:244-256.
16. Pedersen-Sindet, S. & Enemark, H. Mandibular Bone Grafts for Reconstruction of Alveolar Clefts. J. Oral Maxillofac. Surg, 1988, 46:533-537.
17. Akesson,L..; Hakansson,J ; Rohlin,MA.. Comparison of Panoramic and Intraoral Radiography and pocket probing for the measurement of the marginal bone level. J. Clin. Periodontal , 1992, 19:326-332.
18. Van Der Meij, A. J.; Baart, B.P.; Valk,J.; et al.. Computed Tomography in Evaluation of Early Secondary Bone Grafting. Int. J. Oral Maxillofac. Surg., 1994, 23:132-136.
19. Lee,C.; Crepeau,R. J.; Williams, H.B. et al.. Alveolar Cleft Bone Grafts: Results and Imprecisions of the Dental Radiograph. Plast and Reconst Surg, 1995, 96:1534-1538.

Endereço para correspondência:

Prof. Dr. Abrão Rapoport

Pça. Amadeu Amaral, 47 cj. 82 - Paraíso

01327-010 São Paulo SP

E-mail:

cpgcp.hosphel@attglobal.net

Datas de Publicação

Publicação nesta coleção
18 Dez 2008
Data do Fascículo
Dez 2000

Histórico

Aceito
05 Set 2000
Recebido
21 Fev 2000

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Ellis III, E.. Management of patients with orofacial clefts. In: Contemporary Oral and Maxillofacial Surgery Peterson, L..J.; Ellis III,E.; Hupp,J.R. et al.. 2° ed. St.Louis: Mosby Year Book, Inc.,1988, p.657-681.

[2] 2. Sicher, H. & Tandler, J. Anatomia para Dentistas Ed. Atheneu, Săo Paulo,1981, p.283-309.

[3] 3. Spina,V. A proposed modification for the classification of cleft lip and palate. Cleft Palate J , 1973, 10:2512-2516.

[4] 4. Witsenburg, B. The Reconstruction of Anterior Residual Bone Defects in patients with Cleft Lip, Alveolus and Palate. J. Max-Fac. Surg, 1985, 13:197-208.

[5] 5. Boyne, P. J. & Sands, N.R. Secondary bone grafting of residual alveolar and palated clefts. J. Oral Surg, 1972, 30:87-92.

[6] 6. Boyne, P.J. Osseous Reconstruction of the Maxilla and the Mandible Surgical Techniques Using Titanium Mesh and Bone Mineral. Editora Quintessence books, 1997, cap. 1 e 2, p. 3-15.

[7] 7. Shafer, D. M. Secondary Bone Grafting for Unilateral Alveolar Clefts: A Review of Surgical Techniques. Oral Max Surg N Amer, 1995, 1:29-42.

[8] 8. Enemark, H.; Pedersen-Sindet, S. ; Bundgaard, M. Long-Term Results after Secondary Bone Grafting of Alveolar Clefts. J.Oral Maxillofac.Surg., 1987, 45:913-918.

[9] 9. Paulin,G. ; Astrand, P. ; Rosenquist et al. Intermediate Bone Grafting of Alveolar Clefts. J. Cranio-Max.- Fac. Surg., 1988, 16:2-7.

[10] 10. Kortebein,M. J.; Nelson , C. L. ; Sadove, M. A. . Retrospective Analysis of 135 Secondary Alveolar Cleft Grafts Using Iliac or Calvarial Bone. J. Oral Maxillofac. Surg., 1991, 49:493-498.

[11] 11. Amanat,N. & Langdon, J. D. Secondary Alveolar Bone Grafting in Clefts of the Lip and Palate. J. Cranio-Max.Fac.Surg, 1991, 19:7-14.

[12] 12. Schultz,R. C. . Free Periosteal Graft Repair of Maxillary Clefts in Adolescents. Plastic and Reconstructive Surgery, 1984, 73:556-563.

[13] 13. Takahashi,T.; Fukuda,M. ; Yamaguchi,T. et al.. Use of Endosseous Implants for Dental Reconstruction of Patients with Grafted Alveolar Clefts. J. Oral Maxillofac. Surg, 1997, 55:576-583.

[14] 14. Koole,R.; Bosker,H ; Van Der Dussen, N. Late Secondary Autogenous Bone Grafting in Cleft Patients Comparing Mandibular (Ectomesenchymal) and Iliac Crest (Mesenchymal) Grafts. J. Cranio-Max-Surg., 1989, 17:28-30.

[15] 15. Turvey,T. A. ; VIG, K. ; Moriarty et al.. Delayed bone Grafting in the Cleft Maxilla and Palate: A Retrospective Multidisciplinary Analysis. Am.J. Orthod, 1984, 86:244-256.

[16] 16. Pedersen-Sindet, S. & Enemark, H. Mandibular Bone Grafts for Reconstruction of Alveolar Clefts. J. Oral Maxillofac. Surg, 1988, 46:533-537.

[17] 17. Akesson,L..; Hakansson,J ; Rohlin,MA.. Comparison of Panoramic and Intraoral Radiography and pocket probing for the measurement of the marginal bone level. J. Clin. Periodontal , 1992, 19:326-332.

[18] 18. Van Der Meij, A. J.; Baart, B.P.; Valk,J.; et al.. Computed Tomography in Evaluation of Early Secondary Bone Grafting. Int. J. Oral Maxillofac. Surg., 1994, 23:132-136.

[19] 19. Lee,C.; Crepeau,R. J.; Williams, H.B. et al.. Alveolar Cleft Bone Grafts: Results and Imprecisions of the Dental Radiograph. Plast and Reconst Surg, 1995, 96:1534-1538.

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