|Year : 2018 | Volume
| Issue : 2 | Page : 76-81
Evaluation of simultaneous secondary cheilorhinoplasty and alveolar bone grafting
Mohamed A. M. Hussein, Rafic R Beder, Abdelfattah A Sadakah
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta, Egypt
|Date of Submission||03-Jul-2017|
|Date of Acceptance||10-Jan-2018|
|Date of Web Publication||25-Jun-2018|
Mohamed A. M. Hussein
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta
Source of Support: None, Conflict of Interest: None
Correction of cleft lip nasal deformity is very challenging for any surgeon especially when complicated with hypoplastic maxilla and open alveolar defect. Secondary cheilorhinoplasty and alveolar grafting are essential parts in correction of such deformity. The aim of this study was to assess both clinically and radiologically the outcome of simultaneous cheilorhinoplasty and alveolar cleft grafting in unilateral CLND cases.
Patients and method
8 patients aged between 14 and 25 years were selected randomly for correction of unilateral CLND and alveolar bone grafting with autogenous bone graft simultaneously. Patients were assessed preoperatively and postoperatively both clinically regarding nasal function using NOSE scale, photographic evaluation of lip and nose esthetics, and radiologically regarding alveolar cleft graft density. Data were statistically analysed.
The results of this study showed statistically significant difference between pre and postoperative records regarding nasal obstruction, nasal and lip aesthetics and symmetry, and success of alveolar cleft grafting except one case revealed alveolar graft loss and recurrence of oronasal fistula.
Secondary cheilorhinoplasty can be done successfully in the same time with late secondary alveolar bone grafting to avoid several surgical distresses for the patient, to improve facial aesthetic and function in one surgical step, and to reduce risk of psychological consequences. Alveolar bone grafting is an important part for augmentation of alar base. Autogenous bone graft provides good grafting material for repair of alveolar cleft and augmentation of alar base. Standardised photographs can be used for evaluation of aesthetics of the lip and nose. 3d CT scan is a valuable instrument in assessment and follow up of alveolar cleft grafting procedures.
Keywords: Alveolar bone grafting, cheilorhinoplasty, cleft lip nose
|How to cite this article:|
Hussein MA, Beder RR, Sadakah AA. Evaluation of simultaneous secondary cheilorhinoplasty and alveolar bone grafting. Tanta Dent J 2018;15:76-81
|How to cite this URL:|
Hussein MA, Beder RR, Sadakah AA. Evaluation of simultaneous secondary cheilorhinoplasty and alveolar bone grafting. Tanta Dent J [serial online] 2018 [cited 2018 Oct 19];15:76-81. Available from: http://www.tmj.eg.net/text.asp?2018/15/2/76/235134
| Introduction|| |
Clefts of the upper lip and palate are the most common major congenital craniofacial abnormality and are present in approximately one in 700 live births . There are many problems in facial functions and esthetics due to a lack in the continuity of the dental arch, upper lip with nose deformity . If the alveolar cleft is not treated adequately, it can cause many problems. Maxillary anterior teeth can be malposed, malformed or missed. Oronasal fistulas can remain .
The primary goal of alveolar cleft repair is to establish bony continuity of the maxillary alveolar ridge, provide bone support for the teeth adjacent to the cleft, improves the tooth-bearing function of the alveolus, so that spontaneous eruption or active movement of teeth can be induced and seal the communication between the nose and oral cavity, provide alar base support, and improve nasal symmetry ,,.
Unilateral cleft lip-nose deformity includes deviated columella, depressed nasal tip, wide and snub nasal ala, and a flat and V-shaped nostril on the cleft side . The distal, downward, and backward dislocation of the skeletal framework of the cleft lip-nose deformity causes all components of the lip and nasal tissue to be malpositioned three-dimensionally on the affected side .
The basic objectives of nasal surgery are to restore the symmetry of the maxillary support, alar cartilages and septum, to produce a cosmetically acceptable nasal tip, to obtain an optimum functional unit as an airway and humidifying organ and to obtain a satisfactory relationship between the lip and nose ,.
A definitive nasal correction is usually planned after completion of the nasal growth, typically after the age of 14–15 years . The majority of the centers use secondary alveolar bone grafting in the mixed dentition phase between the ages of 7 and 11 years, after maxillary expansion before secondary rhinoplasty ,.
Many of adolescents with unilateral cleft lip-nose deformity – in need for cheilorhinoplasty – presented with nongrafted or inadequately grafted alveolar cleft, so the open alveolar gap and the ipsilateral hypoplastic maxilla are two major problems in achieving consistently good results in a cleft lip nasal deformity . In addition, these patients might have undergone several previous operations leading to significant scarring making further correction difficult .
Mokal and Prabhash  found that simultaneous alveolar bone grafting can be safely and effectively combined with secondary unilateral cleft lip rhinoplasty. This along with a bone graft along the pyriform margin improves symmetry and provides an esthetically pleasing nose without any additional morbidity saving the patients from exposure to several operations and hazards of general anesthesia on the patients' health.
The aim of the present study was to evaluate the simultaneous cheilorhinoplasty with open technique and alveolar cleft grafting in adolescent and adults regarding both esthetic and functional outcome.
| Patients and Methods|| |
Eight patients aged between 14 and 25 years old, six female and two male patients, with unilateral cleft lip-nose deformity combined with nonrepaired or inadequately repaired alveolar cleft were included in this study. They were managed at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University.
- Functional evaluation for the nose was done by Nasal Obstruction Symptom Evaluation scale ,
- Esthetic evaluation of the nose and lip was done by standardized photographic method according to the standards of the European Association for Cranio-Maxillofacial Surgery  of the following views:
- Frontal view: Regarding the alar inclination angle (AIA): The tangential points between the nose wing and the vertical line on each side were connected. The angle formed by the connecting line and the horizontal line was termed the AIA  [Figure 1]a and upper lip proportions; three distance items (L1, L2, and L3) for the upper lip heightL1 is the distance from the crista philtri (chp) point to the subnasal (sn) subalar (sbal) line perpendicular to the cheilion (ch-ch) line
L2 is the distance from the sbal point to the labiale superius' (ls') point. L3 is the distance from the alar curvature (ac) point to the vermilion border perpendicular to the ch-ch line  [Figure 1]b. The proportion index referred to the ratio of the cleft side to the noncleft side for L1'/L1, L2'/L2, and L3'/L3. The preoperative proportion indices were compared with the postoperative indices
- Lateral view: For the nasolabial angle [Figure 1]c
- Submental views: For the asymmetry of the ala-tip angle (angle formed between a tangent drawn to the ala and the mid-nasal tip line) and alar base distance (distance from right ala to mid-columella) , [Figure 1]d.
|Figure 1: (a) The black angle between Nwa-Nw and horizontal plane represents the AIA. (b) upper lip proportions L1,L2,L3 on cleft side and L1 æ,L2æ,L3æ on normal side sn= Subnasale , sbal= Subalar, ac= Alar curvature point , Ls= Labiale superius Ls'= Labiale superius', cph = Crista philtri landmark , ch= Cheilion. (c) lateral view: nasolabial angle NLA. (d) submental view: The ala-tip angle represented by α in the normal side and β in the cleft side, The distance from the mid columella to the bucco-alar groove represented by A in the normal side and B in the cleft side.|
Click here to view
Clinical inspection was done for evaluation of alveolar cleft, presence of any associated abnormalities, lip support on the cleft side. The condition of the oral soft tissue in the cleft area (inflammation, scar tissue) missing teeth or retained teeth in cleft side . Probing with periodontal probe was used for evaluation of the presence or absence of oronasal communication both labially and palatally and its location.
Finally, radiological examination including: lateral cephalometric radiograph for the evaluation of esthetics in the sagittal plane preoperatively and 6 months postoperatively  and three-dimensional computed tomographic scan to assess and follow the outcomes of alveolar bone grafting .
Approval for this study was obtained from Faculty of Dentistry, Tanta University Research Ethics Committee (REC). The purpose of the present study was explained to the patients and informed consents were obtained according to the guidelines on human research published by the Research Ethics Committee at Faculty of Dentistry, Tanta University.
The surgical procedure was started with turn over flap for the alveolar cleft repair. Incisions were made along the alveolar cleft margins. The nostril floor is repaired using nasal mucoperiosteal lining along the pyriform margin. Palatal gingivoperiosteal layers are sutured together to complete the oral lining. Autogenous corticocancellous bone graft was harvested from the chin or the anterior iliac crest. The autogenous bone graft was packed in the alveolar bony defect and another part of graft is added and fixed with miniscrew along the pyriform margin for supporting of the depressed paranasal valley [Figure 2].
|Figure 2: (a) Reflection of mucoperiosteal flap, turn over flap along the cleft margins then closure of the nasal layer. (b) placement of the bone graft in the defect and fixation of the graft with screw to support the alar base. (c) open rhinoplasty incision and exposure of the nasal septum, correction of septal deviation, harvesting septal cartilage graft, z-plasty incision at the left alar base and upper lip and dissection of the different layers of the lip and nose. (d) septal cartilage graft 15 mm × 20 mm. (e) part of septal cartilage graft used as a collumellar strut. (f) suturing of the skin.|
Click here to view
Open rhinoplasty was applied according to the bilateral reverse-U incision and transcolumellar incision . When the base of the nasal septum is severely deviated, the inferior edge of the septal cartilage was excised to allow repositioning to the midline, correction of nasal obstruction and using autogenous cartilage graft measuring about 15 mm × 20 mm for augmentation of the affected ala, lengthening the shortened columella as part of this cartilage was used as a columellar strut and elevation of the dropped nasal tip. The septal cartilage graft was anchored to its new position using a 4-0 polypropylene thread. While suturing the columellar strut, the cartilage graft was fixed in the proposed new position using needle tip of syringes. The malposed lower lateral alar cartilage was exposed from the nasal skin and the distal ends of the lateral crura were freed from the surrounding tissue. The medial crus of the lower lateral cartilage on the affected side was repositioned and fixed symmetrically to the columellar strut using a 6-0 nylon thread. Additional interdomal stitches were passed between the two alar cartilages and the cartilage graft to produce appropriate tip projection. Asymmetry of nostril size corrected by medial Y–V advancement of the alar base if indicated either alone or along with an alar cinch stitch on cleft side to narrow the nostril  [Figure 2].
A full-thickness revision of the lip was performed where all three layers (skin, muscle, and mucosa) were cleanly dissected and meticulously repaired . The medial and distal bundles of orbicularis oris muscle were dissected and connected in an overlapping manner using a mattress suture. At the end of surgery, subcutaneous suturing using Vicryl 4/0 and cutaneous suturing using Prolene 5/0 were carefully performed. Notching or mismatch at the vermillion–cutaneous junction was corrected by realignment or a Z-plasty procedure. A poorly defined tubercle was corrected by V–Y advancement . The open rhinoplasty incisions were then closed all along using a 5/0 polypropylene suture. Intranasal packing was done using paraffin gauze and rubber stent. Sterile paper tapes were applied over the dorsum to facilitate the redraping of the skin envelope to the cartilaginous framework for 1 week postoperatively [Figure 2].
The postoperative care and instructions
Cold compresses were advised during the first postoperative 24 h to reduce postoperative edema and prescription of broad spectrum antibiotic, steroidal anti-inflammatory, analgesic, and nasal decongestant drops. Patients were instructed to avoid positive or negative pressure inside nasal cavity (such as oral or nasal blowing) and to maintain good oral hygiene with mouth wash and teeth brushing. Patients came for removal of the skin sutures after 7 days of surgery but leaving the nasal stent in place for 2 weeks after surgery.
Statistical analysis was done using SPSS program (released 2008, SPSS Statistics for Windows, version 22.0; SPSS Inc., Chicago, Illinois, USA) Data was collected and tabulated and P value was calculated.
| Results|| |
Independent t-test indicated statistical significant difference between the postoperative and preoperative records of the Nasal Obstruction Symptom Evaluation scale (P = 0.001), Alar inclination angle (P = 0.001) and upper lip proportion indices L1/L1'–L2/L2' (P = 0.023 and 0.037, respectively) indicating improvement of the nasal function, esthetic of the frontal view of the nose and lip of the patients, whereas there was no significant difference in L3/L3' proportion index of the upper lip (P = 0.118) [Table 1] and [Table 2], [Figure 3] and [Figure 4].
|Figure 3: Preoperative views (a) frontal view shows unequal lip line, depressed and deviated ala on left side. (b) lateral view shows depressed nasal tip. (c) submental view shows asymmetry of alar base width. (d) intraoral view shows oronasal fistula on labial side.|
Click here to view
|Figure 4: Postoperative views (a) frontal view shows elongation of lip and medialization of left ala. (b) lateral view shows improved nasolabial angle. (c) submental view shows improved symmetry of alar base. (d) intraoral view shows closure of oronasal fistula.|
Click here to view
In addition, χ2-test indicated statistical significant differences between postoperative and preoperative records of photographic nasolabial angle, cephalometric nasolabial angle, ala-tip angle, and alar base distance asymmetry as shown in [Table 2].
Computed tomographic scan was used to assess the integration and density of bone of alveolar cleft site before and after grafting. The density of bone significantly increased from 102.63 HU preoperatively to 480.88 HU with statistically significant difference using t-test (P < 0.001) indicating good graft take and new bone formation. Only one case failed to form new bone in the alveolar cleft site (recipient) with failure rate of 12.5% in our study.
| Discussion|| |
The advantage of this study is to improve the facial esthetic and function in one surgical step. This was agreed with Nakamura  who stated that definitive nasal correction for cleft lip-nose deformity requires reconstruction of the supporting alveolar bone and pyriform margin. In contrast, Ahuja  concluded that all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that esthetically good results are achievable even if no primary nasal correction had been previously attempted.
One of the advantages of this study is to avoid several stresses of multiple surgeries and to reduce their psychological impact on the patients as they suffer from multiple surgical operations since childhood and along their lifetime. This was agreed with Scopelliti et al. , who studied simultaneous correction techniques for secondary cleft deformities and found that, simultaneous correction of the deformities is indicated as to avoid several surgical distresses for the patient and to reduce risk of psychological consequences.
This was ascertained by research done by Turner et al. , who studied the psychological outcomes among cleft patients and their families. He found that the parents may ignore unnecessary or unwanted surgeries (from their point of view) as they were exhausted and tried multiple surgeries for correction.
The study disagreed with Bardach and Salyer  who preferred to augment the maxilla at a separate stage, 1 year before performing a definitive rhinoplasty. They only recommended that moderate septal work be carried out simultaneously with alar corrections but that severe septal deviations be corrected in a separate stage before alar cartilage positioning.
According to our study the nasal obstruction of patients included in this study was improved postoperatively with significant difference than the preoperative evaluation. This was evidenced by the decrease of the score of the Nasal Obstruction Symptom Evaluation scale for the postoperative records than the preoperative. This was due to the septoplasty procedures of resection of cartilage graft and reallocation of the septal cartilage. This result was in accordance with Mokal and Prabhash  and Chaithanyaa et al. , who used the same instrument for measuring the nasal obstruction prerhinoplasty and postrhinoplasty and achieved the same result.
The AIA was measured in the frontal view for evaluation of the symmetry of the nose, the results of this study showed improvement in the symmetry in the frontal view evidenced by the significant decrease in the measurements of the AIA from 3.36° preoperatively to 1.14° postoperatively with P value of 0.001. This result evidenced by the medial and upward reallocation of the downward laterally displaced alar cartilage. This was agreed with Mokal and Prabhash , Chaithanyaa et al. , and Li et al. .
The difference between ala-tip angle and alar base distance on the cleft side and the normal side in the basal view photograph were significantly decreased postoperatively than preoperatively indicating improvement of the nasal esthetics in the basal view. This is due to medial Y–V advancement of nostril sill and medialization of the alar base. This was in accordance with Mokal and Prabhash , Chaithanyaa et al. , who found significant improvement in the symmetry of the nose using Y–V advancement of the alar base medially and an alar cinch stitch taken for narrowing the nostril base.
The vertical lip length on cleft side was increased in comparison to the normal side evidenced by the significant increase of the proportion indices of L1'/L1, L2'/L2. These records were explained due to cheiloplasty procedures of lip lengthening by z-plasty or V–Y advancement. Although the proportion index of L3'/L3 increased postoperatively but without significant difference. This might be attributed to the lateral site of this measurement away from the cheiloplasty surgery.
This was in accordance with Kim et al.  who found significant increase in the upper lip length with z-plasty technique especially in the area near alveolar bone grafting.
| Conclusion|| |
Secondary cheilorhinoplasty can be done successfully in the same time with late secondary alveolar bone grafting leading to avoid several surgical distresses for the patient, to improve facial esthetic and function in one surgical step, and to reduce risk of psychological consequences.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ellis E. Management of patients with orofacial clefts. Contemporary of oral and maxillofacial surgery. St Louis, MO: Mosby; 2002. pp. 623–645.
Witsenburg B. The reconstruction of anterior residual bone defects in patients with cleft lip, alveolus and palate. A review. J Oral Maxillofac Surg 1985; 13:197–208.
Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate J 1986; 23:175–205.
Bergland O, Semb G, Abyholm F, Borchgrevink H, Eskeland G. Secondary bone grafting and orthodontic treatment in patients with bilateral complete clefts of the lip and palate. Ann Plast Surg 1986; 17:460–474.
Da Silva Filho OG, Teles SG, Ozawa TO, Filho LC. Secondary bone graft and eruption of the permanent canine in patients with alveolar clefts: literature review and case report. Angle Orthod 2000; 70:174–178.
Russell KA, McLeod CE. Canine eruption in patients with complete cleft lip and palate. Cleft Palate Craniofac J 2008; 45:73–80.
Millard DR Jr. The anatomy of the secondary deformity of the unilateral cleft lip nose. Cleft graft: the evolution of its surgery. The unilateral deformities. Boston, MA: Little, Brown and Company; 1976. p. 629.
Nakamura N. Surgical strategy for secondary correction of unilateral and bilateral cleft lip-nose deformities. In: Brenner M, editor. Rhinoplasty
. London, UK: InTech; 2011. pp. 57–70.
Sayler KE, Genecov ER, Genecov DG. Unilateral cleft lip nose repair: a 33 years' experience. J Craniofac Surg 2003; 14:549–558.
Cutting CB. Secondary cleft lip nasal reconstruction: state of the art. Cleft Palate Craniofac J 2000; 37:538–541.
Matukas VJ, Louis PJ. Secondary management of the nose in the cleft patient. Int J Oral Maxillofac Surg 1993; 22:195–199.
Ettorre G, Weber M, Schaaf H, Lowry JC, Mommaerts MY, Howaldt HP. Standards for digital photography in cranio-maxillofacial surgery – part I: basic views and guidelines. J Craniomaxillofac Surg 2006; 34:65–73.
Mokal NJ, Prabhash CK. Composite correction of a unilateral cleft lip nose deformity and alveolar bone grafting. Indian J Plast Surg 2009; 42:S71–S78.
] [Full text]
Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004; 130:157–163.
Chaithanyaa N, Rai KK, Shivakumar HR, Upasi A. Evaluation of the outcome of secondary rhinoplasty in cleft lip and palate patients. J Plast Reconstr Aesthet Surg 2011; 64:27–33.
Fakas LG. Chapter 5: photogrammetry of the face. In: Fakas LG, editor. Anthropometry of the head and face,
ed. New York, NY: Lippincott Williams & Wilkins; 1985. pp. 113–165.
Anastassov GE, Joos U, Zöllner B. Evaluation of the results of delayed rhinoplasty in cleft lip and palate patients: functional and aesthetic implications and factors that affect successful nasal repair. Br J Oral Maxillofac Surg 1998; 36:416–424.
Lee C, Crepeau RJ, Williams HB, Schwartz S. Alveolar cleft bone grafts: results andimprecisions of the dental radiograph. Plast Reconstr Surg 1995; 96:1534–1538.
Graviero G, Guastini L, Mora R, Salzano G, Salzano FA. The role of three-dimensional CT in the evaluation of nasal structures and anomalies. Eur Arch Otorhinolaryngol 2011; 268:1163–1167.
Andersson L, Kahnberg KE, Pogrel MA, editors. Oral and maxillofacial surgery. Hoboken, NJ: John Wiley & Sons; 2012. pp. 1261–1266.
Ahuja RB. Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late. Plast Reconstr Surg 2001; 108:1127–1135.
Scopelliti D, Fatone FM, Cipriani O, Papi P. Simultaneous options for cleft secondary deformities. Ann Maxillofac Surg 2013; 3:173–177.
] [Full text]
Turner SR, Thomas PW, Dowell T, Rumsey N, Sandy JR. Psychological outcomes amongst cleft patients and their families. Br J Plast Surg 1997; 50:1–9.
Bardach J, Salyer KE. Surgical techniques in cleft lip and palate
. Chicago, IL: Year Book; 1987. pp. 68–95.
Li J, Shi B, Liu K. A photogrammetric study of the effects of alveolar bone graft on nose symmetry among unilateral cleft patients. J Plast Reconstr Aesthet Surg 2011; 64:1436–1443.
Kim SW, Park SO, Choi TH. Change in upper lip height and nostril sill after alveolar bone grafting in unilateral cleft lip alveolus patients. J Plast Reconstr Aesthet Surg 2012; 65:558–563.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]