Gingivoperiosteoplasty
Mark C. Martin
DEFINITION
Involvement of the alveolus in an oral cleft requires treatment to establish bony continuity of the divided maxilla.
Closure of the alveolar cleft has many positive effects including preventing nasal regurgitation of liquids, preservation of crestal bone height necessary for periodontal health, allowing safe orthodontic movement of teeth, and improving stability of the maxillary arch against relapse after occlusal correction.
Gingivoperiosteoplasty (GPOP) refers to repair of the alveolar cleft without bone grafting with the intention of promoting osteogenic bridging of the cleft by surgically creating a closed space across the alveolar cleft lined by mucoperiosteal flaps.
ANATOMY
The alveolar cleft ranges from a minor notch to a complete cleft of the primary and secondary palate.
The cleft presents as a variable gap that involves displacement, deformity, and hypoplasia.
The cleft margin on the major segment flares anteriorly and deviates toward the noncleft side, and the alveolar stump curves cranially as the growth force of the vomerine septum lacks a restraining connection to the lesser maxillary segment (FIG 1A).
The cleft margin of the minor segment is positioned posteriorly, and its alveolar stump curves in a cranial direction from the frontal view as it approaches the cleft (FIG 1).
The maxillary primary central incisors erupt at a variable age (usually between 6 and 12 months) and depending on the age of presentation and the surgeon’s preferred timing for GPOP, these teeth may or may not be present at the time of surgery.
The primary lateral incisor erupts between 12 and 18 months and on the cleft side is commonly hypoplastic or may be absent or accompanied by supernumerary teeth.
Natal teeth may go unnoticed early in life in the setting of the cleft and be present high in the nose, which can affect the design of mucoperiosteal flaps.
The abnormal anatomy of the lateral cleft must be recognized as failure to develop different tissue types with heterotopic placement of existing tissues; choosing nonosteogenic membranes to line the alveolus repair may diminish the chance of adequate bone formation (FIG 1B-D).
Synergistic with correct lining of the GPOP, the use of a medial nasal lining flap to resurface a lateral vestibular releasing incision between vestibular skin (vibrissae) and vestibular mucosa (hairless) allows correction of alar base position without using nonanatomic flaps.
The anatomy of the medial cleft is difficult to visualize due to the three-dimensional deformity (FIG 1E-G).
Dislocation of the caudal septum into the noncleft nasal floor and the cranial inclination of the medial stump of the alveolus creates an acute angle between the septal mucoperichondrium and nasal floor mucoperiosteum, which can be challenging to dissect and mobilize.
By lifting the medial nasal lining flap in continuity with the septal mucoperichondrium and subsequently correcting the caudal septum in the midline, the medial nasal lining flap can be used for tension-free reconstruction of the nasal floor, as well as to line the vestibular release with thin supple tissue (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
Age of patient at presentation is important.
Early institution of nasoalveolar molding (NAM) is thought to have more lasting effects on nasal cartilages due to the presence of maternal hormones.5
Older children are more likely to disturb the appliance creating compliance difficulties.
An alveolar cleft with alveolar segments in apposition may not benefit from NAM but should be monitored for unfavorable changes in position (increased gap) of the maxillary segments that can occur with oral-digital habits or feeding behaviors.
An isolated cleft of the lip (primary palate) may benefit from the nasal molding effects of NAM, but the change at the alveolus will be limited by the rigidity imparted by bony continuity of the secondary palate.
Infants with medical comorbidities will often tolerate NAM therapy, but individualized attention to the appliance’s effect on feeding and weight gain is indicated.
IMAGING
Imaging in the setting of isolated cleft lip and palate is not normally obtained before GPOP, but may be indicated to evaluate more extensive craniofacial clefts.
Imaging to assess results of GPOP is not standardized and may involve a variety of modalities.
Plain occlusal radiographs are commonly used to assess alveolar bone formation in young patients (primary and early mixed dentition) and periapical and/or panoramic radiographs in older patients (late mixed and permanent dentition).
Cone-beam computed tomography (CBCT) is increasingly used and provides more detailed information than plain films regarding the adequacy of alveolar bone; the clinical utility of CBCT use is still under evaluation.
 FIG 1 • A. The cleft alveolus deformity. The columellar base is displaced toward the noncleft side (yellow arrow). The greater segment alveolus stump is flared anteriorly (red arrow). The alar base on the cleft side is displaced posteriorly through its relationship to the pyriform rim (blue arrow). B. Lateral cleft anatomy. C. Gingival mucoperiosteum shaded green, labial mucosa shaded orange, vestibular skin with vibrissae shaded blue, vestibular mucosa pink, and hairless shaded yellow. D. Yellow incision plan including vestibular release between vestibular skin and vestibular mucosa to achieve medial nasal lining flap during closure. E. Medial cleft anatomy. F. Gingival mucoperiosteum shaded green, labial mucosa shaded orange, vestibular skin with vibrissae fixed to medial crus shaded blue, mobile vestibular mucosa of membranous septum and nasal floor mucoperiosteum shaded pink, and hairless shaded yellow. G. Incision plan including medial nasal floor mucoperiosteal lining flap for nasal floor repair and lining of lateral vestibular back cut. |
NONOPERATIVE MANAGEMENT
There is no dispute that alveolar clefts benefit from repair; however, the timing and techniques for repair remain controversial.1,2,3,4
If GPOP is not done in infancy by design, or if it has been done unsuccessfully, secondary alveolar cleft repair with autologous bone grafting (most commonly with cancellous iliac crest bone) is a well-established procedure with a high success rate.6
SURGICAL MANAGEMENT
GPOP in infancy is technically challenging and reported outcomes vary widely among authors.1,2,3,6,7,8
A surgeon’s technique has been shown to be an important determinant of facial growth after repair of oral clefts in general.
Modern authors have demonstrated useful bone filling of the alveolar cleft from 73% to 100% depending on the specific technique and protocol.1,6
Even in patients who do not form adequate bone after GPOP, it has been reported that subsequent successful standard mixed dentition bone grafting is technically easier than in those not having undergone GPOP.6
Successful GPOP eliminates one operation at school age and the need to use a painful distant donor site (most commonly the iliac crest in North America).
GPOP is often preceded by NAM, which requires a skilled dental professional, significant time commitment from caregivers, may be costly, and can be ineffective in the setting of noncompliance.9Related posts:
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